Speak Up, or You Will Be the Biggest Loser. And That’s Not a Good Thing.

Rapid weight loss is incompatible with mental and physical health. Period.

I beg to differ with Daily Beast columnist Tricia Romano, who believes Rachel Frederickson’s extreme weight loss on the Biggest Loser is none of our business. And I disagree that her weight is just a tad lower than a healthy BMI. And Rachel’s BL trainer Bob Harper is simply wrong when he assumes that “…when contestants leave home ... they are in charge of themselves.” 

Admittedly, I’ve never watched more than a few minutes of TBL—I found it intolerable. Yet the show is unfortunately quite popular. Many of my plus size patients report being inspired, identifying with the desperate contestants, tolerant of the verbal abuse and crazy diet and activity demands. They're smitten by the fairy tale that rapid weight loss through extreme measures works. And that extreme weight loss equals extreme happiness. Let me inform you otherwise; I yearn to protect you from the damage, both visible and hidden, from this diet mentality.

But first, about Rachel—the latest victim 

My summary of The Biggest Loser.

It was a media frenzy as Biggest Loser Rachel Frederickson returned to the show, 45 lbs below her “healthy” weight of 150 pounds when departing TBL. She weighed in at 105 pounds, a 155 pound total weight loss. And the $250,000 reward money was likely the least of the motivators. If you’ve ever known anyone who’s lived with an eating disorder, you know the situation well. It may start with a seemingly reasonable weight loss goal, typically with a common diet. And then once that goal is met, their goal gets reset. “Just five more pounds”, they think. “Then I’ll be happy/ satisfied/thin enough.” Yet for some, no amount of weight is ever quite enough, and the struggle continues. It moves from perhaps a sincere interest in losing some weight—perhaps at the recommendation of their doctor, even—to something completely different. 

And while it is frequently said that eating disorders are about control, the experience of the eating disorder sufferer hardly feels like being in control. Rumination about food and weight and eating consumes thoughts, and normal life comes to a halt. Social activities are put on hold to accommodate diet rules, and isolation becomes the norm. They may be visibly underweight, or appear to be of average or even over weight. Starvation can occur at any size. Really.

As for the Daily Beast writer’s comment “at 5 foot 5 inches and 105 pounds, Frederickson’s is slightly below the recommended BMI. But she’s also small-boned and lithe”, allow me to respond. For her height, midpoint of a healthy range may be 125 pounds by the charts, but at less than 90% of that weight (under 112 pounds), most women lose their periods. As for athletes (she was apparently a world class swimmer prior to her weight gain) a higher weight range is generally expected as healthy, with increased muscle mass. 

Of course there are small boned, women who were always petite, for whom a lower weight certainly may be okay. Weight, as I mentioned, is not the best measure of health. But a significant weight drop below one’s highest weight, referred to by researchers as weight suppression, may have undesirable effects, including precipitating eating disorders. 

Rachel reports feeling fine, but the evidence tells us otherwise. Exercising 3-4 hours per day strikes me as a big red flag for preoccupation with her weight. It’s not her fault, though. The Biggest Loser promotes rapid weight loss and unrealistic goals. We know from a classic starvation study by Dr. Ancel Keys in 1944 that starvation resulting in even a 25% weight loss—much less than her almost 60% drop in body weight—impacts thoughts, moods, sexual desire, and eating behaviors. All that, in addition to the slowed heart rate (no, it is not an athlete’s low pulse), low body temperature, and abnormal menses. 

Three, maybe four exercise classes a day, is her reported activity, while consuming under 1600 calories from a 'healthy' diet. Excuse me? 'Healthy diet' is a term that simply doesn’t apply to this intake relative to activity. I don’t care how healthy the individual foods are, whether they are organic, whole grain, whatever—there’s nothing healthy here. This is a severely restrictive intake for this level of activity.

It’s none of my business, Tricia? On the contrary. I can’t simply sit and watch and not shout out how outrageous and unhealthy this is. I am not, however, faulting Rachel. The Biggest Loser took a vulnerable contestant—perhaps no different than other contestants—a woman who reports emotional overeating resulting in a 100 pound weight gain following a breakup. They turn out an excessive exerciser, who’s restricting her calories and likely quite unhealthy by many measures. 

