Recipe For Life
Is Attuned Eating the Answer to Diet Failure?
It's that time of the year again. Every January, the weight-loss frenzy begins anew as the overeating of the holiday season subsides and millions of us resolve that this will be the year that we will lose weight and keep it off. Dieting has become one of the great American pastimes, and no matter what our size, none of us is immune from the messages that we're too fat—or that we'd better start worrying about becoming too fat.
We read about the latest diet craze, enter weight-loss contests, and talk about our dieting struggles. We celebrate the shedding of pounds, and commiserate about their eventual return. As we stand in line at the grocery store, surreptitiously scanning The National Enquirer, we're filled in about the fat-thin-fat-thin roller-coaster ride of Oprah, Russell Crowe, Kirstie Alley, Jessica Simpson, John Travolta, and any other celebrity who puts on or takes off the pounds. As we unload our shopping cart, magazine covers promise that we can lose weight and keep it off, that we can have firm abs and thin thighs, and that we can accomplish all of this before the spring fashion season rolls in. It's hard to miss the irony that the same magazines feature recipes for delectable five-cheese lasagna and melt-in-your- mouth double-chocolate fudge cake.
The $60-billion-per-year diet industry keeps offering new programs and plans. Low-fat, low-carbohydrate, and low-calorie diets get recycled with new names, claiming that they aren't a diet (since, as we all know by now, diets don't work!), but a way of life. Fitness clubs ready themselves for the onslaught of new members, counting on the fact that these exercise enthusiasts will work out religiously for a month or two and then drop out, fleeing the tedium of Stairmasters and treadmills.
The common cultural notion that anyone can successfully lose weight and keep it off with enough hard work and commitment mirrors the values embedded in the American Dream. Yet despite this collective belief—and the short-term weight loss that occurs with just about any type of weight-reduction plan—the most frequently cited statistic is that 95 percent of dieters will regain the lost pounds. Given that a few percent will maintain the weight loss, we all know someone who can claim "success," yet the vast majority will regain the weight. Although the blame—and shame—for the failure is usually placed at the dieter's doorstep, strong physiological, psychological, social, and even economic forces make dieting a losing battle.
As the New Year's resolution to diet and lose weight for good gives way to the almost inevitable cycle of overeating and weight regain, my phone begins to ring with queries from people weary of this dance. Clients struggling with compulsive or binge eating often seek therapy because they're aware that their overeating may have an emotional component. But the idea that people overeat to soothe or avoid painful emotions, while often true, is only part of the story. If we focus only on the emotional reasons for overeating, we neglect factors that cause the diet/binge cycle to take on a life of its own. In fact, the empirically demonstrated truth behind the pop truthiness of "diets don't work" is that dieting—intentional self-deprivation—sets in motion automatic physiological and psychological factors that actually trigger overeating. In fact, there's growing evidence that diets make us fat!
Why Diets Fail
The most immediate reason that diets don't work over the long term is that they promote a loss of the internal signals for hunger and fullness that are necessary for normal eating. This was the finding of a classic study conducted by Janet Polivy and Peter Herman at the University of Toronto, published in 1999. In this experiment, a group of dieters and a group of nondieters were given the task of comparing ice cream flavors. Participants in each group were divided into three subgroups. Before getting the ice cream, the first subgroup was asked to drink two milkshakes, the second subgroup was asked to drink one milkshake, and the third subgroup wasn't given any milkshakes. Next, the researchers offered the groups three flavors of ice cream and asked the participants to rate the flavors, eating as much ice cream as they desired.
The results revealed that the nondieters ate as you might expect: those who hadn't consumed any milkshakes ate the most ice cream, those who'd consumed one milkshake ate less ice cream, and those who'd consumed two milkshakes ate the least. The dieters, by contrast, reacted in the opposite way. Those who were offered no milkshakes before the taste test ate small amounts of ice cream, those who drank one shake ate more ice cream, and those who'd consumed two milkshakes ate the most ice cream!
The researchers termed what had happened to the dieters "disinhibition," which occurs as a result of a "diet-mentality." The milkshake preload had a different effect on dieters than on nondieters. Nondieters, eating in an unrestrained and normal manner, tend to regulate their food consumption according to internal physical cues of hunger and satiety. Therefore, in the experiment, nondieters regulated the amount of ice cream they ate based on perceived fullness. What could be more obvious and natural?
