healthateverysizeblog

December 27, 2011

the HAES files: dear friend, so your doctor says to go on a diet…

by healthateverysizeblog

HAES expert Linda Bacon, PhD teaches an introductory nutrition course at City College of San Francisco. She recently assigned an essay to students, asking them to write a letter to a friend whose doctor recently informed her that she is obese and encouraged her to diet. Student Molly Breen generously agreed to share her “A” essay.

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Dear Pat,

It sounds like you had a pretty upsetting visit to the doctor, and the first thing I want to do is give that guy a kick in the pants! I don’t think he’s giving you good medical advice, and I definitely don’t think he should have made you feel bad about your weight or your body. I find his suggestion that you “just try a little harder” to lose weight especially infuriating, since I have never in my life met someone with more willpower and self-discipline than you.

But I know you didn’t write for a pep talk. You wrote because you know I’m taking a nutrition class this semester and you want my advice on losing weight. Well, here’s my advice: I don’t think you should lose weight. For one thing, you’re gorgeous, and for another, I don’t agree with your doctor that body fat is necessarily dangerous to your health. However, I do believe dieting is dangerous, to both your physical health and your spirit.

I know, the doctor said you were obese and pointed to the scary number on the BMI chart and told you about all the diseases you’re at risk for, but I’m not buying it. Who came up with that chart anyway? A bunch of doctors and researchers funded by weight loss drug companies and lap band manufacturers? (Don’t even get me started on those!) And how do they come up with these numbers that affect our insurance rates, our rapport with our doctors and our sense of self-worth? Who knows! Consider this: in June, 1998, the National Institute of Health’s Obesity Task Force adjusted the standards of the BMI. As a result, 29 million Americans went to bed with average figures and woke up ‘overweight.’ None of them had gained a pound, but all were now at “higher risk” for Type 2 diabetes, atherosclerosis, and hypertension.

It’s true that, in general, fat people are at higher risk for these diseases. But there is no evidence that being fat is the primary cause for these diseases. My nutrition teacher explains it this way: there is a well-known correlation between baldness and heart disease in men. But we don’t think the baldness causes heart disease. In fact, the heart disease and baldness are related to high levels of testosterone. In the same way, body fat and diabetes may be correlated, but that doesn’t mean body fat causes diabetes. Fat people may be more likely than thin people to have diabetes because fat people are also more likely to be older, poorer, more sedentary and to lack access to decent medical care and grocery stores carrying nutritious foods, not to mention safe places to exercise and play. There is even evidence that the stress of being told that you look bad/ugly/unacceptable all the time takes a toll on the body and can increase risk of disease.

Now maybe you’re thinking, ok, body fat might not be that bad for me, but I still don’t like the way I look. So give me some diet tips already! Well, I won’t, because diets don’t work. Yeah, I know you’ve lost weight on diets before, and that’s because at first, diets do work. Let’s consider a nice, “healthy,” gradual diet and program of exercise. No crazy cayenne pepper cleanses or hot yoga marathons here — you’re just going to cut back on sweets and start power walking for 30 minutes a day. And let’s say that, on average, you need to eat 2000 calories each day to fuel your body. Suppose those sweets you’ve given up equal 200 calories a day and the walking is burning an extra 200 calories a day. That means you’re using up 2200 calories worth of energy a day, but only taking in 1800. Your body has to get the 400 calories it needs from somewhere, and, yup, it’s going to get them from fat stores.

So you’ve been on this diet and exercise program for three weeks, and you’ve lost some weight. Six weeks pass — still losing weight. You buy a pair of $160 jeans. You RSVP yes to your college reunion.

Six months pass. You haven’t lost much weight in the past month. Nothing about your diet has changed. You don’t even crave sugar anymore, and you’re still exercising. Month seven, you step on the scale and realize you’ve gained a pound. After a year, you’ve regained half the weight you lost in the first five months. Two years later, and you’ve regained it all, plus five bonus pounds. And all this time, you never stopped dieting and you kept up the exercise. And then you go into your doctor’s office, and he tells you you’re obese and need to . . . diet and exercise to lose weight.

