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"Overweight" - Do We Really Need This Toxic Term?

5/1/2016

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Anyone who’s ever seen a medieval suit of armor in a museum knows that modern humans have increased in stature over the years. Generally this change has been greeted with approval, as a sign that we are healthier and better-nourished than our ancestors. Our more recent increase in body mass, by contrast, has set off major alarm bells – especially coming as it does during a period in which aesthetic preferences for extreme slimness have become the cultural norm. (This is not true of all periods in human history – just look at the beautiful, saftig women portrayed in the paintings of Rafael and Titian.)

By now we’ve all heard it so often we can almost say it in our sleep: Two thirds of Americans are either overweight or obese, using the standard cutpoints based on Body Mass Index (a measure of weight corrected for height), with a BMI of 25-29.9  being defined as “overweight” and a BMI of 30 or more as “obese.” This is a serious public health problem, right?

Yes BUT.

Yes, it is well-documented that obesity is detrimental to health. It leads to diabetes and hypertension; it makes exercise difficult and unpleasant (and thus undercuts the benefits that exercise confers). Roughly one third of US adults are obese and that is a problem.

BUT unless it’s a way-station on the road to obesity, then being “overweight” is not a public health problem. It is not an individual health problem. It is not a health problem at all.

In fact, carrying a little extra weight as a buffer against disease and starvation may even have some protective effect. In 2005, and in a followup meta-analysis in 2013, Katherine Flegel, an epidemiologist the US Centers for Disease Control and Prevention, touched off a firestorm by presenting data suggesting that "overweight" adults have lower mortality rates than so-called "normal weight" individuals - the so-called "obesity paradox" - a controversial finding for which she has been roundly criticized but that has not been conclusively disproved.

And yet the one third or so of Americans who fall into this weight distribution have been persuaded that they have a serious health problem that needs to be addressed. Here's the thing: Using “overweight” to refer to BMI 25-29.9 is dishonest and misleading, suggesting as it does that something is wrong, and the term should be stricken from our vocabularies. Yes, I’m a little overwrought on this topic, and here’s why:

1) The term is inaccurate both from a statistical point of view (in fact, the BMI of the average American now falls into this category) and from a health point of view.

2) The term is accurate from a cosmetic point of view only to the extent that we have allowed the judgmental terminology to infect our perceptions. It is a formula for stigmatizing what doesn’t deserve to be stigmatized, for making people, and especially women, feel unhappy about something that should not be a cause for unhappiness. I have no problem with creating standard categories using arbitrary cutpoints for research purposes, but giving these categories tendentious names is something else altogether. (Note that the government is now referring to what used to be labeled "normal weight" as "healthy weight" - solving the problem that BMI<25 is no longer normal but creating a new one by suggesting that BMI>25 is somehow not healthy. The words we use matter!)

And lest you think I’ve forgotten the topic of this blog:

3) It has been repeatedly shown, in my own research and that of others, that smoking is used as a dieting tool, especially by women, and that fear of weight gain deters many women from quitting. Most smokers gain a few pounds when they discontinue tobacco use, and yet 40% of women smokers state that they are not willing to quit if it means gaining a single ounce.  Quitting smoking is hard enough without adding the threat of creeping into this stigmatized bracket. And while becoming obese is not desirable, postcessation weight gain in amounts that would offset the health benefits of quitting is unlikely except among "super-gainers" - individuals who may need extra help in managing excessive eating behaviors that they may have held at bay by smoking.

4) Obesity - and in particular, extreme obesity - is a serious public health problem and one that needs attention. That said, it is dishonest to use the “two thirds of Americans are either overweight or obese” mantra to justify the devotion (and in a climate of scarcity, the diversion) of resources to addressing this problem. Based on the arbitrary cutpoints in common use by both researchers and journalists, the most nearly correct statement about the magnitude of the public health problem posed by excessive weight is that nearly one-third of Americans are obese. Period.
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One More Reason for Caring Even If You Never Smoked

2/28/2016

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Every time I see a picture of a pink ribbon on a postage stamp or my package of toilet paper, or receive an email informing me I’ve been “pinked” or asking me to turn my Facebook page pink, I marvel at how effectively advocates of breast cancer research have mobilized their resources. Don’t get me wrong. It’s a beautiful thing, and I’m happy to contribute to the cause. I do it whenever I can. But at the same time, I can’t help remembering that in 1986, lung cancer actually surpassed breast cancer as the biggest cancer killer of women. Where is the lung cancer community to emulate the activism of the breast cancer community?
 
