Archive for November, 2011

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November 29, 2011

the HAES files: the placebo effect: belief and biology – part I

by healthateverysizeblog

by Jon Robison, PhD, MS

There was a flurry of activity on our list serve recently about a study that was actually published back in 2007 by Dr. Ellen Langer at Harvard University. Dr. Langer was interested in testing whether exercise-related health changes might be influenced by people’s “mind-set” (perception) about the amount of exercise in which they were engaging. To examine this, Dr. Langer picked a group of individuals who actually engage in more than enough daily exercise to satisfy recommendations for good health – women whose job it is to clean hotel rooms (room attendants).

The experiment included 84 room attendants from 7 different hotels who were randomly assigned to one of two conditions. Subjects in both conditions received written materials describing the benefits of exercise, including that exercise did not have to be difficult or intense to be beneficial. They were also given specific information about how many calories they were expending in the various activities of their daily work. In the informed condition only, the subjects were also shown how that amount of activity more than met current recommendations for a healthy lifestyle.  Interestingly, regardless of this reality, when surveyed 67% of the subjects had reported not exercising regularly and 37% had reported not getting any exercise at all.  At the beginning of the experiment and again 4 weeks later, physiological parameters (Blood pressure, BMI, W/H ratio, weight and body fat ) were collected and all subjects were told that the information would be used in the study to help them improve their health.

Here is a summary of the physiological changes that occurred after 4 weeks:

1) The informed group demonstrated significantly reduced systolic (- 10 points) and diastolic (-4 points) blood pressure

2) The informed groups’ BMI, weight, body fat and waist-to-hip-ratio all decreased

3) The percentage of subjects in the informed group who reported exercising regularly doubled from 39% to 79 %.

4) There were no significant changes in any variables in the control group

Subjects self-reported diet, activity (off the job) and substance use (caffeine, alcohol, cigarettes) indicated no changes in either group over the 4-week period. Subjects in the informed group reported getting significantly more exercise on the job although their workload during this period did not change. The researchers concluded that the observed physiological changes in the informed group were likely a result of the subjects increased perceived exercise.

As you might guess, the media had a field day with this, suggesting that it might be possible to “sit around on the couch and eat chocolate bonbons while genuinely believing that you are getting a lot of rigorous exercise.” At the same time some medical experts stated conclusively that people’s “mindsets” or perceptions can only influence “subjective types of findings” and not physiological parameters.

What is being tested here is a phenomenon called the placebo effect. We are probably most familiar with placebos through their use in studies by pharmaceutical companies testing new drugs.  A placebo is defined as:

a treatment or aspect of a treatment that does not have a specific action on a patient’s symptom or disease;  an inactive substance, a procedure with no therapeutic value.

 In other words, placebos are useless substances or procedures. Ironically, in study after study after study, across a broad range of medical conditions, 25-35% of patients consistently experience satisfactory relief when these useless substances and procedures are used for a broad range of medical conditions!  In fact, drug companies will not even consider marketing new drugs unless they outperform this placebo effect.

 The research on the power of placebos is extensive and convincing, sometimes even bordering on amazing.  Just a few examples; placebos have been shown to:

  • Increase lung capacity in children with asthma:  Children with asthma who were given a drug and told it would improve their breathing experienced measurable increased lung capacity, even though the drug was a placebo.
  • Provide pain relief equal to that of real knee surgery:  Adults undergoing surgery for knee pain experienced the same relief when they were told they had received the surgery, but in fact only a “sham” surgery had been done.
  • Regulate heart rate in people with neurocardiogenic syncope: Pacemakers implanted in the chest were effective for regulating dangerous heart rate abnormalities in people with this disorder whether the devices were turned on or not.
  • Cure nausea and vomiting:Pregnant women were cured of their nausea and vomiting when told the substance they were being given was a powerful antiemetic even though it (Ipecac) is normally used to induce vomiting.