I know you recognize this scenario, because we’ve talked so many times over the years about this painful, frustrating cycle. But now I know why you keep gaining the weight back. You know what homeostasis is, right? When you get hot, you sweat to cool down; when you get cold, you shiver to warm up. Your body turns these mechanisms on and off automatically, without any conscious input from you, because it is invested in maintaining a body temperature that allows all its vital functions to go on functioning. It turns out your body is every bit as invested in maintaining a healthy body weight, and will see to it that you maintain that weight whether you like it or not. We all have what’s called a set point, which is really a range of weights at which your body feels comfortable and safe. Get below your set point, and your body wants you to gain weight. Get above your set point, and your body wants you to lose weight. But because back in cave people days there was no risk to having extra body fat (and a lot of benefits!) and a HUGE risk to having too little body fat, the mechanisms that prevent you from losing weight are stronger in most people than the ones that prevent you from gaining weight. These mechanisms are slow, gradual, and out of your control. For example, your body might lower your body temperature slightly so you burn fewer calories. It might make you a bit more tired and sluggish, so you move less. It might become extra efficient at wringing every last calorie out of every piece of food you eat. And it might make a wider array of foods appealing to you, especially fatty, sugary, calorie-dense foods. Over time, all these small effects add up to you burning fewer calories and storing more, in spite of the fact that you’re still eating less. And the real kicker is, the more you diet, the more conservative your body becomes in terms of its fat storage. “You’re starving me again?” Your body says. “Well, I’d better sock away some more fat to get us through these scary lean times.” By dieting and making your “thrifty genes” even thriftier, you can actually bump up your set point.

So you can see why I think your doctor gave you crummy advice. He’s operating on popular but scientifically unsubstantiated claims about the risk of body fat and his prescription —weight loss— is not only impossible for the vast majority of people to achieve in the long term, but actually leads to increased weight gain and is damaging to health!

What I really want to tell you, my dear Pat, is to focus your considerable energy on the things that actually impact your health, and let this weight business go. You have so many healthy habits already. You swing dance; you have a million friends; you cook dinner every night; you’ve started using meat – how did you put it? “As a condiment?” You already know what to do. Trust yourself, and trust that bod.

I don’t want you to take my word for any of this. I’ve included a few links to different resources including some info on something called intuitive eating. I also encourage you to check out the counter arguments (a lot of companies stand to gain from the notion that people can lose weight, so they shouldn’t be hard to find!). If you can find studies that support successful, salutary, long-term weight loss for a significant number of the participants, send them to me. We can comb through them together.

I hope this letter answers your question in a way that feels satisfying, or at least intriguing. I totally understand if it also feels annoying, frustrating and upsetting. I don’t for a minute think that what I’m sharing with you is easy to hear. But it is the best advice I know how to give, to someone who deserves nothing but the best.

Yours in fondness and solidarity,

Molly

Molly Breen is nutrition student, author, blogger, and green grocer at Other Avenues, a food co-op in San Francisco.

Posted in LInda Bacon | 10 Comments »

December 20, 2011

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

by healthateverysizeblog

by Jonathan Robison, PhD, MS

In Part I we discussed a study in which room attendants from 7 different hotels were randomly assigned to one of two experimental conditions. Subjects in both conditions received written materials describing the benefits of exercise. 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.

Systolic and diastolic blood pressure, BMI, body weight and waist-to-hip-ratio all decreased in the informed group only, even though subjects self-reported diet, activity (off the job) and substance use (caffeine, alcohol, cigarettes) indicated no changes over the 4-week period. In the informed group, the percentage of subjects who reported exercising regularly doubled, even though the physical activity involved with their work did not change. The authors concluded that the observed physiological changes were likely a result of the subjects increased perceived exercise.

We asked, can placebos actually have this kind of impact on our physiology? If so, do we have any idea how this might happen? We discussed that there are decades of good quality research demonstrating the power of placebos to impact our physiology. In fact, the placebo effect is so powerful, that it appears to operate even when people know they are taking a placebo. Though the mechanisms have not been completely elucidated, we are beginning to understand the most likely explanations. According to a recent article in the prestigious British medical journal, The Lancet:

The overall outcome of a treatment combines the specific pharmacological or physiological aspect of the treatment and the psychosocial context in which it is delivered. The psychosocial context represents the placebo component which is based on patient expectations.

