What if there's no cure for obesity, only management?
Today in a Very Special Episode: there's no cure for obesity
“The history of overfeeding and underfeeding trials and other lines of evidence clearly show that obesity prevention and treatment cannot simply rely on advice to eat less and move more.” — George A Bray1
At fourteen, I was friends with a competitive figure skater. She advised me to get mono because it made losing weight a sure thing. It sounded like solid advice to me, but I was unsure how to go about “getting mono,” and ultimately it didn’t happen. Not to worry, in years ahead I had plenty of chances to implement ill-advised diets.
My relationship to eating, hunger, and food didn’t begin to change until I discovered Health At Every Size (HAES) and the so-called Fatosphere, the blogging community where fat acceptance activists of years past ruled. These concepts are much-maligned online these days, often provoking the refrain that being fat is unhealthy.
But health at every size has always been about redirecting your efforts from weight loss towards health. Which is to say, change the goalposts into something tangible and lasting. But I know that none of that has been absorbed or perhaps even advertised because of the Twitter takes I’ve been seeing, and been suckered into responding to. I recognize that it’s my personal history goading me, and that bias is one I’m fine with being open about. I do think it’s relevant, in this case.
More people know about “Fat Acceptance” but they also only see the glossy aesthetic being pumped out to attract a customer base and the halo of glamour. Brands want their customers to fall in love, and you can’t get that with sensible publicity. None of the visibility has advanced actual HAES principles. Fat people haven’t been humanized, as the request was, they’ve become monetized. Obese people are being seen not as people, but as customers. Yet it’s an improvement over fat people only existing as threatening “headless fatties” in news coverage.2
Dieting is a band-aid, not a solution
In Losing it: false hopes and fat profits in the diet industry, Laura Fraser argues that there are two types of obesity researchers, “pro-diet medical researchers and anti-diet eating disorders researchers.” I’m squarely in the camp of the latter, as you might expect, while it seems a majority of the public is unquestionably “pro-diet.” The starry-eyed faith in what a diet can accomplish seems never to be far away, and fad diets remain for a reason.
The main difference between the two groups is what they see and what they prioritize. Medical researchers will find plenty of ways for people to lose weight—there are endless ways to shed pounds; plenty of diets work short term. These researchers are giving people what they want and solving the acute problem of excess weight, they aren’t responsible for sustaining the weight loss.
But most fat people are intimately familiar with nutrition and diets. Being on a diet is one of the few ways a fat person can redeem themself and lets people know that you’re aware of your fatness. There’s no need to whisper behind anyone’s back because you’re in on it. If you go out to eat with friends you might go out of your way to point out it’s a cheat day, or do the diet math on the spot. Lesley Kinzel, one of the Fatosphere icons, put it succinctly;
“Many behaviors seen as damaging and dangerous in thin people are outright encouraged in fat people. […] Fat people are often supported in hating their bodies, in starving themselves, in engaging in unsafe exercise and in seeking out weight loss by any means necessary. A thin person who does these things is considered mentally ill.”
The unabashed existence of the women of the Fatosphere was so different to me because there were no caveats. These women were out there, existing in the world. They were taking up space, going to the beach, dating, traveling, they were wearing bright colours, capris, and horizontal stripes. They didn’t disclaim their photos with fat warnings or deconstruct daily calorie intake and expenditure or asked to be told they “didn’t look fat.”
It was an entirely new perspective to me, and it was one that came from desperation. It seemed ridiculous, the idea that no food was forbidden and that working out should feel good, not be a punishment. Geneen Roth was a pioneer in addressing the connections between eating patterns, compulsive eating and perpetual dieting, food obsession, and impossible goals. One of the most poignant things she said is part of the title of this piece, “Being thin is only the halfway point. You have to keep moving, eating, and living.”
Whatever has been put off for the new you to experience will not just fall into place, and there’s no new you. There was never a thin person trying to escape, it was just you, and losing weight was only a cosmetic change.
I recognized myself in all I read. I had been putting things off for a better time, a better version of myself, to get on with it. Diets and insane workout regimes were supposed to make me able to cross the threshold into my own life. In school, the act of eating lunch in public was so fraught and took so much of my focus that I never noticed one of my classmates eating napkins, just out in the open, throughout all of high school.
I too, felt bottomless, like my hunger was a curse, an enemy working against me. But I had tried everything else and I already knew that it wasn’t sustainable. I knew people whose yearlong eating disorders resulted in permanent health problems; I knew the impossibility of sustaining highly restrictive diets in perpetuity.
One of my more successful diet regimens was the Weight Watchers program my mother signed us both up for when I was a teenager. It operated on a points system that is different from the one used today, but I know that as far as satiety it was effective back then. At the time, pasta, potatoes, and other starches were a flat two points. Fruits and vegetables were almost all zero points, which meant you could fill up on them, guilt-free. You could binge on them, too, just like I did, and it wasn’t guilt-free, healthy, or fulfilling. It didn’t fix the underlying issue which was the damage caused by the interloper that is the diet cycle. It goes beyond physical, biological impacts, there’s also the emotional rollercoaster those repeated failures lay the tracks for.
