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Bovsun, Mara The diet dilemma. (includes related articles) (Cover Story) Medical World News v33, n5 (May, 1992):17 (6 pages).COPYRIGHT Medical Tribune Inc. 1992
At age seven, Helena Spring started dieting. After 34 years of grapefruit, 270-calorie-a-day hospital plans, fat camps and weight-loss clinics, she stopped. Now 43, the 5 foot 3 inch nurse weighs about 300 pounds. "I'm much happier with myself since I stopped dieting," she said. "I think the word diet should become extinct."
Spring, a member of the Sacramento, Calif.-based National Association to Advance Fat Acceptance, is part of a growing rebellion against calorie counting, starvation diets and the $33-billion-a-year diet industry. For people like her, the question is no longer "which diet" but whether to diet at all.
"Diets don't work and permanent weight loss is elusive," said Sally Smith, executive director of the 3,500-member group, herself a 300-pound woman, who also started dieting when she was seven. "Fat people are here to stay."
A small group of physicians and therapists have joined the diet backlash, according to Joseph McVoy, Ph.D., director of the 120-member Association for Health Enrichment of Large Persons.
"We are at a crossroads," Dr. McVoy said. "It is time we have to change our underlying assumptions about the world.
" Dr. McVoy, who runs an eating disorders clinic at St. Albans Psychiatric Hospital in Radford, Va., said that for 30 years there has been research showing that dieting is not effective for long-term weight control. "There is no diet that can show you a success rate of five years," he said. "Why do we continue to torture these people when we know it doesn't work?"
Practicing physicians are beginning to question whether everyone can, or should, reduce. "It's a kind of madness to say that everybody should lose weight," said Dr. Alvin J. Ciccone, a Norfolk, Va., family physician who admits that he is an "overweight doctor," and does not practice what he preaches. He said he lost about 100 pounds, only to gain back half of the weight.
"The problem with America is that everybody feels that to be thin is to be healthy," he said. "I wonder if this is not a gimmick of America."
The anti-diet revolution alarms Dr. Theodore VanItallie, a leader in obesity research since 1952. "It is a disheartening spectacle to observe so many victims of our obesity-promoting environment collaborating actively in their own downfall," he said. "They shouldn't participate."
Dr. VanItallie says there is overshelming evidence that fat people have an increased risk of diabetes, coronary heart disease, hypertension, gout, gallbladder disease, and endometrial and breast cancer. Fat women, for example, run six times the risk of developing gallstones as their slim counterparts.
"The doctor has the responsibility to inform patients of these risks," he said. "To say that no one should diet is ridiculous."
The health paradox
At a National Institutes of Health (NIH) consensus development conference held in early April, a panel of obesity experts observed a "health paradox" in modern America--many people who do not need to diet are trying to do so, while others who may need to lose weight for health reasons are not succeeding.About one-third of American women and a quarter of American men are trying to lose weight at any given time, according to the NIH, and they spent about six months of the last year on the various weight-loss regimens. The panel also concluded in its consensus statement that those who take part in weight-loss programs quickly regain whatever they lose. The long-term failure rate is estimated at 95%.
"We're in an epidemic of dieting inappropriately," according to internis/endocrinologist Dr. C. Wayne Callaway, of Washington, D.C., and a member of the Dietary Guidelines Advisory Committee of the U.S. Department of Agriculture. Dr. Callaway estimates that only one in 10 women who diets does so for health reasons. "The guys with the beer bellies are not trying to lose weight," he said. "Ironically, those are the people who most need to drop pounds, because abdominal fat poses the greatest health risk."
Despite the dieting craze, Americans are getting fatter. The latest data from the National Center for Health Statistics' health and nutrition survey show that 25% of the adult population, or 34 million Americans, are 20% or more over ideal body weight.That number is within one percentage point of the figure given for the previous two studies, covering five-year spans. NIH statistics put the figure for overweight Americans closer to 34%, said Dr. Jay H. Hoofnagle, director of the division of digestive diseases and nutrition for the NIH.
