Fatphobia, Health, and Fat Activist Ragen Chastain’s Bad Science
Last week, my fellow Skepchick writer Olivia wrote this post about fatphobia, and how people who claim they fat-shame people out of concern for their health are, generally, full of it.
I agree with that central tenet, but I took issue with a number of scientific claims Olivia made. She kindly went back and edited in some of her sources, and so I’ll take those into consideration when rebutting a few of her statements:
Juice cleanses do nothing to actually cleanse and put the body into a starvation state because they give too few calories.
I agree with Olivia that “juice cleanses” are marketing pseudoscience, often pretending to rid the body of toxins that are never defined and don’t actually exist. That said, I’m calling this out because of the use of the term “starvation state.” This is a nebulous and frequently misused phrase, sometimes referring to the idea that eating too few calories will actually cause you to gain weight, which of course is utter nonsense. If you eat fewer calories than you expend, you will lose weight. It is physically impossible to gain weight while eating at a deficit. If your goal is to lose weight, you must eat at a deficit.
It is possible to eat too few calories to maintain a healthy lifestyle, and this can lead to serious problems, which is why most science-based weight loss regimens will suggest that you only lose about 2 pounds per week (so eating at a deficit of about 1,000 calories per day, give or take), unless you’re morbidly obese.
Depending upon what juice you’re drinking and how much of it you’re taking in, you can easily consume nothing but juice and not starve. I can’t imagine why you would, though.
People still use the BMI scale, despite the wide knowledge that it’s based on a statistician’s attempts to understand large populations, not individual health.
I’m one of the people who uses the BMI scale (for myself). It’s true that it was created as a statistical tool, and one that is used often and to good effect in studies like this one showing that pregnant women with obese BMI experience a higher risk of complications. But of course there are other studies showing that while very high BMIs are unhealthy, there are sometimes better methods for gauging mortality, like large waist circumference.
So BMI doesn’t apply to every individual, but it’s also true that it does apply to most individuals. If you’re not a body builder or other elite athlete, BMI is a much better way to gauge whether you’re at a healthy weight then just looking at your weight alone, for the simple reason that it takes into account your height.
New guidelines for doctors treating overweight patients even promote weight loss before treating whatever complaint the patient may have come in for (unsurprisingly, the doctors who worked on these appear to have close ties with pharmaceutical companies that market weight loss drugs).
This one is probably my biggest concern and was the main impetus for me asking Olivia to link to her sources, as this was something I had never heard of. And it turns out, I’d never heard of it because it’s simply not true.
Olivia links to Dances With Fat, the blog of Fat Activist Ragen Chastain. I want to stress, here, that I very much agree with activists who fight against the unhealthy beauty standards that are forced on women every day, and I agree with those (like Olivia) who push back against people who think it’s their place to mock and shame people who are overweight.
It doesn’t do anyone any good, though, to publish dreck like Chastain’s post. The guidelines in question were published by a task force of researchers for The Endocrine Society, and they most certainly do not recommend doctors “promote weight loss before treating whatever complaint the patient may have come in for.”
Instead, these recommendations are, by the researchers’ own words, for doctors treating three kinds of patients:
1. Patients who are overweight or obese and who are seeking weight loss solutions
2. Patients who are overweight or obese and currently taking medications to treat obesity-related diseases like Type II Diabetes
3. Patients who are overweight or obese and are currently taking medications for non-obesity-related diseases that are known to increase weight gain
The researchers strongly recommend that doctors talk to patients and engage in “shared decision making in terms of improving patients’ knowledge, reducing decisional conflict and regret, and enhancing the likelihood of patients making decisions consistent with their own values.” (Emphasis mine.)
The guidelines are there to help patients who want to lose weight but who are having trouble making the necessary lifestyle changes; patients who are essentially treating the symptoms and not the cure, offering doctors suggestions for actually curing Type II Diabetes (with weight loss) instead of managing it with drugs; and patients who are at risk of going on certain medications for disorders like epilepsy and mood disorders that could lead to more weight gain, which in turn will lead to more health complications and a decrease in compliance, which is a further threat to the patient.
Nowhere in those recommendations does the task force recommend ignoring a patient’s complaints and forcing them to lose weight instead. In fact, it’s just the opposite: the recommendation is for doctors to use all the tools they have to help a patient achieve the results they want with as few drug-related adverse side effects possible.
And regarding one of the task force’s ties to pharmaceutical companies: The Endocrine Society is rigorous about declaring conflicts of interest, which is how Ragen even knew what one researcher’s background consisted of. Here are their rules for the task force that created these guidelines:
Participants in the guideline development must include a majority of individuals without conflicts of interest in the matter under study. Participants with conflicts of interest may participate in the development of the guideline, but they must have disclosed all conflicts.
As I’ve stated repeatedly in the past, disclosure of conflict of interest is important, but it is not the thing that discounts research. In fact, these guidelines are all based on other researchers’ studies, all of which are cited in the article along with confidence ratings for each recommendation and suggestion.
That’s enough digging into Chastain. Back to Olivia’s post for one final remark:
Basically every restrictive diet ever rests on the principle of putting the body into a starvation state so that it will start to eat away at its own fat. In the long term this doesn’tgenerally lead to weight loss (it changes the metabolism such that the body tends to gain back the weight plus some), and it’s simply not very healthy.
Again we have the nebulous scare-phrase “starvation state.” It’s simply untrue that (moderately) restricting your calories leads your body to do anything unhealthy. Millions of people do it every day. I did it two years ago when I realized that I had pudged up a bit more than was good for me during a long Buffalo winter. I cut my calories down to about 1,200 per day, which, yes, is fewer than my body was using. That’s how I lost about 20 pounds over the course of about 10 weeks. When I was at my desired weight, I bumped up my calories very slightly so that I stopped losing weight. My current caloric intake is still a “deficit” from where I was before, but obviously now I am maintaining weight instead of losing it because I lost weight and my body doesn’t need as many calories.
