bearing blog

Obesity: A different perspective from what you've seen here.

If you're interested in some of the things I wrote about obesity and finding the power to change, maybe you might be interested in reading other writers coming at the same subject from a very different perspective.  Ta-Nehisi Coates at The Atlantic has been blogging about obesity, class, and race.  This meditation is outstanding.  I recommend it. 

It's messing with my head: A twenty-two-weeks report.

I had that dream again -- the dream where I'm surrounded by piles and piles of food, and I have to eat it all.  It was a new version, one in which I was staying in a hotel room with no fridge, and there were bowls of udon noodles, quart jars of vegetable soup, and platters of chips and fresh salsa sitting around on every available surface.  The precise reason wasn't clear to me, but somehow in the dream I was supposed to finish it all off before the stuff spoiled in the heat.

I woke up feeling bloated.  It  took me a while of being awake before I felt I could have breakfast.

* * *

One thing I haven't written very much about, since I became pregnant, is how well I'm managing to stay away from the cliff-edge of eating disorder.  One reason I haven't written very much about it is that I'm not actually doing very well, or at least, I'm not feeling very secure and I'm not quite sure how to put it into words, or maybe I'm afraid to express it honestly.

Still, I wrote so much about my successes last year, it seems only fair to report on the hard parts, the failures, now.

Yeah, pregnancy has made it hard. 

* * *

It's not that my weight has spiralled out of control.  I put on a couple of pounds quickly very early on, and have tracked the what-you're-supposed-to-gain chart pretty closely since then -- basically, I'm following a parallel line about two pounds higher than the range I'm supposed to be in.   In other words, I've gained a bit more weight than the current standard medical model would suggest I should, but not much more, and the gap isn't getting any wider.  Rationally, I know it's just fine.

But I am having a hard time staying rational about it.

* * *

Look, I know I'm pregnant and that pregnant women are supposed to gain weight.  But somehow there is this twang of anxiety at the numbers going up and up.  I literally have to keep doing the math in my head, lik this:

I've gained 16 pounds.  Oh yuck, that sounds so horrible.  It's more than I'm supposed to have gained by twenty-two weeks.

The upper end of the range says I should only have gained a maximum of 14 pounds by now.  Why can't I get below the upper end of the range?  I must be slipping.  This is awful.

OK, calm down, even the lower end of the range is 11 pounds.  I've only gained 5 pounds more than the minimum I'm supposed to gain.  This is not a crisis...

(repeat)

My brain goes through this, unbidden, several times a day.

* * *

A lot of it is baby and bustline, both welcome filling-out of my frame.  The rest of it seems to be going on below the waist.  My collarbones and arms still have definition, but... I can't stop thinking about how my thighs feel in my jeans.  Every time I slide behind the steering wheel of my car I notice the tightness of my pants on my thighs.  Every time I feel that I make a mental note:  I should be more careful, my legs are getting fat.  And then the rational part of me corrects that:  Women are supposed to put on extra fat stores when they are growing a new baby.  Thighs are an excellent place to put them, probably the best place as it's waistline and upper-body fat that is supposed to be a marker for heart disease and early death -- better to be a pear than an apple and all that.  So quit worrying, it's all fine.  But that doesn't stop me from thinking it again when I slide out from behind the steering wheel.

* * *

Sometimes I think it's simply seeing these numbers on the scale again, numbers that were so welcome on the way down last year.  My first thought is often "I can't believe I've gotten up this high."  And then I remember I'm supposed to see that number; I'm supposed to wind up somewhere between 133 and 143, and logically I have to pass through all the numbers between here and there on the way.

* * *

There's other things too that trigger awful feelings.  The baby is starting to compress my internal organs -- I know I have a little less room in my stomach, for example, than I used to.  Smaller amounts of food make me feel fuller.  And that full sensation, that "oops I ate too much" sensation --- well, it's a bad sensation for the recovering bulimic, let's just put it that way.  I have to go away and list to myself what I had on my plate to prove to myself that I have not been overeating, to remind myself that what I had was healthful, that so much of it was vegetables and fruit, for instance.  

* * *

I keep trying to go back to my "signal breakfast," the single boiled egg and the glass of tomato juice.  And of course I keep being unsatisfied by this, because for pete's sake, I'm almost 5 months pregnant and that is not enough food for a 5-months-pregnant woman to eat after a full night's sleep, of COURSE I'm hungry again by midmorning.  But I still feel like that extra slice of buttered toast, or that cup of cottage cheese, is me "giving in" rather than feeding myself what I need.  I know better, but I am having a very hard time feeling better.