The dieters, however, reacted in the opposite way—the more milkshakes they consumed, the more ice cream they ate. Why did they lose the capacity to regulate their intake? According to the researchers, this "counterregulation" occurs because a milkshake preload disinhibits a dieter's usually inhibited or restrained eating, almost like a switch: "I've blown it anyway, so I might as well keep eating before I go back on my diet." This is an almost irresistible incentive to go on eating well past physical fullness.
Most of us have internalized cultural ideals about the body we'd like to have and how much we want to weigh, based on improbable models of perfection beckoning from just about every media site. But these images usually bear little resemblance to what's natural, healthy, and physically possible for our individual bodies, because genetics plays a major role in determining our size and shape.
Weight is the result of a complex combination of factors that aren't yet fully understood. Although the question of nature versus nurture has long been debated when it comes to weight, research shows that the weight of adopted children resembles that of their biological parents, not that of their adoptive parents. When researchers looked at identical twins raised apart, they found that their body-mass index was nearly identical, despite different environmental settings. This means that the influence of genetic inheritance has an enormous impact on what we weigh.
For example, metabolism plays a significant role in determining our weight. Resting metabolic rate refers to the amount of energy the body burns when not engaged in physical activity; it accounts for approximately 70 percent of the calories we burn each day. About 40 to 80 percent of the influence for resting metabolism is apparently inherited. In the journal Nature Medicine, Jeffrey Friedman, director of the Starr Center for Human Genetics, writes, "The commonly held belief that obese individuals can ameliorate their condition by simply deciding to eat less and exercise more is at odds with compelling scientific evidence indicating that the propensity to obesity is, to a significant extent, genetically determined."
This inherited weight range, known as the set point, is the weight your body settles at when you're eating in response to signals of hunger or fullness and engaging in some level of physical activity. Our set point acts like a thermostat, seeking to maintain our natural body weight within a range of 10 to 20 pounds. When we take in less food as fuel, our body deals with this reduction by slowing down to conserve energy. Metabolism is lowered, reducing the rate at which calories are burned. Within 24 to 48 hours of beginning a calorie-restricted diet, metabolic rate decreases 15 to 30 percent. Our body has successfully slowed itself down to defend against this self-imposed famine. By contrast, when our body takes in more food than it needs as fuel, the metabolism speeds up and burns calories more quickly. In her book Health at Every Size: The Surprising Truth about Your Weight, Linda Bacon, a physiologist specializing in nutrition and weight regulation, explains that when this mechanism is working properly, it functions as a force that pulls you back to your comfortable range whenever you veer away; however, if you consistently override your body's signals of fullness, this system becomes broken. The goal is to find your healthy weight, keeping in mind that even if we all ate the same and exercised the same, we wouldn't weigh the same. Weight is a complicated matter, which can be affected by a variety of factors, including medical issues, such as thyroid problems or polycystic ovary syndrome, the side effects of medications, poverty, stress, and lack of sleep.
Beyond the psychology of dieting and our largely inherited physiology, we're still driven by the evolutionary pressures that drove our ancient hominid ancestors—hunters and gatherers, who had to make the most of every bite to survive. Sometimes their food was plentiful, but during times of scarcity, their bodies adapted by lowering their metabolism to conserve every calorie consumed. Following a period of scarcity, their bodies became even more efficient at storing fat in preparation for the next famine. These fat-layered bodies, better able to adapt to scarcity, were likelier to reproduce. As a species, therefore, we've inherited a predisposition to hold onto fat after each period of scarcity. Today, our bodies can't distinguish between hunger caused by famine and hunger caused by a self-imposed diet—and they react to the latter as if it were the former. The "failure" of diets is actually a "success" in terms of species survival!
When dieting for weight loss, our bodies respond to the perceived famine by feeding off fat and muscle. Muscle is the metabolically active part of our body: the more muscle we have, the more calories we can burn. Since every weight-loss attempt includes the loss of both fat and muscle (but what's regained is only fat), dieters burn even fewer calories, which makes it easier to gain weight and results in a higher fat-to-muscle ratio. Repeated dieting attempts may significantly increase the percentage of body fat over time. In fact, in 2007, Traci Mann and her colleagues at UCLA conducted a comprehensive and rigorous metanalysis of 31 long-term studies of obesity treatment for Medicare patients. They found that despite losing 5 to 10 percent of their starting weight in the first six months, the vast majority of dieters had regained all the weight—and within four or five years, one-third to two-thirds of subjects had regained more weight than they'd lost.
