Tag Archives: eating disorders

Leave the Fat Kid Alone

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Note: A slightly edited version of this piece appears in the April 2016 issue of Boston Baseball Magazine.

If you are like me, you wonder what the baserunner and first baseman talk about between pitches. When an athlete meets a peer, the dynamic is presumably different from an interaction with a fan that likely centers around adulation and an autograph.

When dietitians get together, chances are that at some point, we will touch on whatever nutrition-related myths and stereotypes are currently damaging our society, such as those reflected in the widespread negative reaction Pablo Sandoval received for his weight upon arriving at spring training.

Consider the following separate, but related, questions:

If Sandoval loses weight, will he play better?

Maybe, but not necessarily.

We look at Sandoval’s physique and dream about the offensive and defensive punishments he could inflict upon the league if only he bore a closer resemblance to Adrian Beltre or Evan Longoria. These fantasies have some merit, as a leaner, smaller, or lighter body can certainly have athletic upsides sometimes.

However, a significant difference exists between an athlete who naturally has a given size or shape versus someone who tries to force his body into that mold. Since weight loss does not happen by magic, we have to consider whether the behaviors Sandoval adopts in pursuit of weight loss would improve his game.

The outcome could go either way. We have seen in a variety of sports, including baseball, examples of athletes who played worse after losing weight, in part because over-exercise and/or food restriction left them depleted and vulnerable to fatigue, injury, impaired concentration, nutrient deficiencies, depression, sleeping difficulties, eating disorders, muscle atrophy, and other unintended consequences, none of which are conducive to top performance.

If Sandoval decides to lose weight, will he be able to do so?

In the short term, probably, but in the long run, he will most likely gain it back plus more.

Approximately 95% of people who attempt to lose weight will regain it one to five years down the road, and roughly 60% of these individuals will end up heavier than they were at baseline. Weight regain is common even if someone maintains the behaviors that promoted the weight loss in the first place.

Contrary to popular myth, our weight is largely out of our hands. The calories-in-versus-calories-out paradigm is a gross oversimplification of the complexities affecting weight regulation. While we might be able to manipulate our body size through behavior changes for a short while, biological mechanisms promoting weight regain almost always win out in the end.

If you subscribe to the theory that Sandoval’s weight is affecting his play, what level of performance do you expect out of him in the most likely scenario that he ends up bigger?

What does our treatment of Sandoval say about society?

Fans and media have labeled Sandoval “disgusting,” “lazy,” and “pathetic.” By the transitive property, these derogatory terms apply to everyone who has a body type similar to his.

The message is that fat is to be loathed, that larger individuals are not worthy of the respect enjoyed by the rest of us. We reject stereotypes based on race, religion, ethnicity, or sexual orientation while we inexplicably tolerate those based on body size that are no more accurate than the others, yet are just as abhorrent.

The idea that we can tell how someone eats or exercises based on his shape or weight is a myth. Some people built like linebackers never lift weights, some skinny-as-a-rail folks subsist on fast food, and some obese individuals are more active and have a healthier relationship with food than all of them but inhabit bigger bodies for other reasons.

Weight stigma oftentimes inspires people to sacrifice health for the pursuit of a size. Pressure to be thin leads to dieting, which is a predictor of a variety of problems, including eating disorders. These life-threatening illnesses are so common in Massachusetts that if the crowd at a sold-out Fenway Park represented a random sample of the state’s population, those in attendance with a diagnosed eating disorder would likely fill section 41.

Okay, but professional athletes like Sandoval constitute a different and special class of people, right?

Let’s take a step back and look at the bigger picture. Sandoval is a professional athlete because his talent, practice, and opportunities have coalesced into a skill set that lends itself to strong performance in an activity mankind recently created called baseball and he lives in a culture in which we pay such people to play it for our entertainment.

None of that means he has any more or less ability to manipulate his weight differently from the general population. Sandoval is a product of evolution just like the rest of us, and he has come into being because his ancestors’ physiological mechanisms that resisted weight loss allowed them to survive periods of starvation and reproduce while others perished. In this regard, professional athletes and spectators are all in the same boat.

Fans have every right to feel whatever emotions they may have about a player. If they want to get on someone for not performing, they can absolutely do that. However, I would encourage fans to criticize athletes for lack of production or work ethic directly rather than using body size, weight, or shape as a proxy, as the latter behavior is fueled much more by myths and stereotypes rather than science and sends a dangerous message to everyone who hears it.

BostonBaseball2016-03-27

Objective / Subjective

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Numbers. Nutrition and exercise are full of them. We can tabulate calories and grams, measure portion sizes, count servings, and analyze food journals. Thanks to various electronic gadgets and apps, we can keep tabs on our steps, estimate our metabolic rate, and track other biomarkers.

As a guy who holds a degree in mathematics and used to work as a research analyst, nobody loves objective data more than I do. When I began my career transition and was moonlighting as a personal trainer, I made use of several physical tests – the Rockport walking treadmill, the sit-and-reach, the list goes on – to quantifiably track my clients’ progress over time. My career as a dietitian started off similarly, as I relied heavily upon bioimpedance analysis data, weight, and estimated macronutrient needs to guide my nutrition advice.

Imagine my surprise when, through a combination of additional education and experience, I realized how little these quantitative data actually matter. On the first day of the first nutrition course I ever took, the professor began with a brief survey of the social, cultural, personal, and financial factors that influence eating behavior. In our diet-minded society in which food is thought to be just fuel and any persuasions to the contrary are seen as weaknesses and sources of guilt, we easily forget how important this basic truth really is.

One of my patients recently told me that his wife purchased a diet book that emphasizes the glycemic index and she would like the two of them to begin eating in accordance with the author’s guidelines. Objectively, the glycemic index, which is a measure of how quickly various foods raise blood sugar relative to a standard (usually white bread), makes some sense. If a food breaks down more slowly, we stay full for longer, eat less, and consequently lose weight. At least, that is what the book’s author wants its readers to believe. Just aim for the low-number foods on the glycemic index chart and we are all set.

