Blog 4 Research Annotated

With the amount of information now available to a researcher, organization becomes increasingly vital. An important tool available for reference is the annotated bibliography, which ideally toes the line effectively between brevity and clarity. Much is made as to the different software options which allow the researcher to be strategic in how they organize their information. As I progress in my academic career I am swiftly realizing that this type of software is swiftly transforming from convenient to necessary. Regardless of how comfortable you may find it to dive into new bibliographic software, it seems that annotating references is a valuable practice, and something I have neglected as of yet to engage in with in regards to my paper on obesity–

Sabin Janice A., Marini ,Maddalena,  Nosek, Brian A.

2012 Implicit and Explicit Anti-Fat Bias among a Large Sample of Medical Doctors by BMI, Race/Ethnicity and Gender. PLoS ONE 7(11): e48448.

This article is a survey to measure the implicit and explicit reactions that medical doctors have towards obesity and fatness in general. It would likely interest the psychologist, sociologist, anthropologist and clinician. This paper is typically structured as introduction, methods, results and discussion. The methods separate the implicit and explicit opinions of doctors. Explicit is measured as self-reported by MD’s as their opinion and comfort level with treating obese patients. Implicit reactions are measured by ease of association of thin and fat with positive and negative words. The question to be answered is whether MD’s have differing anti-fat bias from that of the general public. The general public have anti-fat bias both implicitly and explicitly.

This paper supports the contention that anti-fat stigma is pervasive in the general public. It also answers the question as to the reactions and feelings that MD’s have toward fatness and obesity. Most revealing in this paper is finding that the majority of doctors explicitly have anti-fat sentiments. This finding is important in two ways-

1. It supports my claims about culture and its influence in medicine. This is direct evidence that the dissemination of health care may not be blind to cultural influence. This anti-fat bias surprisingly and most interestingly is not necessarily a risk to obese patients. In fact, there is evidence to support that obese patients with heart disease risk factors have better outcomes than those with matching factors and whom are of normal weight. The hypothesis here is that doctors with their anti-fat bias treat their obese patients symptoms more aggressively and urgently, and thus their patients have better outcomes.

2. Also evident in this paper is that anti-fat bias is acceptable. Explicit responses from MD’s measure the amount of bias they freely admit to. This suggests that a large portion of primary care doctors believe it is acceptable to have such bias. This result really amplifies the contention that even among those of our population who are supposed to be the most neutral in terms of patient bias, they still find it ok to admit to biased thinking. I contend in my paper that obesity of one of the remaining acceptable forms of discrimination; this paper will be pivotal to that assertion. This article tackles questions about fatness clinically, psychologically and socially and is a very important piece of the obesity picture in that it makes connections with those three fields.

Kantartzis, Machann, Schick, Rittig, Machicao, Fritsche, Häring, Stefan

2011 Effects of a lifestyle intervention in metabolically benign and malign obesity. Diabetologia 54:864–868

This article describes a study that aims to bolster the mounting evidence supporting the separation of the metabolically healthy and unhealthy obese for the purposes of treatment. The experiment is lifestyle intervention (9 months), diet and exercise, and a comparison of the effectiveness of this change between the obese insulin resistant and the obese insulin sensitive. This intervention is designed to increase insulin sensitivity. This paper is especially relevant for primary care physicians and anthropologist who are interested in first-line treatment in over-weight patients. Methods, results and discussion aim to support the growing contention that special and separate consideration needs to be taken towards obese patients that have healthy insulin sensitivity. Moreover, this study also aims to show that patients who are obese and insulin resistance should be treated more aggressively since their insulin sensitivity can be quickly increased.

This article fits nicely into the popular topic of healthy obesity. The primary literature on this topic has been mostly speculation and experimentation on why this sub-phenotype exists and in what way we can therefore learn about the etiologies of obesity. This study firmly supports the assessment of an obese patient’s insulin resistance as the first step in developing a treatment strategy.

This paper has importance to the practical aspects of a resource limited field like health care. It struck me almost as a type of triage where the obese patient that can benefit most from the intervention should be given priority. In fact this paper could have effectively been reframed with a type of Malthusian tilt towards resource management.

This paper is especially relevant to my work since I am arguing that obesity is erroneously painted with the same brush. Since it is as much about appearance and cultural interpretation of health with modern issues of obesity, I argue that the assumption that all obesity should be treated wholesale is not biologically defensible. This paper is also complemented by several other papers that have tested obesity with respect to heart disease- they too have found that a significant sub-group of obese are not at any elevated risk, and that lifestyle interventions do not always improve outcomes.

Sims, Ethan A.H.

