Frequently Asked Questions:
Warm Regards, Susan Harmony
Dr. Bacon’s response:
It’s disappointing to me that you read my book and are still so strongly entrenched in a dieting mindset. But I do understand how easy it is to hold onto that belief system. Myths about weight are very deeply entrenched, reinforced by many people considered to be “experts.” And the fantasy of dieting as a solution is very tantalizing, given the social rewards and purported health advantages. It’s not surprising that considering Health at Every Size touches strong resistance.
In response to your specific comments, yes, I am aware of the research that shows that calorie monitoring provides short-term success in reducing calories. That’s not at all surprising to me. Many people stick to their diets in the beginning; hope and determination can be quite high in those early stages. That initial stage of watching the scale can certainly provide motivation. Also, physiologically our bodies regulate weight on a long-term basis, not short-term. So many people can get away with weight loss in the beginning, without meeting up with physiologic resistance. The reference you provided was for a study that only monitored people for a year. Many studies show short-term weight loss, particularly when participants are in the throes of the intervention and getting support (and in this case, drugs and counseling).
You referred me to a website which agrees with my reading of the extensive literature: that the vast majority of people regain the weight. As Kriger comments after his discussion, “Those aren’t good odds.” This is completely consistent with the known physiologic mechanisms for how body weight is regulated: Most people’s bodies resist maintenance of weight loss – and the mechanisms are slow and gradual.
But here’s where I part company with the claims on the website. He goes on to say “While the statistics are grim, it doesn’t mean that you can’t be successful at maintaining long-term weight loss.” Kriger and you cling to the fact that if a few people can do it, that must mean that everyone can beat the odds if only they try hard enough. I went to a dance performance recently and saw a contortionist who bent her body like a pretzel. I’m not naïve enough to think that with enough stretching and determination, I will be able to do that too. I recognize that all traits have statistical outliers – but that doesn’t mean everyone else can have the same experience. We’re all wired a little differently and have different outcomes from doing the same things – though we’re enough alike that many people have similar outcomes. I do stretch regularly – I recognize its value – but I hold no illusions that I will ever have the degree of flexibility of that contortionist. If I did hold onto that illusion, I’d feel like quite the failure and I might eventually come to the conclusion that stretching wouldn’t get me there and give up on it, not seeing all the other benefits I get from stretching.
The idea that losing weight – and maintaining it – is simply a matter of monitoring and restricting your calories is well-disproven by the scientific evidence – described in my book and elsewhere. There are so many reasons it is disputed, not the least of which is our inability to control the mythical energy balance equation. Restrict your calories and your body may just compensate by restricting energy expenditure – and eating less could actually cause you to gain weight! (I add the phrase about maintaining weight loss because the body’s regulatory systems are long-term; short term weight loss is relatively common and often unresisted.) There is wide variability in how we respond to eating less; that it results in maintained weight loss for a small percentage of individuals does not mean it is will have the same result for others. I think about a person who encounters that biologic resistance. The message they would get from your belief system is that they’re doing something wrong, just not trying hard enough, it’s all their fault. I encourage you to consider how damaging it may be to continue to spread that message.
It shouldn’t be so surprising that our bodies have regulatory systems designed to keep us healthy – and at an appropriate weight – that’s an important evolutionary trait. I find the science behind that fascinating – the hormonal interplay and how it manipulates our choices and desires – as you know if you’ve read my book. People who had a sufficient food supply used to be fairly weight stable throughout life, long before dieticians were around to tell us what and how much to eat. But you know that: you’ve read my book and have been exposed to the experiments that show that when people don’t try to control their calories, when they just eat when they’re hungry and stop when they’re full, there’s a natural, healthy regulation that occurs.
What concerns me in your note is that you think I’ve given up hope and that I have a defeatist attitude. I want to reassure you that nothing could be further from the truth. Health at Every Size is all about restoring hope, not giving up. I encourage you to re-read the introduction, which includes personal descriptions from participants about this process of gaining hope.
Health at Every Size is not anti-weight loss. We understand that weight loss is a side effect that sometimes occurs when people adopt healthy habits – and we also recognize that many people who adopt healthy habits don’t lose weight. Our goal is to be weight neutral – to encourage the habits and attitudes which we know are valuable, and to let the weight settle where it may. And to support people in appreciating themselves no matter what the outcome. They don’t have to wait until they lose weight to feel good about themselves.
Quite aside from the lack of scientific support to suggest that dieting is successful, I find the idea of monitoring and restricting food quite sad. Seems so disempowering to give up our internal felt sense of what’s right to some outside authority’s idea of appropriate foods or amounts, no? I’d miss the joy and spontaneity in eating. And I love knowing that I can trust myself. Every time I think of diets, I think of some women I once saw standing near a buffet filled with food. One looked at the display and said, “Oh, I really shouldn’t.” Another commiserated, saying, “It really is tempting, isn’t it?” They all looked on sadly. Who wants to feel like they constantly have to monitor and fight their desires? Contrast that to Kelly’s experience, which she allowed me to quote in the introduction:
“Before participating in the Health at Every Size program, I never truly enjoyed food. Either I felt compelled to steer clear of my favorite foods, like potato chips and ice cream, or I ate them and felt guilty. And I felt like I could never get enough. But it’s different for me now. As much as I love pizza, when my body’s had enough I just lose interest. I don’t have to fight my desire to eat because I just don’t want to eat any more.
