The Amazing! Seventeen-Day! Flat-Belly! Grain-Brain! Biggest Loser! Raw Food! Diet
“What some call health, if purchased by perpetual anxiety about diet, isn’t much better than tedious disease.”
—Alexander Pope, eighteenth-century English poet
Every year in January—the height of our annual weight-loss frenzy—fifty million Americans go on a diet. That’s roughly one-sixth of the entire population restricting what we eat, creating a negative energy balance (deliberately burning more fuel than we take in) with the express goal of losing weight. Many of those dieters give up after about two weeks,1 but try again and again over the course of the year, which means, estimating conservatively, that the average forty-five-year-old American woman has been on fifty diets in her adult life.2
Those numbers say a lot about how we see the act of dieting. At best, it works for a while; at worst, it can’t hurt. And that’s true across the board—you’d be hard-pressed to find a woman in America who has never dieted. There’s a social component to dieting, especially for women. Coworkers, friends, and families join Weight Watchers or do the “biggest loser” challenge together. Misery loves company, after all.
I was one of those miserable dieters for many years, starting at fifteen, when my mother and I joined Weight Watchers together, each with the goal of losing twenty pounds. I wasn’t the only teenager dieting, of course; in the 1970s, the average age for girls to start dieting was fourteen. (Now, by contrast, it’s eight. Eight years old.)3 It took us four months to lose the weight, four months of Weight Watchers frozen dinners, packed lunches, and my mother’s homemade “bread pudding,” which contained neither bread nor pudding.*
Eighteen months later I went to college, where I rapidly gained back those twenty pounds plus another ten, and struggled with nightly bouts of uncontrollable eating. This was long before anyone used the term binge eating, or talked about the fact that a history of dieting predisposes people to compulsive eating. Every night I ate ready-made frosting straight out of the can, and hid the evidence at the bottom of the garbage so my roommates wouldn’t see. Every morning I felt shame and despair and vowed to do better. But I stayed trapped in that vicious cycle for a long time.
As a result, I spent the next decade in a classic yo-yo pattern, swinging between extremes of deprivation and overeating. I rejoined Weight Watchers at age twenty-eight to get thin enough to fit into my mother’s wedding dress. (Oh, the symbolism.) This time I lost forty pounds, getting down to a weight that fell into the normal category on the BMI chart but left me weak, tired, and ever more obsessed. I weighed and measured and recorded every bite I ate. I dreamed about food, counting the minutes until my next meal or snack. I ate the same things every day without deviating because that was the only way I could know I was eating the “right” amount.
When I got pregnant three years later, I quickly gained back those forty pounds, despite weekly scoldings from the midwife. I loved being pregnant, in part because it was OK to gain weight, and because now when I ate, I didn’t feel guilty and self-indulgent; I was feeding my baby as well as myself, and I had no ambivalence at all about that. But two more pregnancies, a miscarriage, and a severe postpartum depression treated with antidepressants left me at my heaviest ever. And each time I gained another pound, the voice in my head got a little nastier: You’re worthless and lazy and stupid. You’re out of control. You’re the ugliest woman in the room, the neighborhood, the world.
I went back to Weight Watchers three or four more times, but I never lasted more than a few days. Something in my brain had shifted. I just couldn’t bring myself to count calories and measure portions and weigh every bite I put in my mouth. No matter how determined I felt, how much I hated my body, I just couldn’t do it anymore. I told myself I was weak, I lacked self-control, I was gluttonous, but the usual goads fell flat. I couldn’t sustain the deprivation of dieting. That’s what sent me into treatment, and into that relationship with the therapist that changed my life.
WE DIET FOR one of two reasons, or both: Looks and health. If (a) you’re a woman, and (b) you want people to think you’re attractive, you’ve got to be thin (or least thinnish) by the cultural standards of the day. And whether you’re a woman or a man, if you’re not thin you’ve certainly been told in many ways that your health will suffer if you don’t lose weight.
So we diet. We consider it harmless at worst, and if it doesn’t work, well, that’s our fault for not cutting back enough or sticking hard enough to our unsatisfying meal plan, isn’t it? And the solution is—you guessed it: more dieting, different dieting, stricter dieting. In 2013, Americans spent more than $60 billion on weight-loss products,4 and that number keeps rising. A lot of bottom lines are at stake in the efforts to trim our bottoms.
Unfortunately, the evidence suggests that dieting makes people neither thinner nor healthier. Quite the opposite, actually: nearly everyone who diets winds up heavier in the long run, and many people’s health suffers rather than improves, especially over time. Repeated dieting in particular causes a cascade of negative physical and psychological consequences (which we’ll look at in more depth later in this chapter). In fact, dieting is a major risk factor for both binge eating5 and obesity.6
Dieting can make people thinner for a while—six months, a year or two, maybe three. Which, coincidentally, is about how long most studies follow dieters, and how they claim success. In reality, your chance of maintaining a significant weight loss for five years or more is about the same as your chance of surviving metastatic lung cancer: 5 percent. It doesn’t matter what flavor of diet you try—Paleo, Atkins, raw, vegan, high-carb, low-carb, grapefruit, Ayds (remember those chewy chemical-infused caramels?)—only 3 to 5 percent of dieters who lose a significant amount of weight keep it off. Weight-loss treatments are cash cows, in part because they don’t work; there’s always a built-in base of repeat customers.
You’d never know any of this from reading the weight-loss research, or from talking with most researchers in the field. In fact, when I asked the University of Alabama’s David Allison about dieting research, he insisted that studies do show success after five years, “just less than what we’d push for.” I told him I was aware of only one research project that followed dieters for five years or more, the Look AHEAD project, a ten-year study of people with type 2 diabetes. I asked Allison to point me toward other studies that followed dieters for five years or more, regardless of their findings. He couldn’t come up with any.
Debra, fifty-five, has worked in nonprofit development and is now studying to be a hospital chaplain in Kansas City, Missouri.