In 1993, after it was discovered that less than one percent of dieters could maintain their weight loss for five years (the criterion for success), the Federal Trade Commission charged 17 companies, including Weight Watchers, Jenny Craig, and Nutrisystem, with making false and deceptive claims about the safety and efficacy of their programs. While many programs claim that they aren't diets, whenever food is manipulated for the purposes of weight loss, it is, in fact, a diet, and not one of them has produced research demonstrating long-term results.
The pitfalls of diets have been known for decades. Not only does dieting make people fatter: it affects psychological health. In a classic study during the 1940s, researcher Ancel Keys studied 36 conscientious objectors to see what would happen if they were placed on a semistarvation diet for six months. The men were given nutritionally adequate food, with the same calories as most commercial weight-loss plans. The changes observed were dramatic. In addition to losing about 25 percent of their body weight, they experienced noticeable personality changes, becoming lethargic, irritable, depressed, and apathetic. They became obsessed with food, and they talked constantly about eating, hunger, and weight.
Once the men had begun the refeeding portion of the study, restrictions were no longer placed on their eating. They binged for weeks, often consuming food to the point of feeling ill. Despite their overeating, they continued to report feeling ravenous. The weight previously lost returned rapidly as fat, and most of the men lost the muscle tone they'd had prior to the experiment. Some of them ended up weighing more than they had before the start of the study. Their emotional stability and energy returned only after they'd regained the weight.
Whether our clients meet formal diagnostic criteria for binge-eating disorder or experience similar, but less intense, patterns of compulsive eating and dieting, we must confront the role of dieting in maintaining their behavior. We need to remember that people who diet are eight times as likely to develop an eating disorder, score higher on measurements of stress and depression compared to nondieters, and experience greater health risks, such as cardiovascular disease and Type 2 diabetes as the result of weight cycling. Perhaps most insidious of all is the shame that our clients experience, first about the perceived unacceptability of their bodies, and then about their failure to maintain weight loss after they've struggled to adhere to one or more prescribed diet methods.
The Antidote to Dieting
The prognosis for losing weight and keeping it off as a result of dieting is bleak indeed, yet there's another way—a Zenlike way of eating—so natural, so intuitive, even so commonsensical that it's almost too obvious. Still, it took a consciousness-raising movement to reclaim the idea of eating in response to internal cues of hunger and fullness, rather than following external rules and prohibitions that almost inevitably lead to overeating. The notion that people who'd spent much of their adult lives following entrenched and often punitive dieting regimens should and could relearn how to eat in a more natural, normal way was introduced during the 1980s by pioneers Susie Orbach (Fat Is a Feminist Issue), Jane Hirschmann and Carol Munter (Overcoming Overeating), and Geneen Roth (Breaking Free from Compulsive Eating). While each has her own take on how to stop dieting and make peace with food, their revolutionary work—now increasingly supported by research—generated a movement that researchers often call intuitive eating.
Intuitive or attuned eating teaches people to reconnect with natural, inner signals telling them when, what, and how much to eat. We're born knowing how to eat. Babies cry when they're hungry, alerting a parent or caretaker, who in response offers a breast or a bottle. When satisfied, infants turn away, indicating their fullness. They may need to eat again soon, but they're in charge of the feeding schedule.
As children grow older, numerous factors can interfere with their ability to identify hunger needs and ensure an attuned response. Parents concerned about nutrition may "force" children to eat foods they don't like, or restrict foods they enjoy. The structure of family mealtimes and school may prevent children from eating when hungry or demand that they eat when not hungry. As they become more aware of their body size and the culture of dieting, they may become caught in the dietary roller coaster, compromising their body's ability to self-regulate. Using food to manage emotions can further move them away from their own internal cues for hunger and satiation.
Attuned eating, by contrast, supports people in their journey to reestablish a natural, anxiety-free relationship with food. The first step in this process is to ask clients if they know when they're physically hungry. At workshops, I always pose that question to my audience, and find that therapists, as well as clients, are frequently disconnected from the physical sensations of hunger. Typical hunger cues participants bring up—weakness, light-headedness, irritability, headaches, and poor concentration—actually indicate that they've waited too long to eat. Unfortunately, when we let ourselves become that ravenous, not only do we experience physical discomfort, but we also feel desperate and are much likelier to eat whatever is available.
After years of dieting, Lucy found herself completely disconnected from physical hunger. When she was following her diet, she ate by the clock at prescribed times, following a rigid, low-calorie food plan that had little to do with physical hunger. When she broke her diet, her eating became chaotic. She'd either skip breakfast or grab a few cookies and her morning coffee on her way out the door. For lunch, she often opted for the convenience of fast food, eating quickly in the car to save time, and then frequently continued to munch on the candy and chips available in the nearby vending machine as she tried to tame the boredom and stress of her afternoon. But on other days, she might have only a diet soda and yogurt, so that by the end of the day, she felt headachy and crabby, indicating that she'd waited too long to feed herself. In fact, she reported feeling so ravenous one day that when she met her friend at a restaurant, she consumed half the bread basket, a heaping plate of pasta Alfredo, and a hot fudge sundae.
