7 minute video on YouTube:

https://www.youtube.com/watch?v=yfiWjnStE3w

Spot on, IMO.

My wife is a physician as most of you know. When she wrote in a patient's chart "morbidly obese," they would often blow a fuse.

It was a medical term for people with BMI>40. Some of these people were women under 5'6" weighing in at over 300 lbs. I mean BMI well over 50.

NOT reporting the facts would expose her to liability. Now, of course, the term has been given a nice euphemism ... Class III obesity. Class I starts at BMI>30.

Patients literally do not want the "obese" label. They are offended by a simple medical definition that is a meaningful indicator of their health and of their likelihood of developing severe disease of many sorts (starting with diabetes).

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Patients literally do not want the "obese" label. They are offended by a simple medical definition that is a meaningful indicator of their health and of their likelihood of developing severe disease of many sorts (starting with diabetes).

This is so hard. I have a friend who is quite large, and separate from that (or not separate, probably) she has some health concerns. And she gets very offended when a doctor tells her she should lose weight. She has my sympathy. And at the same time, I can't help but think she might feel better if she were less heavy.

I totally get the push to be accepting of a range of body types, and I think that's a good idea. I also get the push-back against doctors who don't listen to their patients' concerns -- and this happens particularly with women and people of color. And lots of anecdotal stories about overweight women whose health problems were overlooked or undiagnosed because the doc assumed it was "just" because of their weight. More importantly, there are all kinds of stats now about how women have poorer outcomes when the doc is male etc. etc.

So all of that stuff is real. But at the same time, being overweight is bad for your health, and being extremely overweight is extremely bad for your health.

I don't think changing the label from "morbidly overweight" to "overweight category III" is going to help.

If women felt they could trust their doctors, now that would help a lot...

Oh, and one other problem. It seems that tons of research confirms that it is *really* hard to lose weight and that it's even harder to keep weight off once lost.

If a doc is going to tell someone that their health problems are due to their weight and they should lose weight, they need to do so with the understanding that a prescription for weight loss is mostly a prescription for failure. If that was foremost in their minds, how would it change the way they interact with the patient?

P.S. full disclosure, I didn't watch the video!

Obesity over time

This is not something happening exogenously, a swan event of the "OMG we're suddenly fat, how on earth did that happen to us and WHO did it?"

Yes, it's hard to lose weight, but as Maher notes, it was hard in 1969 too, when many fewer adults and children were obese.

It's easy to say "poverty is the problem" and throw up your (or society's) hands at the impossibility of doing anything. But that simply excuses people, individuals, of their own agency ... which is also part of Maher's point.

There are clearly poverty issues involved. Simple carbs are cheap, and many people have limited access to more nutritious foods (they live in "food deserts" so they eat desserts instead!). But this is also cultural and educational, and I'm sure most of us have seen this first hand. Many low-income people gag on the mere idea of eating fresh fruits and veggies, even when available, and reject out of hand the advice to do. Ditto for portion control. I live in the south, where obesity problems are really bad! Can't tell you the number of people who think fruit punch is healthy because there's some apple juice (pure sugar) in it.

My wife keeps an empty box of Fiber 1 cereal in the office so that her low-income patients can take a picture with their cell phone (because telling them about fiber goes in one ear and out the other). These are people who repeatedly clog up ERs because of "belly pain," when what they're really suffering is burgers and fries syndrome. She can regale you with stories of patients who have had huge (and expensive) ER workups to find the zebra cause of their pain problems when a simple KUB study (which my wife orders oh so frequently) shows that they are completely constipated, likely due to poor diet.

Maher is harsh to woke ears, I'm sure. Doctors can help inform, but society / advertising / food economics / peer culture are powerful forces driving obesity and its related problems in the wrong direction. But ultimately, people make choices about what to eat, and how much.

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this is also cultural and educational

Well and it may also be a whole bunch of biological things that are not well-understood. People's microbiomes are not the same as they were in 1969. The science on why people become obese and how they might become un-obese is still very underdeveloped.

Also, I'm sure you don't mean to say that it's cultural as if that means it can just be tweaked. Culture is a powerful force that most people are not even aware of, let alone able to resist or go against.

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ultimately, people make choices.

I think this is unfair, and somewhat unkind.

Sure, people make "choices" but those choices are based on what is available to them. And what is available to a child growing up in poverty is not the same as what is available to a child growing up in a middle-class or higher environment. And it's not just children, adults also have a completely different set of choices depending on their circumstances.

Too many people eat themselves to the point of a disability.

Have gained and lost enough to know that comments from others only makes
the problem worse. The best answer to those who want to "fix" you is a loud FU.

Solution? I have never read or of one.

From my own perspective, one of the most difficult challenges has to do with trying to cook a healthy meal, at home, every night after you've worked a 8-10 hour day (including commute times). I definitely remember coming home after work and having to rustle up some form of dinner for the fam the instant I walked in the door. Our take-outs increased quite a bit when I was working FT and the kids were at home, and I was really conscientious about trying to select healthy foods and still cooked at least 4 meals/week.

It's just hard, and it's not just a poverty or food desert problem.