 Six decades of research all leads to the same conclusion. What we think and believe can significantly influence what goes on in our body. A very recent study from 2010 reinforces the power of this connection between our belief and our biology. The study involved two groups of patients with Irritable Bowel Syndrome (IBS). One group received open-label placebo pills and was told these were “placebo pills made of an inert substance, like sugar pills that have been shown in clinical studies to produce significant improvement in IBS symptoms though mind-body, self healing processes.” The other group acted as a no-treatment control. The open-label placebo group actually did significantly better than the control group even though they were taking a placebo and they knew it.

What is going on here? Can placebos actually have this kind of impact on our physiology? If so, do we have any idea how this might happen? How does any of this relate to the findings of Langer’s study and issues of weight and health in general? Please check back for Part II to find out!

Posted in Jon Robison | 5 Comments »

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November 22, 2011

the HAES files: holiday food for thought

by healthateverysizeblog

by Deb Lemire, President of ASDAH

The holiday season is upon us and for many it can be a source of great anxiety around food and weight, particularly for women. For me  my most favorite and least favorite part of the holidays has always been the food.

First, there are so many wonderful smells and delicious recipes that you look forward to and wait for all year.  My aunt always makes homemade chocolates and my favorites are her chocolate peanut butter buckeyes.

But my most favorite holiday food is my grandma’s potica.  A nut roll made from a recipe with Gram’s own personal touch and its Slovenian roots all rolled into one; just the right mix of flavors, not too sweet with lots of nuts.    Christmas would not be Christmas without Gram’s potica.  Gram would make one for each of our families. We try to make our roll last as long as possible, but it never makes it to Boxing Day. Gram had five children.  And even as our individual families grew, she would continue to make one for every household; whether it was your college dorm or your newlywed apartment.  From those 5 children Gram has 16 grandchildren.  That’s a lot of nuts!  (Literally, but that’s a different story.)  In the last few years of her life Gram was not able to make her potica because of ill health. So my aunt had taken on the duty and continues to do so since Gram has passed.  It’s not exactly the same, but she is the one who makes the buckeyes, so it’s pretty darn close!

My least favorite part starts in October.  Everywhere you look it seems, there is a magazine with some fabulous, mouth watering dessert or delicacy on the front cover.  As the holiday’s get closer the push to create amazing meals that will delight the senses and send your family into dizzying, euphoric states of ecstasy gets more intense.

And even though it is a challenge to suddenly find time in your schedule to be that creative; even if you enjoy cooking whether or not you are particularly good at it; even though you generally are the one who has to do all the shopping for these recipes and all the clean up after the creation is complete…It would all be worth it, if you were allowed to actually enjoy your masterpiece along with everyone else.

But you can’t.  Because right next to that front page picture of the “latest must have on your holiday table” dessert, is a quote from inside “how to avoid those extra holiday pounds!” 

So we go through the holidays being pulled in two directions.  Wanting to cook something special for our family maybe because we enjoy it or maybe we just enjoy making the extra effort for them during this time of year.  And at the same time we go through the season miserable because we feel guilty licking the damn spoon once in a while.  We hold our wooden spoons in the air and shout “Why?!” and “It’s not fair!” 

And we are right.  It’s not fair.  And I will tell you why.

Now I don’t know that the women’s magazines purposefully seek to betray us.  In fact it is more likely their editors feel they do just the opposite.  But we are so used to these mixed messages we barely recognize the damage they do to us as women in our society; a complacency rooted in our patriarchal culture.  Okay, you’re thinking—what kind of feminist rant are we in for now.  For crying out loud, they are just innocent magazines (and let’s not forget all the fitness commercials) trying to make a buck.  They don’t do any harm.  But that is not exactly true.  (Well the ‘trying to make a buck’ part is.)

What happens to us when we are subject to these mixed messages?  Messages that tell us to put ourselves last, that we don’t deserve the same goodness that everyone else does.  We start to feel guilty.  And that guilt begins to manifest as anxiety and negative feeling about how we look and how we perceive ourselves as a person.  And that is damaging.  Not just to ourselves, but to our daughters that witness and ultimately imitate our self sabotage.  Ensuring the cycle continues.