I helped Lucy learn to check in with her stomach on a regular basis by asking herself, "Am I hungry?" every 15 to 30 minutes. If she noticed physical hunger, she needed to eat, so that she could develop the hunger-food connection that's essential for breaking out of overeating patterns. I suggested that she welcome her hunger by saying to herself, "This is terrific. I get to eat!" But after so many years of feeling guilty about food, she found it hard to believe that she was truly entitled to eat and could trust her body to tell her when to eat.
Lucy found it useful to think of a young child who was hungry, realizing that she'd never say to that little girl, "Too bad if you're hungry. I'm not going to feed you." I instructed her to carry food with her when she was away from home and take it to her office, so that even if she got caught up in a project, she could take care of her need to eat. She noticed that, as she learned to listen to her body's reliable internal signals, she became less focused on food and her anxiety about whether she "should" or "shouldn't" eat decreased.
After so many years of deciding what to eat based on diet rules and food plans—or eating in rebellion to those rules—Lucy was surprised when I asked her in our session what she was hungry for. She'd had breakfast earlier in the day, but it was now 12:45 p.m., so I'd asked her to check in with herself and see whether she was hungry. She said she could feel some hunger, but didn't have a clue what she wanted. Usually she ate whatever was in the house, or whatever was convenient. The idea that her body could guide her in her food selection was truly novel.
Most of us have had the experience of craving something—and the wonderful feeling of actually getting it. Many of us also know the feeling of wanting something to eat, deciding we "shouldn't" have it, eating something else, and, feeling deprived and unsatisfied afterward. It's this experience that often leads to standing in front of the refrigerator, grabbing and eating whatever's there.
As she sat in my office, Lucy said that she didn't have a specific craving and really didn't know what she wanted for lunch. I asked her to think about whether she wanted something hot or cold, and she quickly responded, "Hot." I then asked her if she wanted something mushy or crunchy, spicy, bland, or salty. As we narrowed down what would taste good to her and feel good in her body, she settled on Kung Pao chicken with noodles from a local Chinese restaurant.
Her next step was to order this dish and see whether it was a good match. If she did feel physically and psychologically satisfied from the food, she'd strengthen her trust in herself and her ability to figure out what to eat in the future. If the match wasn't right, she could use it as a learning experience. What would have made her lunch more satisfying? As long as Lucy could refrain from judging herself for what she craved, she could begin to gather all kinds of eating experiences that would help her become more attuned to what she really needed and wanted at a particular moment.
Learning not to be judgmental during this process is key. Like most clients, Lucy had a list of "forbidden" foods that she believed weren't OK to eat. Part of the journey toward attuned eating is to realize—and become comfortable with—the idea that our bodies crave a wide variety of foods. I'll frequently say to my clients that I've never met anyone who goes through this process and only wants to eat cookies, candy, and ice cream—nor have I ever met anyone who only wants fruits, vegetables, and salads.
As clients give themselves permission to eat formerly forbidden foods, they're likely, at first, to eat more than they need. After all, these foods have been off-limits for some time, and it's exciting to be able to eat them again. What helps clients get beyond overeating and eat a cookie only when they're hungry for a cookie is the understanding that the food won't be off-limits again. Scarcity makes us feel anxious, needy, and greedy, while abundance allows us to feel calm, satisfied, and fulfilled. If clients believe that the next diet is just around the corner, they'll continue to overeat. If they prove to themselves that they can keep cookies available and eat them when that's what they're hungry for, they'll find that they no longer need to eat them out of a feeling of deprivation.
After several sessions, Lucy told me that she'd binged on ice cream before our first meeting because she was sure I'd tell her that she shouldn't eat ice cream. Now that she understands this philosophy, she reports that she has ice cream in her freezer at all times, and eats some when that's what she's hungry for. She explains that in the evening, she often wants something sweet, and has discovered that eating ice cream when she wants a peach won't satisfy her any more than eating a peach when she craves ice cream does. Attuned eating doesn't mean eating whatever you want, whenever you want, and as much as you want. Instead, this method guides you to eat what you're hungry for, when you're hungry, choosing from a wide variety of possibilities that includes nutritious foods.
