One Handed

I'm typing this with one hand, which is how I've been learning to do lots of things over the past two weeks.

Bear is beautiful and perfect and I love him completely.  After years of nannying, I keep looking at this baby and marveling that I get to keep him, this one is mine.  And that is just as wholly wonderful and utterly exhausting as everyone predicted.

Bear Thomas

Hey there, all six of my readers!  Please forgive the lack of updates - I was busy having a baby! :-)

39 weeks - an absurd amount of belly.

Here he is! Bear Thomas, born 7/22/12 4:24am EDT, 8lbs, 10.5oz after 5.5 hours of labor.

Late Pregnancy

Late pregnancy is super glamorous.  It’s 3:30 in the morning, I was awoken by heartburn so bad it was in my nose. Once I got vertical, I realized I had to go to the bathroom anyway.  Once I waddled down the hall to the bathroom, I noticed I also had a nosebleed. 

So yeah, that’s what I’ve been up to. 

But mostly the hard part is fighting the boredom.  My maternity leave started weeks ago – which is good because I feel too swollen, acid-laden, and exhausted to really function as a new intern.  But it is also bad, because I have nothing to do.  And as anxious as I am about being a new intern, part of me just wants to get it over with already.

Even without the anxiety of eventually starting this whole new career, I don’t do well with unstructured time.  This is the understatement of the year.  I really, really don’t do well with unstructured time.  I get bored and depressed and lonely and become basically worthless to everyone around me.  I’m sure I will be begging for some unstructured free time once I am an intern with an infant, but I wouldn’t know what to do with it anyway.

So the main problem of being a million years pregnant and having so much free time is that the repertoire of things I can do to entertain myself is pretty limited.  Normally, I would be trying to plan this time chock full of Habitat for Humanity builds, camping trips, hiking, kayaking, horseback riding, etc.  I would be off to the beach and the zoo and aquarium and the amusement park.  But I just can’t do those things.  I did two laps around the mall today and then tried to go grocery shopping and nearly collapsed. 

Benjamin has been doing a great job entertaining me and taking care of me despite the fact that I haven’t exactly been a bundle of joy to interact with.  He’s working on starting a video blog about being a stay at home dad.  For his first video, we are doing a montage of natural ways to induce labor.  It’s good to have a project.  Today (after a crucial afternoon nap) we filmed “driving on bumpy roads,” “eating spicy food,” “walking,” “eating licorice,” and “galloping.”  We’ve got some other stuff on deck for tomorrow.  Or rather, later today.

It’s now 5:00 in the morning.  In between writing this I have read everything worthwhile and most things not worthwhile on the whole internet.  I have eaten a fistful of Tums and several pounds of papaya tablets.  Benjamin, who was failing at sleeping downstairs on the couch, has come upstairs and is now snoring adorably into my ear.  Baby Zuses is practicing his acrobatics.  Abby-dog is snoring downstairs.  I’m going to see if I can join this log-sawing chorus.

Graduation

So, I didn’t fall off a cliff or anything, it’s just been a little busy around here.  And no, not busy in the way that I’ve had a baby.  I’m still massively pregnant.

Let’s catch up, shall we?

Graduation happened.

I went back and forth a lot about whether I would even go to graduation.  At one point, Benjamin and I were thinking of skipping it to go off to New Zealand to visit his parents instead.  And I am pretty sure New Zealand would have been way cooler than graduation, but now that I know what the third trimester of pregnancy is like, I am really quite happy to not spend 48 hours of it on airplanes. 

In addition to the lure of NZ, I was thinking of skipping graduation for several reasons.

1. Since I took an extra year to get the Master of Public Health degree, most of my friends graduated last year.  I don’t actually know most people in the class of 2012, so I don’t have this need to celebrate with my class.

2. My parents were being butt-faces and so celebrating with them was unappealing or not an option.

3.  UVA graduation is a clusterfuck (that’s the technical, medical term).  All the various schools graduate together on the lawn and then there are separate diploma ceremonies all over campus.  The proud parents, grandparents, half-uncles, and step-cousins of six thousand students descend on Charlottesville and everybody wants to go out to dinner, drive on the one lane main street, park where you want to park, etc.