I had three “yo-yos” of more than 10 percent of my body weight. The first was in high school, when my mother told me I was the fattest girl in drama class and I needed to lose weight. The second was after my wedding. The third was when I was forty-two and for the first time in my life got a borderline cholesterol reading. I remember crying in the shower and pounding my thigh, mad at how fat I was.
I started walking, then running. I lost about sixty-five pounds. I became a running nut. I was maintaining the loss easily because I was a runner. Then my body failed me—my foot started to swell every time I ran and my joints weren’t behaving. I started researching and had a big stinking oh shit moment when I realized everything I thought I knew about dieting and weight loss was a lie. I saw that only 3 percent of people could keep weight off for more than five years, and even then it was only 10 percent of their body weight. For me that would have been nothing.
What I ultimately arrived at to maintain the weight loss works for me, but I don’t want it to be presented as a panacea. I eat 1,800 calories a day and I always have a running count in my head. I allow myself 200 calories a day of grain-based carbohydrates and I save 200 for a glass of wine at night. And then I exercise as a fat chick. I wear a weighted vest and ankle weights that add up to around thirty pounds. I put on an exercise video and do it at double time for fifty minutes. I also watch the news. That’s how I make it tolerable and possible to do other things with my life besides weight loss. Because this is not a lifestyle. It’s a job.
Maintenance takes up a lot of mental real estate, though not as much as it did in the beginning. There’s the voluntary part, where I’m doing all the research. Then there’s the involuntary—the intrusive thoughts, the preoccupations with food, that kind of thing.
Right now I do my crazy exercise thing on a padded carpet and I don’t twist my ankles. But guess what’s going to happen at some point? When I can’t do the exercise videos anymore, maybe I’ll try water aerobics. To do the equivalent of what I’m doing now I’ll be the pruniest woman. And I am probably going to be fat again. I never want to be held up as someone who will make fat people feel bad. There’s nothing that scares me more than that.
Unlike Debra, most of us believe we just have to try a little harder and the weight will come off and stay off. We must think so because we keep trying, again and again and again. Consider the market for diet books, which seems nearly infinite; no matter how ridiculous, ineffective, or potentially dangerous a given diet may be, desperate people will plunk down $24.99 for the latest fad in weight-loss advice. They’ll eat tapeworms and drink concoctions made from cattle hooves,* have patches sewn onto their tongues so it hurts to eat, chew each bite thirty-two times (once for each tooth),** and blame themselves when they gain back any weight they’ve lost. Something is definitely wrong with this picture.
Traci Mann agrees. Mann, a psychology researcher and professor at UCLA, must be one of the few women in Western society who’s never gone on a diet. Which is ironic, considering she’s made dieting a major focus of her research. In 2006, she and a PhD student named Janet Tomiyama got to talking about Medicare’s decision to start paying for “effective” obesity treatments. They wondered which treatments actually led to long-term weight loss, and decided to look at the evidence. The result of their investigation was a 2007 article confirming what many dieters already suspected: diets don’t work.
The mind-boggling element here is that we’ve known diets don’t work for a long time, and so has the medical establishment. Back in 1958, A. J. Stunkard, a well-known obesity researcher and professor at the University of Pennsylvania, wrote, “Of [obese] people who lose weight, most will regain it.” In the 1970s and 1980s, scientists like Paul Ernsberger, now a nutrition professor and researcher at Case Western University, began to document the ways dieting did (and usually didn’t) work. Nearly thirty years ago—thirty years ago!—Ernsberger and a colleague published an exhaustive review of the links between health and obesity.7 They pointed out that sixteen long-term international studies had found that overweight and obesity were not major risk factors for death or heart disease; a US panel on obesity had relied heavily on data from the insurance industry, and since fewer heavy people bought life insurance (because they had to pay more for it), the mortality rates linked to obesity skewed higher.
Ernsberger also drew attention to the fact that mortality rates were lowest in the overweight category on the BMI chart—the very same U-shaped curve that would cause such a backlash when Katherine Flegal re-documented it in 2013. He and his colleague hypothesized that some of the conditions associated with obesity, like hypertension and elevated cardiovascular risk, actually came from failed treatments—that is, weight cycling, or losing and regaining weight over and over. And they suggested that many doctors’ disapproval of obesity was based on “moral and aesthetic biases” rather than medical facts, a suggestion that has since been borne out by research into doctors’ clear prejudices around obesity.
In the early 1990s, shortly after a slender, belted, and booted Oprah Winfrey rolled a red wagon carrying sixty-seven pounds of animal fat—the amount she’d just lost on Optifast—onto her television stage set, the Federal Trade Commission charged Weight Watchers, Jenny Craig, and three other major diet companies with deceptive advertising.8 In 1992, a researcher at the National Institutes of Health (NIH) concluded that “by five years, the majority of subjects beginning any weight-loss program have returned to their starting weight.”9 Around the same time, psychologist David Garner, who testified before Congress about the failures of the diet industry,10 published an article that started with this sentence: “The purported benefits of weight loss are so well known that to question them is to defy almost unshakable beliefs.”11 That’s still true today, twenty-four years later. Which I guess explains in part why Americans spend so much time and money chasing the elusive fantasy of thinness, and why most doctors continue to push diets on their overweight and obese patients. It’s as if we don’t want to know the truth, or believe it. Because despite what we know, anyone who questions the weight-loss paradigm even a little might as well be recommending crack for kids; people react with horror, judgment, and fear. And sometimes worse.
WHILE THE ULTIMATE effects of dieting aren’t news, we do know more these days about the process, pros, and cons of dieting than we did forty years ago. We know, for instance, that dieting nearly always makes people heavier over time. In one study of Finnish twins, the more diets people went on, the higher their risk of becoming overweight and the faster they gained weight later in life.12 The one exception to that rule involves set point, or settling points, theory, the idea that each of our bodies is geared to function best within a certain fairly limited weight range, usually ten or twenty pounds.13 And our individual set points can vary wildly.
