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Comment by jobs_throwaway | Hacker News Reader

Helping obese people lose weight is unidimensionally a good thing

Very little in health is unidimensional. Suppose, for example, the presence of an effective weight loss treatment caused an increase in suicide rate in those who fail to benefit from the drug or can't access it for some reason?

That's an important consequence to consider. One that often gets omitted. Many drugs - like blood pressure drugs - often have depression as a side effect but it gets overlooked.

> Many drugs - like blood pressure drugs - often have depression as a side effect

Any idea if this applies to Amlodipine-Benazepril?

I think most of them do. That's why I would first try diuretics. If that's not enough, try the other ones.

Take a look at this study [0]. No drugs associated with higher rates of depression but amlodipine found to be protective.

[0]: https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.120....

My mother recently started taking these, and she doesn't have a very great mental health history to begin with. Do you have more information on this, and/or if this can somehow be mitigated?

She really should discuss with her doctor, if possible.

They can absolutely mess with mood, but in both directions. https://www.health.harvard.edu/mind-and-mood/blood-pressure-...

yes. discuss with doctor. But, surprisingly, many doctors don't even address the issue. They just dispense the pills. Patients need to press the issue.

Ah yes, I wanted to arm her with some information (and I value a HN reference above a _more random_ internet source) about it so she can see with her doctor.

Doctors in Croatia tend to be very flippant with medications. This goes as far as pharmacies having to sometime refuse giving medications due to known adverse interactions (sometimes dangerous even). Apparently their software should warn them of this the same way pharmacies get alerted of it, but I guess they dont care?

I think they care. But moderate level depression is not even considered an interaction, so often it gets dismissed as an annoying side effect you just need to learn to live with. Often the patient themselves doesn't even recognize it as a consequence of the drug, it just becomes their reality.

Sometimes you can lower blood pressure with alternatives, like diet, excercise or relaxation techniques. Sometimes a simple diuretic can do the trick. I've heard many doctors say a diuretic should always be tried first.

It's also complicated by the fact that blood pressure is highly individual. There doesn't seem to be one level that is good for all.

The article specifically points out that the link between weight and health on its own is in question:

> Some researchers also worry that by offering a weight solution in societies that prize thinness, these drugs could also inadvertently reinforce the disputed link between excess weight and health. One study found that nearly 30% of people who are considered obese are metabolically healthy.

The abstract from that article also points out that a significant share of non-obese people are metabolically unhealthy:

> Nearly half of overweight individuals, 29% of obese individuals and even 16% of obesity type 2/3 individuals were metabolically healthy. Moreover, over 30% of normal weight individuals were cardiometabolically unhealthy.

Further, the way that study measures (cardio)-metabolic health is itself multi-dimensional:

> Using the blood pressure, triglyceride, cholesterol, glucose, insulin resistance and C-reactive protein data, population frequencies/percentages of metabolically healthy versus unhealthy individuals were stratified by BMI.

https://www.nature.com/articles/ijo201617

I think we may need to admit that weight is a low cost and highly visible variable which is a poor proxy for actual health and as in business, optimizing for the wrong metric will eventually lead to dysfunction.

Maybe that paper just shows that BMI isn’t the best metric. For example, would the results look different if the participants were stratified by bodyfat%?

An earlier study looked at BF% vs BMI-based obesity definitions, when you adjust for fitness (as measured with a treadmill test). They compare the all-cause-mortality risk for normal weight + metabolically healthy vs obese (for each definition) metabolically healthy. When adjusting for fitness, the risks / hazard ratios are not significantly different.

I.e. if you do someone's bloodwork and a treadmill test, and they look metabolically normal, knowing whether their BF% is high (or if their BMI is high) doesn't seem to tell you more about whether they're going to die. If they're fat but fit, trying to lower their BMI or BF% doesn't seem to be about making them healthier.

If we're talking about interventions which might involve putting someone on medication with side effects for the rest of their lives, just do the extra tests! There's no reason to reduce the decision input variables to just "are they obese?" when better indicators are known.

https://pubmed.ncbi.nlm.nih.gov/22947612/

Metabolic health =/= health. Obese people who are metabolically healthy are still at increased risk for adverse long-term outcomes (like heart attack) - source: https://pubmed.ncbi.nlm.nih.gov/24297192/. Obese people are 96% more likely to have heart failure - source: https://www.medicalnewstoday.com/articles/317546

Sure, I'll grant that BMI is not the end all be all metric of health, but its a hell of a strong indicator, and pretending that its okay for your health to be obese is farcical.

