Call for an urgent rethink of the ‘health at every size’ concept | Hacker News Reader

Call for an urgent rethink of the ‘health at every size’ concept

ncbi.nlm.nih.gov

42 pointsDHJSH42 comments

This is significant as well in that it points out that people can legitimately struggle with overweight eating issues as the brain adapts and makes people more hungry. I struggled a lot with losing weight and continue to struggle with keeping it off. It's frustrating when some folks (presumably, who have never struggled with weight and eating, and the psychology issues with eating, such as eating to feel good and then feeling depressed because of overeating) say simplistic things like "just don't eat so much" or "try having a salad". It's not that being big is healthy; it's not. It's that breaking the cycle of being big is hard (for some).

I agree. Earlier this year I read an article highlighting just how extraordinarily rare it is to overcome morbid obesity in adulthood and maintain this progress indefinitely without medical intervention. Ultimately, we need to accept that our bodies, including the organ which gives rise to our behavior, are physical systems subject to occurrences entirely beyond our conscious control.

I've not dealt with obesity personally, but I would speculate that many of the people who enjoy "fat shaming" are unfamiliar with the experience of having internal conflicts which lead one to take actions that are obviously irrational, even to the person performing them. This is an area where more empathy would lead to greater mutual understanding and perhaps increase the probability of finding solutions. (Of course, finding this empathy is perhaps a similar challenge.)

I think you're touching on the heart of the tension behind the "health at every size" movement.

I know a couple of people who are big advocates of it, and surprise surprise, they're all pretty fat. They're still wonderful people, and I of course don't respect them less because they're fat. You know, for me, it's like..who cares? It's not my body. I'm even pretty sympathetic to how much difficulty they have doing basic stuff, just for having their joints and muscles carrying around an extra hundred pounds.

But it really seems to me that what's going on is that they're reacting to the constant onslaught of fat-shaming and moral judgments with this ideology of "health at every size". There is a constant moralizing about fat people in our culture, like if you're fat you're lazy or bad or whatever, none of which is warranted.

But I think that's where things get muddled--culture turns fatness into a moral failing, wrapped under a sheath of health concern trolling. Reaction to the moral judging is to try and take away the health claims, when that's really kind of missing the point.

What would be appropriate, I think, is to push for "human dignity at every size," you know, and leave the moralizing to stuff that matters. But that's not so catchy or easy to distinguish, I guess...

As for the actual health claims, I, for one, don't buy it at all, it seems obvious to me that carrying around excess weight is going to cause a number of immediate problems (joint strain, etc), to say nothing of the strain on your organs for being encased in excess fat. But the health stuff is separate from the moralizing, and I don't know how you'd get the larger culture to separate out "you're fat and it's hurting your body" from "you're fat and you're lazy/stupid/etc".

The HAES people don't seem to have a lot of respect for people at normal sizes. It's less "Healthy At Every Size" and more "Healthy at MY Size".

Perhaps so for some. The challenge for those of us who are not their size is to empathize despite the temptation to adopt a belligerent stance in response.

The gem in the mud of "Healthy at Every Size" is indeed the encouragement of emotional resilience. Perhaps someone is a large person with an unhealthy appetite. This is unfortunate, but it doesn't mean he or she must be resigned to consuming unhealthy foods. Certainly it's better to consume 4,000 kcal per day of vegetables than the same amount in cake.

So often, in a state of despair, we indulge the sunk-cost fallacy by giving up simply because our conditions are not absolutely ideal. This is the emotional phenomenon the HAES seems to have been intended to address.

> and maintain this progress indefinitely without medical intervention

And bariatric surgery comes with significantly increased risk of suicide.

http://www.medscape.com/viewarticle/852616?nlid=89075_2052&s...

This is interesting to learn, though I believe this line is relevant:

Notably, 93% of the self-harm events occurred in patients diagnosed as having a mental health disorder during the 5 years preceding the surgery.

It would appear there's some positive association between incidence of mental health conditions and obesity, which could account for at least some of this difference from the general population. Ultimately, in absolute terms, the increase in self-harm is by 1.3 out of 1000 patients, which is statistically significant, but not so much at an individual level. Considering the much more significant, known health problems associated with obesity, I don't believe this finding changes the expected value of bariatric surgery by much.