Call it the flip side of the same coin—first likely struggling with binge eating now struggling to trust her body and her signals and eat to meet her needs. Are we to view this as success? Not in the least. Were her eating behaviors addressed? Was she given strategies for coping versus using food or food restriction or compulsive exercise? Was she guided to learn to trust her hunger and her fullness again, or simply instructed to count calories? 

A former contestant, Ms. Hibbard acknowledges the unhealthy behavior she and others practiced on the ranch, particularly preceding weigh-ins (similar to what Weight Watchers report). Contestants, she claims, “dehydrated themselves through excessive workouts in warm layers of clothing, drank only coffee because it acts as a diuretic and ate little to nothing.” She adds: “I feel I did a vulnerable disservice by not saying on television the night of my finale. ‘I’m sad, and I’m sick from being on this show’”. (http://www.nytimes.com/2014/02/09/fashion/Biggest-Loser-Rachel-Frederickson.html?_r=0)

Hibbard might have been late to speak up. But we don’t have to be silent. The impact of a show like The Biggest Loser is dangerous—to its contestants, and to its viewers. It promises health, while causing harm; and it delays and potentially complicates contestants’ preexisting eating disorders. It shames participants through their weight loss struggle, and turns viewers to criticizing the Loser, like Rachel, for whom continued weight loss may feel out of her hands. 



Don’t accept the promise of rapid weight loss, or believe that extremes of eating or exercising will work. Because they never do.

Essential Weight Loss Tips? There Has to be a Better Way.

A winter storm has its risks. The biggest? It keeps me home with time on my hands trolling the Twitter feeds and Facebook messages. I read, filter my thoughts, read, filter, read—and then I can’t take it any more and feel the need to speak out. Earlier, I tweeted: ‘The only #cleanse you should be doing is a facial one. You know, soap & water or alternative. GI cleanses are disordered’, after reading an MD’s unintelligent praise of ‘cleanses’ (in quotations, because there’s nothing cleansing except your perception that you are removing those treacherous toxins.)

Then I came upon my professional organization’s tweet, “If you're hoping to lose weight before winter's end, these tips can help!” with this link. http://www.eatright.org/Public/content.aspx?id=6847

It’s hard for me to say just why it annoyed me, but I’ll try my best to explain.

Is this the best message we as RDs can offer? It’s a message of calories in/ calories out. Pick from all food groups! Exercise! Eat smart (as opposed to stupid, I suppose). Personally, I’d run the other way if I were looking for weight management guidance. It feels insulting to intelligent, well-informed readers. And it fails to acknowledge a couple of major points.

1) Actively dieting is not the answer and 2) eating and activity are not simply information-based decisions.

Were the authors thinking readers would respond with “Wow, I had no idea calories and activity were involved?” or “So simple! I’ll just choose from all the healthy food groups! That should work.” Or “Ohhh, it’s about moderation!”

As for BMI

For some, self-acceptance of a weight higher than the population-based weight and BMI charts is in order. A high BMI based on the population charts may be perfectly acceptable for you, if you maintain a healthy lifestyle. Similarly, a normalBMI hardly defines you as healthy (or normal) if your behaviors aren’t so healthy—if you engage in restricting and overeating, use purge behaviors, including compulsive exercise, have a rather restrictive diet, or poor quality intake.

Perhaps instead of having a “Calculate your BMI” ad on their page, they could include a ‘plot your personal BMI’, to help you evaluate whether you’ve been maintaining a healthy pattern over the years; a high BMI at the earliest ages suggests that genetics may play a role in your weight and size. Just as you wouldn’t expect that your shoulders would become narrower or your eyes would change shape, you shouldn’t believe that your BMI percentile should be changing much. Acceptance of this not-so-minor-point may be the best medicine for many!

But if your weight or BMI have been climbing inappropriately, you could use much better guidance than my national organization provided.