Before, I didn’t know that I could trust myself. My fear was that if I let down my guard, I would eat out of control and just keep gaining weight. But that never happened. I don’t count my calories or limit fat, I don’t feel guilty when I eat—and everything is okay. I’m not scared of food anymore. My weight has stabilized and it seems like my body is doing a pretty good job of taking care of me! More importantly, I can now say that I absolutely love food. I never knew chocolate was so amazing!”
I know that it can be very threatening to consider that if you just give up that control and trust yourself, everything is going to be okay. That it’s okay – even good – to enjoy food. That we like food is a good thing – our reward for nourishing ourselves. It saddens me that you can’t celebrate this biologic reward system.
As disappointing as it is to know that my book wasn’t convincing to you, I also recognize the limitations of any book: there is no perfect argument or way of framing things that will resonate with everyone. All I can do is present it in a way that I think is meaningful. And I do appreciate that the book has been meaningful for a great number of people, supporting them on a journey towards increased health and happiness.
Regarding your comment that you are aware of a few studies that demonstrate long-term maintenance of weight loss, I do like to track the science, and I haven’t been finding reputable studies that demonstrate this. Please do provide me with the references you refer to. Thank you for the offer. Thus far, all the studies I’ve read that purport to show long term weight loss have had serious problems – most only track and report on a small minority of the participants. In fact, just last month, there was an article highlighting this, entitled “Validity of claims made in weight management research: a narrative review of dietetic articles,” written by Lucy Aphramor. You may want to read this article and see if it helps you to read the research in a new light. I’ll look forward to reading the articles you are referring to.
Wishing you all the best,
David Heller, M.D., South Weymouth, Massachusetts
Dr. Bacon’s response:
Joint issues are one of the exceptions where a causative mechanism is more evident. But it may not be as clear cut as we think. The rationale, of course, is that the heavier you are the more stress you place on weight-bearing joints. However, the fact that heavy people with arthritis also frequently have arthritis in their wrists suggests that the connection is more complicated than we presently understand. (I’ve also been intrigued when considering a related issue – that the same stress on the bones also confers an advantage: heavier people have reduced risk of osteoporosis.)
But nonetheless, even though there is likely a causative factor involved and weight loss may be helpful in reducing symptoms, my advice would be no different. We don’t have a clue how to help people to lose weight – there is certainly no research to substantiate that any method is effective. (As much as we’d like to believe that consciously manipulating the old calorie balance equation does the trick, it just isn’t proving true!) And there’s certainly extensive evidence to show that prescribing weight loss is damaging.
So my first bit of advice is that you give the heavy person the same suggestions you would give to someone slender. Appropriate exercise? Meds? Surgery? Then do what you can to support them in implementing your advice and handling the challenges posed by a larger body. For example, you may have to be more creative in suggesting ways to get more active. That includes the issue of what types of movement you prescribe in addition to problem-solving how to overcome barriers to exercise. (Example: a slender person out for a run or at the gym gets support and encouragement; a heavier person trying those same things is often subject to ridicule. This makes it harder for the larger person to implement your advice.)
So I see that as your task to best help your patients: learn more about how to support people being functional in their larger bodies.
And of course, if you suspect improved eating habits is warranted, I would suggest a referral to a health care practitioner who specializes in this. (But I’d be wary of making this assumption based on size; many thin people can benefit from this advice as well, and not all heavy people have a problematic relationship with food.)
It is possible that if your patient has poor health behaviors, weight may change as a side effect of improved behaviors, making this a helpful adjunct to your treatment. But I also want to encourage you to be open-minded regarding weight outcome. Though it seems like common sense that weight loss should be a side effect of improved health behaviors, this isn’t always true. Mechanisms for weight gain are very different than weight loss, and reversing bad habits doesn’t always result in weight loss – though it will result in health improvement.
Best wishes in your work and glad to hear of your open-mindedness to Health at Every Size.
And back to Dr. Heller:
It is absolutely wonderful and delightful to finally hear someone speak about weight with such commonsense and clarity. Having sat with many an overweight patient desperately in need of knee pain relief, having performed many knee and hip replacements in such patients and then enjoying watching them become happy once the pain is relieved, and seeing them increase their activity level, has given me great satisfaction as an orthopedist. I always suspected that the establishment was overstating the importance of weight with regards to the risks of surgery, particularly in orthopedics. So, I commend you and thank you for your thoughts and stance on this issue. I now feel I can speak better at our conferences when this discussion comes up in the future.
Dr. Bacon replies again:
Now get yourself over to the Fat-Friendly Health Professionals list and sign yourself up, Dr. Heller. There are countless heavy people with joint problems who have been mistreated by orthopedists or fear seeking treatment and getting the “lose weight before I can help you” lecture. Glad to have you as an ally. We need more caring, competent physicians!