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A friend tipped me off to the blog of Dr. Joe Wright, writer-in-residence for the William B. Castle Society of Harvard Medical School, and I'm glad she did. The jumping off point for this post is Jamie Oliver, the young-ish chef cum nutritional crusader from Britain.

He makes several points, many of them really cogent. Such as...

"Big change comes from changing big systems." His context is that instead of trying to get each family to start sending healthier lunches to school, activists should focus on changing the food that's served at the cafeteria: Change one thing, instead of beseeching individuals to change their behavior.

How this registered with me was in my other interest, sustainability. People who, say, start to recycle are doing something positive, but they're hardly going to stop the world from frying by doing so. They could move entirely off the grid, change to vegetarianism, and never fly again — and still not save the world. But if that guy worked for a utility and helped spread smart grid technology, for example, he'd have far greater effect. 

This isn't to say that what individuals think and do isn't important. Those are, in fact, Dr. Wright's second and third points. He says that a structural change works only if a large number of people believe in it. If I become a vegetarian, I might be healthier and would have a negligible effect on animal agriculture. But look at the rise of organic agriculture — it's grown only because lots of people with changed attitudes are voting with their wallets.

In his prelude, Dr. Wright talks about he usefulness of the world "obese," because it "has become so loaded with moral judgment," and on this point I part with the good doc. It's not like calling someone a "fat pig," which I concede could turn out to be counterproductive.

I don't know what's wrong with using an accurate word, especially a word that has power. Obesity is a serious health issue, and I don't see how soft-pedaling it is in a patient's interest. I don't know I would use such a word to wound, or to shock, but he evidently would be quite a bit more chary.

Almost certainly, this means I would have lousy bedside manner.


Hey Michael, thanks for reading my blog. I appreciate it.

On the word "obese". Most of the people I see in clinic who need to lose weight are like me--people with a body mass index somewhere pretty near to 30. Those people will not be served by thinking there is something magic about the number 30--that they are really bad at 30.1 and only a little bit bad at 29.9. And these folks are medically "obese", but in many respects they are not socially obese.

By that I mean, these are not the people whose big butts the next TV health reporter will film out in public to demonstrate the horrors of obesity. (Seriously, how many times have you seen that shot?) Those folks are BMI closer to 40, and they don't have to be told they're obese. They know it. They might be defensive about it, or fatalistic about it, but it's not lost on them that they are fat. On the other hand, someone who has a BMI of 30 is like a lot of people around him or her, a lot of people at work, a lot of people on the train, etc, etc. In fact, Nicholas Christakis has shown that obesity tends to actually spread in a social manner. ( http://christakis.med.harvard.edu/pages/research/r-images.html )

What that means is that if I say, "you're obese" to someone, and they do more than just blow it off, they'll ask a friend, or a spouse, "Do you think I'm obese? My doctor says I'm obese." Friend (BMI 29) is going to say, "That's ridiculous! Doctors always want you to do something just to justify their paychecks. You're a stocky guy, you've always been stocky, big deal. My dad was husky and he lived to be 80!"

The same is true with drinking. I have a hard time convincing people who don't realize they have a problem, that they have a problem--sometimes because all their friends and family have the same problem. That means I have to focus on what makes it a problem--you've been pulled over for drunk driving twice and you lost your job--rather than on some label like "alcoholic." Then we can agree together that yes, it is a problem, and yes, maybe we should work together to do something about it. And if we really sit and think about that for a while we might realize that the name of the problem is "alcoholism"--but the label as a first step is less important than understanding why it's a problem. The label has to come after people are ready to start thinking about change. Then the wake-up call that the label represents can be useful, maybe.

For people who are really compulsive about food, that might be not only, this is bad for your health, but also, look how you're organizing your life around food and not the people you love. (For instance.) It takes understanding it as a problem to be able to accept a name that has some social stigma associated with it.

So, that's why I don't use the word "obese": in sum, because the people who are a little bit obese won't believe it, and the people who are very obese already know it. The important thing to me is that they understand what they can do to become healthier.

However, a caveat: I have not tested this, and I don't think anyone has tested this, in any clinical trial. And overall, doctors on their own have very little success with any method of getting people to lose weight. So, I may change my mind about this next month. 


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