Earlier this week I posted a link to a news report focussing on the results of a metastudy of 3.5 million men and their development of metabolic diseases over a period of time, which was presented at a conference in Portugal. It is yet to be published and I’m interested to see responses to the findings. In the event that enough methodological criticism arises and the findings are disputed by peers, I’ll obviously post a retraction. It nevertheless fits into a general pattern of studies finding that the ‘obesity paradox‘ is perhaps not as supported by evidence, particularly in the long-term deterioration of chronic conditions like diabetes.
Sharing this cause quite a negative response from some followers, who raised some critiques:
1. That weight loss is impossible to maintain in the long term
2. That it is possible to be fat and fit at the same time
3. That weight stigma is a significant causative factor in poor health, rather than the adipose tissue and excess weight itself
4. That tracking caloric intake and attempting to avoid weight gain through caloric restriction and exercise is causative of eating disorders.
They also linked to a number of studies which I’ve been working my way through reading. Some are quite interesting, though I’m a little critical of the sample size and methodology of a few of the studies included. Unfortunately, being time poor and not very smart, it’s taken me a while to piece my way through some of the readings. Some I’m still reading, some I did have to abandon.
(Long-ass parenthesis alert:
In particular, one reader shared a link to a blog post that referenced Ragen Chastain – a woman who has made the claim that she is training for a full Ironman despite being significantly obese, and who makes claims that obesity does not cause illness and that despite her size she is in the top 5% of fitness, whatever that might look like. On a political front, she associates with a number of prominent members of NAAFA such as her own partner, Julianne Wotasik and Jeanette de Patie. NAAFA an organisation which eventually evolved into an advocacy group for people of size. (NAAFA is worthy of its own blog update one day; suffice to say, to me they bear a striking resemblance to AIDS denial groups, both in their rejection of science and the suspicious and glossed-over deaths/incapacitation of prominent members from the very conditions they deny the danger of.)
I started my blog writing about health fraud, inspired by the death of Jess Ainscough. When people are deceptive about their health and promote non-evidence based health solutions, people suffer. People suffer when women like Ainscough and Belle Gibson promote vegan diets and avoiding chemotherapy as cancer treatment, especially when they are not forthcoming or honest about the actual state of their health and the impact this treatment is having on them. To be perfectly frank, fat activists like Ragen Chastain are no different from them. The basic premise of making wild claims which run contrary to evidence-based medicine, with obfuscation about actual health and fitness metrics, is strongly deceptive and harms people. Just as cancer patients are often desperate, isolated and easily abused, so too are many overeat people. In my eyes, anything that cites Ragen Chastain as a source is as trustworthy as anything that cites Pete Evans, Cyndi O’Meara or insert-your-favourite-pedlar-of-shite-here as a source. Parenthesis OUT.)
I agree with many of the assertions made by those promoting a HAES (or Health at Every Size(tm)) approach. On the other hand, my own lack of experience, confusion or disagreement makes it challenging to accept all the premises asserted.
1. I agree wholeheartedly that a focus on extremely restrictive diets, and the language surrounding weight loss particularly with female patients, is enough to lead to harmful restriction/binge cycles. I’m enough of an example through that. A weight-neutral (or perhaps more appropriately, weight-stable) approach is great for the majority of punters at a normal BMI or low overweight BMI, and it’s a great approach for young people – and preventing these restriction/binge cycles from happening when people are young will do much to halt the rising rate of obesity later in life.
2a. People who are athletic or who participate (or want to participate) in heavy exercise shouldn’t restrict – but do need to be mindful of the physical harm that can come from being too heavy or too light. Maintaining a slight caloric surplus to enable muscle growth and allow for repair following intense injury is generally a sensible idea.
3. Tracking food intake isn’t necessarily harmful. It allows people to see that they are meeting their energy needs for exercise, can help identify macro- and micronutrient deficiencies, manage chronic diseases like diabetes, and allow them to meet athletic and health goals. (It’s also great for people who are unhealthily underweight who are aiming to put on weight for their health.) The idea that anorexic people track food and therefore food tracking is a risk factor for eating disorders is a little fallacious; anorexic people also exercise, drink water over calorically dense beverages, and aim to eat low-calorie, vitamin-dense foods like vegetables to an extreme degree – and yet these are all things recommended as part of evidence-based health maintenance when done to a less-extreme degree. Just because a group of people take a particular behaviour to a dangerous extreme does not mean that the behaviour, decontextualised, is itself harmful. Comparing the extreme restriction that characterises anorexia nervosa to keeping a food log is like comparing dying of hyponatremia due to excessive water intake with having a couple of glasses of water during the day when thirsty.