* * *

Don't worry too much about me physically. I am pretty sure I *am* eating enough, and that the food I eat is all very good and very high-value food.  I eat lots and lots of green leafy vegetables, a habit from weight loss that is well adapted to pregnancy.  I have increased my intake of meat, especially beef and oily fish.  I'm eating lots of fresh berries right now while they're still in season, and all my bread and crackers and pasta and cereal are whole grain.  I don't desire milk to drink, but I eat yogurt, cream, and cheeses daily.  I craved ice cream at the very beginning and enjoyed it thoroughly.  Other than some tiredness that seems to respond well to an herbal iron supplement, I have no symptoms of deficiency:  not a single leg cramp yet this pregnancy, no swelling except once when I was hiking at high altitude.  Very little nausea, even.  And, of course, the weight gain is right about where it should be.  

* * *

The hard part is just accepting it as a good thing, and not something to be feared.

Normal eating vs. disordered eating.

Christy P.  pointed me to a blog item/discussion thread at the NYT Well Blog asking "What Is 'Normal' Eating?"  I started to read through the 150+ responses and after a short while got very fatigued with "arrrrgh!  how wrong most of these people are!" feelings, and had to stop.  It is a good question, but I don't think there is much wisdom to be found there in the answers.  Maybe you are interested, though -- so here it is.  

I will use it for a springboard to write about something I've been thinking lately.    I've been mulling over whether it is at all helpful to think about overeating -- garden-variety overeating, not obviously disordered behavior like binge eating -- as a mental illness (an organic one -- body chemistry is involved)  in and of itself.

I started wondering about that as I was reading through (and participating in) the discussion at Megan McArdle's.  A lot of people, both the obese and the anti-obese, are obsessed with "blame" -- Should we blame obese people for their obesity?  Should we avoid blaming them?  Should we blame the food processing industry?  Advertising?  Is blame counterproductive?  Are overeaters rational actors in an unhealthy environment?   Who's responsible for obesity?

These facts are unassailable:

 - Rigorous control of one's behavior, when it really is rigorous, reverses obesity.

 - Most people who attempt such rigorous behavior don't actually succeed in producing it long-term.  Some think they do and are wrong.  Others are aware of their repeated failure.  

 - It is really, really, really difficult for people to eat less than their bodies tell them they should.  

Whatever our eventual philosophy turns out to be, I think we must refuse any line of thinking that either leads us into "self-control is useless" OR into "obese people must have no self-control."  The first is contradicted by facts, and also rather insulting to human agency and free will.  The second is contradicted by the claims of many, many obese individuals, and also rather unkind and insulting to specific humans.  Let's be charitable and take people at their word when they say they are trying hard, okay?  And at the same time let's recognize that a portion of the people who try hard really do succeed, and their hard work and success is not meaningless, okay?

Which is why I keep coming back to the overeating-as-mental-illness model:

 - It's individual:  no two people can be treated exactly alike.

 - It's not immutable:  hard work, often extraordinarily hard work, and treatment, has successfully treated it.

 - Yet not everyone can overcome it:   many people have to live with and compensate for it their whole lives.

This leads me to two conclusions:

 1.   It is dishonest and dangerous to 'normalize' overeating (that is, to say it's just another kind of "normal")  in a misguided attempt to make sufferers feel better about themselves or to remove stigma.  It is and always will be intrinsically disordered (to borrow a phrase from another field of human behavior) to eat, over long periods of time, more food than is necessary for physical health. 

 (I say "over long periods" because it's pretty obvious that humans rationally anticipate future scarcity by building up fat stores, and also that it's normal human behavior since time immemorial to use food in social celebration during special feasts.  Neither of these, however, describes the constantly grazing, every-plate-looks-like-Thanksgiving behavior that characterizes the overeating I see around me.)

2.  And yet, it is unfair, unkind, and unhelpful to shame and blame people, or categorize them as lazy or without self-control, because they have not succeeded at the kind of drastic, long-term change that would reverse obesity.  It's really hard.  I don't say it's impossible because some succeed.  But many don't.  It doesn't mean they can't.  It does mean that it's asking more than most people can handle without a significant commitment of resources that they might, reasonably, be unwilling to make.  

We know better now than to shame people because they can't handle, say, bipolar disorder or drug dependence on their own.  We know, too, that it's not pointless to try to encourage people to do the hard work of regaining control of their lives.  Maybe we need a similar sort of sanity about overeating.

What does this have to do with normal eating?  Well... 