This won’t work for me in the long term, if I go back to the lifestyle I was leading when I was fatter. That’s why, as Olivia’s first link states, “diets are not the answer.” Lifestyle change is. The lead author of that study is quoted as saying that she thinks the answer is eating right and exercising, which is exactly what the science has told us for ages. And for many people, like myself two years ago, I wasn’t eating right. Eating right meant eating at a deficit.
Of course, not everyone is psychologically able to do that on their own, especially if they’re morbidly obese and the changes they need to make are severe and complicated by other health issues and medications. That’s why doctors develop guidelines like the ones from The Endocrine Society, to figure out the best ways to work with patients to achieve the results they want.
As for “metabolism,” see my earlier point about how I now eat fewer calories to maintain myself at my current weight compared to my weight two years ago. Yes, your metabolism will drop a bit as you take in fewer calories and lose weight. That’s normal and healthy. As Olivia’s citation shows, it will go up again if you start gorging. That’s how metabolism works.
Again, I want to stress that I agree with Olivia’s primary point: fat shaming is not about secretly wanting a person to be healthy. Additionally, it most likely doesn’t work as a way to motivate people to lose weight or to get healthy.
But again, that message gets lost when those fighting for the overweight and obese use bad science and bad arguments to make their points.
First, I knew I should have dug a little deeper on Ragen’s source. Thanks for calling me on that.
Second, I just want to clarify that I hadn’t actually heard starvation state used to mean that you won’t lose weight if you’re at a caloric deficit, so that was sheer ignorance on any controversy surrounding the term on my part. I have heard it primarily in the context of dieticians who treat patients with eating disorders discussing what happens when you deprive your body of calories. It typically results in your metabolism slowing down and depending on how large of a deficit you’re running it can also lead to some non-essential functions in your body stopping (loss of period, hair falling out, etc).
I in no way oppose people eating healthier food and getting more activity. These are good things.
I am curious where you got the number for 1200 calories as a healthy deficit to run. One of the biggest studies on starvation was the Minnesota Starvation Experiments, and they had the participants on a diet of about 1600 calories and it led to things like extreme weight loss, obsession with food, hair loss, exhaustion, some started to exhibit violent tendencies, weird eating rituals, and mental health problems. They did require participants to exercise fairly heavily, but I have heard from multiple dieticians that 1200 calories is unhealthy (again, these are dieticians working with eating disordered patients so it’s possible that they’re adjusting their presentation of facts somewhat).
Of course there’s tons of conflicting information about what an appropriate level of calories is, but I had just never heard one that low.
1200 wasn’t my deficit….1200 was the total number of calories I took in every day. My deficit was ~500/day on days that I didn’t exercise.
I’ve eaten a similar number of calories to Rebecca over the past five months or so. Generally somewhere between 1100 and 1400 calories a day. I’ve lost roughly 40 pounds without much effort or side effects. I know it’s just an anecdote but controlling caloric intake and creating a deficit seems to make it impossible not to lose weight until you hit an equilibrium. Also with smart phones and various apps monitoring caloric intake is super easy.
Adding my anecdote to yours – 1100-1500 calories a day for about 6 months now along with increased exercise and I’ve lost about 35 pounds. The only side effect (besides weight loss and increased energy) seems to be spending less money on food. Someone without extra body fat would no doubt have a much more difficult time with this, and of course a taller man requires more calories than a shorter woman like myself, so there’s no reason to think I would experience the same level of deprivation as the men in the experiment. Plus, they weren’t fed a nutritionally balanced diet – the experiment was to mimic a famine and study the effects. Eating a balanced diet at a reasonable deficit when you have extra weight to lose is in no way comparable to starvation.
The “Minnesota Starvation Experiment” was conducted in 1945 (published in 1950), with only a sample group of 36 men, so it is a 70/65 year old study with a very small number of people being tested. Add to that the result wasn’t even what people now spread around it was those men were semi-starved for 6 months to simulate the conditions at the end of the second world war in europe so they ate 1,560 calories per day for 6 months, but those weren’t obese deskjockes those were healthy men working physical jobs so they probably run a deficite of 1,700-2000 calories per day, the devastating results of the study were because their bodies were actually starving and using up their last reserves breaking down muscles, organs etc. this experiment has little to no correlation to overweight/obese person today trying to lose weight.
“Nowhere in those recommendations does the task force recommend ignoring a patient’s complaints and forcing them to lose weight instead.”
That may be true, but doctors do that a lot anyway. I wrote about what happened with my knee during Weight Stigmas Awareness Week 2013: http://skepchick.org/2013/09/past/
Less anecdotally / personally:
So I think the issue here is that the findings play into an existing bias that doctors already have in favor of telling fat patients to lose weight rather than that they necessarily cause such bias to arise. I think that’s important to mention.
“That may be true, but doctors do that a lot anyway.”
And I assume that that’s why those guidelines recommend that a doctor talk to the patient and understand their values and goals before recommending a course of action. In other words, the recommendations are for doctors to do the opposite of what many overweight and obese patients are currently experiencing.
Regarding the BMI, there’s also an issue of height. At 2 m, 100 kilos seems awful thin (and in fact is in like the second percentile or so in two-meter-tall men), but that’s a BMI of 100*2^-2=25. The reverse is, of course, true if you’re extremely short.
Diet books in general have varying degrees of pseudoscience. At best, they seem to use doublespeak. “You can only lose weight by expending more calories than you consume. And now, here are foods you can eat to help you lose weight!” (And not necessarily truly low-calorie options.)
Obviously, gyms have pseudoscience (known derisively as ‘bro science’) as well. (How many famous athletes and bodybuilders endorse vitamin pills or protein powders?) I don’t imagine that kind of thing shows up as much in cardio or yoga (I’m not getting into yogis who claim to levitate here.) though.
Yoga has it’s share of pseudoscience, mostly about chi and energy bullshit.