It's hard to admit this, but I have found since I lost around 90 pounds (~41KG), I've found myself mentally judging overweight people pretty harshly. I don't mean to do it, it just happens. I think it may come from the, "if I can do it anyone can" line of thinking, but I'm not proud of it.

If we gave voice to every harsh judgment that comes to mind, we would never stop criticizing other people. There's a tension between the need to see oneself in a positive light and the desire to think positively of others.

If you manage to keep these feelings to yourself, I see no cause for shame.

I've been really fat most of my life, currently doing pretty well. When you have this problem most people, if they ever lose weight, experience a cycle- lose a lot of weight followed by cockiness/judginess (maybe, I never got that) followed by imperceptible creeping up back to and past original weight. I've done that at least 4 times

That goes for a lot of issues, it's hard to empathize.

Addict? Just stop using

Alcoholic? Just stop drinking

Gambling issues? Just stop betting

Depressed? Just cheer up

Unmotivated? Just try harder

There are underlying, complex factors to most of these and many other issues. It's easier to ignore them when you've never directly dealt with it.

There's an obvious difference here.

If the addict can't find drugs anymore, he can't use them.

If the alcoholic can't find alcohol anymore, he can't drink it.

If the gambler can't find slot machines, he can't gamble.

If the overeater can't find food, he can't eat.

The same can't be said for depressed and unmotivated people - there's nothing you can take away from them in order to keep them from suffering depression or demotivation.

Since they themselves can't take those things away from themselves for their own good, the addic, the alcoholic, the gambler and the overeater really suffer from the same problem, lack of self-control.

EDIT: atwebb:

Since having self-control would suffice to stop using drugs, drinking alcohol, gambling, and overeating, therefore one who can't stop doing any of those has to be lacking self-control.

Tell me where you got lost in that argument.

>lack of self-control

I don't know where you come from, I don't know what life you've led and things you've seen.

In my experiences, self-control is hardly the actual problem. The addictions/compulsions are manifestations of the depression or the lack of self-worth or mental imbalances or personal issue X.

>Unmotivated? Just try harder

Or my personal favorite, "Work harder."

Yes, absolutely -- but all of these ills, as with obesity, are possibly even more ill-served by an acceptance movement.

We agree though I'd phrase it as, acceptance being the most important part. The individual accepting their status/issue/persona and not society acquiescing. It's all very specific and personal.

You seem to have confused promoting positive health decisions among obese individuals notwithstanding the amount of food they consume, and the acceptance of obesity as a healthy condition in itself. However much some have misinterpreted "Healthy at Every Size," the former is its organizing principle.

I used to think the healthy at any weight movement was a gateway to actually being healthy. Start acting healthy and forming healthy habits and eventually you'll be healthy. Kinda like magic thinking except it would actually work.

But, there's a backlash against people who actually loose weight in the movement. That's the part I just don't understand.

Nutrition is such a vast science, one where new theories and ideas are coming almost every month and one where the general public is either completely uneducated or working off of decades-old assumptions (such as following the surgeon general's dietary guidelines from the 70s or 90s). It's no wonder to me at all that a vast majority of people regardless of their current size have zero idea what to do to eat healthily.

I became interested in the Health At Every Size movement during its inception as part of recovering from an eating disorder and, at its core when it was first started, it had a very positive message- essentially "Hey, everyone, let's promote the idea that we all should eat healthy food and get exercise and do fun active stuff regardless of if we're fat or thin or old or young or tall or short." It was a direct challenge to the idea that you had to be a particular size to be active or to go to the gym or to do active hobbies. However very soon after inception it was perverted into a message of "It is entirely possible to be healthy regardless of how fat you get and if you are fat and your doctor says that you are not healthy because you are fat then it is your doctor who is wrong because it's never, ever wrong to be fat, ever."

Message #1 was great as it was all about promoting eating healthier regardless of your size, getting regular exercise that was fun and that you enjoyed doing regardless of your size, and about being gentle with yourself during that process- so stepping away from hating yourself because you were fat and instead doing something productive with that brainpower. Message #2 corrupted that into "You are perfect because you are fat and if anyone tells you that you should be less fat then they're trying to abuse you and make you change to suit them."

