To the Family Member Who Worries I Am Not Helping Your Loved One’s “Weight Problem”

To the family member who worries I am not helping your loved ones "weight problem"
image by Representation Matters

Dear Family Member,

I understand your fears. I get it. You want the best for your loved one. You want him or her to have the best and healthiest and fullest life possible. I do too.

You believe that helping your loved one to lose weight will help achieve these goals. Here, I disagree—I will explain below.

You believe that weight loss will lead to better health. You have heard the scary information about the dangers of obesity and know there is an all-out war on obesity. Or you have seen or heard your loved one ridiculed or judged negatively by peers because they didn’t conform to a certain size.

 

However, did you know that:

I have been working in the field of eating disorders since my training at a bulimia research lab in 1991. When I first learned to treat binge-eating disorder, a course of cognitive behavioral therapy (CBT) for binge eating was expected to be followed by a course of behavioral weight loss. However, since that time we have learned that behavioral weight loss doesn’t work. And while CBT for binge-eating disorder can be successful, it rarely leads to significant weight loss, even among those considered to be in an “overweight” weight category. However, CBT does lead to cessation of binge eating and prevention of further weight gain, which are lofty goals in their own right.

I firmly believe that bodies are meant to come in a variety of shapes and sizes. We are not all meant to be Size 0 or 2 or 4.

Take shoe size: while the average woman today has an 8 shoe size, most do not—some will have size 5 and others will have size 10. Shoe size has a normal distribution within the population.

Just as with shoe size, so it is with body weight. Every body appears to have a set point, a weight at which it functions optimally. This set point is not destined to be at the 50th percentile for every person—some will be heavier and some will lighter. Repeated attempts at dieting seem to increase a body’s setpoint, which is the opposite of what most dieters are trying to achieve.

I no longer support attempts at deliberate weight loss because I have come to believe it is not only fruitless but in fact harmful. Every day in my practice I witness the destruction left by the war on obesity and failed diet attempts. I see the carnage of past dieting, weight regain, shame and self-loathing in the form of disordered eating and intractable eating disorders. Against this backdrop, I believe that above all else, my duty to your family member is to not harm them.

There is no magic solution. Failing to fit the thin mold can be a burden. I wish I could wave a magic wand and have your loved one’s body transform into one that would not be stigmatized, would be celebrated, and would fit into all spaces. But I can’t change your loved one’s genetic body destiny, just as I can’t change any person’s ethnic background or skin color to conform to the privileged group. And I believe the solution is not to change your loved one’s body to conform—the solution is to fight to end weight stigma and the oppression of larger bodies.

Here’s what I can do:

  • I can help your loved one recover from an eating disorder, using evidence-based treatments backed by scientific research.
  • I can help your loved one work on accepting and appreciating their body and all its capabilities.
  • I can help your loved one unfetter themselves from self-imposed rules and restrictions and live a fuller life.
  • I can help your loved unburden themselves from shame and self-loathing.
  • I can help your loved one to advocate for themselves if he or she needs accommodations from a world that was not built to accommodate his or her body.
  • I can help your loved one learn to stand up to weight stigma and bullying.
  • I can help your loved one request and receive respectful health care.
  • I can help your loved one improve their relationship with food so that eating and social situations are enjoyable.
  • I can help your loved one achieve peace.

If you want these things for your loved one, please let me do what I was hired to do—guide your loved one to healthiest, best, and fullest life possible. Please examine the basis of your own hope that your loved one will conform to the thin standard. While I know this comes from a good place, it’s not pointing to the right destination. There are happier places to land. There is much work to be done. We all have weight stigma.

To learn more, I suggest reading the following articles:

Interested in Weight Loss? I CAN’T Help You. Here’s Why

Are We Setting Recovery Weights Too Low?

Is Weight Suppression Driving Your Binge Eating?

How Health at Every Size Can Help With Eating Disorder Recovery

On Living 100 years in Diet Culture

Living 100 years in Diet Culture

I recently went to visit my 102-year-old grandmother. In 1921, at the age of six, Nana emigrated from Russia to Kansas City.

She entertains her living facility with her piano playing and loves to talk all day. She continues to leave sassy messages on my phone. She sends thoughtful gifts to her great grandkids. With such a full life, the following stands out to me.Living 100 years in Diet Culture

 

Always concerned about her shape and weight, at 102 this is still a concern as evidenced by her bathroom in assisted living. Although Nana walks with a walker and now requires some assistance with getting dressed, she still steps on her bathroom scale every day. (How exactly she does this without falling, I don’t know!)

She declared to me, “I weigh x. If I could lose 10 pounds, I’d look younger.”

Two years ago, when she turned 100, I actually did a brief interview with her about dieting. After all, how many 100-year-olds are there who can offer a perspective on dieting in the 1930s and into their centenarian years?