The final step in attuned eating is stopping when full. At the beginning of this process, Lucy, like most clients, frequently ate until she felt stuffed, finding it easier to recognize her signals for hunger than for fullness. Gradually, she began to notice and pay more attention to these feelings. She realized that when she made the right match in choosing a food that left her feeling satisfied, it was easier to stop. She learned that without a physical signal to start eating—if she used food to assuage boredom, for example—there'd be no physical signal to stop: eating would be entirely disconnected from hunger and satiety. Rather than reprimanding herself for eating past fullness, she allowed herself to consciously experience how her body felt, asking herself, "Is this OK with me?" When the answer was "no," but she still made the decision to continue eating, she learned to do so without self-recrimination. As she became more attuned to her body's messages, Lucy found it much less tolerable to eat past fullness. In fact, she understood that the sooner she stopped eating, the sooner she'd get hungry and could enjoy another satisfying eating experience.
Since we live in a culture that more or less institutionalizes disordered eating, many people—who aren't, or don't consider themselves, overeaters—find they can still benefit from this perspective on eating. In my 18 years of using this approach, I've had many friends and colleagues tell me that just becoming more mindful about their hunger and fullness helped them build a better relationship with food. One friend commented that she used to feel bad when she had an occasional craving for a McDonald's cheeseburger and fries; now she takes pleasure in the experience, without guilt. She realized that it was worth spending money on the fresh raspberries at her grocery store to satisfy that desire.
This approach is well suited to people practicing different eating styles—vegetarian or kosher, for example—as long as their orientation to food is based on philosophical or religious principles and not on the desire to lose weight. Conscious nutritional considerations—as long as they aren't diets in disguise—are well-adapted to intuitive eating. For example, one client felt that putting soy in her diet would contribute to her physical well-being and decided that a glass of soy milk in the afternoon would coincide with her body's need for protein. If your client receives advice from her doctor to make dietary changes that can positively affect a health issue, such as reducing saturated fats to lower cholesterol or understanding the effects of sugar consumption in the case of diabetes, and she's able to follow these recommendations, there's no problem. Unfortunately, many people report that a visit to their doctor in which they were instructed to restrict food triggered overeating.
Most of these clients aren't self-destructive or unmotivated to become healthy. Rather, the dynamics of the diet/binge cycle render them extremely sensitive to perceived deprivation, especially when accompanied by the familiar advice to lose weight. Additionally, if clients frequently turn to food for comfort when experiencing anxiety, the scare tactics or dire warnings used to convince clients to restrict their diets create fear that puts them at greater risk of overeating. Learning to become an intuitive eater of all foods, by contrast, makes it easier to adopt dietary changes as a means of good self-care, without the sense of deprivation that often triggers dysregulated eating.
I believe that most clients can't begin to explore their use of food for affect regulation until they have an internal system of physiological self-regulation in place. When people are caught in the diet/binge cycle, thoughts about eating and weight create anxiety, draining mental energy and making it even harder to face the uncomfortable feelings that may drive them to binge. But once they're no longer in the throes of the diet/binge cycle and have developed a consistent and reliable structure to feed themselves, they're in a much stronger position to explore the relationship between eating and their emotions.
Sasha knew that she overate in response to a wide range of feelings—anger, sadness, loneliness, boredom, and even happiness. It wasn't the feelings themselves that activated her overeating: it was her inability to tolerate a particular feeling that prompted her to turn to food for self-soothing. Clients often use words like numbing, comforting, and distracting to describe how they feel when they eat. This process is often unconscious. Sasha doesn't say to herself, "I'm feeling angry with my husband, but I can't tolerate this feeling, so I'll go eat something to calm myself." Instead, she finds herself at the refrigerator, reaching for food, even when she isn't hungry. She may be aware that she's trying to push away her anger; or, like many clients, she may not even be aware that something is bothering her. This action sets off a chain of events that takes her further away from whatever negative emotion first threatened her.
As she continues to eat, Sasha begins to criticize herself, declaring that she's out-of-control, fat, and disgusting. In the past, these reprimands would have led her to conclude that she must go on a diet to lose weight; however, she now understands that losing weight won't solve the real problem, though she may not yet be conscious of what that problem is. Instead of denigrating herself, she speaks to herself with compassion, saying, "I'm reaching for food and I'm not hungry. Something must be bothering me, and this is the best way I have to deal with it right now. I look forward to the day when I no longer need to turn to food."