So in an effort to redeem them from the pitiful piece, I’m pulling a few thoughts together. Ask yourself:

Is it legitimate to be concerned about your weight? Has it changed inappropriately? Or are you focusing unnecessarily on your weight, the New Year’s phenomena, when really you are a reasonably healthy and fit person? I caught an episode of Sex and the Citytoday at the gym, and Carrie said a most fitting line: “the problem isn’t with your thighs, the problem is with your head.” (This, in response to her friend kvetching about the size of her thighs and her body image.)

If it is legitimate, explore what’s in place, and what needs to change.

Are you aware of your hunger? Do you allow yourself to respond to it, or are you living inside your head, counting calories, or points, or carbs, for instance?

Do you let yourself get to the point of famished, only to overeat, then regret it, then set more rules again, perpetuating this cycle?

Do you eat beyond a comfortable level of fullness? Do you let your black and white thinking get in the way, suggesting that you’ve already blown it, resulting in you throwing in the towel, so to speak? Some CBT (cognitive behavioral therapy) may be in order.

Yes, there are other ways to self-soothe.

Or do you eat for comfort—because you’ve had a hard day—or as punishment, because you feel you don’t deserve any better? Maybe you’ve simply given up, feeling that nothing you do can even make a difference.

Are you overeating as a rebound to years or months of restrictive, rules-driven eating? Are you overeating only on ‘forbidden foods’? Time to learn how to work those in with permission to eat all foods that you enjoy—not just those foods that fit ever-so-nicely into the food pyramid! “Eat desserts less often”, the Academy for Nutrition and Dietetics recommendation, is hardly the advice you need. Setting more rules is not the answer.

Must we view desserts as forbidden?

Is your eating chaotic? Do you have balanced meals and snacks? Perhaps some help with planning is in order.

And have I mentioned patience? You've been living with your eating behaviors for a very long time, many years, no doubt. Let's not expect that they will consistently change after just a week or two.

Do you set realistic goals? You’re not stupid—of course you know exercise might help if your activity is low (and your intake is adequate). But maybe the obstacle is your belief that if you don’t have 60 minutes to spend, or can’t sustain exercise at 85% of your target heart rate range that it’s not worth doing any activity! 

Perhaps it's time you acknowledge your frustration—with messages from the media and the medical community, with false promises of quick fixes for your weight, with conflicting messages about what’s the right way to eat, and with insulting guidance from those who should know better. Yes, there is another way, which includes self acceptance and insight about the limits of what you can change. And, a shift to understanding how your thoughts and behaviors play a critical role in your eating.

Your thoughts? Thanks for reading (and in advance for commenting and spreading this advice!)

“Just Eat it”? Taking that leap of faith to let go of the diets and the rules.

Just Eat it. Designed by Olle Hemmendorff for Nike.

Just Do It has been a memorable Nike campaign, motivating and inspiring athletes and active wannabees for years now. But I really don’t want to talk about exercise and determination.

Rather, let’s talk about Just Eat It, the image circulating on social media with that very phrase. This expression has crossed my mind—but not my lips—during many a patient session way before the creative graphic emerged. Yes, sometimes I’d like to shout out JUST EAT IT! (or even JUST EAT!), at times when rational discussion seems to get us nowhere. But that’s my emotional—and occasionally frustrated—response.

Personally, I struggle with the just part of the statement. Does it feel like a justto you, as an only? Or merely eat? To the person living with disordered eating, I bet just is the worst possible adverb imaginable. To me, it minimizes the struggle. Just eat it? As in, “it’s no big deal, what’s all the fuss about anyway”. EAT it?! If you could just eat, wouldn’t you?

The hike toward the Hornli Hut, heading toward
the Matterhorn. 

My editor was reviewing this piece—by editor I mean husband—and he likened this minimizing to a personal experience he and I have had. You see, I have a fear of heights, and I swear it’s worsened as I’ve gotten older. So now, when we go hiking where the path has narrowed and I can vividly imagine the drop off to my death, I get a bit stuck—think deer-in-headlightskind of stuck. No, not just a bitstuck. There’ve been times when he’s had to talk me through, or physically be there to support me. At those times, he’s clearly communicated the message of “just do it, just get over it”, as in “what’s your problem?” failing to understand that my concern just might be irrational.