Right around the same time my patient told me about this book, another patient relayed to me an experience he had regarding hamburger buns. His parents typically made burgers on whole wheat slider buns that he thought were okay – not great, not awful, but okay – and he normally ate two or three burgers as the meat from the normal-sized patties jutted out beyond the rolls’ perimeter like a UFO. For reasons that remain a mystery to my patient, his mother decided to make burgers on normal white buns one evening. In contrast to their whole wheat counterparts, these white buns hit the spot. He had one burger, felt satisfied, and stopped eating. Turned out that for him, the white bread, which is sky high on the glycemic index, was actually the better choice and kept him from overeating.

The more I work with my patients, the more I am reminded of how the subjective is often of greater importance than the objective, that the qualitative usually trumps the quantitative. Numbers still have their place, for sure, but they really only play a supportive role. This, I have learned, is one of the most significant differences between nutrition on paper and nutrition in real life.

He Said, She Said: “I want to lose weight”

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He Said

When faced with “I’ve got some good news and some bad news,” most people seemingly prefer to hear the latter first. With that in mind, let us first look at the results of weight loss pursuits before coming around to the opportunities we have for change.

Short-term and long-term weight loss are two entirely different animals. The ease with which short-term weight loss is promoted creates false expectations for long-term weight loss. Pretty much any kind of restriction (Paleo, Weight Watchers, gluten-free, low-carb, low-fat, weighing/measuring portions, following a scripted meal plan, commercial meal substitutes, etc.) performs about the same: initial weight loss followed by regain that often surpasses the baseline weight. The overall body of research suggests that pursuit of intentional weight loss is approximately 12 times more likely to result in ultimate weight gain rather than loss.

The patients who come to me looking to lose weight often have similar stories. They list the various diets they have tried over the years before disclosing “and now I am the heaviest I have ever been in my whole life.” Frequently, they look back on their body size and shape from before the first diet, the body they were unhappy with at the time, with a new longing, like an empty-handed gambler wishing he had put his coins to better use rather than wasting them in the slot machine.

While their reasons for wanting to lose weight vary, they are all valid and understandable in the context of our society in which weight stigma, size discrimination, diet culture, and misinformation are so prevalent. These unfortunate realities bleed into our healthcare system and can influence otherwise-great doctors to recommend weight loss rather than evidence-based treatments.

The good news is that the underlying reasons for wanting to lose weight are oftentimes attainable if we pursue them directly rather than using weight loss as a proxy. Whether your goal is to improve your blood pressure, lower your cholesterol, control your blood sugar, perform your sport better, our build a fabulous wardrobe, or anything else along those lines, your likelihood of success is much higher if you put weight to the side and go for your goal head-on.

 

She Said

Weight is a heavy topic (pun intended) in my work with eating disorders. Even though I put a lot of effort into making sure that weight is not the focus of my work with patients, inevitably, it will come up. Usually, my patients express fear around the possibility of gaining weight by eating intuitively (or by following a meal plan). In addition to this fear of weight gain, many of my patients also desperately want to lose weight. When the patient is in the “overweight” or “obese” BMI category (a completely bogus way of measuring one’s health), the discussion of losing weight is particularly tricky. Oftentimes this patient will come into my office with a recommendation from their doctor to lose 10% of their body weight in order to improve their health. This, coupled with society’s belief that “everybody knows that being heavy is unhealthy,” also complicates matters considerably.

When a patient comes to see me with hopes that I will help him or her lose weight, I often feel like the Grinch. As I try to explain to them that weight is not a measure of health, that one can be heavy and healthy (or thin and unhealthy), and that society’s fear and hatred of fat is a real thing, I can see their eyes glaze over. And then, when I talk about how 95-98% of all intentional weight loss attempts (via diets) result in weight regain, sometimes I can see panic in their eyes. You see, even though “everybody knows” that diets don’t work, many people believe that if they just try hard enough and if they really, really want it, they can be part of that 2-5%.

As Jonah and I have written about too many times to count, we practice from a Health at Every Size® (HAES) perspective. This means that we believe that health is a multifactor concept that cannot just be boiled down to how much someone weighs. We believe that when someone eats in a nourishing, pleasurable, and intuitive way, when someone engages in physical activity that feels good to their body, when they manage their stress, get enough sleep, avoid smoking, manage health conditions with the help of a health professional, etc., that they can achieve health regardless of what the scale says. Weight only gives us a tiny bit of information about the person. It can tell us something is amiss if there is a large shift either up or down (unintentional weight gain or loss), but otherwise, by itself, it really cannot tell us if someone is healthy.

Another thing I talk about with my patients is that bodies are supposed to come in all shapes and sizes. Even though our society might disagree, some people are just meant to be larger than others. It’s in our genes. We all have a set weight range where our weight would naturally settle in if we ate and moved intuitively. While we might have some ability to move up or down a couple of pounds within this weight range, trying to go outside this weight range takes extreme measures. Our bodies fight these extreme measures in every way possible, but for 95-98% of us, we will return to our set weight range, regardless of whether or not we continue dieting.

But in our society, being heavy is seen as a weakness in someone’s character, that he or she is lazy, undisciplined, and reckless with their health. People make assumptions about others based on their weight, and it seriously stinks. So when an “overweight” or “obese” patient comes into my office desperately wanting to lose weight, I get it. No one wants to be seen as lazy, weak-willed, or stupid. My hope is that someday soon society’s views about weight will shift and that people will start to understand that we all have different genetic makeups, and that while weight can tell us what our relationship with gravity is, it cannot tell us whether someone is healthy, happy, or worthy.

David Bowie

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David Bowie and Duran Duran are the only two artists I have been listening to virtually my entire life, and somewhere in an unpacked moving box in our basement sits my tape copy of the former’s Let’s Dance album that I got in kindergarten.

Although I do not care for everything Bowie released, I greatly respected his ability to oscillate between styles so drastically that I was left enjoying only parts of his catalog, as opposed to those of artists whose sound is so consistent that I can accurately base my impression of their body of work on a single song.

His versatility, I expected, would form the basis of the numerous tributes that poured in via social media yesterday as the shocking news of his illness and death became public. While some of them certainly did, several centered around the profound impact Bowie had on many individuals and our culture as a whole in terms of empowerment, self-acceptance, and tolerance for diversity and differences.