Four months into therapy, Sasha could report that most of her eating was now in response to feelings of physical hunger. She was ready to work on the emotional aspects of overeating. Gradually, when she found herself reaching for food even when she wasn't physically hungry, she learned to ask herself, "Can I wait?" When the answer was "No," because she felt too anxious in the moment without this form of self-soothing, she gave herself permission to eat anyway, since the objective was for her to outgrow her need to use food for comfort, rather than to exert control over her eating. She learned to give herself gentle nudges in the direction of waiting to eat, by reminding herself that food tasted and felt better when she was physically hungry and becoming curious about what was really bothering her at that moment. Her goal was to feel that she was in charge of her eating—to make mindful decisions that left her comfortable and satisfied—as opposed to controlling her eating, which meant using restraint fueled by guilt.
Rather than using control to stop herself from eating, Sasha learned to say to herself: "I'm reaching for food and I'm not hungry. I wonder what I would think about or feel if I didn't eat right now?" In the past, the moment she'd reached for food, she'd lost access to what was really bothering her, but she'd now gained a window into her feelings. She began to identify more of the conflicts in her relationship with her husband and to talk directly with him about her concerns. As a result, the couple elected to go to marital counseling to address long-standing issues.
As the relationships among dieting, overeating, and emotions become clear, therapy helps clients develop their ability to regulate affect without automatically reaching for food. Clients who integrate attuned eating into their lives will find that their relationships to food, themselves, and the world change in profound ways.
Attuned Eating vs. Weight Management
Mounting research on intuitive eating shows positive outcomes, from improved cardiovascular health, increased pleasure and enjoyment of food to fewer dieting behaviors and food anxieties, greater body satisfaction, and better coping skills. In a well-controlled study in 2002 reported in the International Journal of Obesity, Linda Bacon and her colleagues compared a traditional weight-management program with a nondietary approach. Both groups showed similar improvements in metabolic fitness, psychological factors, and eating behaviors; however, the dropout rate for the diet group was 41 percent, compared to 8 percent in the nondiet group. The diet group showed short-term weight loss and improved self-esteem, but these results weren't maintained after one year; conversely, members of the nondiet group showed improved outcomes over the same time period.
In 2005, a two-year follow-up to Bacon's study appeared in The Journal
of the American Dietetic Association. Participants in the nondiet group had maintained their weight and sustained their initial improvements, while members of the weight-management group had regained their weight and showed little sustained improvement. The researchers concluded that the approach based on intuitive eating "enabled participants to maintain long-term behavior change; the diet approach did not. Encouraging size acceptance, reduction in diet behavior, and heightened awareness and response to body signals resulted in improvements in health risk indicators."
Weighing Our Attitudes
It's ironic that with two-thirds of us moving into the "overweight" or "obese" categories, fat-bashing remains a common occurrence, and weightism (or weight stigma) arguably remains one of the last socially acceptable prejudices. Unfortunately, psychotherapists aren't immune from this bias. In his book Love's Executioner and Other Tales of Psychotherapy, Irvin Yalom acknowledges this prejudice. In the chapter titled "The Fat Lady," he writes, "I have always been repulsed by fat women. I find them disgusting: their absurd sideways waddle, their absence of body contour—breast, laps, buttocks, shoulders, jaw lines, cheekbones, everything, everything I like to see in a woman, obscured in an avalanche of flesh. . . . How dare they impose that body on the rest of us?"
Yalom's honesty is admirable, but his observations raise a topic not often discussed in our profession. Most of us agree that the cultural ideals of thinness are unrealistic and harmful, but how do we really feel about people who are fat—or "large," or "oversized"? At workshops, I ask therapists to brainstorm the qualities they associate with "thin" and "fat." Like most others in the general population, they tend to regard thin people as healthy, successful, attractive, active, and sexy, and to regard fat people as lazy, stupid, ugly, and unhealthy.
Where does this loathing of fat come from? Charisse Goodman, author of The Invisible Woman, points out that "one of the most curious contradictions of weight obsession is that if a woman succumbs to it and keeps her weight unnaturally low by even the most desperate means, she is popularly considered in our culture to be an attractive person who 'cares about herself,' even if she risks her health in the process. On the other hand, a heavy woman who shuns this mania and refuses to waste her life fixated on her figure is characterized as unattractive and lacking in self-regard." In The Obesity Myth, law professor Paul Campos considers the darker side of our disgust with fat as he explores the idea that Americans worry that we've become too big for our own good. He writes, "Nor is it a coincidence that, amid America's whirlwind of overconsumption, with its attendant anxieties about our economic, cultural, and military voraciousness, our anorexic Puritans promise that we can maintain our virtue by refusing to surrender to the most literal of our gluttonous impulses." Could it be that our own desires and fears about losing control are displaced onto the body of a fat person? What other unconscious dynamics might be at play?