Agreed that Yoga has a lot of bullshit and pseudo science behind it; though I see it as a very effective anaerobic exercise.
Put it this way: If one does a exercise that leaves them sore in the morning, that is a exercise that works.
That last sentence is absolutely terrible advice and has no scientific basis. Soreness is not a good measure of whether or not an exercise works. Improved performance is the best measure of whether or not an exercise is effective.
Fitness programs and pseudoscience tend to go hand in hand because people who participate in fitness programs tend to be interested in maintaining their health and so health-focused businesses tend to market to gyms and studios. Gym/studio owners aren’t scientists and often lack the knowledge to tell the good from the bad, but are eager to form beneficial business partnerships that they believe will further support the health of their clients. I don’t think any particular type of fitness is immune – it’s generally dependent on the attitude and knowledge f individual business owners.
And then there’s stuff like Crossfit, where you can become a “certified” trainer in a weekend. At least with yoga and pilates there is a fairly rigorous training involved before you become responsible for what people do with their bodies.
Wait, how are protein powders pseudoscience? Do they not contain protein? Is there something about them that prevents the protein they contain from getting into the body’s cells? Is protein not the nutrient from which the body makes most of its tissues, including muscles? If one is exercising enough to increase muscle mass, does one not need to consume protein to support that increase of muscle mass?
“Pseudoscience” is too strong a term, but supplements of all kinds are very prone to being overdosed. Often, that only causes you to spend money needlessly, but it can lead to health problems in some cases.
From Web MD:
In very specific circumstances, protein powders can be useful. “They’re an easy and convenient source of complete, high-quality protein,” says Carole Conn, PhD, associate professor of nutrition at the University of New Mexico. But remember: Most people, even athletes, can also get everything they offer by eating sources of lean protein like meat, fish, chicken, and dairy products.
(*snip*) Lewin adds: it doesn’t take that much protein to achieve those goals. Most Americans already get about 15% of their daily calories in protein. To build a pound of muscle, Lewin explains, the body needs between 10 and 14 additional grams of protein per day.
“That’s not really that much. Some of these powders have 80 grams of protein per serving. You don’t need that. All your body is going to do is break it down for energy. And too much protein can be hard on your kidneys and your liver.”
John Brewer’s correct about BMI. It’s because a person’s mass increases with the cube of their height, rather than the square as is used in BMI.
I believe it’s a mistake for anyone ever to use BMI as an individual measure. People’s lean mass simply varies too much for it to be useful in that setting, even if they’re of near-average height.
People don’t scale exactly cubically; taller people aren’t perfectly scaled-up versions of shorter ones, they’re leaner and narrower. The true exponent is likely around 2.5, and you can play around with it here.
(The takeaway is that if you do use standard BMI as an individual measure, you’ll overestimate obesity for tall people and underestimate it for short people.)
“Nowhere in those recommendations does the task force recommend ignoring a patient’s complaints and forcing them to lose weight instead.”
As Heina said above, doctors do this a lot anyway, regardless of recommendations. Also, it recommends suggesting weight loss programs for people who haven’t requested it–those Type II diabetics and people who might go on weight gain-inducing drugs. (By the way, some references in one of the articles Olivia linked in the last post, http://www.nutritionj.com/content/10/1/9 , point out that weight loss isn’t necessarily a successful treatment for Type II diabetes: improvement is seen within days after treatment begins, before any significant weight or fat loss has been achieved, and in at least one study patients who were followed up at 4 years and had maintained weight loss throughout that time did NOT maintain the decreased HBA1c. In general, that article is a good overview of the science case for HAES, although it has some flaws. One I noticed on a brief reread: it points out the thing that overweight people have better outcomes for a number of serious health problems such as Type II diabetes and heart disease, but there’s some evidence that those better outcomes are because doctors monitor overweight and obese patients more carefully than normal-weight patients because they expect complications. But that’s really one of the fat acceptance arguments: that weight/adiposity is a noisy proxy for underlying health, and it would be better to use more specific measurements, like high cholesterol/triglycerides or low exercise levels for heart disease, both to avoid unnecessary treatments for otherwise healthy fat people, and to provide necessary treatments for unhealthy thin people. Our current system makes both of those errors.)
One other thing: you talk about patients taking drugs “that could lead to more weight gain, which in turn will lead to more health complications and a decrease in compliance, which is a further threat to the patient.” This is a thing that fat acceptance folks talk about a lot: even though the vast majority of people can’t maintain weight loss (and I should say, this generally means people who were a certain weight for a long period of time and then tried to lose weight–losing weight gained on a shorter time span seems to be easier), you can get labeled noncompliant for failing to lose weight, which can have other effects on your treatment–even if you follow every other piece of advice to the letter. At the point where 95% of overweight people can’t maintain weight loss, despite all the pressures to do so, isn’t it reasonable to consider that there’s something going on besides “fat people just don’t know how to eat healthfully, or are too lazy to do it”?
Hmm. Sorry, one more thing. (Apparently I have a lot to say on this because I really like Skepchick, and read and like a lot of your posts, but I think this one in particular has a bunch of unexamined assumptions in it.) You said: “This won’t work for me in the long term, if I go back to the lifestyle I was leading when I was fatter. That’s why, as Olivia’s first link states, “diets are not the answer.” Lifestyle change is.” But many of the studies that examine the long-term effects of weight loss include “dieting” schemes that fit into your definition of “lifestyle change”–learning new eating habits, increasing exercise even after weight loss is achieved, continued interaction with doctors to maintain this lifestyle change, etc. They still don’t work.
You’ve misunderstood me. If you read the guidelines, you’ll see that by “non-compliance” they mean that many patients who take drugs for serious illnesses will stop taking those drugs if the drugs cause excess weight gain. This is a problem that can be solved by doctors working with patients before prescribing the medication. If weight gain is something that concerns the patient, there are other medications the doctor can try.
