Sunday, February 2, 2014

Is Obesity Always Associated with Poor Health Outcomes?

I will be the first to admit that my headline question seems anathema to me.  I believe that being over fat, if nothing else, puts undo stress on ones joints and can lead to ambulatory problems.  Moreover, I believe in and promote the science suggesting that excess adipose tissue (i.e., being over fat) increases the risk of developing diabetes, heart disease and some cancers.  So why would I question the adverse effects of obesity in a headline?  My pause, if you will, has to do with a provocative and interesting narrative written by Victor Etuk and published in the Hektoen International (A Journal of the Medical Humanities).  In his article, Mr. Etuk describes "fattening rooms," which are a part of Efik culture in the Nigerian state of Calabar. You can read his article here, and another by Enang Oe here.  

As part of a ritual of passage into adult hood, young women between the ages of 15 and 18 , according to Oe, spend up to a year or more in 'fattening rooms.' In these rooms, the young women eat a lot of food (calorically dense food) and engage in very little physical activity.  They also take part in other traditional rituals that signal a rite of passage.  In the Efik culture, plumpness is positive; it signals well being and prosperity, not personal failure and unhealthiness as it does in the US.

Both Etuk and Oe write about the tradition, which has been declining, in an effort to end it. Mr. Etuk focuses on the high level of obesity - in itself a reason for discontinuing the 'fattening rooms' and Mr. Oe focuses on the risk of diabetes associated with obesity - which is associated with (and the purpose of) the tradition.

I exchanged several emails with Mr. Etuk in an attempt to learn one thing:  Is obesity in these specific women associated with adverse health outcomes? Mr. Etuk never directly answered my question, instead he said, "well, the obesity rates are very high in these women."  I expect that we had some communication challenges, but what I specifically wanted to know, and did ask, was whether the obesity in Efik women led to diabetes, heart disease, arthritis, etc.  I think the answer is, 'we don't know."  Mr. Oe's article referenced the diabetes rate for Nigerian woman, a low 2%, and only speculated that, due to the high level of obesity in Efik women, they would have high rates of diabetes.

Of course, it is a plausible theory, even quite likely.  In the US and similar countries, the link between obesity and the adverse health consequences I mentioned are established.  I was pushing Mr. Etuk because his article was calling for a substantial, other imposed, cultural change - a breaking of centuries old tradition.

The end to 'fattening rooms' may absolutely be merited, but I wouldn't dare 'assume' it so.  There could be genetic factors in this tribe of women which protect them from otherwise obesity related outcomes, or other parts of their culture may somehow protect them.  I shared my thoughts with Mr. Etuk - that there might be something protective about the culture, he noted that positives included "homekeeping, good mannerism, femininity and beauty etiquettes" and asked if I thought those would be protective against obesity.  That wasn't exactly where I was headed, but I appreciate that Mr. Etuk spoke with me. I think his article is interesting and obviously thought provoking.  I, however, crave evidence. 

I expect the reason health outcomes are not given is because they are not known.  It is possible that the Efik culture does not wish to share this information, or perhaps its members do not practice traditional medicine or even classify disease the way that Western cultures do.  The bottom line of my post is that while I promote obesity prevention based on the evidence I see, it is specific to men and women in the US and similar countries.  I am conscious of the many complexities of how obesity leads to disease and don't think that what applies to Western nations necessarily applies to a tribe of Nigerian women - it very likely could, but before anyone attempts to topple a meaningful, cultural tradition, they ought to check.

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