A friend who’s the same height as me, and who probably weighs fifty pounds less, gained ten pounds recently from taking a short-term medication. She knew she’d finish the medication and her weight would return to its usual level. She’s not particularly biased against fat or fat people, never diets, and is very physically active. But the extra ten pounds made her excruciatingly uncomfortable, physically and mentally. She couldn’t wait to get off the meds so her body could revert to its set point. Which, in good time, it did.
By contrast, when I’ve weighed what she usually weighs—which falls well within the normal BMI range for our height—I’ve been utterly miserable: starving, fixated on food, and crabby as hell. All I could think about was what I was going to eat next and when. According to the doctor, that weight was ideal for my height, and I should have felt swell. But I just didn’t. I feel stronger, fitter, and happier now, some fifty pounds heavier.
Set point theory suggests it’s relatively easy to lose or gain weight within your range, but a lot harder to go outside it in either direction. And the stories I’ve heard from people who have lost weight and kept it off bear that out. Michelle, a magazine editor in her forties who lives in Madison, Wisconsin, lost about twenty pounds by walking seven miles a day. She says she’s kept it off for nine years without having to diet, and with relative ease, and one explanation is that her lower weight still falls within her body’s natural weight range. (Though some might argue that walking seven miles a day, every day, isn’t so easy.)
Most people who want to lose weight want to lose more than a few pounds, though, and that’s when they run into the unintended consequences of dieting and weight gain: the more you diet, the heavier you’re likely to wind up. There are good reasons for those consequences, according to Janet Polivy, a researcher whose best-known paper is titled “Distress and Eating: Why Do Dieters Overeat?” Polivy grew up on Long Island, and her voice still carries the accent despite the thirty years she’s spent as a psychology professor at the University of Toronto. She says watching her mother struggle with weight over the years inspired her own interest in exploring the psychological obstacles dieters face.
For instance, says Polivy, dieters tend to be more emotional and react more strongly than non-dieters to upsetting events, maybe because dieting itself creates so much stress. Dieters tend to have higher levels of cortisol, sometimes called “the stress hormone,” and free fatty acids, both of which signal stress.14 And dieters tend to exhibit diminished executive function, what economist Sendhil Mullainathan calls “strained bandwidth,”15 maybe because using so much mental energy thinking, worrying, and negotiating about food choices leaves them too distracted to think about much else.16
Polivy believes a lot of the stress of dieting comes from the fact that we’re surrounded by food cues, which may explain why people on diets react differently than lab rats whose food is cut back. “When rats are given food they eat it, and when they’re not given food they’re not necessarily stressing about it,” explains Polivy. “They’re just sitting there. So they live longer.” She laughs. “Or maybe it just seems longer.”
But when the rats’ situation gets a little more real-world, their responses look more like ours. In one study, Polivy attached little baskets of Froot Loops above the cages of food-deprived rats, so the animals could see and smell the Froot Loops but couldn’t get to them. Those rats showed much higher levels of stress hormones than the rats who weren’t tormented by the Froot Loops. And when they were allowed to eat as much as they wanted, the first group ate without restraint, gaining significant amounts of weight, while the second did not. The takeaway, says Polivy, is clear. “Unless you lock yourself in a room, have minimal food brought to you, don’t watch TV, and don’t have access to anything outside, you’ll be surrounded by food cues,” she explains. “Which ultimately take their toll. As soon as you can get food, you eat more and gain back everything and then some.”
Physiology plays a role, too, of course. The drive to eat is so crucial to our survival that it’s supported by a number of powerful biological processes. For instance, a 2011 study showed that starvation (whether intentional or not) triggers neurons in the hypothalamus—a small almond-shaped organ deep in the brain—to literally consume themselves, which in turn amplifies hunger signals sent out by the brain.17
And the effects of dieting last long after the diet ends, at least in rodents. A history of dieting (or, actually, a history of being underfed) led to the rat equivalent of bingeing behavior—overeating Oreos rather than their usual rat chow—in a study done by Mary Boggiano, a psychology professor at the University of Alabama–Birmingham. “Obviously there are lingering effects in the brain that were caused by dieting and produced binge eating,” says Boggiano. “That was the novel finding—dieting can stay with you and put you at risk.”
IN 2002, William Klish, a pediatric gastroenterologist featured in the movie Super Size Me, told a reporter from the Houston Chronicle, “If we don’t get this [obesity] epidemic in check, for the first time in this century children will be looking forward to a shorter life expectancy than their parents.”
As Klish later admitted,* he had absolutely no evidence for this frightening scenario; it was based on his “intuition.” Which didn’t stop it from being replayed in the media and cited by researchers. In fact, as I write, this claim is featured prominently on the websites of the American Heart Association, the Children’s Defense Fund, the American Psychological Association, and other reputable organizations.
One reason no one questioned Klish’s doomsday scenario is that it jibes with our deeply held assumptions around weight. In a culture so entrenched in the fat-is-bad/thin-is-good dichotomy, such a conclusion seems self-evident and, therefore, doesn’t seem to need support. “People who talk about the ‘obesity epidemic’ often adopt a tone of absolute conviction,” wrote Michael Gard in The Obesity Epidemic. “Both the extent of the problem and its causes are held to be self-evident.”
There’s another factor in play here, too, one that’s related to that sense of conviction we have around weight issues. “The way we evaluate research related to weight is not neutral,” explains Abigail Saguy, a professor of sociology at UCLA and author of What’s Wrong with Fat?, “People, journalists, and researchers live in a world where it’s taken for granted that fat is bad and thin is good. We know these influence the way we evaluate findings.”