It appears that patients’ expectations about their treatment can stimulate the release of chemicals in the body that result in the physiological changes we see with placebos. Endogenous opiods like endorphins and neuropeptides like dopamine and serotonin have been implicated in this connection between belief and biology. What is fascinating is that these chemicals are often the same ones that are released by the real drugs themselves. Again, quoting from the Lancet:

Placebo mechanisms can interact with drug treatments even if no drug is given, since every treatment is given in a therapeutic context that has the potential to activate and modulate placebo mechanisms, many of which can act on similar biochemical pathways to the actual drug.

The practical implications of this knowledge are profound. No matter what the therapeutic encounter, the healing/curing process involves not only any biomedical intervention that might occur, but also how patients feel about that intervention, which is based on their attitudes and beliefs and on the quality of the relationship with their health care professional. There is perhaps no better proof of the mind and body connection than the placebo effect. Everything that happens in the therapeutic encounter matters!

Could the placebo effect explain the physiological changes that occurred in the informed group? Or, is it true as one medical expert commented, that people’s perceptions can only affect “subjective types of findings” like a person’s perception of pain or their sense about whether they feel depressed. Is it possible that the perception of increased exercise reduced the stress of worrying about not getting enough exercise to the point of reducing blood pressure? Given what we have seen about the power of placebos, this seems to be at least a possibility. Remember the study from Part I in which the implanted (but not activated) pacemakers modulated aberrant heart rhythms in people with neurocardiogenic syncope?

But, what about the researchers’ contention that BMI, weight, body fat percentage and waist to hip ratio all changed as a result of people’s “mindset” about exercise? In spite of the documented power of placebos, we have a way to go before we can make this connection. The more likely probability is that behaviors in the informed group were altered as a result of their attitudes and beliefs. As the researchers’ themselves confess:

It is possible that the room attendants actually did change their behavior – actually did cut back on calories improve the quality of the food they ate, or work harder or more energetically – but did not report such changes.

Interestingly, they go on to say that this is an unlikely explanation because “previous research has found it very difficult to change behaviors of this sort.” In terms of weight loss, this seems a dubious contention given that many people initially lose weight on all sorts of interventions. The approximately 2 pound loss in the informed group is compatible with short term changes in physical activity and/or diet.

It is certainly possible that the therapeutic encounter contributed to changes in behavior that led to changes in weight-related parameters. If sustained, these behavioral changes could contribute to improved health in these individuals. The focus of the article however (and even more so of the media coverage of the research) was on the weight changes as being “healthy” and desirable in and of themselves. As one writer put it – “maybe it really might be possible to sit on the couch eating chocolates and lose weight.” The fallacy here (oh so surprisingly) is in equating changes in weight with changes in health. In fact, the average BMI of the people in the informed group was in a range (around 26) where people actually live the longest and the change of 2 pounds keeps them in that same range. The changes in waist to hip ratio and body fat percentage were too small to have much practical significance – if they have any significance at all.

So, what is the bottom line? The intervention may have changed people’s perceptions about exercise and their health. This may have impacted their blood pressure and perhaps changed some physical activity and diet-related behaviors. The weight-related changes were most likely the result of the altered behaviors, not good or bad or healthy or unhealthy in and of themselves — right in line with the philosophical approach to weight and health that we all are working so hard to promote.

ps – A number of people requested more information on the Nocebo effect – I will be happy to address that in my next blog – take care – Jon

Posted in Jon Robison | Comments Off

December 13, 2011

the HAES files: truth in advertising

by healthateverysizeblog

by Deb Burgard, PhD

Why do we call it the “weight loss industry” when what we really get for our time, sacrifice, and money is weight cycling? 19 times out of 20, what we are really purchasing is the experience of weight loss and regain.

Imagine if we called it the “weight cycling industry,” and “weight cycling programs.” Would you participate in Weight Cyclers at work? Buy food from NutriCycle? Hire a trainer from the Biggest Weight Cycler?