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It's just hard, and it's not just a poverty or food desert problem.

No, it's not just a poverty problem. It's more concentrated among low-income families, but it affects all income groups.

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it affects all income groups.

Yep, and it's not just because of individual, freely-made choices people are making in isolation...

I'm going to push back. My unkindness is in giving people agency, and in not infantilizing them. Because people operate under constraints does not mean they are powerless non-actors. Most people can adjust the trajectory of their lives by making different choices. And people, like their physicians, who provide obese patients with good information, aren't the enemy because they want people to make different choices.

For the most part, that was Maher's point as well, though as usual he comes on quite strong.

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My unkindness is in giving people agency, and in not infantilizing them. Because people operate under constraints does not mean they are powerless non-actors.

I agree, it's never good to infantilize people. But it also doesn't help to pretend like they have more power than they actually do.

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Most people can adjust the trajectory of their lives by making different choices.

Just from my casual reading, I suspect that the research on weight loss doesn't actually bear this out.

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And people, like their physicians, who provide obese patients with good information, aren't the enemy because they want people to make different choices.

I don't disagree, but the tendency for doctors to make women and esp. overweight women feel that their concerns are being downplayed means that the onus is on physicians to make sure that the way they present that information facilitates its acceptance.

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Originally posted by Piano*Dad:
I'm going to push back. My unkindness is in giving people agency, and in not infantilizing them. Because people operate under constraints does not mean they are powerless non-actors. Most people can adjust the trajectory of their lives by making different choices. And people, like their physicians, who provide obese patients with good information, aren't the enemy because they want people to make different choices.

For the most part, that was Maher's point as well, though as usual he comes on quite strong.

I have been (and currently am) fat. I have been thin. I’m not a yo-yo dieter, but have managed to get “thin” a couple times and stay thin for years at a time. The problem is that in order for me to stay thin it is a constant battle that requires me to obsess over food. It’s not just “eat healthy and watch your portion sizes” for me. It’s living in a state of measuring everything and counting every single thing that goes into my body every single day. I have to keep my calorie count between 1100-1500 calories to maintain a “normal” body weight. When I don’t do this, I gain weight until my body settles at the weight it’s comfortable at. Then I can eat like a normal human. When I say “normal” I mean completely stay away from fast food and have reasonable portions and don’t really snack and make 95% or more of meals my at home. That for me is “normal” eating. Sadly, this is how I can maintain a weight that puts me into the overweight bordering on obese category according to BMI. So I can sit at the borderline and have a healthy relationship with food and my body, or I can have a mild eating disorder and be a “normal” weight. (Just to be clear, “normal” BMI (or thin for me) is a size 12… I dropped to a size 10 once and I was underweight and my doctor lost his mind.)

So yes, I am a big fan of the body positivity movement. I’m a big fan of making it ok to be fat. Because I AM fat and my mental health falls apart and I develop an eating disorder to maintain “normal”. My mom was the same way (for a variety of reasons she struggled more than I have) as was my maternal grandmother, maternal grandfather, and maternal great grandfather. The “choices” that people judge fat people for (because to many people there is literally nothing worse than being fat) might not be the same for all fat people. Regardless of income or anything else.

I’m not saying this because I think I’ll change anyone’s mind. Just know that when you say “choices” there’s a reason some folks don’t take it well, and it’s not always because they are scarfing down a Big Mac for lunch every day.

I'm oh so wishing scientists knew more about leptin and ghrelin - the first being the hormone decreasing appetite, the second governing a sense of satiety. ("knew about" AND could tap their effects.)

https://www.webmd.com/diet/fea...20in%20body%20weight.

That plus what we're learning about the astonishingly varied effects of biomes, I feel could help almost all weight-troubled people (AKA those who don't seem to have a "healthy relationship with food".)

There are important psychological elements too, but the above seem to be capable of fine tuning our healthy weights. NOT so much "healthy choices", except for actually being healthy per se in the sense that we're meeting our bodies' nutritional needs.

(Besides which - as others have said - that economic factors make the notion of choice as key as very unfair.)

My BMI is 22.
Mr wtg's is 34.

He wishes he could lose some weight. He has arthritis and the extra weight doesn't make it any easier to move around. He's tried every "diet" there is. None of them work for him.

I used to think it was a matter of will power but after forty plus years of living with someone who is eating right but has struggled with his weight I am convinced there is too much we don't understand about metabolism.

The less he eats, the more stubborn the weight seems to be. We eat the same food and (literally) in similar quantities. On average, I probably consume more calories and certainly way more carbs than he does on a daily basis. Desserts, snacks, milk and sugar in my tea and coffee; he skips all those things.

We're on the same daily schedule that has us eating all our meals between about 7:30 am and 4:30 pm.

I exercise more than he does. I walk a few miles a day and in the summer I 'm doing heavy lifting in the yard. It's not like I'm doing high-powered workouts in a gym on a daily basis. I break a sweat occasionally, mostly when it's hot and humid outside.

I don't know if going to a real intermittent fasting diet would work, but as dol points out, it would mean our lives revolving around weight maintenance. Not sure that's a good choice for our mental well-being.

I know the problem is real. I have no clue what the solution is.