I'm extremely excited about the nutritional research that's coming out regarding gut microbes and their potential impact on our health and weight because I imagine how awesome it'd be to go to your doctor, spit in a cup, and have it tell you what all you should and shouldn't be eating (due to genetics, microbes, etc) as well as recommend which probiotic you should be taking to get your gut bacteria in line.

I've long disliked the amount and kind of attention the mainstream media devotes to covering research in nutritional science. Not only does it confuse people, even those with scientific training, its vacillation also undermines the public's confidence that science is a valid approach to understanding the world.

Still, I'm not convinced that public confusion on the subject of nutrition is a leading cause of widespread obesity. An environmental or social explanation seems more probable than simple ignorance. After all, obesity is less of a problem in many less educated societies, despite an abundance of food.

(2014)

The authors followed up this article with a subsequent article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4039050/

In modernity, hurt feelings are the ultimate sin, public health be damned.

Not surprising in a world that is increasingly virtual; the space of subjective reality supersedes objective reality.

On the other hand, self-acceptance by those we dislike is often derided, to the detriment of finding solutions to these social problems instead of assigning blame.

For myself, I've found suppressing my initial feelings of hostility toward people who promote incorrect ideas and providing an emotionally neutral answer is a more useful approach than derision, sarcasm, and other such behaviors.

Really? I thought chocolate cake was sinful.... Health, and especially weight, are very moral issues to Americans.

Hurting peoples feelings does not improve their health. My guess is (I don't know you) looking down on fat people is one of the mechanisms by which you make yourself feel worthy. You are not doing it from their benefit. Believe me, it is a vanishingly rare person who is fat and doesn't mind it. The fat acceptance movement is about feeling helpless and just wishing people would stop giving you a hard time on top of it

My guess is (I don't know you) looking down on fat people is one of the mechanisms by which you make yourself feel worthy

I can correct your guess, here. Looking down on my fat former self is one of the mechanisms by which I keep myself healthy.

We quickly lose sight of what it was like to have been a certain way. Whatever the origin of your unhealthy weight, and whatever purpose a negative evaluation of your past self serves, I think most would agree that derision is unhelpful as a tool for reducing obesity. On the other hand, its prevalence and the language many use while doing it seem to suggest that they find it gratifying. Some consider this a problem in itself.

I definitely think almost all of them find it gratifying but admitting to such is shameful, thus the pretense and alternative explanations like they care about healthcare costs for society

If you're interested, Dr. Amanda Sansbury-Salis[1] has a book out, The Don't Go Hungary Diet: The Scientifically Based Way To Lose Weight And Keep It Off Forever[2]. You can read the first chapter on her website.

[1] http://www.dramandaonline.com/

[2] http://www.amazon.com/The-Dont-Go-Hungry-Diet/dp/1863255230

300,000 people die every year from Obesity. It's our #1 killer. And it can be solved by eating less.

See this study in the NEJM:

http://www.nejm.org/doi/full/10.1056/NEJM199212313272701

Discrepancy between Self-Reported and Actual Caloric Intake and Exercise in Obese Subjects

Of all the "diet resistant" subjects studied, ALL of them (100%) were grossly underreporting actual calories consumed and overexerting physical activity. Some of the people in this study were on medication because doctors had believed their self-reported numbers and believed they may have had thyroid or other metabolic problems.

Remember that "bariatric surgery" is just a way to get people to eat less by making it physically impossible to overeat. (Of course, people still manage.)

Except _what_ you eat has a big factor in how much you eat. Some foods are more satiating than others. Some are more addicting than others.

So eating less may also require eating different.

Yes, and the problem is that our food supply is optimized to be more addictive, because it allows everyone in the supply chain to make more money. Quite literally every commercial entity is against an individual eating filling, low-calorie foods, because it means they're spending less money on food in general. This is on top of the evolutionary forces that already make our bodies crave super-high-calorie food. It's a lot for someone to fight.