I question whether "normal eating" is really what recovering overeaters need to be shooting for.  I'm not sure it's possible to eat normally, once you've been a compulsive overeater, just as most people agree that it's not possible for a recovering alcoholic to use alcohol like a "normal" person.  I think it will always be somewhat artificial, never natural, for me to consume the amount of food I physically require.  I am able to celebrate with food, to enjoy it as a social interaction, to feast; but always with a kind of calculation and attention, like a diabetic who must remember to measure blood sugar and apply corrections to the daily insulin dose.

Appropriate eating -- healthy eating -- for a recovering overeater is not the same as for someone who naturally eats "normally."  Part of the reason  that so many people in threads like the one at the NYT blog are so wrong wrong WRONG-- is because they fail to see that normal behavior is not what's best for abnormal people, and the corrections that abnormal people need to make are, well, ridiculous to try to apply to the whole population, especially the healthy ones.

Dosage.

You've heard the expression "to self-medicate with food," right?  Generally thought of as a bad thing.  Emotional eating and all that.  Causes you to envision a lonely woman plowing through a pint of ice cream straight from the carton, or some such thing.

It's not all bad, really.  Food does affect your mood, because it does affect your body.  And sometimes it's simpler than that.  

You have a sore throat?  A cup of hot tea with a generous dollop of honey will really do you good.

Low on iron?  Have some beef at every meal.

Pregnant lady with a sudden attack of nausea at bedtime five hours after dinner?  TRY EATING SOMETHING FOR CRYING OUT LOUD.

So as I was downstairs in my pajamas finishing off my bowl of plain yogurt and blueberries, which I wasn't exactly hungry for but I thought might help me feel better and get to sleep, I found myself wandering into the kitchen to refill my bowl.

Now why am I doing this?  I wondered, even as I scooped into the yogurt carton.  I wasn't hungry to begin with.  I ate what I served myself, and I had a good reason for it.  Now why am I in here getting more?  I  considered it carefully as I started in on the second bowl, and hit on the reason:

Because I don't feel better yet.

That's it.  That's the reason.   I'd decided to eat something because I hoped it might quell the nausea long enough for me to get to sleep.   Well, here I am thirty seconds after finishing my bowl of yogurt, and I still don't feel all the way better, so I'm eating more.

Funny!  I *might* give it a chance to work, before I give myself a double dose.  If I have a headache, do I swallow a couple of painkillers, think, "Nope, headache still there," and use what's left in my glass to swig down a couple more?  If I have a cough, do I take one spoonful of cough syrup, then go back for seconds when I'm still hacking a couple minutes later?  

No, maybe the problem with self-medication with food isn't so much that we use food as a drug.  Maybe we should use it more like a drug -- when we have a problem that food might solve, take the smallest dose necessary, and wait for it to have an effect (or not) before trying something else.  Why should it be different from any other?

Long-distance self-optimization.

Latest thing I have learned about myself:  When on a long car trip, it's better to pick where we are going to have meals ahead of time.   As in, identify a particular chain restaurant at a particular exit in a particular town, and drive there for dinner.  Flexibility has its benefits, but it doesn't suit my particular brand of food insanity.  (We can, of course, stop for the rest of the family to get snacks if it takes us longer to get there than we expected.  And we can change the plan, but that doesn't undermine the importance of having a plan.)

If we don't have an exact plan, then as dinner time approaches I find myself obsessively scanning the horizon for blue highway signs labeled FOOD, and frantically running my mind over the possible combinations and things I could order at the various chain restaurants along the way.  Should we go to a McDonald's where nothing's really great for you but I have a well-developed, reliable strategy?  Or should we go to a Chili's where theoretically I could order something quite healthful but there's a chance that I could be distracted by the choices and wind up talking myself into a giant mushroom swiss burger or something?  Trapped in the car with little else to do, I find I can't think of anything else.  By the time I'm actually sitting down in front of a table, I've lost all my control.

But the last time we made a several-hundred-mile car trip, I made a plan to go to a specific restaurant in a specific city, which we expected to reach around dinner time.  (I had coupons even!)  And I discovered that I didn't obsess over the signage at all.  "We're going to stop at the such-and-such at Exit n and that's that," I told myself, and instead of focusing on the blue FOOD signs I found I was focusing on the tiny green mileage signs instead, which wasn't so bad, and when we got where we were going I knew exactly what to expect and what my strategy would be, and I did fine.   I chose healthful items and had a non-excessive amount, including a small dessert, and felt satisfied and guilt-free.

