Obesity is a …er… huge expenditure accounting for approximately 10% of all annual medical costs. That is a Whopping $200 billion dollars each year in the US. However, mental illness is double that cost if one considers it a separate issue.
I do not. Any extreme behavior affecting one’s health, be it overeating or undereating, is a mental illness.
Questions:
should healthy people be forced into caring for those people?
How many mentally ill people are truly unable to help themselves?
Why? I could publish my food diaries, my bloodwork and my daily glucometer logs to prove that I am doing absolutely the most I can and can not loose weight. If some kind rich person would build me an enclosed [I live in Connecticut, the winters here can be brutal] swimming pool I would be thrilled to swim daily - otherwise the nearest free pool I can use is 30 miles away, the nearest pay to use pool is 20. If you want me to go out to swim, buy me a vehicle as there is NO mass transportation that will haul my ass to the sub base in New London so I can use the base pool that wouldn’t take me 8 or 9 hours one way [I would have to get some form of transport in to WIllimantic, then ride into Hartford, make 2 connections, then ride out to Groton and figure out how to get a ride onto base to the pool. Then I would need to repeat it in reverse.]
Sorry, there is no single simple answer. If I cut my food under the 1800 cal a day that my endocrinologist and nutritionist consider the absolute minimum to keep me from malnutrition and metabolic issues, then I run other serious health risks. Now if you figure out how to whip my flesh off my bones and replace my skeleton, let me know - I will be first in line. Degenerative skeletal issues suck ass.
Yes, that’s the one which impressed me the most. The case-controls weren’t obese people in general, but obese people in hospitals. You’d think them likely to have below-average health outcomes compared to the average obese person who doesn’t get weight loss surgery. And yet the hospitalized controls were living a bit longer than the weight loss surgery patients. This seemed to me to, at least, hint that the massive spending on weight loss surgery is yet another example of medical spending profligacy.
I somehow had missed that Utah study from the NEJM. Thank you for pointing to it. It has some of the same good points as the Pennsylvania study (use of government databases so that patients can’t be lost to follow-up*; follow-up period longer than five years). The Utah docs had a very low one year post-surgical death rate (1 in 200) despite saying that they “denied surgery to less than 1% of subjects because of preexisting health conditions.” Maybe they just are better surgeons. Most likely that’s what those docs think, and the study sort of says it. But I’m not sure how plausible it is that they got such good year one results while being so willing to cut.
I think if both those Utah and Pennsylvania studies were repeated now, so that there could be another ten years of followup, the results would be interesting. The problem with almost all weight loss studies is insufficiently long follow-up.
Are you sure that study? Because that is not what that study did and the results are not what you said they were.
Again: all those in the state who had bariatric surgery in a ten year period compared to all Pennsylvania residents, not just the obese ones, and certainly not case controls of obese individuals who were hospitalized.
Yes it would be of interest to follow up 20 years out.
To me the most salient question would be comparing bariatric surgery patients (who lose massive amounts of weight) with those who are in a program that aims primarily at improving nutrition habits, achieving fitness metrics, and lots of psychosocial support with a secondary goal of maintaining more modest weight loss (5 to 10%). My guess is that the latter would do at least as well and likely better in mortality and morbidity metrics.
Ugh! You are right. My memory of what I read near original publication was far off, as was my glance of the contents before posting, when I read the sentence with the “Berksonian bias” phrase and took it completely out of context.
And kudos to you for owning up to that!
Meanwhile to bring this back to the op, I note that what I promote is not far off from HAES concepts and what the CBT protocols are aiming at … for those who are obese less focus on the scale as the goal (to none for the HAES movement) and more on healthy behaviors and feeling successful if those behaviors are achieved, not based on what the scale says. But a focus on behavioral interventions, even if those hypothetical interventions are defined as therapy and are hypothetically successful, as the prime goal is not the same as defining the issue as mental illness.
Gotta agree with DSeid- obesity is a behavioral issue, which may or may not involve a mental health issue. In either case, there is obese behavior and fit behavior. A person who is obese because of a mental illness could keep the illness and become fit by adopting fit behavior. But that’s the trick, of course.
Here is a nice article expanding on the views I’ve promoted in this thread. They are far more exhaustively research-based than I have been, and probably don’t sound like they are nagging anybody. Sorry if I sound like that- if someone is obese and doesn’t care if they lose weight, I don’t care either, it doesn’t make them a bad person. Anyway, from the article:
This conclusion follows partly from the observation that we have created an ‘obesigenic environment’. We don’t have to move as much as people did 200, or heck, even 50 years ago. Mostly our convenient car-and-office environment alters our behavior in the obese direction, and not mental illness:
Thanks for the link to that Runner’s World article Try2B. And the data on decreased activity levels and its correlation with rising BMIs is very interesting. Good for the writers that they dialed back from an initial angle of only the activity side matters. (Those self-reported calorie counts are notoriously inaccurate.)
Another article to throw into the mix that confirms the importance of activity and, as the RW article circles back to, the choices of sorts of foods.
You could whip the flesh off your bones with yoga. I agree that your condition is an issue, but I know who to forward your case to for advice/instruction. PM me about it if you want.
How much does a car cost?
DSeid: Glad you liked that! Thanks for the New England Journal of Medicine article. It is nice to see a quantification of these things. I’ve never been able to put numbers to these things before.
I am not refuting those results at all, but it is important to look at how Americans behave in the context of what research has uncovered. From the RW article:
The gist is, with a minimum amount of exercise, the body has its own systems to keep weight in check. The option for no exercise is a new one, and our bodies become obese if we go down that path.