No, others really may not get it; fear is often irrational. But somehow reading a draft of this post he did get it. I don’t choose to get anxious at precipitous drops at high elevations. And sometimes the dangers are real. But the risk of stepping outside of your comfort zone to eat (as opposed to the risk of not eating enough), is not life threatening.

I suspect that if you really think about it, you’d realize that you used to eat the very foods you fear will make you fat, or will trigger overeating, with no ill effect. Think back to the time before the rigid rules and diets began, before your eating disorder or disordered relationship with food developed. Sure, you may associate carb restriction with something positive—weight loss perhaps (strictly because it resulted in reduced calories, and not because there’s anything magical about reducing carbs, or fats, or any food or nutrient in particular). 

But you fail to acknowledge that your struggle with binge eating only began with this restriction, with the deprivation. Or, that starting to restrict set you on your path to being unable to nourish your body, to respond to its needs. You hold on to all the ‘good’ you associate with dieting, yet minimize the consequences of your disordered eating on your health—on your mood, on your ability to be social, on your energy level, on your thinking.

There’s a bit of a conundrum we face; by we I mean providers and parents and loved ones alike. I can present all kinds of justification for nourishment—for including carbs, for increasing necessary calories, for adding snacks, whatever—but sometimes that’s not enough. Evidence that food restriction is slowing metabolism may help—such as pointing out that a slowed heart rate or lowered body temperature is a consequence of starvation. Showing evidence that you had previously been both healthy and a normal weight when eating your now feared foods may help, but it doesn’t seal the deal. 

Do you know which are the least read of all these blog posts? They are the ones describing research—the clearest evidence—in favor of normalizing your eating. Few tend to care about the evidence.

No, you can’t always negotiate with an eating disorder.

Sure, it’s easier if you know you can trust me—that I’m not going to mislead you; that it’ll really be okay if you make the dietary changes I suggest. But where’s the proof? Until you actually do it, and see that it really isokay, it’s challenging to trust. You believe that you’re different, that the rules simply don’t apply. And so we’re stuck.

At that point, you need a leap of faith. You need to go on blind faith that it will be okay. It helps to acknowledge that where you’re currently at is clearly not alright—in fact, that you’re quite miserable, if you allow yourself to be honest about how you feel. And it helps if you consider ‘what’s the worst that can happen?’ acknowledging that fear of rapid weight change is a distortion of your thinking; progress on so many levels can start here. Recognize that you don’t have to commit to continuing with this change forever—take it one day at a time, and give yourself the opportunity to back out.

It can be scary getting to the top, but it's worth the effort.
Capu Rosso, Corsica

Sometimes we do need to “Eat it!” or “Do it” giving yourself no option but to not go running, or to cease all purge behaviors, for instance. Sometimes giving your self no option makes the recovery process much easier.

But if you can’t bring yourself to take that leap of faith, or to “Do it”, then eating disorder programs may be the next best thing. Or, for those living at home with family, FBT (family based treatment for eating disorders) may be a great alternative.

Over time, you’ll realize that there’s really no other option for living a healthy life than to maintain the changes you’ve started.

Just saying.

What are your thoughts? Is anyone reading out there?

My Struggle With Obesity.

Warning: you just may not like this post!

Gorgeous, no? Barnes Museum, Philadelphia

I must admit, I’ve been conflicted about obesity. “Why conflicted”, you may ask? “What’s to debate? If you’re fat or overweight you should get down to the normal BMI”, right? Not so fast.

The two sides I struggle with

Diabetes and heart disease conferences bombard me with slides linking obesity with an increased risk of Type 2 diabetes. And I’m warned that obesity is the underlying problem responsible for our ills, including hypertension and even some cancers. For the record, I have had high blood pressure since my 20s as did my father—and no amount of weight loss with our in range BMIs would have been appropriate to lower our risk. So I have my biases when it comes to making assumptions about disease and body weight.

