Coming Clean: My Biases and What They Mean for You

I’m no different than the rest of you. I too, have my biases—my prejudices, my leanings, my preconceived ideas about what makes sense. They influence my actions, my reading of scientific studies, and they impact my professional recommendations.

I make no apologies; my biases effect what I tell you as patients and as blog readers. Like conference speakers obliged to disclose who profits from their research or their words, I’m giving my full disclosure. Here are some insights about why I lean as I do:

1) I’m biased against the weight loss literature's conclusions. In spite of the dismal research that only a small percentage of overweight dieters maintain their weight loss, I’m biased against these results. Weight loss, and maintenance is notan unreasonable goal—for somepeople, that is. Yes, I realize that the weight suppression data may suggest otherwise, as mentioned in my previous post.

Yet I’m skeptical about how study participants lost the reported weight and that impact on weight regain. And I’m cautious about who should have been losing in the first place. If someone had been binge eating and normalized their eating, why wouldn’t they lose weight and keep it off—as long as they remained free of binge eating? If you were disconnected from your physical cues, from your hunger and your fullness, but then turned that around, why couldn’t you maintain the lost weight? That is, if your higher weight was not your healthy normal that you had always been. Which gets me to the next point.

Many patients have appropriately lost and maintained significant weight loss. They were not on diet plans—not calorie counting, no categorical exclusions such as “no white flour” or “no carbs”. Rather, they have slowly modified their actions, and their thoughts. And ultimately, their weight adjusted. Read about my patients such as Erin and Maggie.

I fit into the category above. I have lost about 35 pounds since graduating from college—35 pounds that were not a part of my usual size. My weight had always been in the normal range—I had never experienced weight issues until college, when my yo-yoing began. Dieting, binging, denial of my needs failed to bring my weight back to normal. But changing all that did. I do not work to maintain my weight at this point, but I continually embrace honoring what I feel like eating, and responding to when I need to eat.

2) I believe that you know best about yourself—until your disordered thoughts, your restrictive rules, your lack of trust in yourself take over. Yet I believe that deep down you really know just how much you need to eat—just like when you were a young child before all this craziness began. It’s just so damn scary!

3) I’m biased against light products and diet packaged meals. No, they are not simply better than not eating (shout out to Thursday's patient—thanks for inspiring this!) Why? Because they mislead you! Tricky Weight Watcher’s meals and Lean Cuisines? Sneaky Arnold rounds? Indeed. 

First, they may look like they’re supposed to be enough. The light bread (that has half the calories than the regular bread) looks like a full sandwich. But then when you’re hungry from eating what amounts to only half a sandwich, whom do you blame? You only fault yourself, believing that it should’ve been enough, that you’re the one with the problem. Not so, my friends!

As for the frozen meals, I must say that in all my (50) years I’ve never eaten a diet frozen dinner, so my bias does not come from my experience having them. They just look like not enough to me—or for anyone. Admittedly, you can add a glass of milk, and a fruit or a dessert and it may be just fine. But somehow I don’t suspect that’s what you intend to do.

4) I’m biased against omitting what we enjoy eating. I believe that sweets and all things that taste good have a place in our diet. Maybe it’s because I personally eat things I like, including baked goods and good chocolate quite frequently. Excessively? Mindlessly? Not usually. Not when I’m driving or watching TV. Ok, sometimes the popcorn comes down to the family room (notice how passive that statement was?) while I’m watching TV—there, I’ve said it. Maybe it’s because I see the consequence of banning them, of making them forbidden, that I fight for making them available.

5) Yes, I’m biased against eating disorders.  Eating disorders lie. Which is not to say you are a liar. Have you lost me yet? They distort what you perceive you’ve eaten—yes, you overestimate your calories if you are under eating, and you may minimize or exaggerate them if you overate—it can go either way. 

Eating disorders mislead you into thinking that a yogurt is a meal, or that a black coffee, or even a latte is an appropriate means to respond to your hunger. They don’t volunteer information—I have to ask, and beg and probe to get a full and honest response.

6) It’s not your fault—again, that’s my bias. I don’t believe you want to be struggling with binge eating, or purging, compulsive exercise or laxative abuse or restrictive eating. And I’m convinced that I, that we can’t simply wait around until you’re simply ready.