So this holiday season I want you to keep in mind a couple simple things they don’t tell you in those magazine or commercials.  First of all, it is perfectly natural for mammals to gain some weight in the winter; just as it is natural for mammals to shed that weight in the spring.  Dieting only interferes with your body’s ability to take care of itself and be healthy.

And secondly, your great aunt Mary baked that homemade pie from scratch, not because she enjoys slaving in the kitchen, but because she loves you and she enjoys watching you enjoy it!

So sit down and share a piece of pie with great Aunt Mary.   After all, how many more pies will there be?  But most importantly, make sure you invite your daughter to share a piece with you too.

Posted in Deb Lemire | 6 Comments »

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November 15, 2011

the HAES files: does bariatric surgery cure diabetes?

by healthateverysizeblog

by Laurie Klipfel, RN, MSN, BC-ANP, CDE

Editor’s Note:  November is National Diabetes Awareness Month.  We asked one of ASDAH’s new members, who is a passionate diabetes educator, to answer the question “does bariatric surgery cure diabetes.”   Laura’s piece provides a clear understanding of just how our bodies work when challenged with diabetes and the impact of bariatric surgery.  ASDAH would like to see a more transparent approach by doctors as they make recommendations to their patients about this life altering surgery. 

ASDAH would also like to announce its new series of educational tips regarding  the Health At Every Size model and dealing with disease.  Our first “HAES How To…” is on applying the Health At Every Size approach while managing diabetes.  You can access the HAES How To here.  Five Health At Every Size Tips for People with Diabetes

A couple of months ago Reuters released the findings of a study reported in the Archives of Surgery, touting that weight loss surgery as a miracle cure for diabetes.  As a diabetes educator I feel that this may be somewhat misleading and to be fair, I feel there is a “rest of the story” that needs to be added. 

First, let’s define diabetes.  Diabetes is simply an imbalance of supply and demand of insulin.  Insulin is a hormone that allows glucose (the type of sugar that the body uses for fuel) to get from the blood to the muscle cells.  Insulin works like a pump at the gas station.  Without insulin, you will literally starve to death no matter how much you eat.  This is because no matter how much sugar you have in the blood to use as fuel, you can’t get it from the gas station to the car.  Type 1 diabetes is a problem with supply of insulin.  No matter how much is eaten, without insulin the sugar hits a road block and ends up in the toilet rather than the muscle.  This is why people with type 1 diabetes lose weight.  Without insulin the only thing that can be burned as fuel is fat….hence weight loss.  In type 2 diabetes the most prevalent problem is usually demand.  Rather than being a problem that the body can no longer produce insulin, it is usually more of a problem of insulin resistance.  In other words, the gas station has pumps, but they are pumping very slowly.  This requires many more pumps to get the same amount of gas to the cars.  The pancreas has to work overtime to get enough insulin.  As long as the pancreas can keep up with the demand a person can be very insulin-resistant without having diabetes.  We define diabetes as a build up of sugar in the blood when the demand is greater than the supply of insulin.   

There are things that can affect supply of insulin. The most significant factor is how strong and healthy the pancreas is (largely due to genetics, but possibly impacted by injury).   Pancreatitis can also decrease insulin production.  Type 1 diabetes is an autoimmune disease where the body has attacked the pancreas, making it unable to produce insulin. 

However some claim bariatric or weight loss surgery (WLS) is a cure for Type 2 diabetes, which is often a problem with demand for insulin more than supply. There are many things that affect demand.  The more calories that are eaten, the more insulin is needed to get the sugar from blood to muscle.  The type of calorie (fat, protein, carbohydrate or alcohol) also affects demand.  The faster the calories turn to sugar, the faster insulin is needed ( and the harder the pancreas has to work to supply the demand.) Carbohydrates (especially if it is a sugary liquid) turns to sugar the fastest, which is why we pay most attention to them in diabetes.  