Nobody said it better than Richey Rose, a guitarist living in New York City, in the following tribute he posted yesterday:

“I had my Bowie phase a little over 10 years ago, when I was a sophomore in college. I had just gotten my first record player and found Hunky Dory at Pop’s (best used record store in my hometown of Lexington, KY). Of course I’d always known Bowie, especially because I’d just gone through a massive Velvets/Warhol/60’s & 70’s NYC discovery the year before… but that record was my first effort into becoming properly acquainted with him as an artist. Needless to say it opened Pandora’s box. I became obsessed and fully engrossed in everything he’d done. A friend gifted me an original pressing of Ziggy and I promptly wore it out; teaching myself all the guitar parts along the way. YouTube was just starting and there were interviews, videos, concert footage – it was my own personal archive into David’s creations and contributions to the world. I was beyond inspired. I’d always been self-conscious about being too skinny, too ‘pretty’ if you will, and had grown up being mercilessly teased because of it. Bowie was literally the first artist/person/thing to make me feel strong and powerful because of my body instead of feeling the total opposite, which I’d done for so many years before. I thought he was a total fucking badass; I thought he was God. Reading everyone’s stories today I realize that Bowie touched EVERY one of us on so many different levels… but not just musically. Sure his records taught me an invaluable amount about songwriting, melody, production, etc. but furthermore Bowie inspired and forever changed my perspective on life. For that I am eternally indebted and grateful. There’s certainly a bit of Bowie inside us all… RIP.“

The bold face used above was my own doing in order to emphasize the passage that I expect most universally resonates and relates to our work as dietitians. Joanne and I do a great deal of activism in the size acceptance movement because on a daily basis we see the consequences of people living under the oppression of weight stigma: eating disorders, shoddy medical care, failing weight-loss pursuits, bullying, weight cycling, disordered eating, and other conditions, approaches, and consequences that only serve to worsen health, not improve it.

In an era when another celebrity gained our trust only to abuse it and built us up until it was personally and financially advantageous to tear us down, Bowie’s lessons of acceptance and being true to ourselves juxtapose in even greater contrast and feel that much more important to reinforce. No matter which Bowie era is your favorite, whether you are a Starman, Ziggy Stardust, Young Americans, Scary Monsters, Modern Love, Heart’s Filthy Lesson, Reality, or Lazarus fan, or even if none of those are your cup of tea, we can all recognize that he impacted our world in a way that extended well beyond his music.

The GOAT(’s) Fad Diet

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If you are like me, you wonder what the baserunner and first baseman talk about between pitches. When an athlete meets a peer, the dynamic is presumably different from an interaction with a fan that likely centers around adulation and an autograph.

When dietitians get together, chances are high that at some point we will touch on whatever nutrition-related fads and ridiculousness are currently hindering our work. We laugh, not because we are making fun of anybody, but because misinformation is so pervasive and challenging to our profession that sometimes all we can do is approach our upstream paddle with humor.

The deeper reality, which often goes unspoken but is silently understood, is how terribly harmful nutrition myths, bad information, half truths, and fear mongering are to our patients. All it takes is one meme, 140-character post, headline, hyperlink, or soundbite and the population is led astray in an instant. Just one celebrity endorsement carries more weight in the eyes of many than the educated stances of professionals who have dedicated their careers to the field of nutrition.

Consider Allen Campbell, personal chef for Tom Brady and Gisele Bundchen, and the interview he recently gave to boston.com about his clients’ diets and their shared perspectives on nutrition. Initially I chuckled at the absurdity, but I quickly remembered that hundreds if not thousands of people are likely to risk their own health as they assume this, umm, information to be fact and internalize it.

Let’s look at some of the standout excerpts.

“My philosophy starts in my own life, and with my own lifestyle and eating habits. I make conscious decisions to buy local and organic, and to stay away from GMOs, and to think about the future of the planet and the future of humans.”

He hits on nearly every current nutrition buzz phrase except for farmers markets, raw, dairy free, gluten free, and no white foods, but don’t worry, he brings those up later.

“I took a plant-based nutrition course earlier this year. It was an online course through Cornell, and it’s taught by a doctor named T. Colin Campbell, who’s behind ‘The China Study.’ My philosophy is that a plant-based diet has the power to reverse and prevent disease.”

Four or five years ago, a patient came into my office touting “The China Study” – which has been largely debunked, by the way – and told me, “A plant-based diet is the only one that heals.” She also stated, “The government puts rat poison in the water, but they just don’t tell us.” Sometimes, apparently, hyperbole and paranoia go hand in hand.

“So, 80 percent of what they [Brady and Bundchen] eat is vegetables. [I buy] the freshest vegetables. If it’s not organic, I don’t use it. And whole grains: brown rice, quinoa, millet, beans. The other 20 percent is lean meats: grass-fed organic steak, duck every now and then, and chicken. As for fish, I mostly cook wild salmon. It’s very different than a traditional American diet. But if you just eat sugar and carbs – which a lot of people do – your body is so acidic, and that causes disease.”

Actually, most Americans get more than enough protein. Someone who ate just sugar and other carbohydrates would likely develop kwashiorkor, marasmus, or a similar problem related to protein malnutrition. We learned about these conditions in the first semester of actual nutrition school, but apparently they were never covered in Campbell’s online course.

If your body is acidic, your medical chart probably lists a diagnosis of metabolic acidosis, respiratory acidosis, or diabetic ketoacidosis – none of which are caused by overconsumption of sugar or other carbohydrates – and you are reading this blog from your hospital bed.

“Tom [Brady] recently outed Frosted Flakes and Coca-Cola on WEEI. I love that he did that. Sugar is the death of people.”

As it turns out, your brain runs on sugar, and without adequate glucose in your system, you risk a myriad of problems, including death. What Brady did was oversimplify a complex problem by scapegoating an ingredient, which plays into the fears that fuel disordered eating and eating disorders.

“No white sugar. No white flour. NO MSG. I’ll use raw olive oil, but I never cook with olive oil. I only cook with coconut oil. Fats like canola oil turn into trans fats.”

People continue to fear canola oil based on myths that run counter to actual science. Trans fats, which occur naturally in only trace amounts, are made in large quantities through a chemical process known as hydrogenation. This reaction, while not terribly complex, involves more than just sticking the substrate in the oven.

“[Tom] doesn’t eat nightshades, because they’re not anti-inflammatory. So no tomatoes, no peppers, mushrooms, or eggplants. Tomatoes trickle in every now and then, but just maybe once a month. I’m very cautious about tomatoes. They cause inflammation.”