I think it's important to perform this sort of experiment on yourself from time to time.  The results might not be applicable to others, but hey, you're only responsible for optimizing you, not them.

On being a supportive husband.

When people compliment me on the weight I lost last year, I always take care to give credit to Mark for being very, very supportive.

Mark refuses to take much credit.  He says it's very easy to be supportive of me.  Here is his algorithm, according to him:

1. Listen to me when I wonder out loud why the scale is not doing what I want it to do 
2.  Ask, "Have you been sticking to your habits?"
3. Listen to the answer 
4. Say, "Well, there's the reason the scale isn't doing what you want it to do.  Go back to your habits." 
5. Wait for a chance to say "See?  I told you things would improve if you went back to your habits." 
6. Repeat as necessary  

Of course, this doesn't include all the cheerful schedule-arranging and child-minding he does for me so I can swim and run every week without fail, but I guess he doesn't mind that.

Must be time to listen to him some more (image courtesy of babyfit.sparkpeople.com):

Have I been off my basic background of habits?  Yes.  Namely, I haven't been interested in vegetables and I have mainly been making up the difference with hot buttered toast.  

The last couple of days I've tried to correct this with lots of green veggies.  I'm having the most success with steamed leafy greens, so maybe as boring as it is I'll just try to eat a bag of collards or spinach every day.     And I can go back to my extra habits too -- they're all still really good habits, even for a pregnant person.  

Vague habits are hard to keep.

At nearly 13 weeks pregnant, I have gained 7 1/2 pounds.  That's an okay rate -- I am supposed to gain between 25 and 30 lbs in a whole pregnancy, so I guess I'm on track for that -- but I still feel panicky every time I see a new number on the scale.  I just cannot stop myself from expecting to be back at BMI = 31 six months after having this baby.

Deep breathing, don't worry about the scale, concentrate on habits.  Like measuring all my food.

A friend said to me the other day as we cooked together in her kitchen that she was working on one good habit at a time, and that right now the habit was "portion control."  That's a good habit for anyone to develop, especially someone nursing a brand new baby as she is -- it's a fundamental habit for healthy eating, but in and of itself it's not "dieting" and so working on it isn't likely to deprive her of the nutrients she needs to keep up her strength in such a taxing time of life.  

I mused about it though -- a little bit out loud there in the kitchen as I juiced lemons and minced cilantro, and later over the next couple of days.  I was thinking about it just now as I used a 2/3 cup measure to scoop out my yogurt for my midmorning snack.  

"Portion control" isn't really a single habit.  It could mean a lot of different habits, or some combination of them all.  Think about it:  You might mean that you never take seconds, i.e., you control the number of portions.  Or you might mean that you know exactly how much you eat of everything (whether you stick to a plan or not).  Or you might mean that you plan to eat a certain amount of everything and you actually "control" yourself so that you actually do eat that much.  Or you might mean that you plan to eat a certain number of helpings of things.  Lots of different ideas.

It strikes me that if you're going to work on a habit, you'd do well to abandon a vaguely worded term like "portion control."  Better to sit down and write out the details of the new way you'd like to do things.  A standard operating procedure, so to speak.

I will always plate my food using measuring cups and measuring spoons so that I know I have served myself an appropriate size serving for each kind of food.  I will carry a set of measuring spoons and cups with me for use at restaurants.  

Something like that.  

There are obviously other features of "portion control" that you could include.  For instance, you could decide what is the appropriate size serving of each kind of food (one easy way is to use whatever serving size is listed on the label; another is to use a published system like the one in this book).  You could incorporate an actual "diet" plan by allowing yourself a certain number of these servings per day or per week, or by holding yourself to another rule like "no seconds."  You could increase your awareness by keeping a food diary.  

Or you could just work on the micro-habit of always transferring food from package, to measuring device, to plate, to mouth.  The food has to contact the measuring device and the plate on the way to your gullet.  A simple rule.  You could call it the "three-transfers" rule.  

  Original packaging ---->  Measuring device ---->  Plate or bowl  ----> Gullet

Notice that all by itself, this rule does away with eating chips out of the bag and licking raw cookie dough off the spoon....

I have slacked off on a lot of my habits since beginning this pregnancy.  I am trying hard not to "diet," and to eat when I think I need to eat (careful!  I am good at convincing myself I "need to eat" when I don't), but there are a number of habits that are harmless for pregnancy and not really linked to "dieting."  This is one.  I don't have to limit how much yogurt I eat, but I might as well be aware that I've had about two-thirds of a cup, you know?