Life is like a box of chocolates. It doesn't last as long if you're fat. --Joe Lycett (British Comedian)

The point of the quoted sentence from the psychologist was that people who aren't obese, but who are "large" ("Big and Tall", in the clothing phrasing) and who have body-dysmorphic disorder, might pursue this drug, and, due to being "large", get it prescribed — and that that's a bad thing, because they'd end up with an unhealthily-low BMI.

> people who aren't obese, but who are "large" ("Big and Tall", in the clothing phrasing)

What's the difference, just the degree of being overweight? And the height of course, but drugs won't make anyone shorter.

The taller you are, the larger your build can be + more mass you can carry while still having a very low body fat percentage. This is why BMI is normalized by height.

Someone who weighs 150lbs — but who is 6'8" — is actually underweight. To be that weight at that height, they'd have to have so little fat and muscle that they'd be positively scrawny-looking, and would be experiencing many of the same problems (e.g. always being cold, muscle spasms, brain fog, paresthesia from demyelination of nerves) that someone who is 5'8" and 90lbs does.

Someone who weighs 200lbs at 6'8" looks, and is, healthy; just like someone who weighs 140lbs at 5'8".

Yeah, sure, I didn't get that you were talking about tall people with normal BMI.

Strongly depends on how much they weight in the end and what is the price of weight loss. Loosing too much weight makes you less healthy, sometimes very damagingly so.

It also depends on what is the price of that weight loss. Quite a few diets make you loose weight and simultaneously make you much less healthy or less fit - because your body is missing nutricients it actually needs.

Obese doesn’t mean unhealthy. Correlation isn’t causation. There are many obese people who are extremely healthy. I for one have had no health issues of any sort, have great blood panels, and am in decent physical condition but sit stubbornly at a 31BMI. The only “issue” I face is psychological, and it’s rooted in precisely this statement you made.

> There are many obese people who are extremely healthy

I don't believe that's true. There are some cases (like powerlifters) who can be at an obese BMI but still have strong cardiovascular fitness, but unless you are in that narrow category, if you are obese you do not have strong aerobic fitness. 'Decent physical condition' alone belies that you are not 'extremely' healthy. Decently healthy maybe, but certainly not extremely. Even if you are still metabolically healthy, you are at increased risk for adverse long-term outcomes (source: https://pubmed.ncbi.nlm.nih.gov/24297192/). That is more than just a psychological issue, no matter how much you try to handwave it away.

Your belief in a fact is unnecessary. The issue with these studies is they don’t control for lifestyle and diet. The notion that you can not be fat while eating a high quality low calorie diet and exercising is simply false. A valuable study in this space would be measuring the impact of diet and exercise on health outcomes while holding BMI constant, then comparing across stripes.

In studies where diet and lifestyle are controlled for, metabolically health overweight are not at greater risk.

The issue is we are pointing to fatness and not diet and exercise. It’s causing people to seek ways to get thin assuming it’ll help. But some people are thin no matter what they do, some are fat. However there’s a correlation between poor lifestyle choices and being fat and good life style choices and being thin. This skews uncontrolled studies towards fat is bad even with good metabolic health, because having a good metabolic health but maintaining it with poor inputs will have a long term bad outcome.

In one of the reference below, the conclusion is: (i) Higher fitness should be considered a characteristic of metabolically healthy but obese phenotype. (ii) Once fitness is accounted for, the metabolically healthy but obese phenotype is a benign condition, with a better prognosis for mortality and morbidity than metabolically abnormal obese individuals.

https://academic.oup.com/jcem/article/97/7/2482/2834446?logi... https://academic.oup.com/jcem/article/97/7/2482/2834446?logi... https://diabetesjournals.org/care/article/28/2/391/24045/Met...

> Your belief in a fact is unnecessary.

LOL

> The notion that you can not be fat while eating a high quality low calorie diet and exercising is simply false

You actually believe this shit? If you eat a calorie deficit, you will lose weight, full stop. 'High quality low calorie diet' is gobbledygook to make you feel better. You can eat absolute shit and lose weight if you eat appropriate portions. Or do you not believe in the conservation of energy?