The research supporting the notion that tomatoes cause inflammation is spotty at best, with some studies showing the exact opposite effect. The evidence is about as strong as that showing the positive impact that tomatoes might have on eyesight. Maybe if you ate more tomatoes, Tom, you would not have thrown that goal line interception against Philadelphia.

Do the kids eat the same things Tom and Gisele eat? “Yeah, I mean pretty much . . . . For snacks, I make fruit rolls from bananas, pineapple, and spirulina. Spirulina is an algae. It’s a super fruit. I dehydrate it. I dehydrate a lot of things. I have three dehydrators in their kitchen. I also make raw granola and raw chocolate chip cookies.”

I have no idea what a “super fruit” is, but I am assuming that being a fruit is a prerequisite for consideration, which excludes an algae like spirulina. Anyway, my colleagues and I consistently find that children raised in households where food is restricted tend to have significant overeating problems once they reach adulthood. Westgate SuperBooks declared Brady’s New England Patriots 9-2 co-favorites to win next month’s Super Bowl, while I will set the odds of Brady’s children bingeing on college dining hall pizza and soft serve much, much higher.

As the interview continues on, the topics turn away from general nutrition and instead touch upon examples of dishes the chef makes and his typical workday, neither of which are within the scope of this particular blog entry.

People look at Tom Brady, 38 years old and still at the top of his game, and figure his nutrition regimen must be at least partially responsible. That may be true, but as I have written before, both about Brady in particular and professional athletes in general, their upsides for rigidity are unlikely to exist for laymen, and the virtues they bestow upon their diets can be off base.

Consider Dave Scott, six-time winner of the Hawaii Ironman Triathlon, who famously washed off his cottage cheese before consumption in order to remove as much fat as possible because he believed a low-fat, high-carbohydrate diet gave him an edge over the competition. It strikes me as more than mere coincidence that Scott was doing this in the 1980s when fear of dietary fat was at its peak.

Similarly, while I have no doubt that Brady believes his diet enables him to perform his best, let us also recognize that his eating behaviors are reflections of nearly every single one of today’s nutrition fads.

He Said, She Said: Weight Watchers – Helping You Lose Since 1963

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He Said

We believe that people should have the freedom to choose whichever healthcare paths they wish to take, independent of whether or not we would recommend their selected treatment plans. Disclosure and transparency are corollaries necessary for building a foundation that supports patients as they make decisions regarding their own care. Today’s approaches are likely inferior to healthcare’s future toolbox, and part of what separates respectful collaboration from a sales pitch is candidly discussing both the pros and cons of available options so patients can make informed decisions. We are not afraid to admit “I don’t know” when that is indeed the most appropriate response. None of this makes us exceptional or great, but it does make us honest.

For a look at the flip side, consider Weight Watchers®. A magician once explained to me his secret: misdirection. He gets you to fixate on his right hand so you entirely lose track of what his left hand is doing. Weight Watchers uses ads emblazoned with their “Because It Works” slogan to capitalize – literally and figuratively – on your desire to lose weight while they hope you forget to ask for their definition of “works.” The large font in their television ads demands so much of your attention that you miss the fine print resulting from the Federal Trade Commission’s (FTC) action against Weight Watchers in 1997 that declared they must concede that “For many dieters, weight loss is temporary.” In reference to the commonplace weight regain that prompts clients to re-enroll in the program time and time again, Richard Samber, Weight Watchers’ former financial director, explained, “That’s where your business comes from.” Weight Watchers is profitable, in other words, because it can successfully create short-term weight loss and make you believe that their long-term failures are actually your own.

Weight Watchers distracts you with their glittery new SmartPointsTM system and hopes you will ignore the long list of previous systems, including the Weight Watchers Program Handbook for Ladies, the Quick SuccessTM Program, the original PointsTM program, and PointsPlusTM, that never worked nearly as well as they wanted you to believe at the time. Weight Watchers is not changing their program because “Now we’re enhancing our program based on the latest science,” as their Chief Scientific Officer, Gary Foster, wants you to believe; nor are they changing their program because they suddenly uncovered data showing its poor efficacy. This is not a case of “When we know better, we do better.” They knew for decades that their program was not working as well as their large print made you believe, but they continued to promote it anyway, and when forced by law to tell the truth, they wrote it so small that you probably missed it.

Despite their spin that Weight Watchers always worked and now they are just making it even better, Weight Watchers is changing for one reason: money. Over the last four years, the company has seen their stock plummet from $85.00 to $6.80 per share as customers and potential customers have turned instead to weight-loss apps or more holistic approaches. To combat the former, they are launching a new mobile app and an expanded coaching program that offers more extensive support outside of group meetings. Their response to the latter involves some sleight-of-hand trickery. “Beyond the Scale” appears to be the new slogan, replacing “Because It Works,” and their company logo has been tightened up to two letters, thus removing the word “weight.” Seeing as they are so poor at creating long-term weight loss, taking the focus off the scale would make sense, but it is just a surface-level marketing ploy. Taking a closer look reveals that weight is still the focal point of their approach.

A Weight Watchers spokeswoman recently told Good Morning America, “People would really spend a lot of time trying to figure out ‘How do I get my Doritos in? Oh, I can do it if I adjust this and adjust that.’ Now it’s not as important for them to make sure how they are getting their Doritos in. It’s much more important for them to say, ‘What am I putting in my body? How’s that going to make me feel?'” Sounds very similar to intuitive eating, or at least a perversion of it warped just enough so at first glance it appears to fit seamlessly with their weight-centered approach.

The problem is that intuitive eating and dieting mix as well as oil and water. In fact, the very first principle of intuitive eating, as stated by Evelyn Tribole and Elyse Resch, is “Reject the Diet Mentality.” Sure, some people pursue intuitive eating hoping to lose weight, but intuitive eating is not designed to be a weight-loss tool, and if someone is unable to at least put weight on the back burner, then he or she will never truly learn to eat intuitively. In other words, having one foot in intuitive eating and the other in weight-loss culture will likely get you nowhere.