7) I’m suspect when I only hear that everything is always great. And I’m cynical when I hear that everything is always terrible. Your bias, I suspect, is a lack of honesty with yourself.

8) I’m partial to the value of the relationship. I’ve not reviewed the literature on this, but my bias is that you’re more likely to work to change—at least initially—for your soon-to-be-born child or for your young children. And if you’re fortunate enough to have a positive relationship with a healthcare provider, you’ll work for them too.

9) Oh, and regardless of what they tell you, I believe it’s never too late to change. And this bias is based on the many clients I’ve seen, at all ages, at all stages of their disordered relationship with food. Yes, you too can recover from an eating disorder. And you can change your relationship with food. Even now.

So call me biased.

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!

Reasons to believe in recovery? Take this simple, anonymous online questionnaire.

Perhaps you CAN rise above the clouds.

I don’t know the Harvard psychologist Dr. Sheila Reindl, but I have recommended her book Sensing the Self, many, many times over the years. It’s filled with wisdom about recovery from bulimia, honed from Reindl’s extensive interviews with 13 recovered women. (Not bulimic? Please read on! There’s something here for you too!)  Maybe I was attracted to it having learned that several of the pseudonym-ed women were actually past patients of mine, shared with a therapist who contributed these cases to the book. 

Or maybe that it meshed research with patient stories, extracting the essence of the recovery process into meaningful chapter themes. Personally, I hate reading books about recovery (but I read this at the insistence of a patient). That likely has mostly to do with the fact that I discuss recovery almost 40 hours a week. Do I really want to engage with strangers’ stories on my down time? I don’t think so.

Yet I likely suggest it because I believe it may help readers with recovery. Just as I recommend Schaefer’s fabulous Life Without Edand Arnold’s blog ED-Bites—long before it became chock full of valuable research interpreted into a language we can all understand.

I don’t know if reading recovery stories truly makes a difference in the recovery process—for better or for worse. But I’d like to find out! Because I’d like to have another tool available to help support recovery.

Can recovery stories show us the way?

Enter Lisa Dawson, an Aussie PhD candidate who has the very same goal and is doing the research to find the answers—and I reallyhope you will help! You may remember her name from previous research I referenced. Here’s the description of her research:

Researchers at the University of Sydney are interested in whether reading stories of recovery are helpful for current sufferers of anorexia nervosa. People aged 18 years or over who have anorexia nervosa or an eating disorder similar to anorexia nervosa are invited to participate. This study is conducted entirely online so anyone in the world can participate. Participation involves completing questionnaires on two or three occasions and reading five short stories about recovery. We are very interested in receiving your feedback about the helpfulness of the stories.

The study has been approved by the University of Sydney Ethics Committee and all aspects of the study, including results, are strictly confidential. We are hoping to have as many people as possible take part in the study. If you are interested in participating then please contact Lisa at lisa.dawson@sydney.edu.au.

So if you have a few moments, please email Lisa to learn more. And say hello for me!

Thanks for helping. Oh, and PLEASE share this any way you can!

Diet soda causes weight gain?!

What do you think? Does drinking diet soda cause you to gain weight or not?

Too much diet soda?

This is an old story; the media has summarized some studies done several years back concluding what many of you might fear—something with no calories can make you gain weight. But a look behind the sensationalized headlines showed something else.

Yes, there was a link; more people who drank diet sodas were higher weight. But did drinking diet soda causeit? And were you able to take in this correct conclusion and hold on to it, or do you still fear diet soda?

Oh, this is dangerous. I am notadvocating for diet soda consumption! There’s no nutritional merit—no calories, no vitamins or minerals—and it may even have some negative effects. Namely, it may mask your hunger, making it more difficult to trust your need to eat. And large intakes of colas—regardless of type—may pose other consequences such as impacting your bone density. 

But really my intent was not to discuss diet soda. Rather, I’m highlighting this example to prove a couple of points.

Causation vs. correlation

Wasting way too much time on Facebook the other day, a post by a local, experienced dietitian caught my attention: 

“Very interesting research about vitamin D's potential for significantly slowing MS. Adds to the body of research linking higher vitamin D levels with reduced risk for MS.”

