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.

Role modeling with the Lean Cuisine diet. Who needs the reality check?

Adorable, yet strikingly painful. 

                              (If a video doesn't appear above, click here)

Young, school age children, sharing their observations about their moms’ and their dads’ eating. These are strictly their observations, without judgement— except for the stink of some of the cleansing pepper drinks they refer to. The contrast made by Lean Cuisine is that eating their frozen dinners as a strategy for weight loss—that is normal!

Well isn't it? Not unless you are a 4'8 woman, non-competitive athlete. To have one of your main meals of the day, your lunch or dinner, coming in under 300 calories is hardly adequate for most anyone. Yes, even though it does contain some carbs. And the suggestion that it, in itself, is a meal, an adequate meal, is quite problematic. Who do you blame when you are left feeling hungry after this meager intake? No one but yourself, no doubt. Calling it an appropriate meal replacement is misleading, unless you add a glass of milk, a fruit, a salad with some oil and vinegar or nuts, for instance.

We know all the Lean Cuisine eaters in this YouTube video have families, including kids—young, impressionable, school age kids. So let's think for a moment about dinner time in these homes. "Here, sweetie, you can eat the chicken dinner I made for the family, I'll just eat my (inadequate, 300 calorie) frozen meal. You know, because I need to lose weight." Or "You deserve to eat this great tasting meal I've made, but not me—I'm too fat!" Or maybe, "Why don't we all live on Lean Cuisines, so you can have control over your portions too; because I don't really trust that I or you can manage when there is more than a limited amount of food in front of me!"

Fast-forward several years and let’s imagine these innocent kids as adolescents. Do they feel entitled to eat an adequate plate of food? Or do they, like many a patient I've heard from, feel limited by the messages they heard from their parents (yes, parents, because dads put forth much of the same diet shtick so to speak). Like Dana, she may struggle to ever eat more than half a sandwich—that's how much her mother allowed herself. And like Allie, she might be counting her calories, limiting them to the boxed frozen dinner amount that her mom thought was right.

What do these kids end up taking from this? That their frozen-diet-dinner-dependent moms are the sane ones, as the video implies? Or that their moms and dads (and maybe them, too, when they’re grown ups) dislike their bodies, and certainly can't trust themselves, their ability to eat enough, their body's signals, their ability for their body to be forgiving if they ate a bit too much one day. They learn that normal family dinners are things other people can have, but not them. This is just the price they have to pay to lose weight.

Are you stuck in this place? 

Are you the adult child of such a dieter, who never learned to trust her own eating? Or simply struggling as of late, desperately dieting, relying on prepackaged foods and calorie-restricted meals? Consider cooking--see the recommendations made by "Thursday's patient" to ease the process, or check out Food to Eat for more support, with its 25 recipes in an easy to manage format, justifying the merits of each dish and its nutrient content. Serving sizes are suggested, but are by no means restrictive. Suggestions to enhance the meals are provided, along with sections to help you get out of your own way--to change your perspective about food and respond to your needs. And check out the links below, including sample recipes.

Kudos to Lean Cuisine for pointing out how crazy our culture is, with moms and dads filled with body loathing following all sorts of nonsensical diets. If only they can see that their video stopped short of pointing out the irony of their own product.

http://dropitandeat.blogspot.com/2010/08/size-matters-but-not-how-you-think.html

http://dropitandeat.blogspot.com/2011/03/normal-eating-taken-too-far.html

http://dropitandeat.blogspot.com/2011/02/who-or-what-decides-how-much-you-eat.html

http://dropitandeat.blogspot.com/2010/11/honor-thy-hunger-and-thy-fullness.html

And from Food to Eat: 

http://dropitandeat.blogspot.com/2010/11/pecan-pumpkin-pancakes-you-can-feel.html

http://dropitandeat.blogspot.com/2010/10/how-to-cook-healthy-meal-before-eating.html

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!