As a physician, would you prescribe weight cycling for your patients? As a Human Resources director, would you encourage/incentivize/coerce your employees to embark upon a bracing round of weight cycling this year? As a parent, would you send your child to weight cycling camp?

Because that is what we are doing, folks. Better face the facts: Of 100 people trying to lose weight, the vast majority of people will regain weight. Some significant group – perhaps a third – will gain more weight than they lost. Some tiny number (7? 5? 3?) will maintain their weight loss, and of that group, some number from 0-4 of them will be flirting with, developing, or fortifying an eating disorder. Yes, you read me right. The 1-year prevalence data for adolescents and adults is 2-3% for adolescents and 3-4% for adults – and though it is not impossible to develop an eating disorder without having first dieted, it is the norm to do so. If you read the practices of the people quoted in the Weight Management Registry, a group of several thousand people who have lost at least 30 pounds for at least 1 year, you will see some of the same practices and preoccupations we diagnose in people with eating disorders, including daily weighing, immediate compensation on the occasion of weight gain, logging every bite of food, exercising more than 90 minutes/day, etc. Even people in the Registry regain weight and apparently are allowed to continue being members as long as they once lost 30 pounds and kept it off for a year.

It is an odd requirement, because one year is not rational criterion of “weight maintenance.” Of the few studies that follow people at least 2 years, the 2-5 year range is the critical time period when almost everyone has regained. It is odd that any studies of weight loss shorter than 2 years are published, since all that interesting data in the differences in what happens at 6 months or a year are all wiped out by 2 years anyway. Yet the NIH apparently rarely funds studies – even weight loss studies – for longer than 1 year.

Our tax dollars go to funding study after study of this or that factor which results in faster weight loss, weight loss for more participants, fewer dropouts, etc., all of which becomes moot since almost everyone regains weight shortly after the study ends when no one is watching. In this era of fiscal anxiety, surely it would be a no-brainer to only fund studies that have a follow-up period for all participants of at least 2 years. It seems like a good minimum length for publishing studies in journals as well. And imagine if everyone demanded to see evidence from the weight cycling industry of 2-year follow-up data before they hand over a penny. We would have over $60 BILLION back in our own pockets.

You might be thinking, but I know someone who kept weight off. You might be that person yourself.

And as long as that person is (or you are) not struggling with disordered eating or some other kind of unacceptable drain on your life energy, s/he/you are probably pleased with that outcome. There are certainly times that people lose weight by recovering from an eating disorder, or being more aware of their bodies’ appetite cues, or finding a passion (not a compulsion) for a physical activity, or changing to a less sedentary job, or changing medications, or just feeling more able/willing to feed themselves the kind of fuel their bodies thrive on. Weight loss itself – or weight gain – is not the issue. When people adopt those practices they might lose or gain weight or stabilize their weight. It is the practices that people adopt in the pursuit of weight loss that are the problem, because for the 95 out of 100 people who regain weight during a diet, when the practices are not sustainable they lead to more physical and psychological illness.

The Health at Every Size® model is weight neutral. People using this approach are not pro- or anti-weight loss, but they are mindful that the pursuit of weight loss is usually harmful, unlike the cultivation of sustainable practices that feel life-affirming and support your health. In keeping with the “truth in advertising” theme, the Health at Every Size model does not insist that everyone is healthy at every size, or that anyone anytime is necessarily the size that optimizes their health. “Health” in this context means that whatever size you are, there are practices that will support your health. There are environments that celebrate diversity, free of weight stigma, that will be the healthiest for people of all sizes. Concentrating on those practices and environments are a far better investment than anything the weight cycling industry has to offer.

Posted in Deb Burgard | 7 Comments »

December 6, 2011

the HAES files: there’s no place like home — unless you’re a fat kid

by healthateverysizeblog

interview by Jeanette DePatie (the Fat Chick), MA, ACE

An eight-year-old Cleveland Heights boy was removed from his family’s custody and placed in foster care. The boy weighs over 200 pounds, and county health workers apparently removed him from his family over concerns that his mother wasn’t doing enough to help him lose weight.

How does taking a fat kid away from his parents make him any healthier? Is there data that shows that when you are removed from your family, your home, you lose weight? Of course not.