Really think about the company name: Weight Watchers. Weight. Watchers. People who watch weight. How is someone possibly supposed to jump with both feet into intuitive eating in the context of weigh-ins and an emphasis on mass? It is fine and dandy for Foster to say, “[Weight] is an important metric, but not the only metric,” but when the scale continues to be the focal point and the most important measure of progress in the eyes of everybody involved, consider the bind clients will find themselves in if and when becoming more proficient with intuitive eating is at odds with the scale. With the attention still on weight, how long will it be before the newly developed intuitive-eating skills are abandoned in favor of old-fashioned restriction?

Weight Watchers launched a pilot study of their revamped program in New Jersey, and 38 of the 40 participants lost weight, including three women whose testimonies of having lost between 18 and 50 pounds were featured in the Good Morning America segment. “We still produce weight loss,” Foster said on the show. Pretty much any kind of restriction will lead to short-term weight loss, so it always blows my mind when companies act like their program is unique in this way. Remember, nobody knows how to produce long-term weight loss in more than a tiny fraction of people who attempt to achieve it. The right hand can attempt to distract you with all sorts of glowing testimonials and a small, short-term pilot study, but none of that suggests that this version of their program will work any better than its predecessors, and you know the left hand is still holding the FTC-mandated disclaimer due to the futility of the program.

Weight Watchers certainly has success stories, and they make sure you never forget it. Group meeting leaders are all former clients who have lost weight and kept it off (at least so far) through a combination of behavior change and a boatload of factors out of their control that happened to work in their favor. Their mere presence is a subtle sales pitch that conveys enticing testimonies of hope and success, making you believe that the next winner could be you if only you continue to partake. Weight Watchers emphasizes seduction over expertise and downplays that leaders do not necessarily have backgrounds in nutrition, exercise science, or anything remotely connected to health, but rather disciplines such as drama that lend themselves to charismatic performance. Why hire someone with solid and extensive qualifications in economics and finances to manage your money when you can instead attempt to follow in the footsteps of some dude who struck it rich on a convenience store scratch ticket?

The other issue with their use of leaders and celebrity spokespeople to pitch their product is that neither you nor I know for sure what they do or do not do behind closed doors in order to achieve and maintain weight loss. Both parties have incentive to keep their weight in check regardless of the costs. Leaders can lose their jobs if they regain weight, and my understanding is that celebrity endorsement contracts are contingent on continued weight maintenance. Behaviors kept private can range from the privileged (personal chefs, personal trainers, etc.), to the deceitful (employing other weight-loss techniques beyond the Weight Watchers program being credited), to the disordered (ever-increasing restriction and/or exercise, preoccupation with food and physical activity, social withdrawal), to the outright dangerous (very-low-calorie diets, unregulated supplements, eating disorders). Clinically, we have seen many patients whose eating disorders were triggered by competition in a weight-based sport such as crew or wrestling, participation in an appearance-based activity such as gymnastics or figure skating, or employment in a size-based field such as modeling or personal training. While I do not believe we have ever had a Weight Watchers leader or celebrity spokesperson as a patient, it stands to reason that they are similarly vulnerable to the emphasis placed on their weight and the pressure to maintain it.

For 52 years, Weight Watchers has deceived you by knowingly overstating the efficacy of their programs and blaming you for their own failures, all at the expense of your time, money, and health. Do you really want to bet your resources and well-being that the outcome will be any different this time around? You deserve more than smoke and mirrors, don’t you?

 

She Said

While this might be news to some of you, it’s been nearly two months since Oprah Winfrey announced that she has not only become a member of Weight Watchers (WW), but she has also bought 10% of the company and become a board member and adviser. According to O, she decided to join and later invest in Weight Watchers as she has “always struggled with weight” and was impressed by the company’s “holistic approach” to health and weight loss. On Ellen DeGeneres’s talk show (which aired on October 23rd), Oprah reported that she had already lost 15 pounds since August 12th and was truly enjoying the program.

Oy. Where do I start with how sad this whole situation is? I have always been a fan of Oprah, as I have seen her as a strong advocate for women, someone who has been through a lot in her life and who wants to help young girls and women become their true and best selves. While the media often focused (and still focuses) on her weight gains and losses, I was always impressed by her ability to bring people together, inspire, and educate. Oprah is so much more than her weight!

I remember in 2010, I was so excited to see that Oprah was having Geneen Roth on as a guest of her show to discuss Roth’s best-selling book “Women Food and God: An Unexpected Path to Almost Everything.” Roth’s philosophy is that the way one eats is directly related to one’s core beliefs about being alive. She is an anti-diet proponent who posits that by exploring one’s spirit and soul, one can break free from emotional eating, finding balance with one’s relationship with food and one’s body. On the show, Oprah was giving such high praise to Roth and her book, saying how she was inspired to “never diet again” and that this book was a life-changing read for her.

So that brings me to the present day. Really, Oprah? What happened? Because last time I checked, WW is a diet, a set of externally based rules that tells its members what and how much to eat in order to lose weight to become socially acceptable – pretty much the opposite of Roth’s message. As we have written about too many times to count, 95% of people who alter their diet in order to lose weight will regain the weight and usually end up heavier. Weight Watchers is no different – it is a diet! Whenever anyone tries to tell me that it is a “lifestyle,” not a diet, I really have to contain my eye-rolling reflexes. Want to figure out if you are on a diet? Here’s how: Are you purposefully manipulating your food intake based on a set of external (i.e., not internally based) eating rules? Is your main goal of said food manipulation to watch the number on the scale go down? Well, I hate to break it to you, but you are on a diet, my friend. And chances are, even if you do end up losing weight, you will regain that weight and then some.

In a purely monetary sense, Oprah’s investment in Weight Watchers is brilliant – contrary to its popular “It Works!” slogan, It Doesn’t! The company has admitted that the success rate of its members is embarrassingly low, and much of their research is based on data that was collected over the span of a year. Um, nice try! We all know that weight regain often occurs between 1 and 5 years post-diet. But of course Weight Watchers doesn’t have data that goes that far. What a surprise. The company’s business plan is so clever because it knows that the diet doesn’t work. 95% of their members will regain the weight (blaming themselves instead of the diet, of course) and will rejoin, creating an unending cycle of profit for Weight Watchers.