Smart snacking.

The August 2009 issue of Real Simple magazine has an article I heartily endorse, called "How to Snack Smarter."   It's on page 148 of the dead-tree version and isn't yet online, but will probably appear on the website in a few weeks.

Among the reasons suggested for distributing your daily food intake among a few snacks are that it helps you eat less at mealtimes (I have definitely experienced this), it ensures you get all your vitamins (I certainly eat more fruit than I would otherwise), it puts you in a good mood, and it foils cravings. 

(The author also says that snacking "keeps your metabolism going" and "can help your body burn a few calories;" a lot of what I've read elsewhere indicates that people tend to eat enough extra calories when they snack to make up for that one, so I would take that with a grain of salt.)

Regular snacking -- and by "regular" I mean "at the same time every day," not "constantly putting food in my mouth" -- was definitely part of my strategy while I was losing 40 pounds last year, and it continues to be part of my strategy in this newest pregnancy.    It isn't the solution for everyone -- the "anti-snacking" No-S diet has worked well for at least one friend of mine.  But if you do choose to harness the power of snacks to enhance your health and happiness, some suggestions from the article and from me:

• "Experts suggest choosing a snack that has roughly 100 to 200 calories (a meal should start at about 300)."  I agree.  That's about the right size.  Anything more and you've added a meal.  

• Not sure how many calories are in that stuff you want to eat?  My rule of thumb has always been to limit the size of the snack to about an ounce.   Look, the worst possible case -- an ounce of pure fat --- is 260 calories or so, and you aren't going to eat an ounce of pure fat for a snack. 

• Calcium's hard to get, so "[seek]" out snacks rich in the mineral---for example, ... yogurt or almonds."  Both are staples for me. 

• "[A] fruit or vegetable in every meal and snack."  I do this when I can.

• "[W]hen cravings attack, have a plan for giving in intelligently."  I have learned pretty well to put off my cravings until my next scheduled snack, which is never that far away.  Because my overall diet is so healthful, there's room for some of almost anything.  

•   If you choose protein bars or granola bars:  "Look for a bar that has 150 to 200 calories, at least four grams of protein, and four or more grams of fiber."  I swear by Kashi TLC Crunchy Granola Bars, Chewy Granola Bars, and Fruit & Grain Bars.  The Roasted Almond Crunch variety, for example, has 180 calories, 6 grams of protein, and 4 grams of fiber.  The Dark Chocolate Coconut variety is awesome.  Another nice thing about these smaller bars is they're about the right size for a toddler's breakfast on the go.

• Make your snack a balance of carbs, fats, and protein.   

• "Make it feel like a small meal, with multiple components."   I cannot stress the importance of this one enough, and I'd also add:  take the time to prepare it attractively and put it on a plate (or a portable container) and have it sitting down, in a moment of relative peace if you can manage it.  If you're eating one kind of food out of the package it came in, you're grazing, not snacking.  NO CHIPS OUT OF THE BAG.  If you're going to eat some chips, put some on a plate and give yourself a little dollop of dip or something, or make a little plate of nachos.    

•   I suggest scheduling your snacks and, once you figure out a schedule that works, sticking to it.  I have a snack at 10:30 and another at 3:30 or so.  That's what I need.

• Oh yeah -- remember that when you add a snack somewhere, you have to subtract food from a meal somewhere else, or you're not doing yourself any favors.   

  

A couple of dozen snack suggestions are sprinkled throughout the article, things like "One whole-wheat English muffin with peanut butter," "Greek yogurt with chopped walnuts and honey,"  "Two slices of deli turkey and a handful of grapes."  They are good suggestions, except that they are all low-fat, and I don't believe in low-fat eating, especially for snacks, when cheese, chocolate, lattes, and nuts are so handy and delicious.  Fortunately it is not hard to add fat to most of the suggestions.

One of my favorite snacks is hard cheese cut into tiny cubes with sliced fruit and a few pecans -- finger food, but a really nice combo.  I just now had a Wasa cracker (another staple of mine) spread with cream cheese and topped with sliced tomato and melted Muenster.  A full-fat latte is another snack indulgence I love.

Immediate results.

I'm sitting in an Eat Street diner called the Bad Waitress, musing about inflation.  Remember the Five Dollar Milkshake in Pulp Fiction?  This place has milkshakes for $5.25.  (Bananas in your milkshake will set you back an additional dollar).

