Healthy at every size?

I have been seeing a lot of fuss on the internet about fat acceptance, with the motto “healthy at every size.” The idea is that you can be skinny with high cholesterol and a cocaine habit, or overweight but eating healthy and exercising regularly. Which person is really healthier?

But here is where this argument breaks down: There are aspects of being overweight or obese that ARE unhealthy no matter what you eat or how much you exercise. I agree that a BMI of 25.1 probably isn’t that much worse than 24.9, but it is difficult to argue that it is healthy to have a BMI of 92.

I’m not saying that because I have anything personally against people who are overweight. I do not see obesity as a character flaw. I do see it as a sign of an unhealthy habit (over-eating), much like COPD is a sign of the unhealthy habit of smoking.

Don’t believe me about the health risks of of obesity? Obesity increases the risk of ALL of the following conditions:
– High blood pressure
– Stroke
– Coronary artery disease
– Heart failure
– Type 2 diabetes, which can lead to most of the above, plus kidney failure, eye problems, and much, much more!
– Osteoarthritis leading to chronic pain
– Breathing problems including sleep apnea and something called obesity hypoventilation syndrome, where you slowly suffocate (Don’t believe me? Read )
– Gallstones
– Cancers of the breast, colon, gallbladder, and uterus

In my world, I see the aftermath of the increased rate of spontaneous abortion (miscarriage) in obese women. It is harder for these women to get pregnant to begin with – body fat produces estrogen, and estrogen inhibits ovulation (that’s why it’s in birth control pills).

In birth control pills, the estrogen is balanced by progesterone, which serves to prevent the endometrium from growing out of control. Obese patients have the estrogen without the progesterone, and the uterine lining can grow out of control and become endometrial cancer.

When an obese woman is able to get pregnant, she is at increased risk for miscarriage. Because these statistics are so well-known, many infertility practices will not treat obese women – the chances of success are just too low. Can you imagine being taught that “big is beautiful” and you can be “healthy at every size,” then hearing that you can’t get pregnant because of your weight, and even if you are willing to spend your life savings ($20K for a round of IVF) on fertility treatments, your odds of success are so much lower than average that most doctors won’t accept you as a patient?

If you get pregnant, it’s even worse.
According to the American College of Obstetrics and Gynecology, maternal risks of a BMI 30-39.9 (obese) compared to a BMI of less than 30 (not “healthy” necessarily, but not obese) include
– 2.6-4x the risk of gestational diabetes
– 2.5-3.2x the risk of gestational hypertension
– 1.6-3.3x the risk of preeclampsia
– 1.7-1.9x the risk of fetal macrosomia (Having a large baby increases the risk of birth injury in the baby and severe injury to mother including tearing of the perineum through to the rectum which can lead to permanent fecal incontinence. Large babies also increase the risk of severe and possibly fatal postpartum maternal hemorrhage.)

Cesarean delivery rates also increase with increasing BMI – according to ACOG, the C-section rate in one large study was “20.7% for women with a BMI of 29.9 or less, 33.8% for women with a BMI of 30–34.9, and 47.4% for women with a BMI of 35–39.9”

What about the baby? Obesity increases the risk that babies will be born with birth defects, and makes it harder to detect these defects with ultrasound. Even after correcting for diabetes, infants born to obese mothers have double the risk of neural tube defects such as spina bifida. The worst of these defects is a condition called anencephaly, in which part of the skull and brain are missing – it is not survivable.

Postpartum risks include elevated chance of a severe blood clot, wound infection, wound breakdown, and difficult anesthesia.

Come on, you say, what’s the harm in obese people feeling good about themselves? Isn’t a little self-esteem a good thing? No, not necessarily. What motivated me to study for hours and hours for my medical school exams? What made me spend my summer doing practice questions for Step 1 when I could have been at the park with my daughter? It was the fact that I FELT BAD about my level of knowledge. I didn’t want to love and accept myself as I was, I wanted to BE BETTER. This is why the fat acceptance movement is so dangerous – if you teach obese people that there is nothing wrong with being obese, then why change? Why try to lose weight? Everyone should feel beautiful, but not at the expense of their health. (Incidentally, I feel the same way about anorexia and tanning beds.)

Ok, so the obese patients aren’t going to lose weight. Why does that matter? It matters because, for obese patients, losing as little as 5-10% of their body weight can mean a significant reduction in the risk of diabetes, heart disease, and stroke.

I saw this comment on this tumblr page: “I need fat acceptance because I’m sick (pun intended) of my body being pathologized.”

I wish I could talk to the person who wrote this, to tell her that I don’t want her to feel sick, and I’m not “pathologizing” her to make you feel less like a human being. I believe that she, like every human being, deserves to be happy. She deserves to get pregnant and have a family. She deserves to play soccer with her kids without severe chronic back and knee pain from osteoarthritis, to live to see her children graduate high school instead of dying from a heart attack or a blood clot in her lungs.

It makes me sad to see anyone suffer, even if it is the result of a bad habit. It is awful to see someone with a COPD flare suffocating in front of you. The fact that the patient smoked a pack per day for 40 years makes this less unexpected, but it doesn’t make it any less sad.

So when I saw a young, morbidly obese woman with advanced endometrial cancer, it was heart-wrenching. She had shortness of breath that could have been the result of a pulmonary embolism, a blood clot in her leg that traveled to her lung. She couldn’t get an ultrasound of her leg because the technician said there was too much tissue – she couldn’t see the veins in the leg well enough to rule out a clot. We would normally get a special CT scan of the chest, but the machine has a weight limit of 500lbs. It is too late for this woman. She is going to die. Don’t you think she deserved to hear about the risks of her weight before she had terminal cancer, instead of hearing some cliche about being “healthy at every size?”

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