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

by Health At Every Size® Blog

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.

 

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

  1. dear molly and linda, wow. amazing how wide is the valley of compassion. this is a very compelling and informative piece that many women need to hear. i have attached a piece of mine that i hope speaks to this same issue. http://lifeseedsnutrition.com/2010/12/01/are-you-the-1-in-4/
    thank you for your continued efforts in this regard.
    elyn zimmerman

  2. This is an awesome letter. Thank you for sharing. I have never been fat so I have never had a doctor stare me in the face and suggest a diet, but I wonder if all doctors who advice their patients are suggesting they go on restrictive diets rather than just advising them to eat healthy and balanced meals. It seems like it is always assumed they are telling everyone to restrict, but is it always the case?

    • Ashley – in my experience, most doctors are really not interested if I eat “healthy” or not if I do not lose weight. If this wasn’t the case a doctor should ask the patient what his or her eating habits are before recommending a diet – that never, ever happened to me. Also, I have lost weight quite fast several times in my life (up to four or five pounds a week) and I did so by restricting my food intake to crazily low levels. Yet, every doctor who noticed the weight loss had nothing but congratulatory words for me. If these doctors would have simply been interested in me eating a balanced diet they should have been alarmed by the fast weight loss – my eating back then wasn’t healthy or balanced and the very fast weight loss I experienced was a sign of that. It even went so far that a cardiologist who I saw because my blood pressure was too high (something that became a problem while I was dieting, I might add) told me that my blood pressure would go down on its own if I lost weight. When I told him that I had already lost forty pounds he said I just needed to lose more.

      I do not understand what goes on in the heads of most doctors when it comes to body weight. These people are highly educated and I do not doubt that most of them really want the best for their patients. However, in my experience it is useless to tell most doctors that you do already try my best to eat a healthy and balanced diet and that do exercise – they won’t believe me, or they will simply tell me to try harder. And they certainly cannot believe that weight loss in a fat person can be anything but positive – even if I tell them that I have struggled with disordered eating for more than half my life and that I have a history of gaining back more weight than I lost. They will simply assume that I am a chronic overeater with no self-control; that dieting has played a role in my eating disorder in the past is something they never consider as a viable option.

      (If any HAES-friendly doctors or even not HAES-friendly doctors read this blog I really would be interested in their opinion why doctors often approach weight and eating in the way described in the letter and in my reply. I admit that I do not really trust doctors when it comes to weight-related advice, and I might even be a little bitter because I am pretty certain that doctors’ reactions to my weight have seriously harmed me in the past – mostly by fueling my eating disorder. But in the end I really want to work WITH the doctors that treat me – and given that many of them seem reasonable and compassionate when it comes to other topics I just don’t get their attitude when it comes to weight and weight loss. The only explanation I can think of is some kind of systemic problem.)

      • dear sannanina, you are very right on in your description and assessment here. there is a big systems problem but it is perplexing that it has not been addressed. i think predominantly doctors are trained in a black and white approach to health care. problem/solution. increasingly, the solution toolbox is filled with pharmaceuticals and if that isn’t addressing the issue, the next step is referral to a specialist. primaries and specialists are not not trained in the conversation of lifestyle and behavioral issues so to go there seems like they are stepping into a black hole. limited time demands exacerbate the situation. i have worked as a nutritionist in doctors’ offices for many years. i think they are glad to rely on my presence but with rare exception are they truly interested in my deeper assessments of diet/lifestyle issues. it is painful to watch as drug interventions are prescribed when a few simple, compassionate questions could provide insight that could significantly help address a complaint. it is easy to blame weight and yet most doctor’s don’t know what else to do because they don’t have an easy drug for it. it is sad that old belief systems still color this field and more nuanced care is not practiced. this facilitates a blame the patient approach. it may help to realize that whatever percentage of people we claim to be overweight, those same numbers likely apply to health professionals who are perpetuating the problem as well.