Waiting for my eggs Benedict.  I just finished my morning swim, so I think I've earned it.  It comes with asparagus.  That's a vegetable.  (UPDATE:  Two stalks?  That's a garnish, not a comes-with.  Sheesh.  Oh well, it was REALLY good hollandaise.  I'm not going to have to eat lunch now, I'm sure of it.)

Thinking about habits and about outcomes.

What do you really want to change about yourself?  I mean -- among the things that you could change.  Really.

I know I have a long list.  I wish I reflexively, automatically, responded to my children by strengthening connections, not rupturing them.   I wish that desire for the Lord, rather than duty, would draw me to prayer several times a day.  I wish that my irritation at an untidy house didn't get in the way of welcoming people into my home;  I wish I was more generous to my friends.  I wish I had a better grasp on how much money I spend.  I wish I knew how to teach my children love for Jesus as well as I think I know how to teach them theology and logic.  I wish I didn't waste any time sitting in front of the computer each day.   The list goes on.

Once I would have said "I wish I wasn't so heavy and out of shape."  I don't say that anymore.  So:  hope.

And skill.  I have a theory -- still untested -- that I can apply something I learned with the heavy/out of shape thing, to all those other wishes and longings.  It's the meta-advice that I do dispense to people who really mean it when they ask me, "How did you lose the weight?  How can I not be so fat anymore?"  And that is to let go of the outcome, as much as possible----let go of what you want to BE ---and concentrate on the relevant behavior---what you DO.   Yes, I had weight loss on my mind that whole time, how could I not?  But I tried to put all my mental effort, self-blame and self-praise, onto the habits of regular exercise and control of my eating.  I tried to want those things for themselves.  And as time went on I did want those things for themselves.  That has made the difference.  I am now the sort of person who wants to wait for a nibble till lunch.  I am now the sort of person who looks forward to a vigorous swim.

This is the insight I would like most to share with people who ask me how I did it, how to do it.  A lot of the answers are "I don't know."  I simply don't know why last year and not any of the 20 years before that.  I don't know what changed.  Some grace, I think, an answered prayer, but I would never want to suggest that your problem is that you haven't prayed the right prayer or prayed hard enough.  But I do sincerely believe that cultivating the desire for new behaviors -- not slavishly adhering to behaviors because I thought they would gain me my far-off desire -- was a truly new, truly different, ultimately successful strategy.

It's sort of like "fake it till you make it."  I tried to behave like a healthy, athletic person, and to want to do the things a healthy, athletic person would do, rather than just wish I were healthy and athletic and hope that this wish would drive me to do the right things.

I've wondered in this space before if it is possible to MAKE yourself want something.  The more I think about it, the more I think the answer is yes.  Some things are probably harder to want than others.  But why not try?

Can I apply this to the other things I would like to change about myself?  Probably not all at once, but I could pick one thing and work on it.  Take my response to the children.  I cannot make myself be patient and self-giving.  I can resolve to change behaviors, and I can really want to change them.   Here is an example, a tiny one.  I have an image in my mind of myself that I do not like.  It comes from a day when my five-year-old got a hold of the camera and walked around the house taking pictures -- you know the kind, all the furniture slightly distorted from the kid's-eye view.  There are several pictures of me in that set.  They are all pictures of my back, hunched over the computer.  I do not want my kids to think of me as focused on the computer.  In the picture, it is impossible to tell whether I am reading blogs, or writing email to good friends, or planning the school day.  The kids don't see this.  All they see is my back to them.  I know I do not want to spend their lives with my back to them and my face turned to the computer screen.  If I concentrate on this image, I think I can make myself feel dissatisfied with looking at the screen instead of them.  I think I can make myself want to save the computer time for the blocks I have set aside for it, for early mornings, for the after-lunch recess, for daddy's bedtime story time, for Saturday mornings at the coffee shop.  I think I can make myself want to turn it off when the first child comes stumbling and yawning down the stairs wanting breakfast, so that the first thing he sees is a smile and a good morning, not "Aaagh!  What are you doing up already!?"

"I will be more connected" -- overwhelming, open-ended, vague.  "I will learn to keep the computer in its place --" much more do-able.  And more immediate, too.  At the end of the day I can feel good about having turned it off when I was supposed to and saved it for the right time, even if I don't feel any more patient or connected or different in any way than yesterday.  And the next day is another day.  And then there is another, a string of opportunities for success as long as life lasts.

Counterbalance.

I just finished reading a book that's been out for several years but that I ignored until recently, when I thought I might need a corrective to all the diet books I read last year while I was losing weight:  The Obesity Myth by Paul Campos.  It's been a while since I deliberately read something that I expected to disagree with -- a practice I recommend heartily!