Actually, I think I know the answer.  Breast cancer seems to strike randomly, and all women know that they are vulnerable. Some, to be sure, are at higher genetic risk than others, but most of us have friends or relatives who got breast cancer even though they had no known risk factor.
 
The population at risk for lung cancer, by contrast, consists largely of current and former smokers. The 80% of Americans who don’t currently smoke and especially the 60% who have never smoked are rightfully thankful to have minimized their exposure to the risks of smoking and would understandably prefer not to think about it. They may even dismiss the risks of tobacco use as a problem the users have brought on themselves.
 
Based on my extensive interaction with smokers and the data I’ve collected, I have developed a somewhat different perspective. Most smokers start during adolescence or even earlier, long before the age of consent. These youngsters are no match for an industry that takes an addictive substance, processes it to make it even more addictive, packages it in relatively mild starter products, and markets aggressively (if surreptitiously) to children. Though for reasons of circumstance or genetics some are less susceptible to nicotine addiction than others, few are completely immune and in the absence of societal constraints and public health campaigns, the majority of us would probably smoke (as indeed was true of men before the 1964 Surgeon General’s Report was released). The contention that addicted smokers are then free to stop whenever they wish is a myth, or to put it bluntly, a lie. For most, successful quitting requires strong motivation and perseverance, and often medications and/or psychological intervention.
 
So in case you were wondering why, despite its devastating effects on individual health and the world economy, tobacco competes so successfully with food, that most basic of life’s necessities - please do not underestimate how compelling this product is.


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Why You Should Care About Food and Tobacco, Even If You Never Smoked

2/1/2016

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Welcome to my blog about food and tobacco. This is my retirement project, launched after many years of laboratory research at the University of Michigan on the interactions of nicotine intake, nicotine addiction, and cigarette craving with body weight, body shape, body image, appetite, and eating behavior. In another era, I suppose I might be writing a book bringing together the knowledge and wisdom I like to think I’ve acquired. But this is now, and the bitesize format and breezy intimacy of blogging are more in tune with the balance I seek in my life as I navigate my seventies. I invite you to join me in my explorations as I pursue the next phase of my career as a researcher of nicotine and tobacco use.
 
My writer friend Linda, who has been encouraging my various escapades since we met in graduate school more than four decades ago, wondered aloud why I didn’t just lop off the “tobacco” part of this blog. “Only 20% of the US population smokes; everyone eats,” she reasoned, worrying that I was unnecessarily limiting my readership.  I think I mumbled something about the tobacco tie-in being my own special niche, combining my expertise on smoking and body weight with my passion for food, cooking, and culinary history. Upon reflection, I concluded her question deserved a better answer. After all, the fact that one can do something doesn’t mean that one should do it. So I decided I would tackle this issue head-on in my first post. The following list, though not exhaustive, may be instructive if you think the food-tobacco relationship is something that need only trouble smokers:
 
1) You should be interested in food and tobacco if you care about food security. Over ten million acres of land urgently needed for cultivation of food crops – enough to produce an annual tobacco crop of 6.7 million tons, enough to feed 10-20 million people – are diverted to tobacco production. These acres cannot readily be restored to agricultural food production because of the heavy pesticide application and leaching of nutrients associated with tobacco production. Wood, the primary source of cooking fuel in many regions, is extensively used for tobacco curing.  The resulting deforestation contributes to climate change with potentially devastating effects on agricultural food production globally.
 