4. Sadly, for many people, food is the socially acceptable and widely available emotional crutch we use to medicate against trauma, boredom, futility and hurt – much as alcoholics do with alcohol. I am one of those people. The idea that “people who are successful with long-term weight loss maintenance always have food on their mind” might sound disordered, but for those of us with overeating disorders, food is *always* on our minds, whether heavy or not. For those of us who spent $100s of dollars a week on binge food, who spent hours finding times to hide and eat, to dispose of evidence, to lie in our beds crippled with the pain of a 10k+ calorie binge, constant vigilance and mindfulness is unfortunately our burden if we want to recover from this eating disorder, much like total abstinence from alcohol is the burden of an alcoholic, or tracking blood sugar and limiting carbohydrates is the burden of a diabetic, or abstaining from gluten is the burden of a coeliac. The only mechanism that allows us to live a psychologically and physically healthy life is mindful eating and cutting these binges, which will for nearly all result in weight loss.
5. Maybe we need to become more critical of the fact that we treat adiposity and fat differently to other physical organ systems. Weight stigma and beauty standards (and the backlash against this) has had the consequence of elevating body fat and size to an emotional and psychological dimension well beyond what it physically does and this has come at the detriment of everyone. We don’t have an emotive response when told we have splenomegaly or high blood pressure: we adopt our doctor’s advice and ameliorate this.
6a. With the exception of extremely obese (BMI 60+) people who need to radically reduce liver size and lose weight to prepare for crucial surgeries, VLC diets (of 500-800 calories per day only) and shitty crash/pseudoscientific diets are fucked and the people who promote them are fucked in the head. Seriously, the last thing you need are gallstones, reduced muscle mass, and a lack of energy to actually support making good decisions about food and activity.
6b. Substituting more nutritious and satiating ingredients/meals and cutting the occasional discretionary food or beverage item, while allowing for the odd celebration or blow-out, to maintain a healthy weight doesn’t even come close to resembling a VLC diet or the sort of restrictiveness that categorises fatal eating disorders like anorexia nervosa. Drinking skim milk with your coffee, or ordering the small fries (860kj) at Maccas instead of the large (1530kj), or deciding that you don’t need one of these culinary smashmortions after a lunch out with friends does not an after-school special make. Let’s be reasonable, friends.
7. Physical size and adiposity has an impact on health, period. It may express itself differently for different people, and affect them at different stages of their life. While I had excellent blood pressure, blood glucose and RHR as an obese person, and I was fit enough to walk 15km and lift very heavy weights, I nevertheless suffered physical pain from the conditions my size and shape caused: hydradenitis suppurativa (which spontaneously disappeared when I dropped below a particular size and my skin stopped having as much friction against itself); extreme foot and joint pain that limited my movement and activity (which resolved when I took the physical pressure of weight off my feet); and the swelling, paraesthesia and agony of lipoedema in reducing the size of my legs. The very point of the conference presentation is to argue that it’s only a matter of time before metabolic and musculoskeletal issues present as a consequence of size and adipose tissue. (For men especially – who were the subjects of the study – it’s particularly significant due to androgenic patterns of fat distribution being far more dangerous than for women.)
I suppose a critique that you could make of me at this point is that I am close-minded and ignoring evidence: that I’m unwilling to change my position and have my head in the sand. That would be a fair point. I *must* be ignorant about the plethora of writing about size =/= health, or fatphobia, or HAES as a framework to reconcile size, self-acceptance and health behaviours.
Except that’s not the case.
For many years, I did believe in Fat Acceptance and the idea that obesity had no impact on health. I read, for a long time, blogs like Shapely Prose, Adipositivity, Big Fat Science and Shakesville. I parroted on the words of bloggers like Kate Harding, Lindy West and Marilyn Wann, and shared the work of Dr Linda Bacon with people.
And yes, I did read – and take comfort – in Ragen Chastain’s writing. I knew that if Ragen could train for an Ironman – despite never actually participating in one, and being pretty non-forthcoming with her actual training regimen – then I too could be fit at my size. And that’s a pretty dangerous spiral of poor logic to fall into.