Following is an excerpt from my interview with Nana:

How old were you when you first became concerned about your weight and shape?

At 9 years old people wanted me to start appearing on stage playing the piano. My teacher wanted to speak with my parents and told them he thought I was overweight and should lose some weight. He wanted to groom me for concert piano playing. I remembered how he spoke about my being a little heavy. It didn’t set in right with me. It didn’t bother me. I wasn’t obese, but I was heavy.

When was the first time that you dieted?

On January 2, 1935 (at age 19), I started a strict diet (for me) while at the University of Missouri in Columbia. In 3.5 months I lost 45 pounds. I worked very hard at that. Not only did I have a diet plan, but I also read a great deal. Just before that I also bought a powder that I put in tomato juice and it helped reduce hunger. When I came back to college after Christmas I was told by a friend who was a medical student to stop taking it. He said it was harmful. And then I continued on with the diet plans and that was in 1935. That’s when I really lost the weight. I became ever more popular and I noticed that the weight loss was really helpful.

Do you still worry about your weight?

I’m still concerned about my weight. I watch it very carefully. I get on the scale every single morning because I want to get in the clothes I have. I used to measure myself with a tape measure every day. 

Why do you think it is important to be thin?

I think it’s important. I love my clothes and if I don’t hold my weight to the clothing that I’ve bought, I’d feel very sad so I watch my weight carefully and I am able to get into clothing that I’ve had for years. There are some skirts that I can’t fasten at the waist, but I don’t wear skirts anymore. But weight has always been a very important concern. I don’t think you have to be thin but you have to look good in your clothing and for me, I don’t want to have to buy new clothes.

Nana’s Legacy

It is sad to me that after all these years,  the fear of returning to a bigger size still looms over her. When she eventually passes I doubt many will remember Nana for her shape.

Instead, I expect they will remember her for how friendly and caring she is, how she finds the positive in everything, her desire to make everyone around her happy, the sharp dresser she is, and what a great pianist she is (she makes you FEEL the music).

I know I will always hold dear in my heart her tremendous love for so many people, her years of serving the community as a social worker and volunteer for numerous charitable organizations, her delicious pound cake, her witty jokes (mostly from Readers Digest!), her long stories, her piano playing, and for how she knows (and is loved by) everyone in Kansas City.

 

A most misguided device

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To the long list of desperate and dangerous weight loss products, we can now add the AspireAssist, sadly approved by the US Food and Drug Administration (FDA) this week. The device is marketed as a “minimally invasive” and “reversible” weight loss “solution” for “people with obesity.” Essentially, an aspiration tube is inserted into the patient’s stomach so that the patient can, after eating, empty the contents of their stomach into the toilet by pressing a button on the device. To critics such as me, this device sounds a lot like a bulimia machine.

The AspireAssist has been through limited research; potential negative consequences remain unknown. It represents yet another example of how larger people are stigmatized and then preyed upon by manufacturers (abetted by the US government) who reinforce the belief that their bodies are inadequate and sell them various misguided products to help them attain the thin ideal. These dangerous products range from medications (remember phen/fen?) to surgeries, and now a device to empty one’s stomach.

Dagan Vandemark, Program and Policy Coordinator of Trans Folx Fighting Eating Disorders, stated, “This is a medicalized, surgicalized imposition of bulimia on higher-weight bodies, telling folks that having an eating disorder is better than being fat.” Bariatric surgery is often touted as the solution to obesity. And yet, I have seen clients post-bariatric surgery who were no better off.

A number of compensatory behaviors, including vomiting, exercising, and laxative use, can qualify one for a diagnosis of bulimia nervosa according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The only difference between these behaviors and the Aspire Assist is that the latter is medically prescribed.

Psychologist Deb Burgard has eloquently made the case that the behaviors society prescribes to help large patients lose weight are those same behaviors we diagnose as an eating disorder in lower weight patients. The Aspire Assist goes one step further by mechanizing bulimia nervosa. This device has a potential for the same kinds of weight loss abuse as do laxatives and diabetes medications.

The FDA press release lists among the potential side effects of the AspireAssist “occasional indigestion, nausea, vomiting, constipation, and diarrhea.” The endoscopic surgical procedure to insert the tube includes potential problems ranging from a sore throat, bleeding, pneumonia, unintended puncture of the stomach, and death. Risks related to the stomach opening include infection and bleeding.

As someone who has treated patients with bulimia nervosa and binge eating disorder for many years, this concerns me greatly. Helping clients to stop purging when it involves a behavior as unpleasant as vomiting is difficult enough. The leverage clinicians use to help people stop purging involves the individual’s own shame and disgust as well as negative health consequences. It is appalling that we now have a device that makes it easier (and permissible) for people to remove food from their stomachs.