Even as we begin to acknowledge the unfair prejudice and discrimination against overweight people, the obvious question arises: given the preponderance of evidence that people falling into the overweight and obesity categories have a significantly higher rate of health problems, how can we responsibly ignore this information? While it's impossible to explore the complexity of obesity research fully, my hope is at least to raise the possibility that there's another side to this story. Despite the bombardment of antiobesity campaigns, a mountain of research suggests that the drastic claims that fat is killing us are more problematic than you might expect.
These findings surprised J. Eric Oliver, author of Fat Politics: The Real Story Behind America's Obesity Epidemic. With a background in statistics, he set out during a postdoctoral fellowship at Yale University to understand how the soaring rates of obesity and its catastrophic consequences could be handled politically. What he discovered surprised him: "Based on the statistics, most of the charges saying that obesity caused various diseases or that obesity caused thousands of deaths were simply not supported. Yet consistently, these pseudofindings were promulgated as fact." Paul Campos reports a similar experience: "When I began researching this topic five years ago, I assumed the fact that being 'overweight' was a serious health risk was so well established that this aspect of the subject was hardly worth discussing. Yet in the course of plowing through dozens of books, hundreds of articles in medical journals, and countless interviews with medical and scientific experts, I discovered that almost everything the government and media were saying about weight and weight control was either grossly distorted or completely untrue."
Consider the frequently cited statistic that 300,000 people die from obesity each year—which was based on a 1993 study by Michael McGinnis and William Foege, reported in the Journal of the American Medical Association (JAMA). What they actually found was that "dietary factors and activity patterns that are too sedentary" contributed to 300,000 deaths per year. Inaccurate reporting by media sources, and its use to validate health policies, led McGinnis and Foege to publish a letter in The New England Journal of Medicine saying that the results of their study had been misrepresented. The researchers explained that obesity, high blood pressure, heart disease, and cancer were side effects of dietary and activity patterns, but they hadn't concluded how many deaths actually resulted from each single factor.
In 2004, the Centers for Disease Control and Prevention (CDC) presented new research, claiming that 400,000 deaths per year were attributable to obesity; however, this study was debunked for its poor research methods, and in January 2005, the CDC lowered the death estimate to 365,000. In April 2005, lead researcher Katherine Flegal of the CDC published in JAMA findings that put the actual annual rate of deaths due to obesity at 25,814, and determined that being overweight—or even in the lower end of the obesity range—wasn't associated with excess mortality or a shorter life expectancy. Despite this good news, the 300,000-deaths-per-year statistic continues to be used to justify treatment of obesity, and Julie Gerberding, who was director of the CDC at that time, stated that the CDC didn't plan to use the much lower obesity mortality figure in its public-awareness campaign, nor did it plan to reduce its fight against obesity.
This scenario is an example of how the concepts of causation and correlation frequently get misused in scientific research. While the popular conviction is that obesity causes higher mortality and health problems, it's next to impossible to establish causality in large population-based studies. When, as often occurs, weight is associated with health problems and mortality, it's possible that other factors, such as a sedentary lifestyle and poor nutrition, lead to both higher weights and higher death rates. Consider the fact that bald men have higher death rates. Does that mean that offering a toupee will decrease mortality among these men? Of course not! Instead, it's higher testosterone levels that cause both baldness and heart disease. Likewise, weight loss in and of itself isn't a panacea for the great majority of health problems.
As an acknowledgement of the failure of weight-loss programs, some experts recommend that a smaller reduction in weight, of about 5 to 10 percent of body mass, can improve a variety of health conditions. Remember that the failure rate of dieting is 95 percent, and that dieting frequently launches people into a yo-yo cycle that isn't innocuous. In his book Big Fat Lies: The Truth About Your Health and Weight, Glenn Gaesser, exercise physiologist and professor at Arizona State University, presents the outcomes of research regarding the health and mortality of 17,000 Harvard alumni who were asked how frequently they dieted and how many pounds they lost with each attempt. Compared to men who maintained fairly stable (even if higher) weights, those men in a yo-yo cycle, repeatedly losing and gaining weight, had an 80 percent higher rate of heart disease, and a 123 percent higher rate of Type 2 diabetes, compared to their nondieting classmates. Glaesser warns, "What we have here is a paradox, with potentially calamitous consequences. Losing weight seems to increase the chances of dying from a disease for which weight loss is frequently prescribed to help cure! This brings to mind the most fundamental canon of all helping professions: 'Above else, do no harm.'"