Exercise helps the insulin to work harder.  Exercise will not always fix insulin resistance, but it does help it.  On occasion, exercise actually increases sugar as exercise will only lower sugar in the presence of insulin. 

Stress makes insulin resistance worse due to hormones such as epinephrine and cortisol.  Depression and anxiety, lack of sleep or poor quality of sleep will also make insulin resistance worse.  Heredity also plays a big factor in insulin resistance.  

Insulin resistance often leads to increased hunger and decreased energy, which leads to weight gain.  The increased weight then leads to even more insulin resistance.  This cycle is very difficult to break.  Weight cycling (yo yo diets) also make insulin resistance worse.  

Incorporating healthy lifestyle changes such as eating well, getting exercise, reducing stress, or getting enough sleep, decreases the demand of insulin.  And often, improvement in these areas results in weight loss as a side effect. Improving insulin resistance leads to less hunger and more energy.  So it appears that weight loss is what caused the “cure” of diabetes, when actually the activities that help insulin resistance caused both the weight loss and decreased demand of insulin.  If you lose weight without lowering calories or exercise, you do not get the same decrease in demand of insulin (such as weight loss with cancer.) If you surgically remove fat, such as in liposuction, you also don’t get the decrease in demand.   If you intentionally gain weight, but do it with a healthy diet and exercise, (such as a sumo wrestler might do) you do not get the increased demand.  It is not the weight; it is the behavior that affects the demand of insulin.  When you engage in healthy behaviors, you get the benefit with or WITHOUT weight loss.  That is why even as little as a 5-7% weight loss will be beneficial in decreasing the demand.  And why if you lose weight and keep it off, but now have a stable weight, the benefits in the decreased demand wane over time.  This is also why it is so hard to lose more than 5-10% of the weight. 

So back to the original question….does bariatric surgery “cure” diabetes?  The two most common procedures currently done are: The Adjustable Banded Gastroplasty or Lap band (restricting calories) or the Roux En-Y (restricting calories and limiting absorption.)   The immediate drop in calories (more so with Roux En-Y due to both decrease in food eaten and food absorbed) significantly decreases demand of insulin (less insulin is needed for less calories.)  Depending on the supply and demand, this decreased demand may now make the difference between making budget or not.  Therefore there are times the surgery appears to have ‘cured’ diabetes even before weight loss has occurred. Reducing calories in general such as in garden variety weight loss will produce the same effect and look like it “cures” diabetes, when in actuality it too just decreases demand.  Usually with weight loss diets, the drop in calories is not as sudden and drastic and usually weight is lost before benefit is seen. 

That being said, there is a lot we currently do not understand about hormones that affect appetite and metabolism.  Some of these hormones such as ghrelin and GLP-1 come from the gut as a result of eating.  Eating less or absorbing less has an effect on these hormones as well as hormones such as leptin that come from fat tissue. Surgical manipulation no doubt affects these hormones which is how they claim it “cures” diabetes.  While I have not seen any official studies that show this, I have often seen  when someone drastically and rapidly decreases calories, the same decreased demand of insulin occurs and occasionally this decreased demand “cures” diabetes with no surgery (such as going on a liquid protein Optifast type diet.) 

Either way, as you get older, you need more and more insulin, and your ability to produce insulin decreases over time.  Therefore as you age, the potential for an imbalance of supply and demand is still there even if it was previously “cured.” So whether weight is lost because of surgery or because of healthy changes in behaviors, there is the possibility of diabetes reoccurring. 

So perhaps the more important question is which path is the best path to reducing insulin resistance and perhaps balancing the supply and demand for insulin:  embracing a Health At Every Size® way of life where you meet the nutritional, physical, and emotional needs of your body even if weight is unchanged, or weight loss surgery which may have on average better weight loss but has significant side effects.  