The comment was, on the one hand, harmless enough. The dietitian was referencing a recent article—just an abstract, really— presented at a recent medical conference. The abstract summarized the study findings fairly, stating that average, baseline blood levels of vitamin D link with disease symptoms and severity. Those with a lower average level of vitamin D at the start of the study had a worse disease outcome than those that started with higher blood levels.

This may seem subtle to you, but it’s not to me. The RD’s comment about the “potential for vit D to significantly slow MS” is not, in fact, what the article stated. It merely showed a connection, a correlation. Perhaps there’s something about people with MS that utilizes more vit D when there’s more active disease. Or maybe low levels are simply a marker for more disease activity. 

Nowhere did the study state that supplementing with vit D improved the prognosis. I don’t tend to look at the half empty, but I simply didn’t see the hope for vit D’s potential, at least not in this study.

Maybe it’s splitting hairs. I mean she did, in fact, refer to this as a link. But what troubles me—along with the image on the post showing supplements, is what’s implied and therefore what we end up believing. No, vit D supplements have not been shown to reverse or improve the health of those living with MS. But wouldn’t we all like to believe that a magic pill could do that for us—for our MS, for our cancer, for our anorexia, for our weight struggles?

But besides the false hope, there’s the issue of our getting sucked into believing that correlatedequals caused. No, diet soda doesn’t cause obesity. But those living with obesity may be more likely to select diet beverages than those who are average weight.

Similarly, maybe you gained a lot of weight when you moved from a gluten free to a regular diet. That doesn’t mean that non gluten free diets cause weight gain. Rather, it may be that while being mindful of your intake—like you do on any diet—you may have seen a weight shift—but not because of what the diet was. But then when you regain the weight, you cling to the belief that the gluten free (or carb free, or fat free or whatever diet) was the reason for your weight loss, and therefore subsequent regain. The regain may have been about overeating following deprivation from denying yourself foods you enjoyed—and not a result of some magic involved with the ingredients you omitted.

Unfortunately, misinformation sticks. And trying to scream and shout that information is wrong only solidifies it as fact.  Misinformation can be dangerous, keeping us stuck in our ways, and preventing us from trusting ourselves. And conflicting info in the media confuses us and leads us believing that nothing we do makes a difference.

So instead, I ask you to question what you read. And challenge educated individuals in the health field about the articles and flashy news snips.

Focus on the facts, and work with your team for concrete ways to counter your unhealthy thinking. I hope this blog helps to set you on a healthy path!

Do you believe recovery just isn’t possible, at least, not for you?

Lessons from ICED 2013

I see 30-40 individuals suffering from anorexia, bulimia, binge eating disorder and disordered eating each week. Men and women, preteens through age 70+.  So short breaks and vacations are, of course, quite refreshing.

But last week’s Academy for Eating Disorders Conference, the International Conference on Eating Disorders (ICED) offered anything but relaxation.

Stimulating, inspiring, fascinating and hopeful—even these words do little justice to the conference presentations. I became pumped, and felt validated that the progress I see with my patients is not random. I was sparked by the incredible research demonstrating the progress in the understanding of eating disorders and their treatment. It only confirmed my belief that there’s reason for you, too, to know that recovery is possible.

Let me tell you about a session I was most excited about—Lisa Dawson, a PhD candidate’s research presentation entitled Recovery From Chronic Anorexia Nervosa: The Tipping Point for Change. You don’t have long-standing anorexia? Don’t stop reading. The lessons from this psychologist’s research are inspiring for all.

Dawson decided to select those individuals who recovered from anorexia—and I mean trulyrecovered—because by looking at this population we can figure out what elements are critical for recovery in anyone living with an eating disorder. They had to be free of anorexia for 7+ years, in an objectively normal weight range, and free of eating disorder behaviors. “You mean such people really exist?” you’re thinking? You bet. And she identified the common elements that contributed to their movement toward and their ultimate full recovery, based on extensive interviews with the participants. Here are some key points she identifies:

There are 4 stages to recovery, which individuals move through in one direction, and for differing amounts of time:

1. unready/unable to change
2. the tipping point of change
3. active pursuit of recovery
4. reflection and rehabilitation

In the first stage, people feel like they didn’t know why they were doing what they were doing (wrt ED behaviors) but felt they just couldn’t stop. They internalized the eating disorder and they perceived treatment as unhelpful. They felt misunderstood and lacked insight. In summary, recovery seemed impossible; they didn’t feel like anything they did made a difference for recovery, they had low motivation and had a sense of helplessness and hopelessness.