2) You should be interested in food and tobacco if you care about the epidemic of eating disorders in girls and women. Adolescent girls – especially those with serious concerns about weight and body image – have been repeatedly shown to take up smoking as a dieting tool. Across the age spectrum, smoking is over-represented in women with diagnosable eating disorders such as bulimia and binge-eating disorder, as well as in the many more women with subclinical manifestations of these conditions. These women may be using smoking to hold excessive eating in check - behavior that may re-emerge upon smoking cessation and lead to weight gain in amounts that, unlike normal weight gain after quitting (i.e., around 10 pounds), may actually be detrimental to health; or alternatively, may discourage smoking cessation altogether. (For this reason I have often felt that smoking should be classified as a “compensatory behavior,” along with purging and excessive exercise.)
 
3) You should be interested in food and tobacco if you care about the use of food to seduce children into tobacco use. I’m not just talking about candy cigarettes – although amazingly, those are still around and available for purchase. I’m also talking about low-priced starter products laced with food or food-like ingredients intended to make them mild and sweet. I’m talking about tobacco ads placed at kids’-eye level or near candy, or displayed cheek by jowl with ads for kid favorites like Slush Puppie drinks. (Check out Tobacco Free Kids for further info on efforts to “normalize” tobacco use.) I’m talking about hookah bars and shisha cafes peddling intensely food-flavored tobacco to college students. I’m talking about e-cigarettes.
 
4) You should be interested in food and tobacco if you care about nutritional health disparities. Smoking lowers vitamin C levels, accelerates production of free radicals, and interferes with Vitamin D absorption. Smoking undermines dental health. For reasons of economics, culture, and availability, smoking is associated with poor dietary choices (e.g., fewer fruits and vegetables, more fat). Since smoking and poverty go hand in hand, the nutritional harm caused by smoking disproportionately affects the poor. Why has the dramatic decline in smoking in the U.S. left the smoking rate among the lower classes relatively untouched? Is it in part because smoking relieves hunger? Whatever the reasons – and they are undoubtedly complex - the cost of tobacco cuts disproportionately into the food budget of the poor.
 
5) You should be interested in food and tobacco if you ever visit places where smoking is allowed in restaurants. I remember the bad old days when the non-smoking section, if it existed at all, consisted of a table or two in the darkest and least desirable part of the dining room; nor did the ambient smoke know it wasn’t supposed to drift into the non-smoking area.  Since then consciousness has been raised on this issue, but there are still 23 states that allow smoking in restaurants and bars, at least under some circumstances. Smoking in restaurants, or at table in homes, is still normative or at least provisionally permitted in some countries in both the developed and developing world. (And I doubt that these bans are so thoroughly entrenched that they couldn’t be reversed in response to political or economic pressures, at home as well as abroad, either by sweeping legislation or by piecemeal chipping away.) I am endlessly fascinated by the cultural, political, and economic forces that drive the tobacco-meal association despite the paucity of satisfactory biologically-based explanations.)
 
6) You should be interested in food and tobacco if you care about what the impact of highly processed foods on our national diet and their major contribution to the so-called “obesity epidemic.” Big Tobacco and its various sidekicks (Big Advertising, Big Law) pioneered the transformation of a natural product into a substance more addictive than anything found in nature (definitely not your forebears’ peace pipes!), the marketing of that substance using seductive and misleading imagery, and the downplaying of risk by propagating “junk science” and creating a fog of doubt around legitimate scientific evidence. These lessons have not been lost on Big Food.
 
7) You should be interested in food and tobacco if you care about what you put into your body. Pesticides and fertilizers used in tobacco farming can leech into the surrounding soil and groundwater and thence into the food chain.  Discarded cigarette butts are another source of environmental contamination that can end up in our food supply. Organic cigarettes? Puh-leez!
 
I will talk more about all these issues, and others, in subsequent posts. For now, I hope I’ve persuaded you that you have a stake in this topic - even if you don’t smoke now, even if you’ve never smoked – and that much remains to be said about food and tobacco.


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    Welcome to my blog on food and tobacco. My name is Cindy Pomerleau and I am a Research Professor Emerita at the University of Michigan, where I studied the effects of smoking on appetite, body weight, body image, and eating behavior. Please join me in exploring the ways in which the intersecting claims of food and tobacco have influenced the human condition at the micro and macro levels.

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