With lap band (figure 1), the fluid filled balloon around the stomach is holding constant pressure around the stomach.  As the stomach fills and food moves through there is movement which leads to pressure and friction.  This can lead to ulceration under the band.  If this goes through to the inside of the stomach, GI contents can leak into the body cavity leading to emergency surgery and potentially lethal peritonitis.  The balloon can rupture and then the effect of restriction is lost.  The band needs to be “adjustable” because the size of the opening has to be exact (too big, and food goes through too fast to be beneficial and too small, food gets stuck.)  They can’t make it exact due to variability in the gathers of the stomach as the purse string is pulled.  This means that we have to have a port (a tube that comes to surface to either add or take away fluid to change the pressure applied).  This tube can flip or twist.  It is difficult to secure the band so it can also slip up and down.  This can suddenly obstruct food–also requiring emergency surgery.  If food is not chewed well, it can also get stuck even if the band is in the right place and is the right size. Some medication is too big to go through the band.  If irritating medications such as ibuprofen get stuck it can ulcerate from the inside out. 

 lap band

 

With Roux En-Y (figure 2), there is a staple line across the whole stomach.  Food never goes into the bottom of the stomach.  Instead it is re-directed into the intestine.  How much of the intestine that gets bypassed, varies with the procedure; the more that gets bypassed, the more the weight loss, but the more complications from malabsorption.  The staple line or the anastamosis (connection of the intestine to the stomach) can leak which leads to emergency surgery and potentially lethal peritonitis.  The acid that is supposed to digest food is in the stomach but the food is in the intestine.  Protein needs enzymes from the pancreas and fat needs bile to break down.  Since these don’t mix, protein is not absorbed well.  You need protein to build tissue.  Fat is not absorbed well either.   You may not think this is a problem, but you need a certain amount of fat to absorb fat soluble vitamins, and build tissue.  The bigger problem is what happens to the fat if it does not get absorbed.  If protein and fat aren’t absorbed the only thing that is absorbed is carbohydrate.  When carbs get absorbed and the body responds with insulin, if there is no protein or fat, the insulin lasts longer than the carb and the blood sugar drops rapidly leading to being shaky, jittery, fast heart rate, decreased brain function and can lead to passing out.  This is known as “dumping syndrome.” Hypoglycemia is bad in the short term, but new evidence is showing how harmful it is on the long term as well (increasing risk of cardiovascular disease.)  Another problem is that the part of the intestine that is bypassed is the part that absorbs things like calcium, B12, iron and other nutrients.  Even if these are supplemented, the part that absorbs them is bypassed. Another problem is that stomach acid is in the stomach without food.  If you take an antacid it will not end up where it needs to be. 

Roux en Y

Another problem is that the body is smart and while it can be fooled for a while, it will find ways around restrictions over time.  The body is fooled when the stomach feels full, but you can still be hungry even with a full stomach. To understand what I mean, the next time you are really hungry, eat a big bucket of celery. Eat until you can’t eat anymore.  You will likely still be hungry, even if your stomach is full.  So often over time people end up eating more calorie dense foods to get needs met and feel full at the same time.  Therefore, often at least some of the weight lost is re-gained.

I am not willing to say that no one should make the choice of having surgery, but I do think that to be fair, an individual needs to know both the pros and the cons and be able to make an informed choice.  Often people only find out the cons after surgery.  In my opinion to tout bariatric surgery as a cure without the rest of the story especially to those so desperate for a solution is just not fair.

 

Posted in Laurie Klipfel | 13 Comments »

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November 8, 2011

the HAES files: does the Health At Every Size® approach mean I’m giving up?

by healthateverysizeblog

by Jeanette DePatie (The Fat Chick), MA, ACE

In my work with ASDAH as well as my work as a fitness instructor, I have introduced the HAES™ approach to life to many people.  And over the years, I’ve seen a pattern emerge.  I’ve seen it on email lists, I’ve heard it in the locker room and all around me.  When I start describing the benefits of the Health At Every Size® approach, people are initially excited.  The idea of freeing themselves from the bondage of ineffective diets and the pain of body hatred is very appealing.  But there comes a moment, somewhere down the line, where they quietly ask, “but doesn’t this mean I’m giving up?”