  3. Height weight charts were initially established by life insurance companies to determine a link between weight and longevity. There is absolutely no association with health. Ironically years ago the numbers increased at each height. The underwriters determined that it was important to not include people in the data who had died from cancer. Their extreme weight loss before death was skewing the numbers.

    Even so, height and weight has nothing to do with body composition or fitness. BMI is only a different manipulation of height and weight and was never meant to be applied to individuals. In one study of children, an overweight BMI only predicted 20% of the children with “excessive fat stores.” 50% of the children had some “extra” fat, but not enough to be determined overweight using dual x-ray absorptiometry. A full 30% of the children had “normal” fat stores. Even if you buy into the BMI mantra, that’s an unacceptible amount of physical, emotional and psychological collateral damage.

    The evidence suggests it is time to stop using weight as a surrogate for health. The data do not support assumptions that weight causes increased risk of disease. In fact, it is the metabolic dynamic that may or may not contribute to weight gain that is linked to risk. In this sense weight gain is only one possible consequence of this metabolic difference, not the cause.

    Since disease is linked to insulin resistance and inflammation, the focus should be on improving those conditions. Whatever happens to weight is a complex reflection of one’s genetics as influenced by a wide range of environmental factors. The important part is helping people figure out an approach to food and life that works for them and their health.

    I love that HAES is a beacon of light in this very distorted arena. I am a dietitian in private practice. I also enjoy opportunities to teach and speak to many different health professionals, Please know the HAES message is being shared. This last year I spoke with pediatricians, physician assistants, nurses, school nurses, nurse practitioners, teachers, and other dietitians. This position will prevail–truth has a way of doing that.

    • You raise an important issue here in pointing out the difference between BMI and body composition. That invalidates the use of weight as a direct stand in for health. That still leaves an issue: is it or is it not reasonable for people to set out to lose FAT? What concerns me is a pendulum swing to a position that anybody who tries to get leaner for any reason is “a tool of the Man” or something.

      It seems to me that the actual rate of “successful weight loss” is very, very difficult to measure – no matter which “side” of the question you’re on. I certainly know many yo-yo dieters. I also know quite a few people who were plump children and thin adults. And more than in either group, people who are heavier when they’re older but also much, much more sedentary whether by choice (just not interested in what they used to do,) by circumstance (kids and inactive job,) or due to injury. That suggests a very different reality than a mysterious black box that makes some people fat and other people thin for reasons entirely unknown and out of any control.

      • According to Glenn Gaesser’s book “Big Fat Lies”, it is those people whose BMI puts them in the “obese” category due to MUSCLE that have the higher risk of heart problems. Ironic, given that we often hear people say “muscle weighs more than fat” as a way to suggest fat is bad bad bad but one shouldn’t pay attention to the scale.

  4. This is a great letter! Most doctors are ill-equipped to give advice on weight loss. They have limited, if any training in nutrition and healthy eating. They are also subject to the same weight loss myths as the general public. They read the same newspapers and magazines and see the same advertising that tells you to lose weight by dieting. Which is probably why they make simple but damaging comments like “just try harder with your diet” and “you need to lose weight” without any actual recommendations on how to do that.

    I agree with Lifeseedsnutrition that there is a problem/solution approach to health care with the solution primarily being pharmaceuticals or refer elsewhere. Whatever can be given quickly to the patient seems to be the way to go despite all the side effects of medication. Quick, magical fixes to weight loss are the preferred option by the health care and weight loss industry.

  5. This is the same argument that a gastrc-bypass surgeon (Dr. Sharma) uses in favour of gastric bypass surgery. I have to wonder would this person use this same argument on a morbidly obese individrual. Personally, I am sick of hearing that I am powerless to do anything about it. That I must mutilate my innards and spend the rest of my life fighting the effects of gastricbypass in order to lose weight.

  6. I’m doing Master in Nutrition and Dietetics and I so wish we had lecturers that gave assignments like this. Even entertained the idea of HAES and intuitive eating. This letter is a great idea for any professional or friend to consider using. Being supportive and encouraging of ourselves and others seems to be overlooked for the more popular shame, blame, giult etc. Well done

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