Experiment: go to Wal-Mart and try to buy maple syrup (actual maple syrup; mostly what they call syrup at Wal-Mart is literally just water, corn syrup, and dye). Now try to buy canned pears without any added sweeteners (if you find one without sugar, it has Splenda). Now try to buy a loaf of bread without any added sugar (most loaves contain brown sugar). Almost everything in almost every conventional grocery chain in the U.S. is loaded with sugars, sweeteners, and other addictive substances. Even if you try really hard to buy healthy foods at a normal grocer, you are going to have a hard time.

Not everyone with a weight problem is shoving 50 Snickers down their gullet every day, and that characterization has to stop if we're going to realistically address the issue.

Nobody with a "weight problem" eats fewer calories each day than their body burns. Nobody.

I didn't say they did.

1. Organic, Pure, Maple Syrup at Wal*Mart

http://www.walmart.com/ip/Great-Value-Pure-Maple-Syrup-12.5-...

2. Pears in pear juice (no other sweeter). WalMart's own brand: http://www.walmart.com/ip/Great-Value-Fruit-Pear-Halves-Bart...

3. Organic sprouted whole wheat bread: http://www.walmart.com/ip/Alvarado-St.-Bakery-Sprouted-Whole... (All bread needs some "sugar" for the yeast to work on. Some that say "sugar free" get sugar from milk or fruit juice.)

"Healthy Life Sugar Free 100% Whole Wheat Bread" http://www.walmart.com/ip/Healthy-Life-Sugar-Free-100-Whole-...

It's not that they always don't carry it, and I should note that Walmart's online selection contains practically every product possible, and is not necessarily analogous to what you can find on the shelves at your local store (that's why I said go to your Walmart).

Even if a healthy alternative is on the shelves at your local Walmart, and it sometimes is, virtually all of the shoppers are going to come back with an unhealthy option thinking it's healthy. The one or maybe two items that are actually healthy (and by "actually healthy", I just mean real food; something you can make from a plant or animal without a chemist's involvement) have to be picked out from dozens of nearly-identical SKUs that are deceptively labeled.

Try this on someone who doesn't know you're going to try it on them: check the ingredients and values on someone's healthy food item that they got at a mainstream grocer (Target is almost the same as Walmart, they just have a more prominent nut section) and see how much sweetener was added to it. My health-conscious buddies usually find out that their premium "super-healthy" green band 100% whole grain wheat bread has added sugar.

I actually have bought real maple syrup at Walmart. It was tucked in the very top corner of the shelf and there were only three units stocked. By contrast, there was a whole section of thickened, dyed sugar water syrup on the wall, probably 25 SKUs. Again, the issue is not that it's hypothetically impossible, the issue is that 99.9% of the patrons, even those who are intentionally trying to buy a healthy option, are not going to be able to do it successfully. There's a reason for that, and that reason is that the grocer, the distributor, the manufacturer, and all the rest of the way up the supply chain, they don't want you to be able to buy healthier, because access to more filling, low calorie options means not only that you'll be healthier, but that ultimately you'll buy a lot less food.

I strongly disagree with you. Obesity is not Wal*Mart's fault. Eating too many calories is.

You haven't written anything I can show to be factually inaccurate. But the trouble is with one word: "simply."

Unless you subscribe to a metaphysical interpretation of human behavior, the fact that obesity is such a widespread health problem is ipso facto strong evidence that some set of environmental factors is at play.

The insistence that this large population of people bear some kind of personal responsibility for their condition completely misses the point and is, in my opinion, an obviously useless suggestion to make. I'm not aware of any evidence that instilling a sense of shame in people who are obese is likely to ameliorate their condition, and the experience of many would seem to suggest it is likely to have the opposite effect.

Eating fewer calories than your body needs every day will always lead to weight loss. Certainly it's easier if you rearrange your diet, but that's a secondary point.

You're not engaging with what I wrote. The trouble is with refraining from consuming so many calories. The fact that so many people find this so difficult is proof enough that it is not "simple" in the sense of being easily accomplished, and that environmental factors likely contribute to its difficulty. Thus attention should be focused on discovering and addressing these factors, instead of applying social pressure to the obese to eat less.

Reply on news.ycombinator.com