4. Graduations in general are sort of….stupid.  Commencement speeches are long and generally not entertaining or full of good life advice. 

But I went anyway.  My parents recently had a major change of heart and have been being significantly less butt-faced, which is great.  And they wanted to go, and I was not in New Zealand, so why not?

It was exactly as hot and crowded and logistically difficult and as boring as I predicted – and I am still really glad I went.  My parents were exactly as wacky and exasperating as I expected them to be, and I was really glad that they were there to celebrate with me.  After months of agonizing over my relationship with them and coming around to a place where I don’t crave their approval – it was still great to have them say they were proud of me.  I didn’t need to hear that, but it was good.

We had a picnic on the downtown pedestrian mall and it was good to have a meal with my family – my parents, my sister, and my husband all together.  I felt honored that they were all there for me, and I felt good knowing that they would all be able to come together for the baby, too. 

And the graduation itself was more meaningful to me than I expected.  Sure it was hot and there was a lot of standing and my feet were so swollen that I thought my flip-flops would become permanently embedded in my skin.  But I stood with the other MPH-ers (the only people in the class I really know well) during the lawn ceremony, which was fun.  And during the medical school ceremony I got called last (yay Z last name) to get my diploma – so the general applause sounded like it was all specifically for me, which was pretty awesome.  And in general I had fun waddling my super-pregnant self around in my Dr. Seuss t-shirt and getting lots of thumbs up and smiles.

So overall, even though I was totally exhausted afterward – I am really glad I went.  For me, I would always rather err on the side of having an experience that turns out to be bad, rather than missing out on something.  (This does not always work out as well as it did in this case.)

Whew.  I’m a doctor now.  Graduation didn’t totally make that sink in, but acknowledging this transition in public with my professors and classmates and family is certainly a good way to start integrating this part of my identity.

More catching up soon.  (Seriously, I promise.)

NYC Large Soda Ban: Right Law, Wrong Reasons

So New York City is banning the sale of sugary beverages over 16oz.  (http://www.cnn.com/2012/05/31/us/new-york-sugar-drinks/index.html) Bloomberg is touting this as his administration’s way to “do something” about the city’s obesity epidemic, and he claims that sugary drinks are the leading cause of obesity. 

One of my favorite bloggers, Regan at Dances With Fat, recently wrote a post about her opposition to the law (http://danceswithfat.wordpress.com/2012/06/01/sixteen-ounces-of-dumb/).

Regan and I usually agree – in fact, her blog was my primary introduction to Health At Every Size and Size Acceptance.  In this case, though, I strenuously disagree with her.

While I also disagree with everything about the phrase “obesity epidemic,” I do think this law is a good idea.

Now, don’t get me wrong, Bloomberg’s obesity-based justification for the law is problematic.   In fact, he should just stop talking.

Obesity is not a health problem, it’s a body size. When people talk about the “health consequences of obesity” what they really mean to address (I hope) are the health consequences of sedentary lifestyle and poor diet.  Conflating obesity with poor diet and lack of exercise is problematic for several reasons.  First, good diet and lots of exercise don’t necessarily make obese people thin.  Secondly, plenty of thin people have a bad diet and get no exercise – these people are not healthy by virtue of being thin, they’re just smaller.  Thirdly, you’ve muddied your discussion of an important public health issue with the rhetoric of anti-fat prejudice.

So let’s just leave obesity out of it.  Poor diet is still a public health problem.  It’s a public health problem that affects people of all sizes – the consumption of thousands of calories of sugar-water is not good for you, whether it leads to weight gain or not. 

A 2007 meta-analysis (Vartanian, et al. “Effects of Soft Drink Consumption on Nutrition and

Health: A Systematic Review and Meta-Analysis,” American Journal of Public Health) found that increased soda consumption led to increased caloric intake over and above the calories in the soda itself, suggesting that soda consumption stimulates the appetite or affects satiety.  Increased soda consumption was also associated with decreased milk and calcium consumption.

In terms of health outcomes, daily soda drinkers had double the risk of developing type 2 diabetes compared to infrequent soda drinkers.  This was true even when controlling for BMI.  Let me say that again - the behavior of drinking soda was associated with increased risk of developing type 2 diabetes, regardless of weight.  Skinny soda-drinkers – you are not safe!