This is a critical moment, and I think it needs a carefully considered and gentle response.  And at the risk of sounding wishy-washy in this moment, I usually answer along the lines of, “yes and no.”

Yes you are giving up the frustration that comes from banging your head, repeatedly, against the same “weight-loss-wall” and feeling like a failure.  You are giving up the idea that your body should be conquered and controlled.  You are giving up the notion that all other health and life goals mean nothing if they are not accompanied by weight loss.  You are giving up the need to put your life on hold until you reach an arbitrary goal weight and fit into a certain pair of pants.  And that is good.  Most people like this.

But truly embracing the Health at Every Size approach tends to ultimately result in another kind of “giving up.”  You have to sacrifice your skinny fantasy.  This fantasy implies that when you reach your goal weight, or the “skinny jeans zip” (even if you have to lie on the bed to do it) other things in life will magically get better.  You’ll land that fantastic new job.  You’ll be the envy of everyone you know.  A fantastically attractive and wealthy person (who also happens to be your soul-mate) will swoop in and “take you away from all this”.  In our world, this fantasy is incredibly strong.  You have to give up the “highs” of the diet roller coaster as well as the “lows”.  Most people don’t like this too much.

But I think the area where people struggle the most is with their own idea that the Health At Every Size® approach means you are giving up your body altogether.  They often believe that it means A) not exercising (because without weight loss, why bother?) and B) eating whatever you want, whenever you want.

But the HAESSM approach does NOT mean giving up on your body.  It means honoring your body in a uniquely effective manner.  HAES does not mean giving up on exercise.  It means finding a kind of movement that you enjoy and feels good to your body.  It means recognizing the good feeling you get after moving your body and making opportunities to feel that way often.  And HAES does not mean just eating cookies three times a day. It means honoring your hunger and satiety signals.  It means caring for your body with a variety of nutritious foods.  It means learning which foods fuel you and make you feel well and which foods leave you feeling less well.  In short the HAES approach does not mean giving up on your body, but rather owning and inhabiting your body in a special way.  In a certain thoughtful and unregimented way, the HAES approach is a lot of work.  A lot of people find this idea very confusing.

And it’s no wonder.  In a world of “get everything you ever wanted by following my ten easy steps, five point plan or three rules” the Health At Every Size approach offers subtlety and complexity.  The HAES approach means that people have to honor their own bodies and seek to find their own rules.   And the markers for success aren’t as clear-cut.  There’s no “after” picture.  There’s no goal weight victory party.  And for a culture that is obsessed with winning at all costs, this is also a sacrifice.  For many people, the HAES model means giving up the external validation offered by doctors, friends, families and even total strangers that can come with weight loss.  It even means a sacrifice of the notion that health and mortality is under our control—as many of us secretly believe that if we lose weight and do everything “right” we’ll live forever.  Most people find this incredibly hard.

When you’ve lived the Health at Every Size approach for a number of years and experienced the joy and inner peace that comes with accepting and honoring your own body, it can be hard to understand why others don’t seem to “get it”.  You remember the pain of the diet roller coaster and constant self-hatred and don’t ever, ever want to go back there.  But as we help others along the way, it’s important to remember the things you gave up on the road to self-acceptance, and honor the grieving process that goes along with that.  And it’s important to help those new to the HAES way of living to understand that while the Health At Every Size approach means giving up certain things, it means the precise opposite of giving up on yourself.

Posted in Jeanette DePatie | 15 Comments »

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November 1, 2011

the HAES files: assumptions

by healthateverysizeblog

By Michelle May, M.D.

Not long after graduating from medical school, I was sitting in a hospital nurses’ station between two other residents, writing progress notes and orders on our patients. Suddenly a woman ran out of a patient’s room and over to the desk where we were sitting. She came right up to me and said, “Hurry! It’s an emergency!” As I stood up to help, she added, “My father needs a bed pan!” The other residents chuckled as I went in search of the urgently needed item, having no idea where to begin to look. I located a nurse to help her and returned to my work.

