Shame on you, Dear Abby

I'll cop to reading Dear Abby, despite the often off-the-mark advice she doles out. But today's column went beyond off-the-mark and into just-plain-dangerous-and-wrong territory.

Here's the letter in question: "I'm an attractive, single, successful, 27-year-old woman who has struggled with anorexia ever since I was 12. I have learned to live with it and feel no need to advertise it to the world. However, I find that many strangers, including a large number of people I associate with at work, feel a compulsion to comment on my weight (105 pounds and 5 foot 9), the size of the clothes I wear, or what I eat. It's as uncomfortable a subject for me as I imagine it is for people who are overweight, and I have no 'pat' answer for them." --Annoyed at 105

Here's Abby's response:
Dear Annoyed: Clearly, your weight issues are more obvious to those around you than you chose to believe. However, you are under no obligation to answer these intrusive questions if it makes you uncomfortable. When confronted, reply, "That's a very personal question (or subject) and I'd prefer not to discuss it." Then change the subject.


Argh! Please write to her and set her straight about anorexia: It's not a "lifestyle choice" but a lethal mental illness. Ask her why she would sanction this writer's settling for a life distorted by anorexia. Invite her to list resources that might be helpful to "Annoyed" and her family, including maudsleyparents.org, NEDA, eatingwithyouranorexic.com, and others.

This is a teachable moment on a national scale. Go for it!

Couldn't resist this one, either

Check out this satire on all the "war on obesity" news of late. Hee hee.

Because I can't resist . . .

You won't be able to, either. It's a musical love letter from a young Brit to the "big girls," and it really rocks!

"Fitnessgrams" for kids

My 11-year-old daughter's report card came in the mail today. Along with the usual list of academic subjects and grades came another piece of paper with a big orange bar at the top. In blue blue letters it read FITNESSGRAM. Below was a graph of how my daughter had performed on a series of fitness tests, including a one-mile run, abdominal curl-ups, trunk lifts, push-ups, and flexibility. Then there was another little box labeled "Body Mass Index," showing her past and current BMIs plotted against a bar graph. Her scores were in the green "healthy fitness zone." To the right was a large red area--danger! fatsos coming!--labeled "Needs improvement." That's where your bar graph ends up if your BMI is "too high." To the left was a tiny red box labeled "very low," which is, I suppose, where your bar graph ends up if you're anorexic.

I guess this is supposed to be a cute, non-threatening way of communicating with parents, a kind of casual, unofficial, "Say, did you know your kid's in great shape?" or "Hey, by the way, your kid's kinda fat!"

This is insulting on any number of levels, of course, but let's just pick one: the suggestion that it's better to be too skinny than too fat, which as we know is not supported by any actual science.** Why isn't the "too skinny" area labeled something like "needs medical attention now!"? Why isn't the "too fat" area labeled "plenty of nutritional reserves!"?

My daughter was more upset about the fake activity pyramid on the back of the fitnessgram, modeled after that most famous of irrelevancies, the USDA food pyramid. At the bottom, the widest section was labeled "lifestyle activity," and it listed walking, biking, skateboarding, housework, yardwork, dancing, and playing active games. The next level held two smaller squares labeled aerobic activity and aerobic sports. One level up, another two squares were labeled muscular activity and flexibility activity. The smallest section, the point of the pyramid, was labeled "rest," and it included schoolwork, homework, reading, computer games, TV, videos, eating, resting, and sleeping.

Clearly these are the things you're supposed to do as little of as possible. My daughter was outraged. "I wonder what the teachers would think about this!" she cried. "You're not supposed to read?"

Imagine boot camp. Then imagine a sergeant from boot camp running the schools. "You there, cadet, stop wasting time with your nose in a book and give me 50 on the floor!" Never mind the fact that kids are supposed to be developing their intellectual capabilities at this (and every) age; in the new Fitness World, only activities that burn calories are sanctioned. Even by schools.

I feel like we're living in a Kurt Vonnegut story. And it's only gonna get worse.


** Calorie reduction (CR) nutcases notwithstanding.

Why dieting is the ultimate health risk

Big kudos to Sandy Szwarc, whose most recent post looks at how the American Heart Association's "heart-healthy" diet recommendations don't actually add up to better health or longer lives for women.

Eating healthy, in other words, doesn't protect you from heart disease. (We're talking about women who aren't sick; the statistics are different for those who already have heart disease.) And eating "not-healthy" doesn't put you at higher risk--at least, no studies have been able to show a cause and effect relationship.

In fact, all "eating healthy" (read: dieting) does, as we know, is make you fatter by messing up your metabolism with the deprivation-and-binge cycle. So dieting itself is a risk factor for obesity.