So type 2 diabetes is no fun.  It is a legitimate public health issue.  In fact, I might even let Bloomberg call this one an epidemic.

So soda is not a benign substance – what is the best way to address that?  One ever-popular approach is to encourage individuals to “make good choices.” (Can’t you just hear Michelle Obama’s voice saying this?)

“Making good choices,” is appealing to Americans, because we tend to believe in this fantastical individualism myth – individuals can pull themselves up by their bootstraps, it’s the American dream, etc, etc.  (The more conservative you are, the more likely you are to subscribe to this worldview). 

Regan argues the other side of the individualism argument, asserting that people have the right to prioritize or not prioritize their health.  This comes up a lot in her blog, where she argues that while it is possible to be fit and fat, it is also not the responsibility of every fat person to be fit; that fat people have just as much right to have unhealthy habits as thin people.  And in general, I agree, that individuals have the right to prioritize health as they see fit for themselves; but as a public health scholar, I am interested in maximizing the health of populations.

And I take issue with the idea that freedom means being able to buy a Double Big Gulp.  New York banning large sodas is not the nanny state restricting individual freedom.  It’s a public health measure countering the enormous marketing pressure of the beverage industry.  Your choice to buy a Double Big Gulp isn’t a free choice, it cost Coca-Cola many billions of dollars in clever polar bears, dancing young people, and a cultivated Pavlovian response to their red logo. 

Individuals can’t realistically resist a mammoth like Coca-Cola using will-power alone.  Instead, systemic unhealthy influences are best countered by public policy.  And the large soda law is a great example of putting the pressure in the right place, not on the consumer, but on the seller. (I’d love to see the law targeting the beverage companies themselves, but at a city-wide level, targeting restaurants is probably as high up the food chain as they can go.)

Regan argues that using the obesity justification for this law will make thin people resent fat people for restricting their choices.  I agree the obesity justification for this law is terrible.  But the whole anti-obesity campaign is terrible.  Thin people already resent fat people.  Fat people are blamed for everything from health care costs to global warming. 

So yes, it is important to resist anti-obesity rhetoric.  But pitting Size Acceptance against public health is not the way to go.  A broader understanding of both Size Acceptance and public health reveals that Size Acceptance is public health – it’s a movement advocating for the improved social standing and mental health of 2/3 of American adults. 

My Fetus is Against the Patriarchy

At 32 weeks gestation, it recently occurred to me that in addition to shelter and food, the kid is going to need some sort of clothing.  We were in Richmond, VA last weekend and hit up some thrift stores for cheap baby threads.  Incidentally, if anyone is in Richmond, I recommend Diversity Thrift, which benefits GBLT-friendly HIV organizations (a direct counter to the philosophy of the Salvation Army) and has baby and kids’ clothes for 25 cents. Twenty-five cents, people!  On top of that, we are planning a major tie-dying event, so slightly stained items were desirable.  We may have gone a bit crazy, but anyway, the kid will have plenty to wear.

On our shopping trip, there were some prime examples of problematically gendered baby clothes:

Boys are all about danger and trucks and football!

And girls are all about shopping!

A common critique of gendered baby clothing is that girl clothes focus on looking cute and boy clothes focus on actions and non-aesthetic attributes (such as strength and intelligence).  But don't worry, value based on your attractiveness is now equal opportunity: 

"Does this diaper make my butt look big?"  

Seriously, people?  This is not cute, this is not harmless, this is not a joke.  This is introducing body hatred to BABIES.  It is not ok.

(I understand that babies can't typically read.  However, I would argue that 1. Our baby will be a genius, and can probably already read, and 2. emblazoning a child's torso or butt with such slogans will inevitably affect the way literate people interact with him/her, and allow the message to be sublimated).  

It feels very…greedy to say that this is why we aren’t telling people the sex of the baby.  But it's more than that.  It isn’t simply that we don’t want to receive clothes like this for gifts.  It isn’t just that we don’t want to dress our child in this absurdly gendered clothing.