Listen, I don’t really blame Oprah for making this truly unfortunate decision – she is human, and she is not immune from the body-shaming, weight-loss messages women receive on a daily basis. But I am disappointed that she is choosing to participate in and endorse a company whose sole purpose is to tell women that they are not enough, that their worth should be measured by a piece of metal, and that weight loss is the only way to find one’s true and best self. Oprah, I really expected more from you.

“Real” Science

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Some of you may or may not know that one of my favorite activities is solving crossword puzzles. Not just any puzzles, mind you, but the Sunday New York Times crossword found in the very back of the magazine. Every Sunday, I eagerly sift through my newspaper and find the magazine, ready to start working on the puzzle and figure out all of those elusive answers. This week, as I was thumbing through the pages, I came across an article under the “Well” section of the magazine, which caught my eye: “Mind What You Eat: Can ‘intuitive’ eating be as effective as calorie counting?” written by Gretchen Reynolds. The picture accompanying this article was that of a corpulent, blind-folded man, whose stomach was feeding itself a piece of pizza.

Given the nature of the work that Jonah and I do, I was intrigued to see what Ms. Reynolds had to say about intuitive eating, especially since the idea of intuitive eating is still relatively unknown to most of the general public. As I read on, however, my curiosity turned to disappointment and frustration. The article was riddled with inaccuracies, and, above all, truly missed the point of what intuitive eating is all about.

Although the idea of intuitive eating (also called the “non-diet approach”) has been around for many years, Evelyn Tribole and Elyse Resch, two registered dietitians, brought the topic to the public’s attention in their 1995 book “Intuitive Eating.” In the book, the authors explain the 10 Principles of Intuitive Eating, including such ideas as “Reject the Diet Mentality,” “Honor Your Hunger,” and “Make Peace with Food.” The authors assert that by following these principles, an individual can create a healthy relationship with food, mind, and body. The basic “rules” of intuitive eating are quite simple: eat when you are hungry, eat what you are hungry for (not what someone else or some diet is telling you to eat), and stop eating when you are satiated.

While the book does discuss the likelihood that by eating this way one will reach their “healthy weight,” it is in no way meant to be a diet book or a how-to weight loss treatise. One’s “healthy weight” is not based on the BMI or what popular culture says is healthy – it’s the weight that one’s body arrives at when he or she is engaging in healthy behaviors such as eating intuitively, engaging in pleasurable physical activity, and managing stress.

Since weight loss is not the ultimate goal of intuitive eating, I was confused as to why Ms. Reynolds decided to compare the approach with calorie counting to see which resulted in more weight loss. In addition to this, the article was flawed in a number of ways.

Ms. Reynolds begins her article by saying that intuitive eating has not been studied extensively by researchers. This statement could not be further from the truth! Per the Intuitive Eating website, there have been over 40 studies which have looked at the health benefits of intuitive eating. According to Ms. Tribole who posted her reaction to Ms. Reynolds’ article on her own Facebook page, “last month a systematic review was published on Intuitive Eating with 24 studies, totaling over 9,000 people.”

Ms. Reynolds’ article goes on to discuss a study in which 16 overweight men and women were split up into two groups of eight: one group was assigned to a restricted-calorie diet between 1,200 and 1,800 calories per day, while the other group was to engage in intuitive eating. At the end of the study, which ran a total of six weeks, the researchers found that those in the calorie-controlled group lost more weight than those in the intuitive eating group. Given these results, posits Reynolds, limiting one’s calories is a more effective way to lose weight than engaging in intuitive eating.

Yikes. This article is problematic for a number of reasons. Firstly, the study itself is a poor one to use, as it has an extremely small sample size of 16 subjects and is conducted over a measly six-week time period. Secondly, to draw any conclusions about health outcomes from this study is wildly irresponsible. And thirdly, duh, of course the calorie-restricted group lost weight! This study literally gives us no useful information!

We all know that going on a diet results in weight loss for the vast majority of people. The question is: how likely is it that those individuals will actually keep the weight off for a significant period of time? Given that we know that approximately 95% of people regain the weight they lost through dieting, I’m willing to bet dollars to donuts that all of the individuals in this silly little study regained the weight they lost during the first six weeks of the study. In fact, I wouldn’t be surprised if they ended up heavier than when they started!

I guess the thing that bothers me most about this article is how it completely misses the point of what intuitive eating is all about. Intuitive eating is about eating in a way that promotes one’s health, not in a way that is meant to result in weight loss. Ms. Reynolds reinforces the diet mentality of the general public by her assertion that cutting calories is what is necessary to reach a healthy weight. Articles like this one just create more confusion for Jonah’s and my patients, as it backs up the ideas that weight loss should be one’s ultimate goal and that long-term maintenance of weight loss is achievable.

Stocking

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“I have to get rid of these leftovers or I will eat them all.” Sound familiar? The “them” in question could be leftovers from any holiday celebration that includes food, such as Halloween candy, Thanksgiving pie, Christmas cookies, New Year’s Eve hors d’oeuvres, Easter jelly beans, Memorial Day barbecue, or birthday cake and ice cream.

The aforementioned strategy for dealing with such leftovers sounds logical on the surface and might even seem to work for a little while. If the food is not there, you cannot eat it, right? As the never-ending cycle of holidays continues though, the strategy of avoidance reveals its downsides: stress, anxiety, deprivation, reinforcement of an oversimplified and misleading good/bad food dichotomy, and increased risk for episodes of overeating or outright bingeing.

An alternative does exist, one that takes less mental and emotional energy, allows people the freedom to enjoy holiday favorites without going overboard, and makes peace with food. This alternative is stocking, which is a well-known technique among practitioners who help people with emotional eating, compulsive eating, binge eating disorder, and supposed food addictions.

Stocking is the antithesis of quickly ridding the house of holiday leftovers, and it may initially seem counterintuitive. A full explanation of the technique requires more time and space than would be appropriate for this newsletter, but here are the highlights for your consideration.

Uncouple morality from food and eating behaviors

In order to feel more comfortable with stocking, people need to rid themselves of the good/bad food dichotomy and be able to temporarily put the hard science of nutrition on the back burner. Not all foods are the same nutritionally; it would be ridiculous to proclaim that an apple has the same nutritional value as a Twinkie, and I am not arguing otherwise. What I am suggesting, however, is to strip the moralization away from food. An apple is just an apple; you are not good or virtuous if you select it for your snack. A Twinkie is just a Twinkie; you are not bad, guilty, or weak-willed if you choose it instead. Sometimes your body’s cues will lead right to the apple, other times to the Twinkie, and either outcome is okay.