I was surprised to find that the book was in more than one way a wake-up call for me.

The basic thesis of the book is that our public policy towards obesity, and the amount we spend in public and private dollars to combat obesity, doesn't make sense for three reasons. 

Number one:  there's no credible evidence that obesity in and of itself (except at the extremes) causes health problems.   

Number two:  there's no credible evidence that losing weight in and of itself makes obese people healthier.

Number three:  We're not getting much bang for our buck anyway, since the money and effort we've poured into the goal of getting people to lose weight is not resulting in weight loss.  

I will begin with several significant caveats.  I am not entirely convinced by Mr. Campos's review of medical data.  There is not that much of it; I would like to see a much more thorough and detailed cataloguing than is present in this book, one much more like Gary Taubes' analysis in Good Calories, Bad Calories.  I am also certain that some of Campos's data points raise questions that require answers before one can come to a conclusion.  (One example:  he writes that, excluding extreme thinness and fatness, life expectancy increases as you go from lower to higher BMIs.  I thought:  Now wait a minute -- life expectancy also increases as you get older, and people gain weight as they age, so shouldn't there be a correlation there anyway?)  Third, he seems to sort of selectively criticize and praise the practice of controlling for confounding variables.  I agree that this statistical tool can be used judiciously or maliciously, but Campos does not explain why he says it's justified here and not there.  Has he proven that "there's no credible evidence" that obesity causes illness? I don't think so.

However, I think he does succeed in showing something a bit less ambitious:  that the evidence is not nearly as strong as most people assume it is based on media reports and public policy recommendations.   Five arguments he made struck me as very persuasive, if they are true, of this less-ambitious thesis.  I feel I have to add that caveat because I think Campos needs more evidence to demonstrate that they are true.  But if they are true, I agree with him that they call into question the obesity-health connection.

(1)  To demonstrate that obesity causes health problems, most of the studies had to exclude smokers.  (He says this isn't legitimate; I say it is; but regardless, the following point still stands.)  After you exclude smokers and maybe a few other classes of people, the number of deaths in the studies are small.  Nonsmokers in one study had a less than 1-in-600 chance of dying of cardiovascular disease; thinner nonsmokers were less likely to die than fatter nonsmokers, but the number of excess deaths attributable to obesity alone is perhaps not high enough to justify the effort we're putting into combating obesity.  At the very least, the harm of obesity is likely dwarfed by the harm of smoking.  Which do you suppose our country spends more on:  attempting to lose weight and get people to lose weight, or attempting to quit smoking and get people to quit smoking?

(2)  Public policy advisory boards have an astonishing level of conflict of interest.  It goes beyond the level of "this study was funded by that industry which has a stake in the findings."  For example, he says that a claim of a strong international consensus that BMI>25 was based largely on the report of a World Health Organization panel that "consisted entirely of physicians who run weight loss clinics."  Even if you assume a good-faith effort, could such a group really be objective?

(3)  Campos says that studies that purport to show a connection between weight loss and improved health have not adequately controlled for the effect of improved nutrition and increased physical activity; and news reports fail to distinguish this effect too.  Campos gives an example of a study where participants significantly increased their physical activity and as a result both lost a few pounds and improved some measures of their physical health:  the media reported it as "losing a few pounds can improve your health."   It is now very well established that, independent of your weight, physical activity makes people healthier.  (I wrote about this in my post about reasons to exercise.) Because of that, it's obvious that a study purporting to show that obesity causes poor health must control for physical activity.  Campos says that many of the studies don't have that control. 

(4) Taking all the methods together, the act of losing weight introduces significant health risks that have not been adequately compared to the risk of not losing weight.  For instance, he claims that bariatric surgery is shockingly dangerous (the risk of death within a month of the surgery is somewhere between one in 20o and one in 50!).  Is it really proportionally dangerous not to have bariatric surgery, especially at the lower-BMI end of the market?  He says there are health risks associated with traditional methods of weight loss as well.

(5) Being "BMI-normal" or less appears to cause some serious diseases that obesity protects you from.  Osteoporosis, which can lead to deadly hip fractures, is one such disease; there are others.  When you include these "diseases of mild thinness," does the relative danger of mild obesity start not looking so bad?

Since it's true that physical exercise really is well established as something that improves health, it's apparent to me that it's dangerous to suggest "You should exercise to lose weight, because the weight loss makes you healthy."  Physical exercise is not actually that good at bringing about weight loss.  If someone starts exercising to lose weight for their health, they could really be improving their health and yet not see a weight loss; and will they then conclude that it's not doing any good, and so quit?  Or will thin people dismiss exercise because they don't think they need to exercise to be thin?  