Going against something I believed passionately in for several years in acknowledging that my own obesity was having a significant impact on my quality of life and health took a lot of knocking down the hubristic ladder. As the evidence changed, so too did my opinion. It meant stepping back from an emotional response to food and to my extreme self-harming behaviours, and being objective about my intake, about my rationale for eating, and about what this was doing to me. I was lucky in my endeavours to have many friends support me – some of whom had lost very significant amounts of weight and maintain this loss for 10+ years. Their advice was nothing short of supportive:
- To be patient and have compassion for myself
- To find activity that I love and keep it up (and hey, come join them for a Sunday run and coffee or a walk after work along a beautiful stretch of coastline!)
- To ignore the nonsense of “nutritionism” – I did not need ridiculous superfoods, nutritional supplements or even a 100% perfect diet to maintain health. (If anything, my diet is *less* perfect than it used to be when I was obese.)
- To let loose on occasion and enjoy the second beer or slice of cake
- To use food as vital, helpful fuel and to appreciate its role without elevating it to emotional support, medication or source of excessive enjoyment to the cost of other parts of my life, as it had in the past
- To remember that everything is the accumulation of hundreds of little daily choices that eventually become less cognitively and emotionally demanding to make.
My story is not representative of all obese people. There are plenty of reasons why people eat at a caloric excess, just as there are plenty of reasons for why people eat at a caloric deficit.
The mechanism of weight loss – calories in being less than calories out – is pretty basic. Achieving this at not only an individual level but at a whole population level is catastrophically challenging. People are people: we all suck at making gestalt estimations when it comes to food intake (obese people and underweight people especially), our society is the opposite of conducive to maintaining health, and we all have social and cognitive limitations that prevent us from making those hundreds of little decisions over a very long period of time. Some individuals – with psychological and social support and education – can lose weight and maintain it permanently; for many, they lack the support, cognition, education, practicality or behavioural attributes to achieve this in the long term.
But the challenge of identifying a long-term, effective and safe means of losing weight does not mean that we shouldn’t be concerned about the impacts of obesity and the fact that rates are rising everywhere. It does not change that body fat itself has a significant role in affecting human health. It does not change that eating disorders – both of the restrictive and compulsive overeating nature – need to be treated and that we all need a better understanding of their causes and consequences.
While I agree that we should all participate in healthy behaviours at any size – mindfulness over food quality and intake, exercise, seeking support and engaging in salf-care and that it is possible to make healthy improvements even if people remain overweight, the plight of the critically underweight and overweight is evidence enough that at some sizes, health is impossible because of the size. The super-obese who incur life-threatening skin infections due to being unable to clean a body of their size, who require diabetic amputations, and who become dangerously immobilised due to their size are clearly unhealthy because of their size, just as the extremely underweight who develop fatal arrhythmias, refeeding syndrome and multiple organ failure are unhealthy because of their size.
So, what’s the answer more broadly? I like Ben Goldacre’s quote “I think you’ll find it’s a bit more complex than that” to cover it. Whatever the case, empathy, supportiveness, moderation and education is critical; stigma, shaming and hatred is surely verboten. Health authorities and the law needs to take a stronger stance on responding to and critiquing shit like this. The answer may not be “diets”, in the way we understand diets – prescriptive, short-term interventions with a focus on significant restriction or eliminating food groups – but there’s a significant difference between long-term, moderate food modification and mindfulness and throwing down a glass of apple cider vinegar and avoiding eating anything white ever. If the trade off is weight maintenance or slowing the halt of weight gain, it’s a good start, and perhaps time will only tell if the study I initially linked to is debunked (and in the game of open-mindedness and critical inquiry, I am interested to follow discussion of it).
I appreciate that I’ll lose followers with this post. I ruffled feathers when I first posted about cancer fraud, vaccines and paleo diets, after all. But the same scientific methodology, doctors and peak bodies that advocate for vaccine programs are those that recognise the harm posed by obesity. To me, as a skeptic, this was enough to crack my recalcitrance. I might not convince the die-hards, but I might get through to the fence sitter or the reader who hasn’t taken the time to consider the issue in more depth.
And while this post might not be the thing to win you over, it might be enough to shake that ladder a little.