Establish an abundance of food at home

Identifying what food will feel best in your body means little if you do not have a reasonable shot of providing said food for yourself. Therefore, one of the tenets of stocking is to keep a wide variety at home, including foods that are seen as taboo and can trigger overeating or bingeing.

When our body is asking for a food we do not have on hand, we tend to overeat on the foods that are in the house. This can certainly occur with both adults and children, but we especially see this with teenagers who live in food-restricted households. Well-meaning parents might keep foods high in salt, sugar, or fat out of the house because they think that doing so creates a healthy food environment, but oftentimes it backfires. For example, the teenagers overeat on low-sodium potato chips that never really hit the spot while a small amount of regular chips would have done the trick, or they overeat on Newman’s Own fig cookies when really they just want a couple of Oreos.

Select foods based on intuitive-eating cues

One of the logistical differences between those who practice intuitive eating and those who do not is how food selection begins. Standing in front of the open refrigerator or scouring the pantry and cabinets and selecting whichever foods call to you is an external process that differs greatly from asking internal questions about what temperature, texture, flavor, color, etc., food will feel best in your body at that moment and seeing where it takes you.

These cannot be treated as leading questions. In other words, if you have stocked up on, let’s say, Ben & Jerry’s Cherry Garcia, and you are trying to convince yourself that your body does or does not actually want the ice cream, then stocking will not work. Keep an open mind, ask these questions neutrally, and see where your body’s cues take you.

Maintain the inventory of foods at home, especially of triggering foods

Maintaining the abundance of food in the household is an important element of stocking. If the supply dwindles, you might feel like you need to hurry up and eat a particular food while it is still around. Should you ever run out and then buy it again, the food regains its luster. If you are stocking Doritos, for example, maintain a supply of, say, ten large bags at home. As soon as you finish two bags and are down to eight, go out and buy two more.

Be patient and use a neutral voice

Initially, you may find yourself eating certain foods when your body does not actually want them, but as you keep up the practice, eventually your trigger foods will blend in with all of the other foods in your pantry and no longer sparkle the way they do when they are brand new to the house. Until then, abstain from judging yourself harshly for eating episodes that do not go as you would have liked. Remind yourself that you are still in the early stages of the process and you are learning. With a neutral voice, examine what happened so you can respond differently when similar circumstances arise in the future.

Enjoy your new-found peace with food

Imagine how different your experience with leftover Thanksgiving pie would be if you routinely kept slices of pie in your freezer for whenever your body wanted them. Contrast the fretting you feel about the remaining Halloween candy to the relaxed liberation of always having a few bags of peanut butter cups in the pantry year-round.

For the stocking technique to be successfully implemented, foundational work to dispel nutrition myths, break up the good/bad food dichotomy, and uncouple moralization from food choices is necessary beforehand. Because this process takes time, it is probably too late for the stocking technique to be much help for you this Thanksgiving unless you have already been working on these prerequisites.

The cycle of holidays will continue though, so if you get started now, you might find you have a much more relaxing and enjoyable experience with this February’s Valentine’s Day chocolates than you would have if you continued down your current path.

Beginning to See the Light

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[Preamble: After the conference I am about to discuss came to an end, I sought and received permission from the organizers to use their slides in my blog. The only stipulation was that I had to credit the authors, most of whom I disagree with strongly, and this requirement gave me pause. While I may not see eye to eye with these doctors, I respect them enough as colleagues not to publicly embarrass them by name. The internet is an unnecessarily harsh place sometimes. Everything I am about to say is in the spirit of constructive criticism, not trolling, and I can make my points without calling anybody out. When it comes down to it, all of us are on the same team. Or at least we should be.]

Last year’s Cardiometabolic Health Congress spurred a wide range of reactions, the vast majority of which were various permutations of anger or disgust. Despite such unpleasantries, I returned for the Congress’s 2015 edition late last month. Self-flaggelation is not my thing, but if we do not venture out of our own circles and challenge our biases and beliefs by listening and talking with people who hold different points of view, then we risk deluding ourselves and repeating the same messages back and forth among people who already share our stance.

During an early break between presentations, I took a walk through the exhibit hall to see which vendors were in attendance and approached one weight-loss company that advertises, “The [company name omitted] was developed by doctors and is clinically proven to be safe and effective for weight loss.” Pretty much any kind of restriction will lead to short-term weight loss, so I always find it interesting when companies act like their program is unique in this way. According to the company representative working the table, he told me the people who go through their program consume between 800 and 1,300 calories per day.

Let’s put this calorie intake in perspective. According to the Food and Agriculture Organization of the United Nations, Somalians consumed an average of just under 1,700 calories per day per person between 1999 and 2001, which made the citizens of this east African nation some of the most undernourished in the world during that time. The situation in Somalia continues to be so dire that in fiscal year 2015, the United Nations World Food Program, with help from countries including the United States, delivered 40,680 metric tons of emergency food assistance to the people of Somalia.

Think about that. American dieters who follow this “safe” weight-loss program consume a level of nutrition so inadequate that if they were eating this little and living in a different region of the world, the United Nations would be sending cargo ships full of food to help them. When is Bob Geldof going to organize a star-studded benefit concert for dieters?

The diet program’s marketing material advertises, “And once you’ve reached your goals, [company name omitted] support continues with our Healthy Living Program, where you’ll learn how to transition and maintain your new, healthier weight for the long term.” Where is the evidence to support this claim? It only took the gentlest of pushes for the rep to concede he had none.

We do, however, have plenty of evidence to the contrary, including, but not limited to, the starvation study Ancel Keys conducted in 1944. After consuming approximately 1,570 calories per day (which, just to hammer home the point, is more than people on this diet program are afforded) for an extended period of time, the subjects, according to Judith Matz and Ellen Frankel, “. . . engaged in binge eating for weeks yet continued to feel ravenous. They overate frequently, sometimes to the point of becoming ill, yet they continued to feel intense hunger. The men quickly regained the lost weight as fat. Most of the subjects lost the muscle tone they enjoyed before the experiment began, and some of the men added more pounds than their pre-diet weight. Only after weight was restored did the men’s energy and emotional stability return.”