Does that mean that someone who's large must passively accept that there's nothing effective to improve health? The answer is a resounding no! People of all sizes can participate in behaviors that improve health and longevity. Steven Blair, former director of research at the Cooper Institute for Aerobic Research in Dallas, followed 26,000 men and 8,000 women between the ages of 20 and 90 for 10 years. He discovered that both obese fit men and lean fit men had low death rates, and that the obese fit men had death rates half that of lean unfit men. Lean unfit men who fell into the ideal weight category had twice the risk of mortality from all causes, compared to the fit men who fell into the overweight and obese categories. Blair declares, "By tracking the health status of thousands of women and men who have had fitness tests and medical exams at the Institute over the past 30 years or so, it has become abundantly clear to me that in terms of health and longevity, your fitness level is far more important than your weight. If the height-weight charts say you are 5 pounds too heavy, or even 50 or more pounds too heavy, it is of little consequence healthwise—as long as you are physically fit. On the other hand, if you are a couch potato, being thin provides absolutely no assurance of good health and does nothing to increase your chances of living a long life."
If there's so much evidence challenging conventional wisdom that fat is bad for us, then why don't we hear about it? Probably because we tend to view information through a thinness-bias lens, seizing upon results that favor thinness and ignoring content that doesn't support thinness as the optimal health and beauty standard. This bias was made crystal clear when a doctor was interviewed on CNN to discuss the results of two major studies in 2008, one from Canada and one from Japan, which concluded that people who fell in the "overweight" category live longer than those in the "ideal weight" category. At the end of the interview, the doctor threw in the caveat that, "It's probably still a good idea to lose some weight."
Economic issues play a role in perpetuating the hysteria around weight. Not only do people pursuing weight loss spend billions of dollars each year, but obesity researchers often have their work funded by the diet industry. A clear example of this conflict was the National Task Force on the Prevention and Treatment of Obesity, created and funded by the federal government to set national health policy. In 1996, JAMA disclosed that eight out of nine board members were university-affiliated professors and researchers with financial ties to a minimum of two, and up to eight, commercial weight-loss and pharmaceutical companies apiece. Laura Fraser, author of Losing It: America's Obsession with Weight and the Industry That Feeds on It, explains, "Diet and pharmaceutical companies influence every step along the way of the scientific process. . . . What it comes down to is that most obesity researchers would stand to lose a lot of money if they stopped telling Americans they had to lose a lot of weight."
What does all of this mean for clients who feel they must lose weight to become healthier and happier? As clients end their compulsive or binge eating by becoming attuned eaters, they usually hope they'll lose weight. From the outset, I empathize with that wish, and point out that if weight loss occurs, it'll be a side effect of normalizing their eating. Since weight is the result of complex factors still not completely understood, my goal is to help clients feel more comfortable in—and take better care of—their bodies, no matter what their size.
I consider myself to be weight neutral—meaning that I don't assume anything about people's physical and mental status based on weight, and I don't use weight as a measure of a person's success or failure, a framework now commonly known as Health at Every Size. Since health relates to much more than the number on the scale, factors such as a healthy relationship with food, physical activity, good sleep habits, and regular medical care are better indicators. I encourage clients to focus on the fitness, strength, and flexibility they develop through physical activity, as well as on the joy of movement. I know that when many clients use weight loss as their motivation to exercise, they stick to a regime for a while, but as soon as they miss a day or two, they feel guilty and quit working out. This is a shame, since the reality is that exercise is a healthful behavior for all of us, and that people become healthier when participating in physical activity regardless of whether any weight is actually lost. As my clients focus on sustainable behaviors, normalize their eating, and work on building a more positive body image, we view any weight loss as their body's making an adjustment, but not as the main event.
No matter where therapists find themselves on the continuum of size acceptance, it's our duty to become more aware of this issue and familiar with the research. By increasing awareness of our own behaviors in our professional and personal lives—negative comments about weight, fat jokes, talking about being "good" or "bad" in reference to eating behaviors—we can help change societal norms. If America is truly a melting pot, it's time to throw size diversity into the mix. If we're truly interested in the well-being of our larger clients, then we need to fight discrimination toward them, including our own. As Gandhi put it, "We must be the change we want to see in the world."
Illustrations © Bek Shakirov / Corbis
CategoriesThe Larger Conversation Mind, Body, Brain
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