Obesity, it turns out, is a risk factor for diabetes, but not much else. Fat people actually do better after heart attacks than thin people. Older people who are fat live longer than their skinny peers.

Another thing dieting does is trigger eating disorders in those who are susceptible. Once more, dieting itself is a risk factor for anorexia, a serious illness that kills up to 20% of those who suffer from it.

Oh yeah, it does one more thing: Make money for the multi-billion-dollar weight loss industry, for the bariatric surgeons, and for the obesity researchers. Cui bono, baby?

So forget the war on obesity, which is as ill-conceived and well-funded as the war in Iraq. I think we need a war on dieting.

**This post is dedicated to the memory of my dear friend Marilyn "Mimi" Orner, who founded the Anti-Anorexia/Bulimia/Dieting Project. She was an advocate of size acceptance, a survivor of anorexia, and a powerful inspiration to a generation of young women. She died of ovarian cancer in 2000 but has not been forgotten. You still rock, Mimi!

How can you tell if your child is developing an eating disorder?

Go here to listen to my radio essay on the subject, which aired today on "To the Best of Our Knowledge." The essay aired as part of the show dated 6/17/07.

Fat--it's all in your head

At least according to this editorial in the American Journal of Psychiatry, exploring the question of whether to make obesity a brain disorder in DSM-V.

Of course, it's not really clear what exactly they mean by brain disorder. Anorexia and bulimia are listed in DSM-IV as brain disorders, sorta, and I have to say, I'm not sure what that means, either. Insurers still treat them as mental health issues rather than biologically based illnesses, and use that as a way to skive off covering them (at least in beknighted states like Wisconsin, which have no mental healthy parity laws).

It depends what the rationale is here, really. What we now know about eating disorders like anorexia is that some people are genetically and biologically predisposed to them, and that environment seems to play some kind of role in triggering those who are susceptible. Maybe that's true for obesity. That makes more sense to me than suggesting that all so-called obese people are compulsive eaters, which we know ain't true. Yo-yo dieting might be the environmental trigger, resetting the metabolism over time in ways that result in obesity.

But if an entry in DSM-V is going to result in more stigma attached to being obesity, I think we should say no thanks.

What do you think?

The obesity paradox

Thanks to fat fu for pointing me toward this article on the so-called obesity paradox. It reads like something straight out of Jonathan Swift. Or Lenny Bruce. You can just hear it, can't you?

Judge: You say that fat people live longer after heart attacks? Impossible.
D.A.: I know, your honor. Fat kills! Most of the time.
Judge: What's your evidence, counsel?
D.A.: Everybody knows it's bad to be fat!
Defense: Objection! "Everybody knows" is not admissible in court.
Judge: Overruled. In this case, no evidence is necessary. [rises from seat, points accusing finger at defense counsel] You're not eligible to serve as counsel in this case, Counsel, because . . . you're FAT!

And so on.

The real obesity paradox, of course, is our culture's blind and stubborn insistence on vilifying and demonizing fat people and fat, in the face of any and all evidence to the contrary.

Fat kills. Except when it doesn't.

Deaths from coronary artery disease in the U.S. went down by half between 1980 and 2000, and researchers at the University of Liverpool attribute this to positive lifestyle changes and better treatments.

Now for the bad news: Those same researchers go on to say, on no cited evidence, that the number of deaths would have been reduced even further had it not been for the rise in obesity and diabetes.

How do they know this? Well, they don't, actually. One researcher is quoted as saying, "The increase in obesity and diabetes are a wakeup call. They reflect the increasing consumption of large helpings of junk food."

Hmmm. So deaths from heart disease have decreased during the same time that rate of obesity have increased, yet obesity is still to blame. That's what I call having it both ways.

An epidemiologist could look at the same information and come to the opposite conclusion: That obesity has a protective effect when it comes to death from heart disease.

Seems like more of the same fat-is-evil ranting to me, liberally laced with assumptions and a heaping helping of bias. Mmm, mmm.

Another reason to look beyond weight and BMI

The New York Times reports the results of a study showing that young women who weigh enough to menstruate may still be eating too little to be healthy. Researchers at Ohio University found that bone formation, which is critical in adolescence, may not be taking place even if women get regular periods.

This is relevant because doctors so often use menstruation as a marker of health among those recovering from anorexia. But it's clearly not the criterion to live or die by.

Here's the money quote, to my mind: “Regular menstrual cycles do not reliably indicate that they are eating enough for what they’re expending,” Dr. Loucks said. Read more about it here.

Sandy Szwarc does it again

This morning I read the following sentence in Sandy Szwarc's most recent post in her Junkfood Science blog:

"Far more young people are dying from anorexia than . . . from being fat."