 * * *

Not all of the book is about the medical research.  A large part of it is about the social pressure to be thin.  This is the part of the book that, for me, was a wake up call.  Because I've probably been contributing to it a bit over the past year, as I chronicled my own struggles with weight loss.  I hope on the whole my writing has been positive, because I firmly believe that physical activity and well-balanced, not-excessive nutrition are worthy goals in and of themselves, even if they don't result in thinness, and I want my writing to have reflected that.  Still, I measured my success last year largely in the pounds that came off the scale, and I'm a bit more aware that I emphasized the number too much.

Even in my personal experience, Campos's points ring true.  I've been telling people that I've never felt better since I lost the weight -- but maybe I feel better because I'm so much more physically active, and the weight loss is just a side effect.  

And then there is the lengthy discussion of why we criticize obesity so much.  We say it's about health, but is it really?  Particularly if the medical evidence against it turns out not to be so damning?  Campos makes a strong case that it's about the need for us to have some kind of social pariahs among us, a need to feel superior to others.  (Hoo boy, that hit home.  Consider this post.  And consider that it was after I started to lose weight that I started to write that I was "conquering gluttony."  Look, I'm getting thinner!  It proves I'm becoming a better person!)  

A point I found especially interesting:  Campos, a Mexican-American, argues that the freedom to look down one's nose at fat people has functionally created a way for elite, highly-educated white people to continue to sneer at low-income black and Hispanic people, without having to feel guilty about it:

Precisely because Americans are so repressed about class issues, the disgust the (relatively) poor engender in the (relatively) rich must be projected onto some other distinguishing characteristic... In 2003, any upper-class white American liberal would be horrified to imagine that the sight of, say, a lower-class Mexican-American woman going into a Wal-Mart migt somehow elicit feelings of disgust in his otherwise properly sensitized soul.  But the sight of a fat woman -- make that an "obese"-- better yet a 'morbidly obese' woman going into Wal-Mart ... ah, that is something else again.

He has got a real point (made only clearer by the fact that some upper-class white people would be disgusted merely by the mention of the Wal-Mart, without any reference to obesity at all).

Race intersects with obesity culture in another way I wasn't aware of.  According to Campos, girls and young women in the U. S. who are black or Hispanic are much more likely to have a positive appreciation of their own bodies than are white girls.  They are more likely to evaluate their self-worth independently of their appearance.  They are also likely to have a higher BMI.  And (this is the kicker) at least for African-American women, the denonstrated connection between obesity and poor health is even weaker than it is for white women.   Campos seems to suggest that public health authorities are actively promoting educational campaigns that will sensitize young black and Hispanic women to the dangers of obesity.  If this is true, it is really hard not to come away with the impression that some public health policy amounts to "Let's make black and Hispanic girls feel bad about their weight."   

So here's my final word on the book.  It's not perfect.  It's flawed.  It raises questions that go unanswered.  I'm not convinced of Campos's thesis.  But I think I'm convinced that he raises good points, points that people like me -- who tend toward the weight-obsessed, and who like to tell ourselves that it's "about our health" -- need to read and take to heart.  Some of this seeking after thinness is not necessarily healthy, and it's not necessarily virtuous.

Over the months after I reached my goal weight, it took constant vigilance to keep my weight at 108 instead of, say, 112.  Is it reasonable for me to fear those four pounds?  OK, the truth is I'm really afraid that if I let myself gain 4 pounds, I'll let myself gain 40.  Is that a reasonable fear?  All my clothes still fit at 112.   If I relaxed my diet slightly and became stable at 112, would I be happier or sadder?  And does it make any sense at all to be "proud" of my weight loss?  Even if it's true that gluttony was a big problem before, am I better off if I replace it with vanity and pride?

I think I came away very convinced of one sentence in the book, one of the principles of the "health at every size" movement:  A healthy weight is the weight a person maintains while living a healthy life.  To me, that means while being physically active and eating a well-balanced diet in response to real hunger signals.  Campos derides the traditional approach, but I disagree.  I think traditional "diet and exercise" can help a person create that healthy life; you may have to exercise on purpose in order to get enough physical activity, and you may have to control your eating in order to balance your diet and learn to eat in response to hunger.  I did.  But it does suggest that the number on the scale ought to have less sway on our decisions, personal and public,  and especially on our compassion towards others, than it currently does.