2001 Are there persons who are obese, but metabolically healthy? Metabolism 50: 12: pp 1499-1504

This is an early paper on those who are obese yet have a healthy metabolism. This article is much more like an anthropological discussion than it is like a medical one; it even begins with a lengthy anecdote about a woman who is doing everything to lose weight yet remains unsuccessful. This paper is important for anthropology and medical theory as it addresses why some obese are more metabolically ‘normal’ than others and how this is relevant to the practice of medicine. The organization of this article is reminiscent of a logical discussion as to the evidence of this sub-group, the number of studies that suggest this, explanations as to why this might be the case, and why this is important news clinically and academically. This paper effectively answers the question of so what; why should be care about healthy obesity. It also thoroughly addresses ideas about what to do in the future, and what this might mean as far as the obesity epidemic.

This is one of the seminal papers about healthy obesity. In fact the term MHO (metabolically healthy obese) had not been coined yet. This type of investigation into healthy obesity stems from some of the anomalous findings in the data when comparing BMI to health. This study is one of the first to suggest that these anomalies are because of this healthy sub-population, whose physiology operates as if they were of normal weight. This paper is quite bold in offering explanations as to why this might be -which is of great interest to my work. It suggests that healthy obesity may involve adaptive mechanism in the body. The authors claim that people who have been obese since early childhood preferentially display healthy obesity as adults. This claim has not subsequently been supported by evidence, but it has stirred myself into forming ideas as to anthropological perspectives in obesity.

This paper now is quite outdated; the MHO phenomenon has made a serious dent on the landscape of obesity study as of late. It does offer a more anthropological framework than the typical and more recent papers on MHO. It does focus much of its attention on the practical aspects of MHO; diagnosis in particular, but also more generally commentary on clinical thinking and physiological theory, aspects that I intend to be focused heavily on in my work on obesity.

Obesity in Biocultural Perspective

Stanley J. Ulijaszek and Hayley Lofink

Annual Review of Anthropology Vol. 35 (2006): 337-360

Never before have I read an article in The Annual Reviews of Anthropology- my first one, titled ‘Obesity in Biocultural Perspective’ I would like to comment on in regards to its approach and argument in general. The article is only 7 years old but the face of the literature on obesity has certainly changed since this review was published. As such I will attempt to be more constructive than simply criticizing the outdated theories and ideas in the paper.

This review can be summarized rather simply but its content gets quite complex. Ulijaszek and Lofink have organized a good review of most of the prevailing ideas about the biology, epidemiology and evolution of obesity.  Rather typically this review begins be sounding the alarm in regards to the obesity epidemic and the force and swiftness in which it is sweeping both the developed and developing world.  Unfortunately this alarm now seems to have been muted some because of the prevalence with which it is used to begin any obesity paper.

First the article does acknowledge the fundamental flaw in the way the developed world measures obesity.  But simply admitting this and then proceeding like it is not influencing the way we study obesity is very dangerous.  BMI is weight over height squared.  With this measurement, favoured because of its simplicity and applicability, the fatness of an individual in almost every conceivable way is mismeasured.  BMI does account for gender, males and females put on weight differently, have different metabolisms and have fat tissue that is active in different ways.  It does not adjust for age, very important when considering that muscle skews the measurement upward because it weighs more than fat, nor fitness level. It does not account for bone or muscle density as well as water retention. You would be hard-pressed to identify very many professional athletes outside of billiard champions that would not be obese as measured by BMI- this system is a big problem and deserves more attention as a real issue in a real discussion about obesity.

The discussion then shifts and the authors take a position that humans have developed a propensity for obesity through the selection of genes throughout our and our ancestors’ history that would increase our ability to store fat.  This discussion included some interesting ideas about encephalization being man-kinds defining character; that our brains are metabolically hungry; and that they demand a significant reserve of fat on our bodies so it may function in times of famine.

The story then shifts again quite drastically to summarize the current ideas about the genetics of obesity and the specific proteins spit out by these genes that could be affecting how we perceive food and our appetites, and our ability to use the energy we consume.

The authors finally comment on the culture of obesity in the modern context and tackle issues of food security and inequality of access; our increasingly sedentary lifestyle; and issues surrounding the perceived attractiveness of overweight individuals. A point that was made early and often in this section was the inevitability of obesity considering modern technology and lifestyle. This is interesting, and worth discussion.