For instance, says Saguy, a 2004 study estimating that four hundred thousand people die each year from obesity got little or no public scrutiny because it reinforced what most people (including researchers) already believed—that fat will kill you. But the next year, when the CDC somewhat sheepishly revised that estimate down to around twenty-six thousand excess deaths from obesity each year—a huge difference—reporters couldn’t stop questioning the new estimate. “Almost a third of the journalists interviewed researchers who weren’t the authors and who said the research wasn’t good,” says Saguy. “They didn’t do that for the earlier study.” The journalists were, of course, doing their jobs in taking a skeptical stance about the new number. The question is why they didn’t feel the same skepticism about the original and much higher estimate.
So Klish’s doomsday scenario lives on in part because it’s frightening. And fear (whether justified or not) is a big part of the way we talk about weight—especially when it comes to children. The already heated debate about dieting gets even more volatile when it centers on kids.
According to the most recent numbers from the CDC, almost half of American kids and teens fall into either the overweight or obese category on the BMI chart. Like the categories for adults, those cutoff points were moved somewhat arbitrarily within the last fifteen years. Starting in 1994, the National Institutes of Health considered children whose BMI put them in the 95th percentile or above for their age overweight; those in the 85th to 95th percentiles were labeled “at risk of overweight.” In 2005, the categories shifted; now kids above the 95th percentile are labeled “obese,” while those in the 85th to 95th are “overweight.”18 And, according to University of Colorado law professor Paul Campos, author of The Obesity Myth, another little-known change happened at the same time: those percentiles were defined using data from the 1960s and 1970s rather than data on kids today, who are both taller and heavier than kids back then. In other words, writes Campos, “When Michelle Obama claims a third of our children are too fat, what she’s really saying is that what was the 85th percentile on the height–weight charts forty years ago is about the 67th percentile today.”19
The changing definitions make it hard to track how kids’ weights (rather than their weight categories) have actually changed. Like adults, kids’ average weights rose between 1980 and 2000, when they more or less stabilized. (What’s rarely reported is that the percentage of young people who are underweight dropped from around 5 percent in the early 1970s to around 3.5 percent now—good news, because underweight is strongly associated with malnutrition and other health conditions.)20
Childhood obesity is commonly referred to as both an epidemic and a call to action: in 2010, when First Lady Michelle Obama launched her Let’s Move! campaign, her goal was “to solve the challenge of childhood obesity within a generation.” Some researchers have even called for obesity prevention starting in the womb.21 Others, notably David Ludwig, a professor of pediatrics at Harvard Medical School, have argued that since “even relatively mild parenting deficiencies, such as having excessive junk food in the home or failing to model a physically active lifestyle, may contribute to a child’s weight problem,”22 obese children might need to be removed from their families, put into foster care, and, presumably, made to lose weight.*
I wonder why we’re not having the same conversation about, say, kids who live in homes where one or both parents smoke. We know the dangers of second- and thirdhand smoke very well: it causes and/or contributes to a range of diseases, including asthma, respiratory infections, lung cancer, and heart disease.23 Yet no one is calling for children to be put into foster care if their parents can’t or won’t stop smoking. No one is calculating the health-care costs of secondhand smoke over a child’s lifetime, or suggesting that cigarettes and cigars have any sort of environmental consequences.
Doctors and researchers know that dieting is no more successful in kids and teens than it is in adults—that in fact, it’s probably even less successful and more damaging. Dianne Neumark-Sztainer, a professor of public health and epidemiology at the University of Minnesota, has studied weight, dieting, and health in children and adolescents since the 1990s, as the principal investigator for a series of ongoing studies known as Project EAT. Her research consistently links dieting in kids and teens with long-term weight gain and with patterns of dangerously disordered eating that can last a lifetime.24
Neumark-Sztainer has found that the younger kids are when they start to diet, the heavier they tend to become and the higher their chance of developing risky behaviors like purging, abusing laxatives, bingeing, and overexercising.25 In fact, children and teens who diet are significantly heavier ten years later than those who don’t—even if they weren’t fat to begin with.26 They feel worse about their bodies than non-dieters, which in turn makes them even more vulnerable to disordered eating, eating disorders, and weight gain.27 And—here’s the kicker—dieting kids and teens are also less likely to pursue healthy behaviors, like regular moderate exercise and eating balanced meals.28 “People often feel like body dissatisfaction or being unhappy with how you look can be motivating,” says Katie Loth, one of the researchers involved with Project EAT. “We’ve found that’s not true.”
So why, then, do we keep pushing kids to diet? It’s one thing to make that kind of decision for yourself, as an adult; it’s quite another to encourage or even force a child to diet, to start her on a set of behaviors that can last her whole life. A couple years ago, New York City mom Dara-Lynn Weiss had a moment of fame (or infamy, depending on your point of view) after writing an article for Vogue describing how she put her seven-year-old daughter on a diet. “There are lots of times I looked like a crazy, overbearing mom and I felt like a crazy, overbearing mom,” she told a reporter for the Huffington Post after her book on the experience was published. “But it was the only way I found to help my daughter.”29
Mandy, thirty-six, works at an environmental nonprofit in Gainesville, Florida.
I developed early, around eleven, and was self-conscious about my body. My family made jokes about it a lot. There was a song that was popular, “Da Butt,” and they would sing it to me: “Mandy has a big ol’ butt.” So I was hyperaware of my body even before I really understood that stuff.
The first time I changed the way I ate to lose weight, I was about twelve. My parents hid “their” food, the Oreos and ice cream, the things I wasn’t allowed to have, so I would sneak food a lot. I became a secret eater and a binge eater for the next twenty years.
At fourteen I bought my first diet book and started doing exercises and eating fat-free foods, counting calories, chewing gum all the time, walking all the time. I became a compulsive fidgeter because being still meant I wasn’t burning calories. I still do it and am completely unconscious about it.
By the time I was nineteen I was very skinny for me. There was some drug use going on in my life. I was restricting, and I was obsessive about eating. I was miserable, and so uncomfortable in my own skin. When I turned twenty-one, I stopped doing drugs and started putting on weight. For the next ten years I’d go on a diet, restrict pretty heavily, exercise a lot, lose weight, maintain it for a while, and then slowly gain. Every time I lost weight and regained it, I gained more and my weight stabilized at a higher level.