Data presented throughout the conference reinforced the long-term failure of diets as well. Among the slides are nine graphs showing data from various weight-loss attempts and they all depict the same pattern: sharp initial weight loss followed by slow and steady weight regain. A couple of the presenters discussed the hormonal and neurological survival mechanisms that kick in to promote weight regain after the body has experienced a period of restriction.

The discussion of these data and physiological reactions represented what I consider a noteworthy shift since last year’s conference. In 2014, very similar graphs were shown as well, but back then the weight-loss attempts were presented as successful because the end points were lower than baseline, even if the studies were short term and the trajectory of weight regain was still going up at the time of the study’s conclusion. This time, presenters were more forthcoming about the dismal results of weight-loss interventions.

Of course, that did not prevent them from hosting a vendor who sells weight-loss programs, nor did it keep some presenters from going into detail about lifestyle interventions that would supposedly lead to weight loss. The height of irony was at the end of a long day of discussing how diets do not work, the last presenter stepped to the podium and offered a how-to tutorial on dieting: measuring portions, daily weigh-ins, using apps that track calories, etc.

Not only did she recommend Weight Watchers, which in itself was as funny as it was horrifying, but she also cheerfully offered a list of “Plans that may be effective short-term (≤2 years) for weight loss,” including low-carbohydrate, low-fat calorie restricted, Mediterranean, vegan, vegetarian, and Dietary Approaches to Stop Hypertension (DASH), without any mention of what happens beyond two years. Did she think we would not notice such a glaring omission?

She also included a slide depicting a large polar bear trying to fit into a tiny igloo with the caption, “When it comes to management of obesity, one size does not fit all. Keep trying . . . and eventually you will find the perfect fit.” On what is she basing this claim? We saw no evidence presented whatsoever that any current methods of weight loss work in the long term except for a small fraction of individuals.

Presenting these behaviors and diets as the key to long-term weight loss makes no sense, not when so many other people perform the same actions without achieving similar success, as evidenced by, among other indicators, the multitude of graphs and data they just showed us. The lottery crowns new millionaires every single day, but that does not mean your financial advisor is giving you sound, ethical, evidence-based advice if he suggests you take your life savings and invest in Powerball tickets.

“Big Soda”

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A friend recently sent me a New York Times article entitled “The Decline of ‘Big Soda'” and asked me my thoughts. The article begins with this opening line:

“Five years ago, Michael A. Nutter proposed a tax on soda in Philadelphia, and the industry rose up to beat it back.”

Okay, let’s stop right here. Once upon a time, I felt ambivalent about the idea of a soda tax. Now, however, my stance is clear: I am firmly against a soda tax.

Our country’s health woes are complex, only partially understood, and not entirely in our hands to fix, yet for reasons that baffle me, we continue to place too much confidence in our oversimplified supposed solutions. Perhaps people are scared, yearn for a sense of control, and find it more comfortable to point fingers at scapegoats than to face the truth. Human history is riddled with atrocities stemming from scapegoating, and in the world of nutrition, the blame game is harmful as well.

Taxing one food, nutrient, or ingredient separate from the others reinforces a “good food, bad food” dichotomy. Eating only “good foods” is largely unsustainable for most people, and although doing so might sound good in theory, the reality is that such rigid eating often comes at the expense of health’s other facets. When we ultimately consume foods we view as “bad,” feelings of guilt and shame quickly follow. A popular misconception is that feeling bad about ourselves will inspire change, but actually quite the opposite is more the norm. The worse we feel about ourselves, the less inclined we are to treat ourselves well. We eat a “bad” food, feel guilty about it, and proceed to take worse care of ourselves.

Better to recognize that the “good food, bad food” dichotomy is a harmful system, remove moralization from eating, and instead teach people the importance of individuality and moderation. After all, one person’s “bad food” is someone else’s “good food” and vice versa, so what do those labels really mean anyway? Cantaloupe is high in potassium, which makes it very helpful for my patients with hypertension but quite problematic for my patients with kidney disease who are on potassium restrictions. So, is cantaloupe a “good food” or a “bad food”?

If the basis of the soda tax is the beverage’s sugar content, then why are sodas singled out while sports drinks, iced teas, chocolate milks, smoothies, lemonades, fruit drinks, milk alternatives, yogurt drinks, and other sugary beverages skate by without a special tax? Orange juice has almost as much sugar (31 grams per 12 ounces) as Coca Cola Classic (39 grams per 12 ounces), so why are we not stigmatizing OJ?

One might argue that orange juice has upsides despite the sugar content, a point with which I completely agree, but the same is true for soda as well. Every single food you see in the grocery store, including soda, has its upsides; otherwise, nobody would buy it, the store would cease stocking it, and it would not reside on the shelves for you to see.

Sugar is dense in calories, and calories are a measure of energy, so for our neighbors whose financial hardships make getting enough food a daily battle, soda is a cheap source of energy. Increasing taxes on low-cost foods places additional pressure on the already financially strapped people who are most likely to make such foods a staple of their diets out of necessity. When people talk about racism, classism, and privilege in healthcare, the soda tax is an example of what they mean.

For those with medical conditions that make consuming enough energy a challenge, such as cancer, HIV, and anorexia nervosa, the caloric density of sugar-sweetened beverages makes these drinks, including soda, helpful options. Let’s not create additional issues for people who are already sick by specially taxing and stigmatizing the beverages that are part of their care.

For other people, soda is a play food, something that they simply enjoy even if it is not the best option for their health. Whether they partake only occasionally or frequently is irrelevant. All of us engage in a whole slew of activities that do not prioritize our health. We know how detrimental inadequate sleep can be, so why not institute a special tax on people who do not get enough? Why don’t we impose a tax penalty on people who live in cities with poor air quality? Let’s place an additional tax on people who are not physically active, or at least not as active as some other people think they should be. High heels can lead to orthopedic problems, so let’s tax stilettos more than other footwear while we’re at it.

Penalizing other people for their behaviors and how they choose to balance their health with life’s other elements suddenly loses its coolness factor once we realize that opening the door to this kind of judgment means we ourselves are subject to similar stigmatization and punishment, too. In other words, the finger that currently points at them might someday swing right around and point directly at you.