Tears sprang to my eyes. That is exactly right.

The emphasis on "overweight children and teens" clouds the issue for the public and for health professionals. So long as doctors and the rest of us are so terrified of being fat, and of having our children be fat, lethal eating disorders like anorexia and bulimia will be underdiagnosed, mistreated, and poorly researched.

Thank you, Sandy, for putting it so plainly.

Repeat after me: Fat is good

An interesting study crossed my desk this week, from a team of researchers in New York who posed the question, "Does percent body fat predict outcome in anorexia nervosa?"

They looked at a number of factors they thought might contribute to relapse in anorexia recovery, including BMI, leptin levels, waist-to-hip ratio, the subtype of anorexia, and percentage of body fat. Only one--body fat--seemed to affect the rate of relapse. "In recently weight-restored women with anorexia nervosa," they wrote, "lower percent body fat was associated with poor long-term outcome."

We're so used to thinking of fat as the Ultimate Evil, which must be banished at any cost, that news like this can feel downright shocking. Fat can be not just good but essential. Without it our brains don't work very well. We're supposed to have a certain amount of fat in our bodies.

This is important for those in recovery from anorexia, especially people (like my own daughter) who are naturally athletic and build a lot of muscle mass. Nothing wrong with muscles, but you've gotta have fat, too. Lean muscle mass without body fat is associated with relapse. And that's not what anybody wants.

So repeat after me: Fat is necessary for human life. Fat is not evil. Fat can even (dare I say it?) be a Very Good Thing.

Advocacy for what?

I've given a lot of thought to how those of us who have children with eating disorders can model our advocacy efforts after those of other groups. Parents of kids with autism, for instance, have been very effective in pushing for legislation covering treatments and other issues.

The thing is, most people aren't busy arguing about what causes autism in the first place, and they pretty much agree on treatments. Whereas folks in the e.d. world are divided in every possible way.

My friend Laura Collins says she'd like to lock all the e.d. experts in a room until they come to an agreement. Ha!

One of the biggest arguments, of course, is the biology-vs.-psychology one. Both parents and professionals have vested interests in taking one side or the other when it comes to both cause and treatment.

When I imagine trying to bring together a coalition of eating disorders parents and professionals to push for legislation and advocacy, I get a sense of how great the conflicts are. For instance, I don't think individual therapy is useful in treating anorexia, at least not during the active recovery phase, so I'm not sure I would want to push for legislation to cover lots and lots of individual therapy.

In case you couldn't tell, I'm of the biology camp, as in the Minnesota Starvation Study. I don't believe kids "think" their way into eating disorders, and I'm damn sure they don't think their way out of them.

I think what's needed most are more and better treatment studies, like the one Dan Le Grange is doing at University of Chicago. We need to know what the best treatments are for anorexia and bulimia.

What do you think we should be pushing for?

How cliches hurt us

What do the obesity epidemic, anorexia nation, and healthy eating all have in common?

They're all cliches, code phrases created by the media. And by "the media" I mean not only the Gray Lady and the Sly Network but small local newspapers, big national magazines, and--oh, yeah--those of us who write and blog about these subjects.

Each of these code phrases contains layers and levels of meaning that never get unpacked. They're like cue balls careening around a pool table, knocking all the other balls out of their way.

When you read the words "the obesity epidemic," you are, in essence, being told what to think and how to think it when it comes to the issue of overweight in America. The phrase itself shapes the way you think about it. If the language were different--if the issue was framed in another way--you might think about it differently.

And this is where I hold the media, and all of us, accountable for the superficial and slick way these deeply important subjects are framed and discarded. Each time yo say the words "the obesity epidemic," you're validating the notion that the nation is in the grip of a contagious pandemic of overweight. If that's what you truly think, you're all set. (I'd like to argue the point. But that's another post.)

But chances are it's not really what you think or what you mean to say. But each time you use that code phrase, you're buying in to someone else's conception of the dialogue. You're letting yourself be co-opted.

It's hard to unpack these code phrases. It's even harder to go against the mainstream, to question the conventional wisdom, to challenge the status quo. But more and more, I think it's crucial that we do exactly that. So next time you find one of these cliches or code phrases flying out of your mouth or tripping off your fingers, take a minute, or five, to consider what you really think. Then say it in your own words.

I'll start: I think the idea of an obesity epidemic is a sadly unimaginative construct that has little or nothing to do with reality. It's a cover for institutionalized prejudice against overweight people, a trigger for eating disorders, and a big waste of our collective time and energy.

Your turn.

There's a sucker born every minute

As P.T. Barnum is often (mistakenly) quoted as saying, There's a sucker born every minute.* And right now, those suckers are us.