Additionally, to help clients break a bulimia cycle, clinicians help clients employ strategies to stop restricting and purging. Bingeing is often the hardest behavior to change. Clients who continue to purge give themselves permission to engage in bigger binges. The thinking is, “Since I am going to purge anyway, I’m going to go ahead and eat more and then get rid of it.” An important intervention is for clients to remove purging as an option; this makes binges easier to modify. Outfitting clients with a no-fuss purge device will only encourage more binge eating.

Eating disorders occur commonly enough; there is a shortage of adequately trained professionals to treat the current number of patients with eating disorders. Let’s not make the problem worse by inducing eating disorders in even more patients.

We need to stop preying on and oppressing people in larger bodies and leading them to believe they are a problem to be fixed. We need to stop subjecting them to insane procedures in an effort to conform to an unnecessary standard. No treatment for obesity has been shown to work long term. We need as a society to accept that people come in all shapes and sizes.

Interested in Weight Loss? We CAN’T Help You. Here’s Why

Learn more about the non-diet approach at Eating Disorder Therapy LA - Health at Every Size (HAES)
Yale Rudd Center for Food Policy & Obesity

Learn More About Our Non-Diet Approach

At Eating Disorder Therapy LA, we treat eating disorders (including Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, and Other Specified Feeding and Eating Disorder or OSFED) across the weight spectrum. We often get inquiries from clients interested in help for binge eating or emotional eating, with their primary goal being to lose weight.

We always tell them that while we believe we can help them with their disordered eating, if weight loss is their real goal, we cannot help them. By contrast, we are willing to help with, and in fact are rather insistent upon, weight gain for our patients who are below their body’s healthy weight.

Many prospective clients seeking help with weight loss have completed a diet regimen (or often, in their minds, “failed” one) and are suffering from binge eating. They want to eliminate the binge eating and concurrently lose weight. While we are expert at helping clients to stop binge eating and learn to regulate eating, we will not consent to “help someone” lose weight.

Here’s why:

  1. We don’t think anyone really has the answer to help someone lose weight. The research shows that diets don’t work. We are not so grandiose as to believe that We are any different.

    • Traci Mann’s 2007 review of 31 weight loss studies showed that on average, 41% of dieters regained even more weight than they lost on the diet. In an interview about the study, Dr. Mann said, “You can initially lose 5 to 10 percent of your weight on any number of diets, but then the weight comes back. We found that the majority of people regained all the weight, plus more. Sustained weight loss was found only in a small minority of participants, while complete weight regain was found in the majority. Diets do not lead to sustained weight loss or health benefits for the majority of people.”
    • Harriet Brown, the author of Body Of Truth – a detailed analysis of the war on obesity and the diet industry – wrote in an article about the book, “In reality, 97 percent of dieters regain everything they lost and then some within three years. Obesity research fails to reflect this truth because it rarely follows people for more than 18 months. This makes most weight-loss studies disingenuous at best and downright deceptive at worst.”
  2. Dieting and weight suppression may be the major drivers of binge eating and ironically, can cause weight gain.

    • Research on “weight suppression,” which is the difference between someone’s current weight and their highest adult weight, shows it is linked to both anorexia and bulimia. Drexel University psychologist Dr. Michael Lowe, Ph.D. is one of the leading researchers on weight suppression. His research shows that the greater the weight suppression, the more severe and difficult to treat was the eating disorder. His research also shows that the more weight-suppressed a person is, the more likely they are to regain weight in the future. To me, this suggests that some bodies are naturally larger and will resist all attempts to reduce in size. Attempting to fight the body’s predestined weight may contribute to binge eating behaviors and even higher future weights.
    • Evelyn Tribole, coauthor of Intuitive Eating in a review of dieting wrote: “Dieting increases your chances of gaining even more weight in the future, not to mention increase your risk of eating disorders, and body dissatisfaction. “
  3. Weight cycling – the repeated cycle of losses from dieting followed by the usual weight gains after going off the diet – creates its own health issues, in particular, additional stress on the cardiovascular system.

  4. Weight loss can trigger both anorexia and bulimia. Research from the Mayo clinic shows that 35% of the young people who visited the clinic with anorexia started out in the “obese” or “overweight” weight range.

  5. Dieting is incompatible with Cognitive Behavioral Therapy (CBT), the treatment we provide for adult eating disorders.

    While CBT is very effective for eliminating binge eating, it relies on a non-restrictive approach to eating. The goal of CBT is to disrupt the diet-binge cycle through a pattern of regular eating and relaxation of dietary rules. Patients are encouraged to end restrictive dieting and behaviorally challenge dietary rules through behavioral experiments and exposure to forbidden foods as part of treatment.