I have the highest respect for nurses so I wasn’t offended, but I found it telling that the daughter made an assumption based on a single external attribute: we were all in our twenties, all working on charts, all wearing scrubs with white coats, and all had stethoscopes around our necks, but I was the only woman. I told the other residents that perhaps she didn’t assume that I was a nurse who actually knew something, but perhaps she assumed that as a female, I would be the most friendly and helpful, and therefore, she was right!

While that story has brought many laughs at cocktail parties, it is a good example of an outdated assumption that led to a misdiagnosis and a brief delay in addressing her father’s problem. Any time we make assumptions about a person based on a single attribute, especially an external one, we are likely to make mistakes. You know the old saying: When you assume, you make an …

There is extensive data about the bias, prejudice, and discrimination that occur on the basis of a person’s size and the harm that causes. As destructive as it may be, this form of stigma, when called out, will be judged harshly by rational, fair people. However, it is the hidden assumptions by my generally well-meaning colleagues in the medical and wellness fields that I want to address here.

The erroneous assumption that thin equals healthy and fat equals unhealthy is still deeply entrenched in healthcare despite numerous studies, books, articles, and experts challenging the scientific basis of those assumptions. On the basis of a patient’s size alone (typically using BMI as their defense), smart, rational people justify their assumptions about that person’s health, risk factors, diet, physical activity, emotional state, compliance, and even character.

Even where correlation exists, it does not prove cause and effect—and certainly doesn’t accurately predict an individual’s behaviors or health. It is disrespectful, lazy, and even dangerous to assume one knows anything about a patient’s health, risk factors, or choices without taking a thorough history, performing a skilled physical exam, and ordering necessary labs and diagnostic studies. It is tantamount to guessing.

At best, these assumptions are a shortcut that damages the patient-clinician relationship. At worst, it is discrimination that has potentially serious medical consequences. Here just a few examples of errors made as a result of size assumptions.

  1. A medical assistant compliments a teenager on her weight loss. The teen has been restricting and purging.
  2. A 47 year old woman is told by her doctor that she needs to go on a diet and start exercising to lose some weight. The doctor neglected to ask her patient about her diet and exercise patterns. If she had, she would have known that her patient was vegan and had run five half marathons in the past two years.
  3. A 29 year old male with a BMI of 22 is complimented on his apparent good health. The doctor neglected to ask questions about his diet and exercise patterns. If he had, he would have discovered that his patient eats fast food eight to ten times a week, spends six or more hours a day playing video games and watching TV, and never exercises.
  4. A male with a BMI of 33 and a strong family history of premature cardiovascular disease is diagnosed with hypertension and is told to lose weight. He is not offered antihypertensives for over eight months despite persistently elevated blood pressure.
  5. A 27 year old obese woman comes into the emergency room with severe abdominal pain and delivers an infant into the toilet during the urine collection. She had been diagnosed with polycystic ovarian syndrome but a pregnancy test was not ordered on follow-up office visits despite continued amenorrhea.
  6. A woman being seen for an upper respiratory infection is lectured about her weight.
  7. A 62 year old male with severe knee pain and limited mobility due to osteoarthritis is told that he must lose 50 pounds before he will be considered for knee replacement surgery.
  8. Patients with a BMI over 25 are advised to lose weight—despite lack of evidence for the long term effectiveness of dieting. When unsuccessful at either losing weight or maintaining weight loss, the patients are perceived as non-compliant.

Sadly, there are many other examples of medical care that is adversely affected by size assumptions. (Please feel free to share your stories in the comments section below). While some of these examples are just bad medicine, these mistakes can be avoided if the clinician adopts the Health at Every Size® principles.  It boils down to the clinician asking themselves, “If I eliminated all of my assumptions based on this patient’s size, what would the appropriate questions, exam, diagnostic studies, recommendations, and treatment be?”

Posted in Michelle May | 7 Comments »

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