So is obesity inevitable? Is it like global warming, in that the relentless march of civilization forward may leave in its wake a couple unintended outcomes. Moreover, it is also similar to global warming in that ‘we’ don’t like the fact that we are globally packing on the pounds, but ‘we’ are unwilling to sacrifice any of the luxuries that are at the cause. Increasing evidence is suggesting that now that women make up a significant proportion of the workforce, parents generally have less time to prepare food and thus tend to serve their children more processed, less nutritional food. Does that mean we should tackle the problem of women in the workforce? I think it is incredibly naïve to think that in our growing attempt at sophistication of culture and sensibilities that there will be no negative side-affects. Video games have a price- they allow kids to spend their leisure time not moving anything other than electricity in their bodies and muscles in their thumbs. But kids can be distracted so parents can finish their work and technology can move forward.

The approach of this article is far too heavy on the biology and far less thorough on the culture. Their treatment of the biological aspects was quite comprehensive save any discussion about environmental affects regarding our fattening communities.  There is good evidence now that toxins in the air and in our food could be, what are referred to as in the literature, obesogens. These toxins are also postulated to be actively modulating the function of certain hormones and thus the homeostatic environment in our bodies.

Some of the real interesting theories that have emerged since the publication of this article focus more upon how we now live and how our culture is contributing to obesity. There are quite compelling papers now in regards to sleep deprivation and obesity; the fact that more people have heating and air-conditioning so they don’t spend the calories cooling off or heating up, and that less people are smoking cigarettes. What strikes me again, is the alternative. Should we be sleeping more and taking less care of our kids, should we be depriving families of heating and cooling and should we dismantle every campaign against smoking?

The answer lies not in undoing the causes of obesity but in coming up with novel solutions to the problem. The answer, like that of global warming, is not to stop progress but to be smart about it.

This term’s writing project will be on obesity. This project began last year during a reading course with my supervisor. Originally the topic was mainly focused on body mass index (BMI) and its specific problems when used in reference to measuring metabolic fitness.  My supervisor and I tailored this topic as such because of a call for papers for an obesity journal that focused on ‘healthy’ obesity. Unfortunately problems arose with submitting our piece to this specific journal, and since the second term has begun, the paper has evolved to include a larger emphasis on the culture of obesity. Here is an outline of the newly designed paper, a general schedule to which I would like to follow in order to submit the paper at the end of the term, and some of the difficulties I am anticipating having to tackle in order to end up with a final product of sound quality.

This paper will argue for a shift in the way we view obesity. The first part of the article will describe why obese individuals not at considerably higher risk of disease than their normal-weight counter parts.  This will include discussion about a new phenomenon called ‘the metabolic healthy obese’ a sub-phenotype within the obese category of BMI over 30 who seemingly have no undesirable physiological symptoms of obesity.  They are not at an elevated risk for heart disease, they have normal levels of inflammation, and their lipid profiles are healthy. What this condition is suggestive of is that ‘fitness’ not ‘fatness’ is more important with respect to health and maintaining it. I will also introduce a phenomenon now prevalent in the obesity literature called the ‘obesity paradox’ which claims that in fact being over-weight or mildy obese, in certain circumstances, can be advantageous to health.

The second part of the argument will focus more on why we are so misinformed as to the health risks of obesity and how it is our culture that is driving this misinformed position. This argument will develop first from discussion of the BMI system and why it can be a deceiving form of measurement. I will also discuss what I feel is an interesting simantic point regarding the use of the word ‘paradox’ in the literature, and why this particular word, defined as ‘something contrary to its nature’, is important with reference to cultural perspectives driving biological ones. This section will also emphasize how skinny ideals are driving obese negativism and how issues of publication bias are perpetuating certain obese stereotypes.

In the third section i will discuss why we should care about cultural influences on the biology of obesity and why it matters to the health of our communities. Here I will discuss how body shape is used to make certain judgements regarding the character of an individual and how issues of morality and discipline tend to be conflated with body size. This obesity stigma also seems to be one of the only remaining accepted discriminatory practices and I will make an argument as to why this form of stereotype is still prevalent. There are also relevant clinical consideration in this discussion and I will outline why they are relavent  in the delivery of proper health care. I will finally discuss some evidence that the obesity paradox does not apply to measures of quality of life and that there are important mental health considerations in addition to the biological ones with regards to obesity.

Ideally, I would like to submit this article to an anthropological or social science journal by the end of this term.  My supervisor and I are anticipating that some revisions will be necessary if the article is fully reviewed and ideally the final revisions for this paper will be during this summer.

I am anticipating quite a few challenges with this writing project, and I am happy to be able to share some of my fledgling ideas here on a public forum. The principle challenge will be in the organisation of the argument.  The material for this article is from discussions I have had with my supervisor in our review of the obesity literature.  As such the pieces of the article are somewhat disparate and I have found it difficult to fit all of the points I would like to make within a logically consistent argument.  I feel that once I can clarify in my mind, and on the page, what it is exactly that I would like to offer in the article, the transition from ideas to words will come rather smoothly.