  6. Counterintuitively, when overweight binge eaters successfully complete CBT treatment for binge eating, they do not lose appreciable amounts of weight.

    Even adding a behavioral weight loss program following completion of CBT for binge eating does not lead to additional significant weight loss. However, it is possible that long-term abstinence from binge eating may prevent future weight gain especially as compared to untreated binge eaters.

Our first responsibility as practitioners is to do no harm. Even if weight loss is a client’s stated goal for treatment, and even if their doctor is advising it, we fear that “helping” someone to diet may increase their binge eating and disordered eating. This may in turn cause greater weight gain or weight cycling – a far worse alternative than remaining at the current weight.

Here is how EDTLA can still help in the absence of weight loss:

  • We provide CBT-E for bulimia, binge eating disorder and subclinical disordered eating. I trained with one of the original developers of cognitive behavioral therapy for eating disorders. Clinical trials show 65.5% of CBT-E participants meet criteria for remission from their eating disorder. Relief from cycles of binge eating usually leads to benefits such as freedom from obsessing about food, greater productivity, decreased anxiety about food decisions, and improved self-esteem. Commonly, patients experience decreased guilt and shame around eating and food. Relationships improve as clients become more able to fully participate in meals with loved ones and friends. It also commonly leads to the expansion of other enjoyable areas of one’s life outside of dieting and body image.
  • We work with clients on challenging weight stigma (both their own internalized and in the larger community). We also work on improving body image.
  • My associates and I follow a Health at Every Size® approach. At Eating Disorder Therapy LA, we recognize and celebrate that bodies come in all shapes and sizes. We focus on creating and maintaining healthy behaviors including flexible eating and enjoyable exercise.

Many clients arrive in therapy feeling that they cannot feel better unless they lose weight. However, the majority of those who go through a full course of treatment make significant improvements in their eating behaviors and are surprised at how much better they are able to feel even without weight loss.

Suggested Reading and Viewing:

Bacon, Linda, Health at Every Size

Brown, Harriet, Body of Truth

Mann, Traci, Secrets from the Eating Lab

Saguay, Abigail, What’s Wrong with Fat

The Problem with Poodle Science (video by the Association of Size Diversity and Health)

Why Dieting Doesn’t Usually Work (TED talk by Sandra Aamodt)

Warning Dieting Causes Weight GAIN (video by Evelyn Tribole MS RD)

Why do dieters regain weight?

Additional References:

Berner, L.A., Shaw, J.A., Witt, A.A. & Lowe, M.R. (2013). Weight suppression and body mass index in the prediction of symptomatology and treatment response in anorexia nervosa. Journal of Abnormal Psychology, 122, 694–708.

Mann, T., Tomiyama, A., Westling, E., Lew, A., Samuels, B., Chatman, J. (2007). Medicare’s search for effective obesity treatments: diets are not the answer. American Psychologist, 62(3):220-33.

Lebow, J., Sim., L., and Kransdorf, L. (2015). Prevalence of a History of Overweight and Obesity in Adolescents With Restrictive Eating Disorders. Journal of Adolescent Health 56, 19-24.

Additional HAES articles

Various articles that are found on the ASDAH website:

“Attitudes Toward Disordered Eating and Weight: Important Considerations for Therapists and Health Professionals”, Matz, J & Frankel, E

“Obesity and Anorexia: How Can They Coexist?”, Bulik, C. and Perrin, E.

“Obesity, Disordered Eating, and Eating Disorders in a Longitudinal Study of Adolescents: How Do Dieters Fare 5 Years Later?”, Neumark-Sztainer, Dianne, et. al

“Shared Risk and Protective Factors for Overweight and Disordered Eating in Adolescents”, Neumark-Sztainer, D., et al

“Multiple Disadvantaged Statuses and Health: The Role of Multiple Forms of Discrimination”, Grollman, E.A.

“The Problem with the Phrase Women and Minorities: Intersectionality–an Important Theoretical Framework for Public Health”, Bowleg, L.

Children/Teens

“Dieting and Unhealthy Weight Control Behaviors During Adolescence: Associations With 10-Year Changes in Body Mass Index”, Neumark-Sztainer, D., Wall, M., Story, M., Standish, A.

“Helping Without Harming – Kids, Eating, Weight and Health”, Robison, Jon; Cool, Carmen; Jackson, Elizabeth and Satter, Ellyn

“Overweight and Obese Children Eat Less Than Their Healthy Weight Peers”, Hoyle, Brian

“Weight Status as a Predictor of Being Bullied in Third Through Sixth Grades”, Lumeng, J.C., Forrest, P., Appugliese, D.P., Kaciroti, N., Corwyn, R.F., and Bradley, R.H.