It’s simply not true that actual lifestyle change is proven not to work. When a patient’s calories and exercise can be counted exactly (and not self-reported), a deficit will absolutely always 100% of the time lead to weight loss.
That’s interesting – what’s the source for this? I didn’t know anyone had done a precisely controlled long-term study like this.
I’d also like to know if the subjects in this study were all otherwise healthy, or did they include people with PCOS and other such conditions?
The laws of physics, for one.
But yes, there have been a few studies placing people in metabolic clinics to gauge their intake and energy expenditures, and sure enough, the number of calories going in has a direct impact on their weight. There are about a hundred more studies proving that most people under-report calories by a significant degree, and obese people are the absolute worst at it. Maybe I’ll write a follow-up, because it’s a very interesting example of how easy it is for people to fool themselves.
Any study claiming to deduce real results of lifestyle changes while using self-reported data is useless.
There were only 25 participants in that trial, and they were in the clinic for only 10-12 weeks. Only healthy participants were involved. Do you have a source for a large, long-term study? I’ve never heard of one, and perhaps that’s because the cost would be enormous. But given that even lab rats with a controlled diet have been gaining weight, “the laws of physics” you mention might work in a slightly more complicated way in human bodies than you suggest.
Here’s a study on the increased weight of even research animals:
I’m sure you’re right, though, that people are very bad at reporting their calorie intake accurately.
Kaloikagathoi, your cite is crap evidence against what should be the null hypothesis, increased weight requires increased calories. To cite a relevant part from the discussion: “These animals are typically fed ad libitum, so if weight increases are attributable to
increases in food consumption (which is possible), it is difficult to understand why animals in controlled environments on diets of constant composition are consuming more food today than in past decades.”
They’re not saying the animals were getting fatter on the same diet, they are saying they don’t know why they should be eating more.
That’s interesting – I missed that bit. I don’t have time to look further right now, though I thought I’d seen a reputable study where the caloric intake was controlled and the animals were still gaining weight. It was probably by David Allison, but all I can find at the moment are articles about his study. This one:
does say that the lab animals’ food intake was controlled, but it doesn’t cite the original study unfortunately.
Regardless, it shows how complicated weight loss and gain is. If what’s changed is animals’ and people’s appetites, is it difficult to explain why that should be happening.
Less difficult than explaining mammals gaining significantly more weight with the same diet and lifestyle.
Kaloikagathoi, Bjornar already got to this one so I’ll just +1 him and underline the simple fact that you must take in more calories then you expend to gain weight. This is not a fact that needs a study to prove it. The competing claim would be that mass can accrue from some source other than calories ingested, which is at best a “perinormal” claim that would require a great deal of evidence to prove. I’d say “paranormal,” but maybe you would be claiming the mass comes from particles breathed in the air, or something.
I can’t tell if you’re trying to insult me, or if it’s your snarky sense of humour, Rebecca. I’ll assume the latter, as my sense of humour is also sometimes misinterpreted as hostile. :-)
There is no need for magical thinking to potentially explain why you might be over simplifying when you say:
“When a patient’s calories and exercise can be counted exactly (and not self-reported), a deficit will absolutely always 100% of the time lead to weight loss.”
It is conceivable that a body might fail to absorb all the calories it consumes, or absorb more than another body would. Exercise may not be the only way calories can be consumed.
Or people’s and animals’ weight gain might indeed be due to a very simple diet and exercise equation, as you suggest. I don’t think anyone has proven this yet, however, and it would be a useful thing to try to prove.
Indeed, given some of the recent findings on gut microbiota and weight gain/loss, it may be that some people may store energy a bit more readily — on the other hand, said microbiome could affect satiety or something else that causes people to eat more.
Exercise is actually a pretty modest way to expend calories, when you consider that you’ll burn the majority of them by just existing. A lot of people think they can exercise their way to weight loss, but it’s really about the calorie intake.
It leads to weight loss, yes–the problem is that the weight doesn’t stay off. Any diet or lifestyle change can produce weight loss in the short term, it turns out that’s not actually that hard; when I say it “doesn’t work”, I mean the longer you follow the patients the more of them gain back the weight.
Here’s one study that looked at very rapid weight loss (not analogous to your lifestyle change, of course): http://www.nejm.org/doi/full/10.1056/NEJMoa1105816 They found that a whole bunch of hormone indicators that promote weight gain were still different a year after the diet ended. So it may be that they were eating more, I don’t see that information on a quick reread, but many of the hormones they tested were different–they didn’t look hormonally like a person with an equivalent weight and exercise level and demographics who’d never been heavier. Self-reported hunger, fullness, and food obsession were in fact worse at the year followup than they were at the end of the 10-week diet.
And that’s rapid weight loss, so you might say slow weight loss via lifestyle change is different; but the same group performed a study where they split dieters into two groups, had one of them do rapid weight loss and one slow weight loss, and put the successful dieters from both groups on a weight maintenance diet for almost 3 years, and there was no difference in whether or how fast the two groups regained their weight. (At that final checkup, the groups had regained, on average, 70% of what they lost.) http://www.thelancet.com/journals/landia/article/PIIS2213-8587%2814%2970200-1/abstract
Or, from a different angle: formerly obese people have a different resting metabolic rate than demographic-matched people who were never obese, which also makes weight regain more likely; one meta study is here http://www.ncbi.nlm.nih.gov/pubmed/10357728
I think the way to sum this up is, one, a weight loss diet is a weight loss diet for anyone (perhaps of differing speeds of weight loss), but a weight maintenance diet for a person who was never fat is a weight gain diet for a person who once was; and even that nominally weight maintenance diet is harder to keep to because of the changes due to the initial weight loss.
This NYT article http://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-fat-trap.html?_r=0 has some first-person discussion from people who have maintained significant weight loss, in the section beginning “The National Weight Control Registry.” One says she couldn’t do it if she had kids at home, because it consumes so much time and energy to plan her life around staying at that weight.