Over time, they realized that their eating disorder wasn’t helping them. Those who recovered also started to experience feeling understood. They were able to externalize the eating disorder and over time gained insight into their condition. They became more worn out by their eating disorder as well. Motivation increased. They started to feel that they had the power to change their situation, that they could impact their curse.

More value was placed on life outside their eating disorder. They learned skills to help them cope as they let go of their eating disorder behaviors.

Self-discovery, self-acceptance, and learning to love oneself were components of the maintenance stage.

It was a long, and slow process. But it happened.

So here’s an email I received this week from a patient of mine who, in spite of living with anorexia for more than 25 years, is now in recovery. The timing couldn't have been more fitting for this post:

"I've been continuing to do well with food.  I know I was upset at my last apt with life in general, but that did not affect my eating.  To date, I still have not purged or restricted or exercised.   Can you believe it? And... I don't want to forget to tell you so I'll share now, re: exercise...  I have been taking walks after dinner with either one of the girls or my husband or all (not every night, but several) and it didn't dawn on me til yesterday that I can go on these walks and I haven't:

• thought about how many calories I'm burning
• gone at fast pace to burn more calories
• obsessed over having to walk each and every night/same time/same pace/same path 

Instead, I:

• go on a walk if I feel like it
• enjoy whatever pace I seem to be going at, without thoughts of burning calories
• actually enjoy being present with the people I'm walking with!!! 

I do not fret if I can't make a walk.  I do not keep track of how many nights I've walked. I do not feel it's necessary if I've eaten a larger dinner. The obsession is not there!  Where did it go? I don't feel it, all I feel is the happiness that I'm going on a walk with a very loved family member where we can chat and talk and laugh. 

Huh? When did this happen?! Although it may not seem big, it really didn't hit me until yesterday that these walks are not the same walks as in the past. Not one bit. I am totally present and I completely enjoy them. And I continue to eat. Normally. I think I now know what normal is. At least, my normal. And I never, ever thought I would find "normal". And "normal" to me means:

I can eat when I'm hungry, know when I'm full, eat what I want in moderation... and because of this, I have not gained 30 lbs in 5 days as previously thought. I have gained weight.  I am working on accepting the feelings that accompany this. I think I'm in a better place to work on this. Nobody likes to gain weight, that's pretty much reality. But... I'm healthy.   

I put myself, my body, through hell. Can you imagine deliberately depriving your own body of nutrients it needs to stay alive? Can you imagine the destruction throwing up food causes? Or ingesting a plethora of pills to help further the weight loss process? How good is THAT for your body?! Oh my God, I sit and think how the hell am I still alive!!!  This has been going on for decades!  

I am at a really low point - sad, lost, confused, lost, angry, lost...  I feel like everything is out of control in my life.  Where did I turn for all those years to gain control over something when everything else felt so out of control? Ed. But what is happening now? Everything feels so out of control, yet the ONLY thing that feels IN control is my decision to eat well. Isn't this the complete opposite? What is going on here?  

So, the point of this email is to tell you that I have the strength to continue fighting this and I will succeed.  You are not going to see me relapse. Everything about this eating disorder is finally beginning to make sense. I have so much more to share but I'll save that for our next meeting. 

Lori, boy I can't begin to tell you how everything you've taught me is now landing in place and making sense and how in the world do I thank you for that?I was so, so sick.You saved my life.I still have work to do, I'm a work in progress, but slowly I'm regaining inner strength - which is just what I need to move forward. 

Thank you, thank you, thank you..."

I share this, with her permission, because while recovery is challenging, to say the least, it happens. And what I hear from her and from others confirms what Lisa Dawson shared in her study—that belief that you can recover, that change is in your hands, is essential for recovery. And that working with providers who get it and help you feel understood, and provide hope that full recovery is possible, can make all the difference.

Your thoughts?