When I was thirty-one, my husband got into an accident and almost lost his leg. As soon as the accident happened, I gained thirty pounds. And something in my head just snapped at that point. I was just tired of it. I was exhausted with hating my body, being at odds with my body. It became so apparent how futile the effort was. And I thought, I can’t do this for the rest of my life.
It’s been a big realization for me that there’s nothing wrong with me, that this is what your body does when you try to manipulate your weight.
That’s the rub: we want our kids to be healthy and successful, so when the pediatrician warns us a child is in danger because of weight, we feel compelled to take action, which can mean anything from teaching a child to count calories to criticizing her body to locking the refrigerator. (Weiss, for instance, admits in her book to humiliating her daughter at parties and with friends about how much the girl had eaten.) As parents, especially as mothers, we not only bring our own baggage around food and body image to the table, but we’re often directly blamed for our children’s problems, especially with weight. And we blame ourselves.
I know I did just that when my daughter developed anorexia; in fact, on some level I wished her illness was my fault because then, I reasoned, I might be able to fix it. (No one thinks clearly after an anorexia diagnosis.) As I learned from talking to eating-disorders researchers and experts like Dr. Thomas Insel, director of the NIH, while many factors contribute to the development of an eating disorder, including genetics, neurobiology, and hormones, families do not. Specifically, the fact that I’d struggled with food and weight didn’t cause my daughter’s anorexia; if anything, it reflected our shared genetics and brain circuitry.
Given our love for and anxiety about our children, it’s hard to go against the mainstream when it comes to kids and weight. When we hear that unless our child loses weight she’ll be obese for the rest of her life, or she’ll get diabetes or heart disease, or all of the above, of course we want to protect him or her, to do something, even if we suspect that that something is counterproductive or damaging. As renowned pediatrician William Sears told an April 2012 roundtable on childhood obesity campaigns, “For every eating disorder we might create, I think there are probably hundreds of health consequences of obesity that are much worse.” It’s tough to push back against a message like that, coming from an “expert.” I can’t help wondering if Sears has ever actually treated a child with an eating disorder, if he’s seen the physical, psychological, and developmental havoc such disorders wreak on kids and adolescents. For a pediatrician, he seems curiously cavalier about these serious diseases.
And that tells me a lot. For one thing, it demonstrates that doctors like Sears either aren’t looking at all the research or they’re dismissing some of it. Their laser focus on the dangers of overweight and obesity—whether those dangers are real or exaggerated—prevents them from stepping back and seeing kids as whole people, more than a number on the BMI chart. Even if they truly believe, as Sears obviously does, that overweight and obesity are urgent health problems, they must also know that there are no effective long-term “solutions.” We don’t know how to make kids thin any more than we know how to make adults thin. But as the work of researchers like Dianne Neumark-Sztainer and Janet Polivy show, we do a hell of a lot of damage in trying.
Sears’ comment also suggests that (a) eating disorders are incredibly rare, and (b) they’re not all that bad, especially when compared with being fat. (It also ignores the reality that you can be fat and have an eating disorder.) That’s precisely the kind of rhetoric that can and often does trigger kids into a spiral of unhealthy eating and exercise behaviors. And pediatricians really should know better,* as most eating disorders are diagnosed in childhood or adolescence—by pediatricians.
This end-justifies-the-means thinking is a big part of the national conversation about weight and dieting, especially when it comes to kids. Three years ago, when a pediatric hospital in Georgia created a series of controversial ads on childhood obesity, many people praised the campaign for telling the truth on a tough issue. The campaign featured stark black-and-white shots of fat children looking unhappy, with captions like “Warning: It’s hard to be a little girl if you’re not,” “Being fat takes the fun out of being a kid,” and “Big bones didn’t make me this way. Big meals did.” The children in the videos spoke about having hypertension and diabetes, though it later turned out they were actually healthy actors. A hospital administrator involved with the campaign told CNN, “Flowery ads don’t get people’s attention. We wanted to come up with something arresting and hard-hitting to grab people.” They did grab people, but maybe not in the way the hospital intended. The backlash to the campaign went viral; critics said the ads stigmatized, shamed, and ultimately harmed the very children they were supposed to help. They were eventually taken down.30
The “means” here—shaming people into “doing something” about their child’s weight, whatever that means—rarely if ever result in the hoped-for “end” of making kids thinner or healthier. Self-loathing in kids doesn’t lead to positive change any more than it does in adults, despite arguments from experts like bioethicist Daniel Callahan, who has called for increasing stigma and shaming of fat people—which he described as an “edgier strategy”—to end obesity.31
Even when such efforts don’t set out to shame kids, they can backfire in serious ways. For instance, many schools now require classes in “wellness” or “healthy eating,” which may or may not be grounded in science. One student told me about a high school health teacher who instructed her class to go home, take off their clothes, stand in front of a mirror, and jump up and down. If anything wiggled that shouldn’t wiggle, said the teacher, they’d know they were at an unhealthy weight.
Really?
Such classes often scare kids into destructive relationships with food and their own bodies. And that’s the point, isn’t it? To get kids to eat less and move more? But using fear as a motivator sets up all sorts of negative messages and behaviors. And while there’s no evidence these classes help kids in any way, weight loss or not—in fact, decades of school-based initiatives to make kids thinner have repeatedly failed—many middle and high schools require them. And such classes can and often do trigger full-blown eating disorders in kids who are vulnerable.32
My daughter was one of them. A sixth-grade “wellness” class kicked off both her anxiety about eating and her interest in health. Though her weight was normal, she started to worry about being fat. She cut out desserts, telling us she’d learned that sugar was unhealthy. Over the next six months or so, her restricting took on a life of its own, and eventually turned into full-blown anorexia that nearly killed her.33
Researchers like Leora Pinhas, a child psychiatrist who directs the eating disorders program at Toronto’s Hospital for Sick Children, have pointed out the risks of these targeted school-based health promotions. “These cases underscore the need to promote health, regardless of size, for all children and adults in the homes, schools, and neighborhoods they live in,” wrote Pinhas in 2013. In other words, isn’t it a good idea for everyone to be encouraged (not threatened) to engage in healthy behaviors like eating well (not minimally, but well) and exercising, whether they’re fat, thin, or in between? Isn’t the ultimate point health rather than weight?