So one set of questions is, if it’s so hard to maintain weight loss, is it reasonable to expect that most people will? And if they’re not going to keep it off, is it a good idea to suggest that they try, when weight cycling is correlated with increased blood fats, insulin resistance, and high blood pressure? Another one is, we know that many health problems are found in obese people; if we take obese people and have them lose weight and keep it off, do they have those health problems at the rates of thin people, or the rates of obese people? (No study that I know of has been done on that one because so few people keep the weight off for long periods that it’s hard to contruct samples.) That is, is it the weight itself that’s the problem, or the underlying differences in biology that make weight gain more likely? The evidence from Type II diabetes, for example, is consistent with the idea that obesity predisposes you to the condition, but it’s also consistent with the idea that obesity is one of its earliest symptoms.
And to be clear, as somebody says below: I’m not saying we should never recommend changes in diet or exercise to obese people. I’m just saying, I think it’s better to do that with the goal of eating more healthfully or getting more exercise, and not with the goal of reducing body weight: replacing sugar calories with protein or vegetable calories is a great idea if you’re eating too much sugar, for example, whereas just cutting out the sugar calories seems to be ineffective for long-term health outcomes.
Hmm “replacing with protein or vegetable calories” doesn’t actually make any sense, I should have said “replacing sugary foods with vegetables or protein-rich foods.”
I’m the unicorn of the weight loss industry, having lost more than a 140 pounds and kept it off now for about seven years. But I’ve been the standard weight loss success/failure story before that, having gained and lost more than a hundred pounds three times in my life.
I started out life as a rake thin kid, but since my parents put it on my back that I wake up with enough time to make my breakfast and lunch starting with grade two, three days out of five my first meal of the day wouldn’t be until supper. It’s not hard to stay super skinny when you’re seriously starving. I can’t think about elementary school without remembering how hungry I was or how betrayed I felt when I realized when I was six that the reason why everyone always had amazing lunches was because they weren’t the ones making them.
Fast forward to grade six and my first after school job. Every dime I made I spent on food. I ballooned out from a rake to a pear. I was never not hungry. With two sisters of the same age with the same parents, we were like wolves. If you didn’t eat all you could when you could there wouldn’t be anything leftover. Unhealthy relationship with food, meet Barb. Barb, this is your unhealthy relationship with food.
I left home for college. The weight fell off. I lost a hundred pounds. I came home after no longer wanting to work up in the territories for fear of my personal safety. Living back home, I gained back a hundred and twenty pounds
I moved away from home. Met a nice girl. Weight fell off. My relationship with my parents soured. I had to face the fact that I wasn’t a bad kid, my dad was an abusive asshole and that the decade of ignoring the fact that my mother had stolen tens of thousands of dollars from me while I was working and sending money home was making me eat and eat and eat. Not dealing with the trauma caused me to gain all the weight back. Dealing with the trauma and putting it to bed made the weight fall back off again.
I’m forty now and weigh as much as I did when I started jr high. My scale starts with a 1 now. Whenever you’re dealing with a person who is morbidly obese, food addiction may play a small role, but there’s a reason that person had turned to food to fill the hole that something else had carved into them.
Food is a fast, readily available drug that has been scientifically designed to be as addictive as possible. Whether it’s because our brains don’t recognize drink calories as calories, how much effort goes into finding the bliss point, food is designed to melt on the tongue so that the brain thinks the calories disappear or that our parents unwittingly trained us to think of food as reward and love, we have to stop hating people who were hit by a bullet that you might have dodged.
I’ve lived in this world as a three hundred and sixty pound person and I’m just about two hundred pounds less than that now. The way adults treat people, especially fat people should be criminalized. For some people, the hate we all faced in junior high never ends. No matter what diet, trend, or operation the person puts themselves through, unless they fix that part of their body that can never feel full, everything is a bandaid on a festering wound.
This is absolutely without a doubt completely untrue. Everything scientists know about obesity and Type II diabetes is that the latter follows the former due to people placing unnecessary stress on the body’s ability to regulate insulin. Weight management is the single best thing you can do to prevent getting it.
I went looking for my source on that, and discovered, yep, he was a hack. So you are absolutely right, as I’m sure you know. My apologies for including that argument.
Harlequin, Rebecca: Care to share your notes with the class, either of you?
To be clear, from what I’ve read it’s possible if not probable that both are happening (both that high BMI leads to insulin resistance and that insulin resistance leads to weight gain and/or difficulty with weight loss). I can list my own sources later, probably won’t get a chance until tomorrow, but I’ve seen it from a wide enough variety of sources, including non-FA/HAES sources, that I’d like to know more.
Closet Puritan, I first heard it in a Ted talk from Peter Attia: https://www.ted.com/talks/peter_attia_what_if_we_re_wrong_about_diabetes?language=en where he talks about his experiences with obese patients as a doctor, and then discusses how his thinking changed when he himself rapidly gained weight and was diagnosed with Type II diabetes. I found it thought-provoking and trusted his summary of the current research, given his more relevant background than mine, but he’s got a nutrition website now that seems…much more pseudoscience-y than his initial talk was. So I worry that his overview and interpretation of the research was biased. (Though I do recommend it, actually, just for his thoughts on his unconscious biases towards obese patients before he suddenly gained a lot of weight.)
Looking for numbers on this, I found this delve into data from the Whitehall II survey of around 7,000 white UK civil servants: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001602 who had a whole bunch of health characteristics measured every 5 years for a study length of 18 years (most people followed for some subset of that time). About 650 of the people in the study developed diabetes. 604 of them were stably overweight (not obese) throughout the study and slowly developed diabetes; 26 were stably obese and slowly developed diabetes; and 15 experienced weight gain, raised blood pressure and exponential increase in insulin resistance in the couple of years before being diagnosed. So it’s plausible that in that last cohort, the weight gain was a side effect of the developing diabetes (since excess insulin can promote fat deposition instead of other uses of calories), but they’re only about 2% of the people who developed diabetes.