The focus on weight loss is unrelenting. Doctors, for instance, will often refer their diabetic patients to me, pounding them with the message that it’s all about their weight. Sure, weight loss may improve their levels. But simply modifying aspects of their intake, and their activity, regardless of weight change, can yield great improvements in blood sugar. Yes, regardless of whether they have had much shift on the scale. And we’ve become so focused on those darn BMI charts, using norms for the population as our targets, that we’ve failed to consider what normal truly is for the individual.

Good outcomes with minimal weight change

A recent diabetes webinar referenced a few large, well done studies about obesity, weight loss and development of type 2 diabetes. On average, a weight loss of only 7% was enough to reduce the risk of developing Type 2 diabetes by 50-68 %, in these 3 studies (one referenced above)! That’s right. If you are a 200 lb individual (regardless of your BMI), a 14 pound weight reduction can dramatically lower your chances of getting diabetes.

A 5-6 % to 10% loss in body weight in obese individuals significantly decreased BP in those with hypertension. That said, an even greater improvementwas seen in those who also followed a diet high in fruits, vegetables, and low fat dairy products—consistent with the DASH diet for lowering blood pressure.

They’d still be considered obese, mind you. But that amount of weight loss may be just fine!

Why pushing for weight loss may be a bad idea

Recently, I attended a 2 hour presentation at the Renfrew (Eating Disorder) Center by a Dr. Lowe, from Drexel University, a researcher who studies weight suppression. Weight suppression  (WS) is the difference between your highest, non-pregnant, non-ill BMI and your current BMI. It was truly fascinating and in some ways depressing, what his and other studies show.

Priceless.

The degree of WS predicted many undesirable effects. CBT, the treatment strategy that engages your thoughts and feelings to change your actions, was less effective in those with greater WS. In addition, the impact of staying at a lower BMI (lower than your historically normal BMI) doubled the rate of binge eating (although this was not seen in some other studies). Higher weight suppression predicted worsened symptoms, including depression and ED psychopathology in anorexic patients, too. In ‘weight restored’ AN individuals who do not resume menstruation, there was a correlation with higher WS; even though they were at healthy BMIs (based on population norms) at program discharge, their normal-by-the-population-based-BMI-charts were not necessarily healthy and normal for them!

Larger sized, and beautiful. Seemingly content, too.

Residual symptoms in those we view as ‘weight recovered’ may be a red flag indicating that weight may further need to increase. I know, I know, this is not what you hoped hear.

Also of note, (and also depressing), is the data on pre-eating-disorder weights, even in young kids (think elementary school and up). Before their eating disorder, those who went on to develop anorexia or bulimia were at higher weights than their peers. Maybe healthy and appropriate for them—just higher.

In other words, pushing your body to get to or to maintain a less than ideal weight for you based on your history may add to your risk of getting an eating disorder, will increase your odds of being unable to use well-known strategies to change your thinking and actions, and is associated with more subsequent weight regain.

The Fat Nutritionist also gives a great summary of why it’s a constant battle to lose weight in her recent post Why Diets Don't Work.

If you struggle with bulimia, and have not had significant weight suppression, your weight may possibly drop as behaviors improve.

Are you confused now? Do you question whether your actions can really make a difference? Or frustrated that you are hopelessly unhealthy, given your obesity?

So where am I at in this debate?

We come in all varieties--& we are not all at the 50% percentile for weight!

I know all too well that modifying lifestyle factors can both improve your health and support weight loss and well being, in those who are overweight. I have witnessed significant weight loss—up to 150 lbs.—with a high degree of weight suppression—that has been maintained over many years in my patients. Perhaps the weight suppression data isn’t looking at weight loss via mindfulness and healthy lifestyle changes, but rather just focuses on absolute weight shift? That may be true for some studies.

But I have also seen some patients do all the right things while their weight stayed steady. Which leads me to this: if you are doing your part—eating mindfully and listening to your body, staying (or getting active), and you’re not losing weight, then the answer is simple: you shouldn’t torture yourself. You are doing what’s in your hands to do, to keep your risk low and to be fit and healthy—in spite of the population-based links between weight and disease. So don’t let these study summaries bring you down!