There have been studies into the HAES approach, a conclusion from one study concluding that “long-term behavior change” was sustained in the HAES group, showing that having motivations and rewards other than weight makes lifestyle changes more likely to persist.3 Meanwhile, the long-term results of diet cycling have been observed by eating disorder researchers, and “[They] know that although every diet doesn’t lead to an eating disorder, almost every eating disorder begins with a diet.”4
A red herring in the health debate?
Before drugs were used as a weight loss solution, there were practices of jaw wiring, urine injections, and tapeworm ingestion. In many cases, it seems like the approved treatment was worse than the fat. All of this makes it difficult for me to take stated concerns for obese people’s health seriously.
As controversial as it might be, fat healthy people do exist. Rudolph Leidel at Columbia recruits healthy obese subjects for his studies, and it really isn’t that hard to find those people. His years of work have convinced him, “that many have none of the common risk factors that go along with the condition.” As nothing but a casual observer, there’s no way to “diagnose” the type of obese someone is.
The Illustrated BMI Categories project on Flickr is one example of regular people and where they fit on the BMI scale. You will most likely be surprised at how healthy some of the people that qualify as obese people appear. Is their obesity the result of the same factors as other obese people? It seems clear cut that there would be variables in how we process and store fats as humans, with the influence of hormones and ghrelins and leptin receptors. Yet, the “obesity as a disease” cause of action is the most prominent and the most encouraged.
This is to say the goal should always be to treat obesity first, no matter what a patient is seeking help for. Long-term success doesn’t matter, because a temporary dip in weight can only be positive, should this be believed. Getting rid of fat first, before treating any other health concerns, sets up a stumbling block for fat people. Especially since in many cases, this focus on weight alone as a measure of health leaves people waiting for their treatment to start. As one study showed, “chronically ill patients may be denied truly effective pharmaceutical therapy while pursuing the elusive goal of permanent weight loss.”5
The “miracle drug” fen-phen, the combination of dex/fenfluramine and phentermine, was as popular as you might expect, and it was being sold as a diet pill to anyone who wanted it, no weight limit required. The FDA originally voted against approving the combination, and many were unhappy. Some of the accusations were oddly personal, like the lobbed question, “Is the FDA staffed at the highest levels by men who are into fat women?”
The decision was eventually reversed, and less than a year later some serious side effects of the drug were being reported.6 This included a lung disease with a fifty percent mortality rate, and a heart valve problem that might affect up to a third of users. Heart valve problems had never been associated with drugs before.
When fen-phen mix was pulled, some doctors weren’t shy to prescribe their own off-label drug cocktails. As documented by the New York Times,7 some of the prescriptions included: combining phentermine with Prozac, phentermine with trazodone, Parkinson's disease drugs, phentermine combined with chromium picolinate. None of these combinations had been trialed, but the logic at hand must be that it’s better than being fat, no matter the potential repercussions. Is it any surprise that the medical profession’s commitment to fat people’s health is questioned?
I know I’ve been guilty of prioritizing weight over health myself. Tallying the pros and cons of pharmaceuticals, with weight gain being a very influential ‘con.’ Hormonal birth control, antidepressants, antihistamines, and corticosteroids are just a few medications that can result in weight gain, among other side effects. I know people who stopped taking their medications against recommendation because of the possibility of weight gain, so certain it would happen and be unbearable. It wasn’t a fear that the weight gain would counteract the medications; it was that the existing health problem was more tolerable than the possibility of gaining weight.
There are plenty of studies that focus on the complexities of obesity. In one study, a cold virus was identified as a potential culprit for a third of the obesity in our population.8 Just a few years ago there was progress in a study comparing the genes of obese, normal weight, and underweight people. Dr. Sadaf Farooqi, the lead researcher, told BBC,
"This research shows for the first time that healthy thin people are generally thin because they have a lower burden of genes that increase a person's chances of being overweight and not because they are morally superior, as some people like to suggest."
Over the last century, there have been multiple studies into weight gain and weight loss that all documented the differences between fat and thin people on a cellular level. Despite the still common refrain of “calories in, calories out,” the commonly held belief that a pound of fat is equivalent to approx 3,500 calories has been proven inaccurate. It’s simply not that simple.
There was a time when this information would’ve been unwelcome to me, so I can only assume some may have a kneejerk aversion to it. Perhaps there are even some doubts around potentially faulty self-reporting skewing results. Luckily, there is enough data out there for me to avoid such studies altogether.
A prison experiment in the 1960s is one of the most informative, it’s also one that likely never would take place today. Dr. Ethan Sims recruited Vermont state prisoners to participate in an overfeeding study. Because of the circumstances, and the ease of control and supervision, the study was thorough.
The goal was for these naturally slim men to gain between 20-25% of their body weight, which turned out to be much harder than expected. Some men were eating upward of 10, 000 calories a day and still failed to hit the targeted weight gain. Even more surprising was that the prisoners lost all the weight easily. They reverted back to their start weights in a matter of weeks of returning to their regular routine and diet.