(Also, presumably, hi from other places! :))
OK, that’s a bit of a relief–he is not my source.
I originally heard of this from Linda Bacon. (Linda Bacon describes it as a “cycle” and “self-perpetuating”–the fact that she described it as both fat contributing to insulin resistance and insulin resistance contributing to fat, and Rebecca seemed to primarily be defending the truth of fat->insulin resistance is why I didn’t take Rebecca’s statement as truly contradicting it–though Bacon does also say “insulin resistance develops first”.) Linda Bacon cites two sources for the statement “Research shows that high levels of insulin appear *before* weight gain in future diabetics”. One is this Ernsberger and Koletsky piece. The other is this Peter Bennett piece. I don’t have access to the full text of either.
However, I’ve also found several government, university, or otherwise-reasonably-trustworthy sites saying this as well. This pdf from UCLA, This article from SFGate, and this document from the Nueces County Medical Society. Additionally, some of the information about PCOS, such as this piece from WebMD, state that insulin resistance causes weight gain–logically, that wouldn’t stop being true when the insulin resistance is diabetes-related rather than PCOS-related.
The 95% number gets batted around a lot, but I’ve never seen it well-supported and I’ve seen it contradicted as well (here for example: http://www.ncbi.nlm.nih.gov/pubmed/24355667.) I would love for someone more qualified than I to look into the science and see if it’s actually true that “95% of overweight people can’t maintain weight loss.” It seems unlikely just based on the number of people in my life who have done it – I can’t know that many statistical outliers.
Hmm. I’m going to have to retract that, because I can’t find a citation for it. It is true that the majority of people don’t sustain weight loss: http://www.ncbi.nlm.nih.gov/pubmed/17469900 and that that number of people who regain goes up the longer you follow dieters, but I don’t think the 95% comes from a real study, so I should stop using it.
The National Weight Control Registry is designed to follow successful dieters, so you can’t draw statistics from it on how successful the average dieter is: the sample they start with is already a small minority of people who attempt to diet.
And again–this applies to people who were heavier for a long period of time (several years at least) and then tried to lose weight. I’m never sure exactly how scientific the “internal set point” concept is that gets used a lot in FA, but it does seem to be true that internal hormone regulation etc gets changed slowly, so if you lose weight that you haven’t had on very long, that’s qualitatively different than losing long-term weight. Most people I know who were successful dieters were only up at the higher weight for a year or two.
Here’s a great place to start on the mythology of “95%”
It’s from a single study from over a half century ago
from the NYT article – we don’t kn ow what % can’t lose weight, but it may be below 50%
I always assumed people meant “starvation ketosis” when people said “starvation state”. I guess that’s further indication that the term isn’t very useful.
I’m generally on the “Calories in, Calories out” team, but while it’s simple, that doesn’t mean easy. It’s usually easy for me, but when I had a stint on a medication that made me simply psychologically unable to restrict my food intake, I gained some sympathy for how hard it might be for others (and also 15 lbs). I imagine that’s how some people are all the time, but they can’t just stop taking a pill and fix it.
What I’d really like to see is the end of fat-shaming without the “healthy at any size” nonsense and misrepresentation of the risks of obesity. If we can just get to a place where being obese isn’t any more shameful than having high blood pressure, but where we also acknowledge both have risks, I think we’d be much better at reducing incidence of obesity.
I agree completely, muletonic.
I think there’s a misunderstanding here: it’s not “healthy at every size”, but rather “health at every size”. I think that’s important because the former implies that you can just say, “Hey, I’m healthy” and presto, you are – like you can argue your way into health regardless of reality. What it actually means is something very different.
Health At Every Size (as I understand it, I’m not their spokesperson) basically means trying to live a healthy lifestyle whether or not it leads to weight loss or a change in body size. So if you’re pursuing HAES, you’re trying to eat a balanced diet that’s good for you, and you’re trying to get exercise, and you’re trying to follow whatever medical regimen you work out with your doctor . . . but you’re not putting emphasis on whether it makes you weigh less or more. Essentially, it’s about focusing on health as a set of behaviours, not as an appearance or body size. I don’t see that as nonsense: I see it as a good way to make sure I keep my eye on the goal (which is feeling my best – a multifaceted thing where my weight has to be balanced against other health risks and benefits).
I think you put it very well.
I appreciate not using obesity as a surrogate measure for health and encouraging healthy lifestyle regardless of size — it’s a very sensible approach. My objections to HAES are a) the name implies that you can be healthy at every size, which is quite simply not true (though perhaps this is me being pedantic), and b) I’ve seen its proponents spreading quite a bit of horribly cherry-picked information glossing over the risks of obesity.
So, I guess I mostly agree with the general approach, but the way it’s presented can be sketchy.
I don’t have anything to add, except to say that I love that we have a website where two writers can disagree in public like this, in a completely mature and reasonable fashion, and it adds to the value of the discussion and site as a whole. Good work ladies!
Thank you for posting this. I am 100% against fat shaming and fully agree that making people feel bad about how they look is unlikely to help them be healthier. I have however always been a little uncomfortable about some of the claims made by some HAES activists, suspecting that the science might be misrepresented to make certain points. Because this is such an emotional issue, and because there is so much money to be made from misinformation, it can be difficult to find reliable information about the relationship between weight and health.
Whilst it may be true according to the laws of thermodynamics that a strictly controlled (in a lab) ‘calories in, less than calories out’ approach must cause weight loss, I think it is necessary to base medical advice on lived experience. I opposed abstinence only education because, although it is certainly true that not having any sex will avoid STIs and pregnancy (leaving aside rape), the reality it that it is bad medicine and social health practice not to acknowledge that people will generally be unable to be abstinent and will instead expose themselves to life threatening risk.
