Yesterday, I posted part one of my interview with assistant professor and author Jon Robison, Ph.D. Dr. Robison is an ardent advocate of the Health At Every Size (HAES) movement, which focuses on health, not on weight. It promotes self-acceptance, intuitive eating and an active lifestyle. Instead of shaming people into being some arbitrary weight, HAES encourages everyone to be happy with their bodies, to listen to their internal cues of hunger and fullness, and to move their bodies by doing activities they love.
One of the criticisms of HAES is that “obesity” is associated with many health risks; therefore, you can’t discount the importance of weight. Below, Dr. Robison talked to me about this pervasive misconception (yes, that’s right), the validity of body mass index (BMI), what to do if your doctor suggests weight loss, how to stop worrying about your weight and how the “obesity epidemic” began. I think you’ll find the interview to be eye-opening, as I did.
1. Q: Many people think that diabetes is caused by obesity and that mortality increases as your weight does. What are your thoughts about mortality risk and diabetes?
A: I can provide statistics with people with a BMI in the overweight range who don’t have increased mortality. In fact, mortality doesn’t start increasing significantly until you get to a BMI of around 40, and that’s still just a correlation.
In our society, this is an ingrained idea that fatness causes diabetes and when you lose weight, you lose diabetes. But this is not what the research suggests. Certainly there’s a correlation between weight and diabetes. About 70 to 80 percent of people with diabetes are fat. This correlation, however, doesn’t mean causation. For instance, baldness is a risk factor for heart disease, but that doesn’t mean that if you give a bald man a toupee, you’ll reduce that risk. It is increased testosterone that promotes both premature baldness and atherosclerosis.
It’s very likely that diabetes and fatness are caused by insulin resistance rather than the other way around. Just because fat people are more likely to have diabetes doesn’t mean that fatness causes it. People who are insulin resistant also gain weight and also develop diabetes, and the other side of that is if you have type-2 diabetes, your blood glucose will go down after a skipped meal – that doesn’t mean that weight loss is causing blood glucose.
Many studies have shown that “obese” women (BMI over 30) who are physically active and change the quality of their diet can actually normalize their blood glucose. Their diabetes is ameliorated. If that’s the case, how can it be that weight causes diabetes?
If a person loses weight but then gains it back (which usually happens), in the long run blood glucose is likely to get worse. But if you can work with people on stress management, quality of diet, and level of activity, then you can really ameliorate and sometimes normalize their blood glucose. The importance is to focus on health and not weight.
2. Q: If a person’s doctor recommends that they lose weight (and the doctor may or may not provide a program), what should a patient do? What should be their next steps?
A: If the individual is comfortable speaking to their doctor (and the doctor is receptive), I would recommend educating him/her about HAES and saying that you want to be treated in a weight-neutral fashion. If the doctor is unable or unwilling to do so, changing doctors may be an option worth considering.
Margarita: I wanted to highlight Dr. Robison’s advice in his article on easing up on weight concerns, which was originally published in the Wellness Council of America Special Report in 2009. If a doctor tells you that you need to lose weight, consider the following.
If you have a health condition commonly considered to be “weight-related,” (most likely candidates are
hypertension, abnormal cholesterol, abnormal blood glucose) and a health professional recommends weight loss as a solution, ask her/him the following questions:
- What is the long-term success rate of the approach you are suggesting? What is the likelihood I will regain the weight I lose?
- What is likely to happen to my health condition if I lose the weight and then regain it?
- Is there any way to treat this condition that does not involve a focus on weight loss? (How would you treat a thin person who had the same condition?)
The answers given by your health professional to these questions should look something like:
- The success rate is no better than 5% and it is quite likely that you will gain back all of the weight that you lost and perhaps a bit more.
- It is quite possible that your health issues (high blood pressure, diabetes, abnormal cholesterol, etc.) will get worse when you regain the weight.