Overfeeding was also part of Dr. Claude Bouchard’s Quebec twin study. Not only did the chosen identical twin pairs gain weight in the same places, but they also ended up in the same weight bracket. And when they returned to their regular routine, just like with the prisoners, the excess weight was shed without trouble. Dr. Bouchard’s conclusion was, “The most important message is that under the same caloric load, we find large differences in the amount of energy stored in the body.”
Dr. Jules Hirsh, an obesity expert from Rockefeller University, performed a landmark study in Pennsylvania. Individuals who were serious about losing weight were housed at the hospital for nearly a year, and they were closely supervised. On average they each lost about 100 pounds, something that initially sounds like a success story.
But the weight didn’t stay off, not for any of the participants. It was a disappointment to the researchers, but also to the subjects themselves who had been eager to lose weight. The study was repeated again, and then again. Ultimately there was a total of 50 subjects who had lived on hospital grounds for the study. Most regained the weight and those who didn’t were described as, “maintaining themselves in a permanent state of starvation,” both psychologically and physically. The few that sustained their weight loss were not an exception, but they “made staying thin their life's work.”9
The state of starvation isn’t a hyperbolic description of people’s hunger levels, but rather that their body itself was fighting against the diet. The metabolism of fat people on diets slowed down, hoarding more of the fat being consumed. The Rockefeller researchers concluded,
“It is entirely possible that weight reduction, instead of resulting in a normal state for obese patients, results in an abnormal state resembling that of starved nonobese individuals.”
None of these studies claim that it’s impossible to lose weight and keep it off—they do emphasize that it is possible. It’s rare because of the maintenance of starvation mode in perpetuity while internal functions strive to return to a comfortable weight.
Dr. Robyn Toomath argues in The Obesity Epidemic, that we need to shift the blame for obesity away from individuals and look at the food industry. She isn’t pro-diet as she’s seen their long-term failure over and over, but she also believes in surgical intervention if necessary.
She believes our environment is the key to the rise in obesity, outlining obesogenic factors. In part, it’s our modern technology, increased screen time becomes a problem because of the overwhelming ads and sponsorships for fast food, often coming from sports figures. For many, increased screen time also leads to a decrease in sleep, which is associated with weight gain.
Toomath emphasizes the responsibility of the food industry and that we need, “to see nutrition as an issue of societal responsibility.” She cites examples such as fish and chip shops using salt shakers with fewer holes, resulting in lowering the daily salt intake of the population. Putting fruit next to the cash register instead of candy is another small move that could be easily implemented and lead to population-wide positive effects. Then there are the corporations themselves; Coca-Cola committing to fighting sugar consumption by offering more cup sizes instead of reducing sugar or scrapping the biggest size entirely. What is best for our health is inconvenient to most of them.
These solutions, while sounding quite doable, are really out of most of our hands. We can, and should, work on our own health. But to expect others to fit your vision of health, especially when it has been proven to be a nearly impossible task, is inappropriate.
It may be too much to expect for society at large to become more accepting of fat people. For now, I would settle for less hostility. After all, humans developed to store energy for survival. The world of abundance we live in is not something our bodies were prepared for.
George A Bray, The pain of weight gain: self-experimentation with overfeeding, The American Journal of Clinical Nutrition, Volume 111, Issue 1, January 2020, Pages 17–20, https://doi.org/10.1093/ajcn/nqz264
Headless Fatties, 2007, Cooper C. http://charlottecooper.net/fat/headless-fatties-01-07/
Biomedical Rationale for a Wellness Approach to Obesity: An Alternative to a Focus on Weight Loss, 2002, Journal of Social Issues
Losing It: false hopes and fast profits in the diet industry, 1997, Laura Fraser
Biomedical Rationale for a Wellness Approach to Obesity: An Alternative to a Focus on Weight Loss, 2002, Journal of Social Issues
How Fen-Phen, A Diet “Miracle” Rose and Fell, 1997, New York Times
ibid.
Can a virus make you fat? 2000, BBC
Genes Take Charge, International Herald Tribune
>These solutions, while sounding quite doable, are really out of most of our hands.
Yeah, this is kind of the despair sentence. I've been getting more cynical in the sense of "if this is to change, our governments need to not be in the pockets of these big businesses" and I know that's a long shot. There would also need to be someone willing to take the political hit to be able to lead us there, and that person would not need to get Epstein'd in the process.
Bit doomer, sorry, but as a person who stresses about his weight a ton and how things don't really feel like they're in my hands, this piece hit me a bit hard.
I really enjoyed this, thanks.
This is such an interesting topic, there’s so many ‘facts’ about obesity that we grow up just kind of accepting unquestioningly that turn out to be wrong. That picture of the sugar ad in your piece is wild!
I recently read The Obesity Code by Dr Jason Fung. His hypothesis is (in a nutshell) that obesity is caused by hormone imbalance, specifically insulin.
Like Toomath, he talks a lot about all the bad conclusions that have been drawn by studies over the years and looks at the way the food we’ve been eating for the last 30-40 years has changed and how our bodies have reacted to it.