I believe the evidence indicates the same of weight-loss diets and ‘lifestyle changes’, ie. that in the actual lived experience, the vast majority will not in fact achieve the desired result and there is good evidence to suggest that setting people up for failure (which is the most likely outcome of a weightloss program) is in fact harmful.
If your health care provider is able to place you for months in a care facility that can strictly monitor your intake and output, then I would probably support offering that treatment. Otherwise I believe that offering ways to improve activity levels and access different types of movement will achieve better outcomes. Movement for movement’s sake will not prompt the same learned helplessness response when failure to lose weight almost inevitably results (as there can be no failure).
I agree with what you say here. This is such a fraught subject because the simplistic solution involves ignoring the evidence for real human behaviour.
I’m not sure even the strict monitoring of intake and output facility you imagine would work if taking away the patients’ freedom of choice regarding food would potentially cause a problem once the patients leave the facility.
Your analogy to abstinence only sex education is really good, and is not one I’d thought about before.
Me too! That’s exactly why I support the above mentioned guidelines’ recommendation that doctors work closely with patients to educate and form a plan based on that patient’s values and abilities.
Yes. It has to be based on what people will realistically do. Aside from the fact that it’s well-established that formerly-fat people have different metabolic rates than never-fat people at the same rate, it is also well-established that weight loss causes hormonal changes that encourage people to eat more (see, e.g. Tara Parker-Pope’s “The Fat Trap”, linked elsewhere in comments). “If you eat fewer calories than you’ll burn, you’ll lose weight” is trivially true; not only is your only measure of “how many calories do I burn” probably “what is my weight doing?”, but for people who eat based on hunger–or people who *try* to eat based on calorie-counting but whose ability to ignore hunger is limited–it’s not a particularly *useful* piece of information.
This is an excellent write up, and highlights fantastically the problems I saw in the previous article. Thank you Rebecca!
As Heina mentioned, LOSE WEIGHT! is usually the first thing fat people get to hear. Without doctors even looking at anything else. My neighbour nearly lost her leg. After knee surgery she put on some weight. Hard not to do when you can hardly move. And she was in constant pain, the knee did not improve. For months (!) doctors told her that the reason she was having pain was because she’d put on 20 pounds. Until one doctor finally looked at the knee after she begged him to. Turned out there was a growing infection and they were not sure if they could safe the leg. That’s the reality fat people encounter, especially fat women.
Have you ever had your blood pressure taken three times because they simply could not believe that it was in the perfectly healthy range?
Discussing each and every possibility of weight gain as a Serious Health Hazard! is wrong. What it achieves is making us give up. Really, why try to lose 5 or 10 pounds. You’re 50 pounds overweight, you’ll drop dead anyway!
Change your life! All of it! I don’t care if you have to shoot the children, drop out of college and quit your job!!!
Really, I’m glad for every person who wanted to lose weight, managed to and then managed to keep it. Worked well for me for some years. Then my life changed. Because our “lifestyle” isn’t always as easily controllable as people suggest.
I’m not sure if you meant to leave this in response to someone else’s comment, but in response to my post I’m not seeing the relevance.
“The new treatment paradigm … is to manage the obesity first with lifestyle change and medications, and then manage the remainder of comorbidities that have not responded.” (Quote from Dr. Carolina Apovian in the Journal of Clinical Endocrinology & Metabolism.)
Pay attention to the article and how many weight loss drugs name checked in it. Pay attention to the fact that if you look at disclosures that Dr. Apovian has had to make, she has a MAJOR stake in the drugs listed. But I’m sure she’d totally be willing to declare that weight loss drugs SHOULDN’T be put first if that were her finding. I’m sure at no point was this at all influential on her scientific point of view.
Also, I’d challenge you to explain how you can state the words “If your goal is to lose weight, you must eat at a deficit.” and then say that “starvation state” is a scaremongering term.
They mean the SAME THING. The hope (and it is a hope, not a guaranteed outcome) is that by giving your body less than it needs in the hopes that it will start devouring parts of itself (ie adipose tissue) so that you will have less of that tissue.
When your body is given less calories than necessary to maintain the current weight, that is a state of starvation. Starvation can be in degrees, of course, but the fact is that is A STATE OF DEPRIVING THE BODY IN THE HOPES THAT YOUR BODY WILL BECOME LESS.
I’d also urge you to consider that when it comes “curing” Type II diabetes, that it’s not clear that it’s necessarily the weight loss that causes it. What I cite here is that many people who have type II and have undergone weight loss surgery find their type II basically “cured” – but only after a week or so. Before any appreciable weight loss has occurred.
Never mind that you and this article are just adding to shame and stigma around Type II diabetes. The kind of shame that keeps people from seeking treatment or continuing with it. Diabetes is not a “fat people” disease, it is not a punishment that automatically follows being fat. It is not simply about “eating too much sugar”.
I’d ask you to think about how much you’re STILL contributing to stigma and shame even when you claim you agree with the article you’re rebutting.
So first off — why are you quoting an article out of nowhere, that nobody has mentioned, that you apparently disagree with? Is this supposed to prove that doctors are all big pharma shills or something?
“Also, I’d challenge you to explain how you can state the words “If your goal is to lose weight, you must eat at a deficit.” and then say that “starvation state” is a scaremongering term. They mean the SAME THING.”
That is factually incorrect. Starvation is a severe caloric deficit, resulting in muscle loss and organ damage. It happens after your body’s fat reserves are exhausted, and after caloric deficit has led to ketone synthesis. Your body still functions perfectly fine when you eat at a slight deficit — calling that “starvation” is pure hyperbole.
“I’d also urge you to consider that when it comes “curing” Type II diabetes, that it’s not clear that it’s necessarily the weight loss that causes it.”
Yes, it’s just very heavily correlated, probably because eating healthier and getting more exercise tends to have the side effect of losing weight. It’s not as simple as “lose weight and you’re cured”, but “do the things that make people lose weight” is a significant part of the approach. Diabetes isn’t a “fat people disease” in the sense that most fat people have diabetes — it’s a “fat people disease” in that the majority of people that have it are overweight. The evidence doesn’t warrant treating them as totally independent phenomena.