The fact that baby clothes like this exist shows that these sexist, body-shaming, consumerism-frenzied, and generally problematic ideas in our culture are being delivered directly to people small enough to wear a 0-3 month onesie.  And I am not sharing the sex of my child because I want him/her to be sheltered from these gendered expectations for as long as possible.  At least until, you know, birth. 

Sorry again for the lack of updates – the thesis is finally done!  I graduate on Sunday! If all goes as planned I will have a baby in 7-12 weeks! (Holy shit, how did that happen?)

So yeah, there has been a lot going on.

But before I catch you up on that stuff, I wanted to take a moment to reply to some great comments I got on the last post. 

Lou de B made some great critiques that I would love to address.  Here is Lou’s comment, reposted for archival purposes:

Ok, but here is the thing. First the disclaimer: I am a linguist, not a medical Dr. I am overweight so this is not a thin person ranting at fat person thing. I have a long line of short tubbies above me on my Mum's side. But...

you cannot deny that obesity is a bigGER problem in the US, Aust etc than in - say - I dunno, Siberia. And that we just happen to be those that eat HUGE servings and a load of crap. In the US (I've been a dozen times or so) I have so much trouble remembering to ask for small everything so I get something equal to large in Aust. I am not kidding. Some of those coffee or drink cups are buckets. Not cups.

IF people are not drinking gallons of sugar etc AND they are still overweight, then sure, they can be healthy. I bushwalk, climb, canyon etc as do many friends who are overweight and fit. But if I'm drinking gallons of soft drink (you call soda) then my Dr should tell me to stop it. It isn't good for my health. Or my joints (which is where I'm having trouble).

This is not to deny other issues. I read The Beauty Myth at Uni and Real Gorgeous by Kaz Cooke etc. I'm very aware of the role of the media to distort images etc. But being overweight DOES lead to an increase in some conditions AND we did not evolve joints etc to be that size.

Feel free to rip all this apart. I know you know more than me!! And I ought, I guess, just read your thesis when it's done.

So let’s break this down point by point (mostly because my brain used up all its transition sentences over the past 9 months).

1. Obesity is more prevalent in the US and Australia than in places like Siberia.

This is absolutely true.  According to data collected from 1994 to 2002, the prevalence of obesity (BMI >30) in the US is 27.6% for men and 33.2% for women (Baskin et al 2005, "Prevalence of obesity in the United States"). According to a 2005 paper (Thorburn, "Prevalence of obesity in Australia") the prevalence of obesity in Australia is 19% for men and 22% for women. I could not find data for Siberia specifically, but in Russia as a whole, in 2000 the prevalence of adult obesity was 16% (Jahns, Barturin, & Popkin, “Obesity, diet, and poverty: trends in the Russian transition to market economy”). 

2. The places where obesity is more prevalent have larger serving sizes and more junk food and soda.

I can’t find any articles to specifically support this, but based on my personal experience alone, I agree.  (I know that is really flimsy, but stick with me, I will do more research on this in the future.)

That being said, the implication here is that the larger serving sizes are responsible for the increased prevalence of obesity in the US.  There are a ton of differences between the US and Russia – we could really pick any of them and make an argument.  For example, it is colder in Russia than it is in the US.  Thermogenesis burns calories.  Therefore, the temperature difference could be responsible for the difference in obesity prevalence.  I’m not saying I believe this to be true, I am just saying that the causes of obesity are very complex and singling out any one thing is unlikely to be instructive.

3. It is possible to be fat and fit.

Yes, yes, a million times yes.  This is one of the concepts that a lot of people have trouble accepting, because we have been so conditioned to believe that fat = unhealthy.  Here is one of my favorite graphs that I found in my research (Matheson et al, 2012 “Healthy Lifestyle Habits and Mortality in Overweight and Obese Individuals”):

This study looked at four different healthy habits – eating 5 fruits and vegetables a day, getting moderate exercise, not smoking, and drinking in moderation.  Researchers grouped people according to how many of these healthy habits people had adopted (0 – 4 on the X axis) and then further divided people based on BMI (normal weight, overweight, or obese).  On the Y axis, you have mortality hazard ratio – the risk that someone will die prematurely compared to a thin person with all four healthy habits.