I’m not so sure. We know putting kids on diets not only doesn’t make them thinner in the long run, it often makes them fatter than they might otherwise have been later on. We know being thin doesn’t necessarily equate with better health—on the contrary, for some children and adults, weight loss is a symptom of medical problems. We know the vast majority of people can’t maintain intentional weight loss, and so that first diet often triggers a lifetime of weight cycling that may be far worse, healthwise, than staying at a stable but higher weight. But doctors keep prescribing diets for children of all ages. In fact, the latest twist in the race to “end childhood obesity” calls for putting infants on diets.34
Joslyn, thirty-six, is an artist and legal assistant near Ithaca, New York. She grew up in Arkansas.
My history of dieting goes back to when I was eleven, when I started losing and regaining weight over and over. When I moved to California for college, I was at my heaviest. So I started eating less and walking a lot. I lost weight and immediately got all sorts of compliments from people. That progressed to me restricting calorically even more and exercising obsessively. I was walking about three miles in the mornings and evenings, and going to the gym for a couple hours, too.
I developed some health problems and eventually raised the issue with a nurse practitioner at school that I wanted to lose weight. At this point I’d lost sixty-five pounds, but my weight was still high based on the BMI chart. She didn’t know how fast I’d lost the weight. She didn’t ask what I was actually eating. She just gave me a goal weight and examples of what I should be eating, and had me come in weekly for weigh-ins to track my progress.
That was when I started purging. A couple months later I started abusing laxatives. But I lost weight every week. I was being monitored for weight loss, and being encouraged to keep losing. I lost about 115 pounds in eleven months, and then I started passing out randomly. Eventually I had an EKG and found I’d developed an arrhythmia. I needed to go into the hospital for inpatient treatment, but I was still overweight according to the BMI chart, and there was only one place that would take me.
I’ve now been in recovery from eating disorders for almost six years.
Too many professionals still seem to feel that pushing weight loss on children and teens is not just a good idea but an imperative, that few of those young people will develop eating disorders or other problems in response, and that even if they do, the good of the many outweighs the potential harm to the few. One of those professionals is psychologist Thomas Wadden, a prominent obesity researcher at the University of Pennsylvania. “Although health professionals, teachers, and parents will continue to be concerned about misguided weight loss efforts in children and teenagers, all should be increasingly concerned by the growing epidemic of pediatric obesity,” he has written.35 But who really benefits from this kind of approach? Wadden’s allegiance to the fat-is-always-bad perspective suggests it’s OK to disorder kids’ eating and self-image in the name of making the fat kids thin—which doesn’t work anyway. (And what about the eating habits and physical and mental health of the thin kids? Is anyone paying attention to those?) Wadden also directs the Center for Weight and Eating Disorders at the University of Pennsylvania, a frightening thought given his clear priorities around children and weight. I’m glad my daughter wasn’t treated there.
SO DIETING, it turns out, doesn’t make people thinner in the long run. But it must make them healthier. At least that’s the premise Janet Tomiyama, now a professor at UCLA, set out to explore a couple of years ago. Tomiyama, who describes herself as a “huge foodie,” traces her interest in weight issues to the fact that she spent much of her childhood in Japan. “Everyone there is much thinner than in the U.S., and there’s a more pervasive stigma against overweight,” she says. “I went to an American school, so I heard two different messages around weight. The American message, was, Your body is beautiful!” She grins, making a dimple appear in one cheek. “And then I’d go home to people blatantly putting me down because of my body.”
Tomiyama’s most recent collaboration with psychologist Traci Mann investigated whether intentional weight loss—regardless of whether people kept the weight off or regained it—improves health. They reviewed studies of dieting interventions, looking for those with common health biomarkers, and chose five measures to compare: total cholesterol, triglycerides, blood pressure (systolic and diastolic), and fasting blood glucose. The results stunned them. “We found basically no relationship between any health outcome and the amount of weight lost or gained,” says Tomiyama, adding dryly, “we had some trouble getting it published.”
Their finding is deeply disturbing, given the fact that virtually everyone in this culture uses weight as a proxy for health. My neighbor who bemoaned the actress’s body size, for example, was conflating weight and health. Ditto the doctor who told Dara-Lynn Weiss her daughter had to lose weight but who asked nothing about her eating or exercise habits.
Tomiyama’s study doesn’t mean that weight loss never benefits health, of course. Some people who intentionally lose weight see improvements in blood pressure or glucose levels or cholesterol or joint pain. It does underline the fact that health is essentially an individual measure. What’s healthy for me might not be healthy for you, and vice versa. But that’s not how the issue is typically framed. Instead, weight loss has become a reflexive prescription for improving nearly everyone’s health, and we’ve all come to think of it that way, including doctors. When medical experts automatically recommend weight loss for any and every medical problem—and I’ve heard stories ranging from ear infections to brain malformations being blamed on being overweight—they’re not only relying on an assumption that’s untrue; they’re also potentially missing other health issues.* Weight stigma is a real problem, especially among doctors (see Chapter 4).
One of the largest and most recent comprehensive studies on weight loss and health, the Look AHEAD trial, set out to see if weight loss via “intensive lifestyle intervention” could improve the prognoses for people with type 2 diabetes, who are more susceptible to heart problems, amputations, and other medical complications. The study followed five thousand or so overweight or obese patients with type 2 diabetes for close to ten years—far longer than the usual one or two years of follow-up most studies offer.