Fast and abundant food and hectic but sedentary lifestyles helped to put on the weight, and spawned the diet industry. The Calorie Control Council, a diet-food trade group in Atlanta, Ga., said that about 48 million Americans are on diets, and 101 million are eating light, surgar-free or low-calorie fare, according to a 1991 survey.The number of dieters is down from the 1986 figure of 65 million. But at that time, there were only 78 million consumers of pared-down foods.
In 1989, about 1,000 new light products were introduced. Estimates for the total industry--diet books, fitness spas, commercial and hospital-based reducing plans, foods, pills and supplements--were in the range of $33 billion in 1991, according to Marketdata Enterprises, Inc., a consulting firm in Valley Stream, N.Y.
If the diets are doing little to slim down the American population overall, they have been wreaking havoc with those people caught on the diet merry-go-round, commonly known as yoyo dieting. The psychological impact of losing and regaining over and over can be devastating.
"I felt like a total failure. I had no sense of self-worth," said Aleta Walker, 35, who carries about 300 pounds on her 5 foot 6 inch frame. She started her life-long diet, which she said cost "tens of thousands of dollars," at age 12, when her doctor prescribed amphetamines and a 500-calorie meal plan. She quit just five years ago, after her second attempt at a liquid diet gave her gout. "All the diets have contributed to my being the size I am today," she said. "I was hungry all the time, constantly hungry and deprived."
That deprivation leads to depression and binge eating, said San Diego therapist Susan Ward, who runs a group she calls Beyond Feast or Famine. Her patients are encouraged to throw away the diet books and eat when they are hungry. But her major goal is getting her patients to abandon the self-loathing that accompanies repeated failed diets. Do they lose weight during her 12-week program? Ward admitted that some do, but most don't. When Ward takes people off diets, they "run rampant," she said. "Maintaining weight, not gaining, is a big goal." She focuses on getting her patients to start an exercise program, and make healthier food choices.
Dr. Callaway said that the idea that people can control their body fat is simplistic, and "based on the notion that all fat people are gluttons." This idea totally ignores heredity, he added. "Physicians think it is a matter of control, when 50% of the variation in weight is genetic," he said, citing studies on adopted twins that showed that no matter where a child was raised, weight patterns reflected those of the biological parents. "We start out with a pre-set tendency to be a specific height and weight," he explained.
Research is also indicating that genetically heavy people are sabotaged by their own bodies each time they try to lose weight.
"Our many years of research into the biological effects of weight reduction have shown that weight reduction is accompanied by metabolic changes that return the patient to the antecedent weight," said Dr. Rudolph L. Leibel, an associate professor at Rockefeller University in New York City, who has been studying obesity for 12 years. Long-terms efficacy is very difficult to achieve because calorie restriction provokes compensatory alterations in the body's use of energy.
Human bodies were designed to survive famines, and that mechanism undermines low-calorie diets. "If you cut back on your food, your body will adapt to starvation by burning less and less," Dr. Callaway said. In a normal person, food decreases appetite, he said, but it has the exact opposite effect in a person who has starved.
More harm than good?
A big surprise at the NIH meeting was a collection of epidemiologic studies contradicting the conventional wisdom that extra fat shortens lives. David F. Williamson, Ph.D., an epidemiologist in the division of nutrition at the Centers for Disease Control, Atlanta, said that what "made people sit up and take notice" were 15 studies observing trends among several hundreds of thousands of people, all pointing to the possibility that dieting--not being fat--may increase a person's relative mortality risk about 1.5 to 2.5 times. "I was surprised by the consistency of the data," Dr. Williamson said. Another issue that "struck a number of us" was the strong relationship between weight loss and cardiovascular mortality, he said. "That is a twist that has puzzled folks." Dr. Williamson hypothesized that the cardiovascular complications may be a result of the loss of lean muscle tissue that is commonly seen with low-calorie diets.
Since epidemiology is an inexact science at best, Dr. Williamson said that the studies reported at the NIH need to be taken seriously, but require further study in a more controlled setting before they can be used to determine medical recommendations. "The anti-diet people are looking at this as another brick in the wall of their argument," he said.