Being responsible for change. A case in point

A recent experience when I was traveling leads me to clarify my position on weight change. I was eating dinner in a remote town in Washington state, far from the foodie finds in the not so distant Seattle and Vancouver cities. To set the scene, let me describe: the place was a dive, to the point that my husband selected a deep fried entree figuring that that was the greatest assurance that any contamination would be killed. There was a salad bar—but it looked like week-old decay ready for the compost. If we weren't so hungry, there's no way we would have stayed. But there was truly nothing else around.

A family walked in. Dad, a very large mom, and a very large school-aged girl, dressed in a snug-fitting cheerleading uniform.  And here's what I observed. The girl wanted to order the steak tips and vegetables, but was urged to get the cheeseburger and fries platter—it was cheaper. The dinner came with the salad bar, so she chose from the limited options—a fruit salad and sad looking iceberg, with creamy dressing. And she ordered a large soda—it just might’ve been part of the package deal.

From my limited observation of her and her family, (admittedly being in the booth behind them, I overheard much of their conversation), they have frequent meals out, and rely on hunting season to put food on the table seasonally. Food insecurity might play a role in their decision to pack in the calories when the price is right at the diner. Her parents’ role modeled consumption of large sodas and desserts in addition to calorie rich entrees. And from what I heard, cooking wasn’t something that the missus had any inclination to do. So eating in might have been no healthier than a frozen pizza and a regular soda.

Some things just might need to change.

It was quite enlightening, this uninhibited overeating which was seemingly the norm for this family. Seeing this, I would be foolish to believe that the young girl’s large size was solely due to genetics, uninfluenced by her environment and limited alternatives.

Perhaps when she gets older she may decide to shift her lifestyle—if she has the financial means to do so. But changing behaviors and patterns is quite a process. In the meanwhile, she may suffer the bullying of weight stigma and the weight yo-yoing consequences of fad diets. Perhaps the impact of her weight will make team sports too challenging to partake in—kids can be cruel. So in the end, her activity may decrease as she continues on her path, living in her current environment.

She may embark on many attempts to lose weight when she is a bit older, each attempt leaving her more despairing as the weight regain exceeds weight loss, in spite of her good intentions to restrict her intake and lose weight.

Or she may have success modifying her eating behaviors and physical activity in a sustainable way. She might learn to cook healthier balanced meals, and eat out less frequently. Perhaps she’ll learn to trust that the food will still be there, that she can stop when she’s eaten enough. Addressing eating behaviors—separating eating from distraction and distinguishing physical need for fuel from all the other reasons we eat—may result in significant weight change. I see this in my patients, and I’ve written about a couple of them in past posts. 

But don’t look at her at 25 or 30 years old with scorn and disgust—she is not to blame for her situation and your sneers will do nothing to better her situation.

And let me restate what I wrote in the Cupid post about kids and BMI. If a child is high on the charts, but gaining each year like any other healthy child, they may be just fine—if their behaviors are appropriate. But if they are sedentary, or spending too many screen time hours, or eating in front of the TV, or eating minimal amounts of fruits and vegetables, and low fat dairy, for instance, then yes, I would address those behaviors. And you know what? I’d suggest the very same thing if I saw an average weight child, too.

Final words

Rethink being the 'skinny girl'.

So think again about your idealized goal weight. If you’re a normal weight by the standard BMI, but you deny your hunger and restrain your eating, then weight gain may be the key to release the hold of your disorder. And if you are overweight or obese and have been adhering to healthy eating behaviors and physical activity, staying where you’re at—even though you remain many pounds from your goal weight—may be just what you need.

And if you haven’t changed anything and maintain unhealthy eating habits, some weight loss may result from more healthy behaviors. Modest change may be enough to improve your health measures, even if your weight remains in the obese range.

Pushing yourself by denying your body’s signals and its history will only create harm. You will struggle with your thoughts and your weight will likely climb as a rebound to over restriction.

There’s no simple answer. Significant weight loss has its risks. And staying at a high weight without addressing lifestyle factors also places you at risk. But focusing on healthy behaviors may be the most reasonable solution.

Please feel free to debrief after this lengthy post! As always, I care what you have to say, so do leave a comment!