The results were somewhat mixed. People in the intervention group did lose more weight than those in the control group (though not much—6 percent versus 3.5 percent of body weight at the end of the study); they also showed significant improvements in fitness and biomarkers like waist circumference and glycated hemoglobin (a marker for blood glucose levels). But they had just as many heart attacks, strokes, other cardiovascular “events,” and premature deaths as those who didn’t get the intensive interventions. In fact, the study was stopped ahead of schedule because it found no significant differences between the two groups.
That doesn’t stop doctors from clinging to the weight-loss prescription for patients with type 2 diabetes. According to Rena Wing, the chair of Look AHEAD and a professor of psychiatry and human behavior at Brown University’s Alpert Medical School, “There are many reasons you should be encouraging patients with diabetes to lose weight.”36 Twenty years ago Wing, who holds a PhD in social relations, developed the National Weight Control Registry to track people who lost “significant” amounts of weight and kept it off for “long periods of time,” defined as anyone who’s kept off at least thirty pounds for a year. She’s also published more than two hundred research articles about obesity treatment and prevention.37 Like many researchers in the field today, she has gotten financial support for some of her work from the weight-loss industries. And like them she’s deeply invested on a number of levels in the idea that losing weight improves health, despite the lack of clear evidence supporting that hypothesis.
ONE OFTEN OVERLOOKED factor in the conversation around weight and health is the effect of yo-yo dieting, also known as weight cycling. An ever-growing body of research suggests that losing and regaining weight over and over correlates with higher levels of heart disease,38 impaired immune function,39 cardiometabolic risk,40 insulin resistance,41 triglycerides,42 hypertension,43 and abdominal fat accumulation.44 In other words, weight cycling can be far worse, healthwise, than obesity. And these health risks apply whether you’re thin or fat, judging by a fascinating 2001 study done in Japan.
Researchers at Nagoya University took five healthy, nonsmoking, “normal”-weight women in their twenties and thirties and put them through two major periods of weight loss and regain within 180 days. Studies of weight and health typically use self-reported measures of weight, height, food intake, and exercise routines, which are notoriously inaccurate; most of us under-report what we’ve eaten and our weights, and overestimate how much we exercise. These women were actually weighed, measured, and to a large extent supervised by researchers, meaning that the data was more accurate.
The subjects first dieted for thirty days, eating around 1,200 calories a day and losing six to ten pounds each. Then they were allowed to eat whatever they wanted for fourteen days; all of them gained back the weight they’d lost, plus a little more. Next came another thirty-day diet period, during which they didn’t lose quite as much as they had the first time around. Finally, they ate freely for the last three and a half months.
At the end of the study, the women’s weights were around the same as when they started. But their lean body mass had dropped, meaning they now had more body fat even though they weighed the same. Their resting metabolic rates had also dropped, meaning they now required fewer calories to sustain the same amount of energy. Finally, their blood pressure and triglycerides rose, too. They may have looked the same on the outside and on the scale, but weight cycling caused physiological changes that hurt their health and could likely lead to more weight gain and disease down the line.45
What’s interesting about this study (besides the fact that researchers somehow persuaded five women to undergo such a grueling process) is that it tracked and monitored individuals, not groups. So while the sample size, five, is too small to generalize from, the study’s design offers a window into some of the otherwise invisible changes that accompany weight cycling. While more research needs to be done (and no doubt will be), the bulk of the data suggests that yo-yo dieting is not benign. The kind of up-and-down weight cycling so many of us do, over and over, believing that we’re trying to make ourselves healthier, is almost certainly hurting our physical health in ways we don’t yet understand.
While many of the studies on weight cycling suggest it’s dangerous, a handful have found no correlation with mortality46 or disease.47 (Nearly all of those, interestingly, were worked on by Harvard’s Walter Willett, who refused to talk to me.) As with pretty much every aspect of the research on weight and health, there’s no absolute consensus, and there’s a lot we still don’t know. Still, when a respected obesity researcher like Donna Ryan, a former director at the Pennington Biomedical Research Center in Baton Rouge who’s worked on some of the biggest weight and health studies in the United States, claims not to be familiar with any negative effects of weight cycling, I have to wonder why. In an interview, Ryan told me, “I am not convinced there’s any harm whatsoever in losing weight and regaining it. I think the risk reduction while you’re at a lower weight is good for you.”
That perspective, which appears to be shared by Willett, doesn’t jibe with most of the research. It certainly doesn’t match up with what we know about the psychological effects of weight cycling. Pretty much every study that’s looked at the question has found strong connections between weight cycling and binge eating, which makes sense, since part of the body’s physiological response to starvation is to up the drive to eat. Binge eating, in turn, is closely linked with mental distress. In a 2011 study of overweight and obese African American women, weight cycling correlated with a higher drive for thinness, lower body satisfaction, and lower self-esteem.48 Earlier studies found correlations between weight cycling and disordered eating, higher stress, lower well-being, and less confidence about food and eating.49 In other words, the more loops of the yo-yo you go around, the worse you feel about your weight, your eating, your very self.
AMONG THE HUNDREDS of women and men I interviewed for this book, I talked to maybe four or five who lost more than twenty pounds and kept the weight off for more than five years. In the world of obesity research they’re known as “maintainers,” the 5 percenters, and they’re few and far between. Almost all of them say keeping the weight off is their top priority, and that when their focus slips even a little they start to regain weight. Almost all have done some weight cycling.
One of those “maintainers” is Patrick, a slender thirty-eight-year-old university librarian with deep dimples who grew up in Texas. He describes himself as a person with a big appetite. “I did a lot of eating and drinking in a celebratory way,” he says. “I felt like it was part of my personality.”
Patrick’s first diet started nine years ago, after his doctor lectured him about his weight. “I knew I was overweight, but it had never officially been on the record before,” he says. “It was like I was getting yelled at. And that was a very big incentive to me, to not upset the doctor.” He started walking every day, eventually transitioning to running. He became more mindful about what and how much he ate. Over the next three years he lost eighty pounds.