Remember the 2001 case of Anamarie Regino, in Albuquerque, N.M.? She was removed from her home at age 4 because she was considered dangerously overweight. She was put on a medically-supervised, highly restrictive diet and still gained weight. After a month, they admitted they didn’t understand why she was gaining weight and sent her back home to her parents. It was later determined Anamarie had a genetic condition that explained her weight gain. So Sorry! Our bad! Other than traumatizing an entire family, what exactly was accomplished there?

I am sure authorities will say they are acting out of concern for the child’s wellbeing. But what about a concern about the emotional scars borne by fat children who are removed from their homes? Scars that leading size acceptance expert and author Cheri Erdman, Ed.D., remembers all too well. Erdman speaks eloquently about size acceptance in her two books: Nothing to Lose: A Guide to Sane Living in a Larger Body and Live Large: Affirmations for Living the Life You Want in the Body You Already Have.

When I was six years old, my kindergarten teacher knew two things about me—I had a high I.Q. and I was fat. The teacher and school social worker called in my parents and told them they thought I would be better off if I were thinner. They suggested I be sent to a Fresh Air camp to lose weight and my family agreed.

Erdman spent the next 13.5 months living away from her family at the camp. Her parents were allowed to visit on Friday nights. She was not allowed to see her brother or to go home—even for her birthday or for Christmas. Remember, it was for her own good.

I was only six, so I really didn’t understand the nuances of what had happened. I was convinced that I had done something very, very wrong to cause them to take me away from my family. I didn’t understand entirely what I had done wrong, but I knew that my body was bad and that I couldn’t go home until my body was good.

Having a good body meant losing about 30 pounds. Naturally she regained the 30 pounds and more shortly after returning home from the camp. This set the stage for an unhealthy mix of body hatred, yo-yo dieting, resentment, shame and regret in the years ahead.

Over the year and a half after I came home, I regained all the weight, and it really upset my Mom. She was upset with me for not keeping the weight off and I imagine she was upset with herself for sending me away, regretting her decision. And I was upset with her for constantly obsessing about my weight and what I ate. It was a hurtful and confusing time for me and it created this very negative dynamic with me, my mom and food.

Removing a fat kid from the home doesn’t just hurt the fat child, it damages the entire family.

After I came home, we didn’t talk about it for years. When I finally talked to my Dad, he told me that their Friday visits to Fresh Air camp was part of a weekly ritual of pain. My Mom would start crying on Wednesday and Thursday, and then cry all day Friday anticipating the visit. After the visit she’d cry all night Friday and into Saturday. By Sunday they would have a little peace at least until the whole thing started over the following Wednesday. My Mom and I never talk about it, even to this day. My brother was only four when this happened, and what did he learn? He learned that if you were fat they send you away.

Erdman willingly shares her story with us out of a hope that it will help people understand the deep trauma and ultimate futility that comes from taking kids out of their family environment simply because they are fat.

I went through all of that, and my family went through all of that, for no reason. I didn’t keep the weight off and decades later, I’m still fat. And it was so unnecessary! If we had known about HAES^SM and simply followed a common-sense, Health At Every Size® approach, we could have avoided the whole mess.

We don’t know all the details about this specific Cleveland Heights case, and we may never know. But this case has drawn national attention to a very important question. We aren’t removing kids from homes where family members smoke. We aren’t removing kids from families that don’t exercise. And there’s no evidence that fat kids removed from their homes become thinner or healthier in the long term. So is removing a fat child from her home about better health for that child? Or is it really about our own prejudices towards fat people?

For ASDAH recommended resources on working with children and weight visit ASDAH’s resources.

About Cheri Erdman, Ed.D.

Cheri K. Erdman, Ed.D. is Professor Emeritus at the College of DuPage in Glen Ellyn, Illinois. She is the author of “Nothing to Lose: A Guide to Sane Living in a Larger Body” and “Live Large!” and was an early activist for size-acceptance. Dr. Erdman currently lives in Florida with her husband where she practices as a Celebrant, officiating weddings and other life-cycle ceremonies. She is a mixed media artist and a volunteer for several non-profit organizations.

Posted in Jeanette DePatie | 16 Comments »

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