> metabolically healthy but obese phenotype is a benign condition, with a better prognosis for mortality and morbidity than metabolically abnormal obese individuals

so, if you compare yourself only to obese people, you're healthier if you're metabolically healthy. And that is some kind of interesting scientific conclusion? Is this a study done exclusively by fat people to make themselves feel better?

This is unfortunately completely untrue. Obesity, especially severe obesity, underlies the diabetes and heart disease epidemics. However obese people, particularly in the US and Western Europe, now represent a sufficiently large lobby (no pun intended) that there is significant public messaging parroting the 'healthy at any size' propaganda.

I didn’t say there is no level at which you’re clearly unhealthy. If you are obese because of unhealthy habits or lifestyle, this will impact your overall health. Being fat alone, with a healthy eating habit and lifestyle, is not indicative of a lack of health. Eating with abandon, especially of low quality food, and not exercising is what underlies the lack of health. It happens you also get fat doing this. People with a high metabolism that stay thin no matter what they eat or do still develop heart disease and diabetes.

Healthy at any size doesn’t mean someone who is morbidly obese is healthy - the strain on their heart is significant. But that’s true for any human of large size regardless of “what” constitutes their body mass. But the correlation is the fat goes with unhealthy diet and lifestyle. But not everyone who is fat is unhealthy.

They even discuss this in the article for goodness sakes.

In another comment I provided these references: In one of the reference below, the conclusion is: (i) Higher fitness should be considered a characteristic of metabolically healthy but obese phenotype. (ii) Once fitness is accounted for, the metabolically healthy but obese phenotype is a benign condition, with a better prognosis for mortality and morbidity than metabolically abnormal obese individuals.

https://academic.oup.com/jcem/article/97/7/2482/2834446?logi... https://academic.oup.com/jcem/article/97/7/2482/2834446?logi... https://diabetesjournals.org/care/article/28/2/391/24045/Met...

The goal of that idea is to push for being being more healthy regardless of size, not to validate that you can become obese if you want with no downsides. It's basically "being obese and having issues dieting doesn't stop you from making healthy changes in other ways".

> There are many obese people who are extremely healthy

I don't think that's true. However, some people can withstand bad diets. As an example, I had a morbidly obese uncle that ate copious quantities of bacon, white bread, and processed food, yet his blood work and lipid levels were always in the healthy range, which always surprised my family (my mother managed a clinical lab and did the bloodwork for my uncle).

My uncle eventually passed away after he became crippled after a bathroom fall due to his weight. He became depressed and committed suicide (he was a physician and had access to morphine). Overweight is always a health risk, even if your bloodwork is ok.

I didn’t say morbidly obese. Likewise, check my other comments on parallel replies for several studies showing cardiovascular fitness is the predictor for metabolically healthy obese people.

Can you run a mile? Do ten pushups?

Yes. I’m fairly active. I do two one hour swimming sessions a week, a daily Tabata HIIT, and other activities in the week. I’ve no interest in becoming an iron man competitor, but I find the maintaining of decent cardio improves my mental well being considerably. I am personally fine with my weight - when I look at the extreme athletes in my family they all have a similar body makeup, and their body fat percentage stays constant even as they add muscle. Everyone in my family live into their 90’s without onset health issues. When I do medical histories with my GP it’s short and boring.

Let’s give them all meth. That should help with weight loss.

Amphetamines are great, I fail to see your point.

I know that you are trying to make a point, but I think meth would be a viable treatment option for some people. Medically supervised and monitored. If you need to lose 100 lbs, it might be worth the other tradeoffs. For a short period of time.

Stimulant medications have been and still are sometimes indicated in Binge Eating Disorder.

It is actually prescribed sometimes.

I think surgically removing parts of your organs is more extreme frankly.

That'd imply it's okay to put obese folks in cages without food until they've lost weight and I'd suggest that that's fucking insane. We've discovered another dimension!

That'd imply it's okay to put smokers in cages without cigarettes until they've stopped smoking and I'd suggest that that's fucking insane. We've discovered another dimension!

Are you saying that it wouldn't be insane to jail smokers to get them to quit?

There are no fat POW's.

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