Dr. F. Xavier Pi-Sunyer, co-director of the Center for Research in Clinical Nutrition at St. Luke's/Roosevelt Hospital Center in New York City, views the research on the dangers of weight cycling as "inconclusive." But he said that trying to set a predetermined weight goal for a fat person is not advisable.
Dr. Pi-Sunyer said that obesity-related health risks do not start until a patient is 20% or more above ideal body weight, or if there is an existing condition, such as hypertension. "There is reasonable data to suggest these people will benefit from losing," he said. "But they don't have to lose all their weight, reach a goal on the actuarial tables, to get a health benefit.
"If a person weighs 290 pounds, it makes no sense to choose a goal weight based on the average height-weight tables," Dr. Pi-Sunyer continued. "The initial weight loss might be 15 pounds, achieved slowly at a maximum rate of about two pounds per week. We do it in increments; we don't set the patient up for failure by moving too quickly."
Reducing programs should be based on an invididual's metabolism, not a pre-printed menu card, and a great emphasis should be placed on improving diet composition, reducing fats, for example, Dr. Callaway said. "The idea that everyone will lose weight on a 1,200-calorie diet is silly," he said.
Extreme measures, such as gastric reduction and 400-calorie liquid diets, should only be considered when there is a clear sign that a patient has an obesity-related disease, Dr. Pi-Sunyer said. "We consider gastric reduction only for people who have serious effects of obesity, such as heart disease," he said.
Ironically, by removing the patient's contact with a realistic eating environment, these techniques succeed in helping patients dro pounds, but fail in helping them keep the weigh off. "They don't have to think about it," said Dr. Pi-Sunyer, who added the same is true of ultra-low-calorie liquid diets. "When people are on a liquid diet, they don't deal with food, so they don't learn much," he said. "What one wants to do is get them to change lifestyles."
Both anti-diet and traditional weight-loss advocates agree that some form of exercise is crucial in maintaining weight loss or establishing a healthier lifestyle, no matter what the scales say.
Whether patients weight 150 pounds or 600 pounds, they require "healthy physical activity" like walking, Dr. McVoy said. But shoving a formerly sedentary 500-pound person into "an aerobics class with mirrors, and a lot of lycra and spandex" is sure to fail. Slowly, painlessly introduce the activity, Dr. McVoy said, and the patient will continue and make it part of a daily routine. With one of his larger patients, he said he recommends five minutes on a treadmill. "Now that patient walks about a mile a day, and has slowly lost 100 pounds," Dr. McVoy said. "Water aerobics is another good choice because the water's buoyancy reduces joint stress."
Dr. VanItallie said that the activity level recommended for cardiovascular fitness--20 minutes a day, three times a week--is not adequate if you want to burn calories. "It does not have to be rigorous," he said, nothing that two hours of walking a day consumes nearly 500 calories.
Unless a person is willing to make exercise and eating less a lifetime commitment, Dr. VanItallie believes that it is a waste of time to start a weight-loss program. "The physician has to assess whether the patient has an understanding of the problem and the intellectual ability to change lifestyle and manner of eating," he said.
As in other chronic conditions, earlier intervention may keep the problem from getting out of hand. "Don't wait until a patient is 300 pounds," Dr. Pi-Sunyer advised. If weight starts to drift about 20% above normal, he said it is time to alter lifestyle with small increases in activity and decreases in caloric intake. Early interventions can be valuable for preventing obesity in women, who in general continue to gain weight throughout adulthood.
On the flip side, he said that his clinic turns away people who say that they want to lose 15 pounds just to fit a cultural image. "There, I tend to agree with the anti-diet people," he said. "The ideal image out there of women who are so thin is biologically incorrect." He estimated that fashion models may have body fat around 6%, where an average woman will carry around 20% to 25% of her weight in fat.
Dr. VanItallie summed up the problem by stating, "In prehistoric times, primitive man hunted for food; modern man is hunted by food. While we can't change society, patients have to learn to defend themselves against this."