I completely agree that activity is important but I cannot jump on a wagon that says only activity matters. It is not so simple.
Few exercise regularly, but few ever did. Trends actually have been for a modest increase in structured exercise. The articles referenced, by Church and Archer document that there is less time spent doing housework and a move into industries and occupation that have less activity built in - non-exercise activity. Church rated industries by METS associated with them, 4.0 for construction, 3.8 for mining, to 1.5 for information and financial. Indeed more work in the latter than the former than before. Pretty big assumption on those METS to then make precise calorie estimates, but the overall concept? Sure. We move less at work and getting there even on average than we used to.
But let’s make a prediction based on the hypothesis that the overall move into lower METS jobs is the cause of obesity - those currently in those higher METS jobs should have lower obesity prevalence than those in lower METS jobs. Is it so? No.
Construction, mining, agriculture, forestry and hunting all average rates, even when potential confounders of demographics and health behaviors are controlled for. No different than for information and for financial services. Architecture and engineering, and protective services particularly high. Real estate, rentals, professional, scientific, and technical services particularly low.
The hypothesis that a minimum amount of activity/exercise will automatically allow a body to keep its weight in check does not pan out.
Movement matters, and likely much more for health than for BMI. And it matters for BMI too, just not as the single factor.
T2B you may also find this more recent bit by Archer of interest. His thesis there is that relative maternal inactivity and excess energy input has prenatal impacts on the next generation. His focus is on metabolic effects of excess energy and swings into mild hyperglycemia on the developing fetal pancreatic cells and fat cells … such also can happen when the fetus is deprived of adequate nutrition. He thus proposes that a tendency to obesity is amplified intergenerationally and
He does not even address the studies that demonstrate brain changes to the centers in control of appetite and metabolism that occur prenatally in response to maternal obesity and high saturated fat diets (animal studies) and how those changes exacerbate with postnatal exposures.
Hence the logic of the HAES approach … aim for the target that matters most and that is more achievable, moving more and eating better/smarter, not to lose weight per se (although nothing wrong when it occurs to some modest degree) but to prevent the tendency to obesity from becoming manifest, to optimize health at every size, and to help break the intergenerational cycle.
What about morbid obesity? someone who reaches over 400 pounds, for example-there has to be aspects of mental illness involved in this.
I’m not convinced. I used to work with an extremely fat woman, and she always seemed pretty sane and relatively normal except for her weight. She had stomach surgery and lost a lot of weight, dropping to just “fat”, without much obvious change in her mental state. I guess if you consider something like cigarette smoking a “mental illness”, so is getting very fat. But it’s a very narrow type of mental illness that doesn’t affect much else.
Nope. The only mental problem obesity, even extreme obesity, correlates with is depression. And even there it is still unclear what causes what.
The only exception is prader- Willy Syndrome. That rare syndrome is Well documenten an can be tested for. Prader-willi causes both slight mental retardation and, because patients never feel sated, they can get extremely heavy.
This argument is common but doesn’t hold water IMO (be it for obesity, smoking, alcohol, etc…). People with unhealthy habbits are ill earlier and die earlier. But treating the terminal diabete, cancer, heart disease, etc… of the 50 yo guy with unhealthy habbits doesn’t cost anymore than treating the same terminal disease of the 80 yo guy with healthy habbits (and you spared the cost of medical care during the 30 intervening years on top of it).
Everybody dies of something, so staying healthy is just delaying the unavoidable, along with the unavoidable expenses. The major part of health expenses are incured during the last year of life. It doesn’t matter if the person dies at 40 because he was obese or make it to 90 because he wasn’t. You’ll still end up paying for a costly cancer treatment, bypass surgery or whatever.
I’m sorry, but this sounds rather pulled-from-the-ass. Do you have a cite?
Because I have one: Economic costs of obesity.
Even if I were to accept your premise that health costs are all a wash in the end because “we all gotta die of something!”, I disagree that the societal cost of a healthy 85-year-old living in assisted living is the same as a chronically ill middle-aged person. The former is no longer employed, so he has no coworkers or employers to leave in the lurch if he should have to take off work due to sickness. All his children have been raised and sent off to college, so he isn’t leaving behind responsibilities if he should keel over. No one expects the old man to fight in any wars, discover any cures for cancer, or dig any ditches. The old man has already done these things.
In other words, there’s a greater social value placed on a healthy younger person than a healthy old person. Young people who are too infirmed to work and to care for others represent an extra burden on society. The old man helped to care of his parents and grandparents by funding social security and other taxes. Younger people who are unable to work (or work suboptimally) are a monkey wrench in the circle of social welfare. Imagine being responsible for an aging parent when you’re stuck in a Jazzy motor scooter your own damn self.
For smoking such is an argument that has been hard to argue against. Lung cancer and heart attacks killed people young and quickly, “saving” the system dollars in an absolute sense.
The circumstance is different for poor nutrition and exercise habits (not quite the same as obesity) though: they don’t kill you so fast but they do make you ill (and costly) early, and disabled both physically and cognitively fairly early as well. You live nearly as long just with expensive chronic diseases most of the time and disabled such that you are a drag on society at points in life when many now are still active contributors otherwise.
The consequences of smoking were less often (oh sometimes, like COPD and emphysema) chronic as much as fairly rapidly fatal events fairly early on; the consequences of poor nutrition and exercise habits are much more often multiple decades of medical care and many years of missed productivity.