Patrick’s daily routine now starts with the same breakfast every day (shredded wheat with milk). He walks or bikes two and a half miles to work and goes to the gym at lunchtime. Lunch, too, is the same every day—currently several ounces of hummus, half a pita, cherry tomatoes, spinach and arugula with a little cheese and vinaigrette, and fruit. (He changes it up every few months.) He walks or bikes home, goes for a run, and then sits down to a small dinner with his wife.
He runs twenty to thirty miles a week and says it’s become both his passion and his refuge. But he worries about what might happen if, say, he was injured, or found himself having to work three jobs. Or if, for whatever reason, he didn’t have fifteen hours a week to devote to fitness. “The day-to-day practice of being a healthy person is ingrained in how I live now,” says Patrick. “But what if the thing that I know works for weight loss, and that I enjoy, gets pulled out from under me?”
His concern illuminates one of the core confusions at the heart of the weight-health debate. When Patrick began walking, and then running, his health improved—not because he lost weight but because he started getting regular exercise, and the physical and psychological benefits of regular exercise are well known and well documented. But he attributes his improved health to the fact that he’s eighty pounds lighter, not to the behavioral changes he made. It’s as if a former smoker attributed his new improved health to the fact that his teeth were now whiter; yellow teeth are, after all, a risk factor for lung cancer, as I mentioned earlier. If we lived in a culture that fetishized white teeth the way it does thinness, we might agree. But of course the real reason for his better health is the fact that he changed his behavior; he stopped smoking.
Not long ago Patrick did indeed regain thirty pounds, mostly, he says, by just not paying attention to what he was eating and how much he was exercising. This time around it was much tougher to drop the weight.*
This is the reality for pretty much everyone who loses a significant amount of weight. As the researchers at Nagoya University learned, dieting changes metabolism. The body becomes more efficient after a period of restriction, spending its calories frugally. People who have intentionally lost weight generally use about 15 percent fewer calories than non-dieters to perform exactly the same activities,50 which means they gain weight eating fewer calories than non-dieters. “We know scientifically even if someone loses weight, they will never be like a thin person,” says Asheley Skinner, PhD, a research professor of pediatrics at the University of North Carolina at Chapel Hill. “They will always need fewer calories and will need to exercise to stay at that lower weight. We know there’s some sort of derangement of the metabolic pathways, and that has a cascade effect on everything from the hormones involved with obesity to hunger.”
A few years ago, Skinner used data from the NHANES study to test the concept. She analyzed two days’ food intake for “normal”-weight and overweight children, and found that while heavier toddlers and preschoolers ate more than their thinner counterparts, older children and teens ate significantly less.51 One possible explanation is that the older kids and adolescents might have lost and regained weight, even once or twice, making their metabolisms more efficient.
GIVEN WHAT WE know about how ineffective and often harmful dieting is, why is it still so widely prescribed, pushed, and promoted? I think one reason is that most of us feel trapped when it comes to weight. We’re constantly hammered with the message that fat is bad, that we need to be thinner, that our kids and pets need to be thinner, that we’re all going to die (or live alone with too many cats for the rest of our foreshortened lives) if we don’t lose weight. We live in a time when we believe we can control our destinies, and that includes our bodies, despite mountains of evidence to the contrary. We believe we might even cheat death if we do everything exactly right—eat right, exercise enough, de-stress, make time for friends, fill in the blank. So when our bodies don’t measure up, when our lives look less full or less desirable than other people’s, we feel incredible shame. We live in a culture where failure in anything is a sign of unforgiveable weakness. So we keep pushing ourselves and our children; we keep running around and around the same closed loop trying to get it right. To get our bodies and our appetites right.
And one way we try to mold ourselves into the shape du jour is by controlling, obsessing, and angsting over food.
*If you’ve ever spent time at Weight Watchers (or even if you haven’t), get hold of The Amazing Mackerel Pudding Plan: Classic Diet Recipe Cards from the 1970s, by Wendy McClure. Her snarky commentary on recipes like Fluffy Mackerel Pudding, Crown Roast of Frankfurters, and Cabbage Casserole Czarina (I am not making these up) makes me howl every time.
*The ProLinn Diet, popular in the 1970s, had dieters eat nothing and take only one daily four-hundred-calorie drink made from slaughterhouse by-products like hooves, horns, and tendons. Mmm, mmm, good.
**Fletcherism, also known as the chewing diet, was created in 1895 by one Horace Fletcher, an American dietitian who believed, as he often said, “Nature will castigate those who don’t masticate.”
*According to “An Epidemic of Obesity Myths,” published by the Center for Consumer Freedom. The CCF is a controversial source because it is, essentially, a front for food manufacturers, who have a vested interest in continuing to produce and market junk food to American consumers. Still, I haven’t been able to find any evidence to support Klish’s claim.
*Ludwig made this argument in response to the growing popularity of bariatric surgery for kids and teens; he believes foster care would be a better solution than irreversible surgery. Putting kids into foster care is also a radical solution, though, and its effects might also be irreversible. And it has been happening. In October 2011, an eight-year-old Ohio boy was put into foster care because he weighed 218 pounds and was considered at risk for type 2 diabetes and high blood pressure. He didn’t actually have either of those conditions, but the county still considered it a case of medical neglect. He went home five months later and more than fifty pounds lighter. I haven’t been able to track what happened to him after that.
*Anorexia nervosa, for instance, has the highest mortality rate of any psychiatric illness.
*To read some personal stories on the subject, visit the blog First, Do No Harm at http://fathealth.wordpress.com.
*A 2003 study of successful weight maintainers found that few if any were able to re-lose weight they’d regained, even small amounts. Patrick’s success may have something to do with the fact that he doesn’t have a history of weight cycling; this was his first yo-yo.