So, for people who have none of these healthy habits, we see that BMI matters – those in the obese category are 7 times more likely to die than thin folks with all four healthy habits, while those in the normal weight category are only twice as likely to die.  However, as people adopt more healthy habits, the difference between the normal weight and obese groups disappears. 

Remember, these people are not losing weight as they adopt the healthy habits, because they are still in the obese category.  Just having the healthy habits is enough to change their mortality risk, independent of weight loss.

I would also like you to look closely at the middle bar of each group – the overweight category.  As soon as overweight people have just one healthy habit, their mortality risk is actually lower than normal weight people.  (This is a whole separate rant for another day).

4. Some fat people are not fit – they have poor health habits such as drinking soda.

This is absolutely true.  There are also thin people who drink a lot of soda.  This is a poor health choice in either group.

5. Doctors should tell fat people with poor habits to improve their habits for the sake of their health.

Yes, I agree.  Doctors should tell their fat patients that drinking two liters of Pepsi a day is not a great choice.  But there are a number of caveats I would add:

• ·         The purpose of lowering the Pepsi consumption should not be to lose weight, because it is unlikely to be effective.  I know, I know, it seems like eliminating 830 calories from the diet would cause weight loss, but long term, a ton of research suggests that this isn’t the case (Mann et al, 2007 “Medicare’s search for effective obesity treatments: diets are not the answer”).  The leptin feedback loop is a squirrely little thing. 

• ·         Instead, the point is just to replace that space in your stomach with some fruits or vegetables.  We actually have proof that eating fruits and vegetables is good for you (it’s one of the healthy habits in the Matheson study above).

• ·         Suggesting that a patient stop drinking soda is something that a physician should do from a place of understanding of both the broad environmental factors that surround consumption in general and the individual factors that affect that patient’s life.  Pepsi’s 2012 advertising budget is $1.7 billion.  (That’s Billion, with a B!) I’m just some schmuck in a white coat and I certainly don’t have $1.7 billion.  Also, if my patient is the single mother of three kids working two jobs and drinking some Pepsi to stay awake through the third shift…nagging her would be poor form.  And by ‘poor form,’ I mean judgmental and insensitive. (Though plenty of doctors think nagging is their Hippocratic duty).

• ·         Doctors should also tell their normal weight patients not to drink two liters of soda.  It’s not just unhealthy for fat people, it’s unhealthy for everyone. The other side of the ‘fat = unhealthy’ assumption is that thin = healthy.  But as we see in the above chart, thin but sedentary, drinking, smoking, and eating crap still makes you twice as likely to die prematurely.  Bringing the focus back to habits rather than bodies means bringing the focus back onto things we can actually control that are more likely to make a difference.

6. Though there is cultural bias against obesity, obesity is still legitimately linked to increased morbidity and therefore is a medical problem.

This is probably the part of Health At Every Size that I struggle with the most.  I feel like some of the more zealous Fat Acceptance folks try to argue that obesity has absolutely no corresponding health risks. 

Are all the studies of obesity and health risks done in an environment of unrecognized fat phobia so that all their results are suspect?  Yes.  Much the way those old fashioned studies about how the Negroid skull was associated with lower intelligence were conducted in an environment of racism – the world view of the scientists absolutely colors the results. 

Do almost all the studies of health effects of obesity fail to control for obvious confounding factors like health habits and socioeconomic status? Yes.

However, I still believe there are some negative health consequences of obesity.  The data on hypertension is pretty convincing.  Also, the joint issues you bring up are a great example.  That’s just physics – more weight on those joints causes more degradation.

But, as we have seen, the cause of obesity is outside of an individual’s control and weight loss efforts are unlikely to have long term success.  So yes, I think it is silly to say that obesity has no health consequences, but I also think it is silly to say that because there are negative health consequences people need to just try harder. 

Age is also linked to joint problems, cardiovascular disease, and cancer.  And physicians use this information when calculating a person’s disease risk, but no one suggests their patients try really hard to age more slowly.  And I’ve certainly never heard of a doctor refusing to treat the patient until they successfully get younger.

 

So yeah, I hope that helps flesh out my stance – I look forward to your responses/questions/etc!

Also, now that I have learned how to add pictures – here is a picture of me, planting some vegetables.  Which I totally plan on eating at least 5 of per day.  As soon as they grow up.