I’ve approved your comment, mmethursday, because it’s a pretty apt illustration of why I can never fully support the Health at Every Size movement when such blatant misinformation and privileged bullshit infests it.
You, personally, can define “starvation” any way you want, but if you use the word in front of me or here on my blog to refer to an obese person willingly reducing their calories so that they can use up their fat stores, take a fucking seat. Hunger and starvation are real world problems, not the slightly occasionally uncomfortable result of someone taking efforts to get healthier. Real starvation leads to stunted growth in children and malnutrition and wasting in people of all ages. An obese adult eating a few hundred calories per day less than what they’re accustomed to will not lead to any of those things. At all.
To deal with the rest of your ridiculously ignorant comment, many weight loss drugs are “name checked” because the entire point of the recommendations is to help doctors choose better and more effective medications for their patients. As the article makes clear, the previous recommendations didn’t do that because at the time, none of the drugs had been tested enough for there to be any clear recommendations. This represents an improvement in choice for patients.
Please reread my post re: disclosures. I’ve already addressed it and I put it in exceedingly simple terms.
Finally, I never suggested that diabetes is a “fat people” disease or that it’s “punishment.” Type II diabetes, however, thus far appears by all evidence available to be mostly caused by obesity + genetics. If you don’t like that, it doesn’t matter. Science doesn’t change based on what makes you angry.
Stating the facts while firmly and unequivocally stating that fat people have the right to live their lives the way they want without mockery or discrimination doesn’t contribute to stigma and shame. What does contribute to stigma and shame is people using bad logic and bile to vainly hand wave away science and continually attack the doctors who are working to help patients who want help getting healthy. You make the people fighting fat discrimination look like idiots and assholes, like Peta is to vegetarians.
Open your eyes, read the research, and feel free to actually point out anything in my post that is incorrect so I can fix it immediately.
I don’t think I could ever support a single movement if my standard was “some of the people support privileged bullshit”. For example, feminism, there’s a movement utterly free of privileged bullshit right there!
(Not to mention that the commenter acknowledged that there were different degrees of starvation, but Rebecca still seems to read the comment as saying malnutrition and a 100-calorie deficit are more or less the same.)
Okay. Feel free to let me know what that has to do with me not *fully* supporting a movement that is completely infested with pseudoscience.
Did you forget that you’d written the bolded part? That isn’t intended to be insulting; that comment was from over a month ago.
Or do you think it’s bad form for me only respond to part of it? (I chose that part mostly because it’s shorter/easier to respond to.)
If the latter–So, in your second comment you emphasize fully support. Depending on exactly how heavily you’re leaning on fully support, maybe I don’t fully support HAES either, and maybe neither of us fully support feminism, and neither of us even come close to fully supporting the Democratic Party. And you presumably do not come close to fully supporting weight loss evangelism, with cleansing this and this-is-what-our-Paleolithic-ancestors-totally-ate that. I have bloggers/commenters who I agree with and those I don’t, in any of those categories, and I’m sure you do as well.
Picking the worst exponents of HAES to “prove” that HAES is bad is like picking the weirdest-looking signs at an Occupy protest to “prove” that Occupy people are absurd. It’s not that I’m asking you to fully support HAES, but I don’t think you’ve made the case that HAES in its best form is pseudoscience; which may sound weak at first, but weight loss evangelism in anything but its best form is alsopseudoscience. (90% of EVERYTHING is crap.)
[by “best form” I mean the best versions of HAES or weight-loss evangelism found “in the wild”, not a theoretical ideal version.]
@Closetpuritan1: Do you know what the verb “infests” means? Hint: it’s not a synonym for “contains to a very slight degree”.
I don’t think it’s bad form to only respond to part of what I said. But I do think it’s idiotic to pick one thing to respond to and then still get it completely wrong because you don’t understand words.
And LOL at the idea that I’m cherrypicking, as opposed to criticizing one of the most famous and popular HAES bloggers on the Internet. Nice.
I didn’t say you were cherrypicking. I said 90% of EVERYTHING is crap. If you don’t think 99% of weight loss evangelism is crap, you’re fooling yourself. “LOL read what I wrote” back atcha.
Also, double “LOL read what I wrote why don’t you understand words?”: I wasn’t criticizing your choice of Ragen Chastain, I was criticizing your choice of “this comment on my blog is why I can never support HAES”.
This has been an amazingly illustrious set of exchanges here, and I’ve learned a lot about the kind of arguments both sides put forward.
There is a ton of hand waiving on the part of those who are downplaying the risks of carrying excessive adipose tissue. And many of it boils down to appeal to final consequences.
A common theme among fat acceptance activists and HAES proponents is that merely saying that carrying excessive adipose tissue is associated with negative health risk, has the effect of perpetuating stigma. This is an appeal to final consequences. Just because something makes you feel bad doesn’t invalidate that truth.
And Rebecca, the point you made about the absurdity of these people using the term “starvation” is so spot on. Medical interventions aren’t always pleasant. There are side effects. But an intervention is medically justified if the benefits outweigh the risks. One of the side effects of controlling one’s diet is cravings. And cravings aren’t fun. For some people, managing these cravings is incredibly difficult, sometimes causing noncompliance. But saying that these uncomfortable feelings and emotions are even on the same scale as genuine hunger and starvation is so irresponsible.
Thank you so much for this article! I’m sick of dreck like Ragen, This Is Thin Privilege, and Jes Baker claiming that weight loss is impossible and that any doctor who claims that there are health consequences to obesity is a conspiracy-addled shill. They’re as bad as anti-vaxxers. Worse yet, they try to lump their nonsense in with feminism and bully people who actually care about medicine and science out of feminist safe spaces. Pseudoscience has no place in feminism!
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