- All of these conditions can be helped through lifestyle changes with little or no weight loss. (A Health-Centered Approach) The best treatment for a fat person for any of these conditions is the same treatment that would be recommended for a thin person. (For Diabetes, see the following red box.)
NOTE: If you don’t get something like these answers, consider seeking help elsewhere.
3. Q: What are some ways individuals can stop worrying about their weight?
A: By learning about cultural weight prejudice, working on self-acceptance and internally regulated eating (intuitive), and being reasonably physically active women and men can begin the process of coming to peace with their bodies and their food.
4. Q: Anything else you’d like to add?
A: The definition of obesity, a BMI of 30 or above, is so absurd. How is it possible to say that everybody with that BMI has a disease? We know that there are lots of people with a BMI of 30 who are healthy. There is plenty of research to show that. Calling anyone who is “obese” diseased is unscientific and unethical.
The original obesity epidemic started in the 90s, when the average weight gain was 8 to 10 lbs., according to the CDC (Centers for Disease Control and Prevention). Since then, it’s been blown way out of proportion. Basically, what happened was that over the course of 10 years, a whole bunch of people at a BMI of 24 moved to a BMI of 25 (one BMI unit is between 6 and 7 lbs.), and now, these people are considered to be overweight. People who were at a BMI of 29 moved to a BMI of 30, and are considered to be obese. If you look at the normal distribution, it’s not that big of a deal.
Now research is showing that people aren’t gaining weight anymore. The trend is flattening out for kids, women and men. The only place where this trend is not flattening out is the heaviest folks, who seem to still be getting heavier. People have to understand that health organizations like the CDC have to have something striking to ask for money for. The “obesity epidemic” is that thing.
BMI isn’t a good measure of anything. It doesn’t correlate well with blood pressure, body fat morbidity or mortality, but it’s an easy number to measure. Just take someone’s height and weight, and plug it into a graph that you can find anywhere. Research shows clearly that there are a significant percentage of people – about 30 percent in one big study with BMI over 30 – who are metabolically healthy, and 25 percent in the normal range who were not metabolically healthy. BMI is just the cover of the book!
BMI is a population statistic. It was really developed to look at changes in body size of the population over time. It was never intended to diagnose any sort of health issue, so using it for that purpose is a misuse of BMI.
One other question that health professionals ask me all the time is “what do I recommend to a patient who is overweight and has type-2 diabetes, if I can’t suggest weight loss?” It’s a really good question, and there’s an easy answer that encapsulates what HAES is about. If you don’t recommend weight loss, the answer is you do the same thing you would with a thin person who has type-2 diabetes. You stay weight-neutral.
I ask these professionals, “Well, what would you do with thin people with type-2 diabetes?” The professional will typically say, “I’d look at quality of diet, what they’re eating. I’d want to know about genetics, certainly about their physical activity and stress.” That’s also what you would do with a fat person and leave the weight out. Research shows that you can help fat people even if they don’t lose weight.
In some ways, it’s extremely simple, not easy. And it’s the same with blood pressure and the same with cholesterol. The reasons for going in this direction are powerful: 1) we don’t have anything to offer patients for weight loss that has got anything but a tiny chance of succeeding, 2) we do have things we can offer that are the same we would offer a thin person, and 3) if we do offer weight loss, there’s a good chance weight will be regained and blood glucose will go back up (the same happens with cholesterol and blood pressure). This makes a really powerful argument for not offering weight loss. Weight fluctuations can make matters worse.
Margarita: I wanted to put BMI into perspective. Dr. Robison includes a chart with BMI comparisons in his article in the Absolute Advantage, a publication from the Wellness Council of America. Individuals considered overweight included George W. Bush, George Clooney and Johnny Depp. Individuals considered obese included Matt LeBlanc and Tom Cruise. Something about this just doesn’t seem right…
A huge thanks to Dr. Robison for sharing his insight in this Q&A! We greatly appreciate it! Again, I was blown away by the information.
What are your thoughts on Health At Every Size? What are your reactions to the above info?