At least, those of us who are rushing out to buy the newest FDA-approved diet pill, Alli.

Let's start with the fact that Alli doesn't actually work. Or rather, it doesn't work quite the way you think it might. Taken before meals, it prevents your body from absorbing the fat in food. But it has another mechanism that isn't being touted quite as enthusiastically. Think Antabuse for fat. If you eat fatty food while you're on this stuff, you are likely to have explosive and uncontrolled bowel movements that "smell like fish oil," according to one website I read. This site cautioned consumers to carry a package of baby wipes and an extra pair of pants while taking Alli. Presumably you need experience this only once before you're frightened out of eating fat. Or out of taking the pill.

Don't bother to take Vitamin E while you're on this stuff, either. Alli is likely to decrease your body's ability to absorb fat-soluble vitamins--E, A, D, and K, along with beta carotene.

As Sandy Szwarc points out in her May 25th blog on the subject, this little pill is getting a great big push from its U.S. distributors, GlaxoSmithKline, playing up the FDA's approval (what in the world were they thinking?) and betting that consumers will pony up two bucks a day for the privilege of taking this pseudomedication. And talk about disingenuous! If this article from the New York Times doesn't make you want to scream, your b.s. detector's not working.

How stupid do they think we are? As stupid as we are, apparently. Thin at any price--even wearing adult diapers or buying a whole new wardrobe of all-black pants? I don't think so.

*(If you can tell me who actually said that quote--no fair using Google to find out--I'll send you a free Mr. Wrong T-shirt.)

Thin at any cost

The most horrifying news story I’ve read this spring wasn’t about terrorism or war but about a hormone called leptin, known for its role in regulating appetite and metabolism. Since its discovery in 1994, leptin has become the holy grail of anti-obesity crusaders, a miraculous substance that could suppress appetite at the source: in the brain. In this society, anything’s better than being fat.

Leptin’s superhero status was enhanced last year when a study in the American Journal of Physiology showed that infant rats who were fed lots of leptin never got fat or developed diabetes, no matter how much fat they ate. The idea, explained one of the study’s researchers, was to change the way the body uses and stores energy. In utero and/or early exposure to leptin apparently makes the body metabolically inefficient—not just for a little while but for good.

This finding made leptin the A-bomb of the War on Fat, at least according to a group of researchers at the University of Buckingham. They’re developing a line of baby foods and formula laced with leptin. The goal: to make children thin for life.

Before you start cheering, remember fen-phen, the miracle drug that was supposed to make people thin? It damaged their hearts, and has inspired thousands of lawsuits, many still ongoing 10 years later.

Remember thalidomide?

Even if leptin-laced formula does what it’s supposed to, even if there are no immediate negative side effects, it’s still a worrisome proposition. The nifty little feedback loop we call metabolism serves us well. Human beings are designed to get hungry and eat. It’s a matter of survival.

Witness what happens when the link between appetite and behavior weakens or breaks. My husband and I watched our 14-year-old daughter nearly starve to death after developing anorexia. For two long years, she never felt hungry. She was hungry, of course; many of the behaviors associated with the illness—obsession with cooking, cutting food into tiny bites, pouring mustard on everything—proclaimed this appetite, despite the fact that she herself didn’t feel hunger pangs. But the connection between her brain and her body had been disrupted by the illness.

For my daughter, recovery from anorexia meant gaining quite a bit of weight. What if she’d been a leptin baby, her metabolism engineered to make weight gain difficult or impossible? No matter how many calories a day we fed her, she might not have survived. Some researchers believe that breakdowns in leptin regulation and processing might be part of what causes anorexia in the first place. Certainly an important step in my daughter’s recovery has been learning to recognize feelings of hunger and fullness again—feelings she would never have access to, if the Birmingham researchers have their way.

As a recent UCLA study showed, 98 percent of diets fail, causing a rebound effect that winds up making people fatter. Ditto the no-fat craze of the 1980s, which may well have something to do with the current rise in obesity.

No matter how well-intentioned, our attempts to micro-manage our metabolisms usually cause more harm than good. Better to teach kids to eat when they’re hungry and stop when they’re full, and to accept the fact that humans come in different shapes and sizes, than to mess up the next generation’s neurochemistry in the name of thinness.

More inspiration from autism advocacy

A reader sent me this link for an inspiring story about success from a group of parents with autistic children and their advocacy work.

What's it gonna take for those of us with children who are eating disordered? What would it take to force insurers to cover e.d. treatments at the same level they cover other biologically based illnesses?

Maybe we each need to pledge to do SOMETHING on the advocacy front when we're able.

Taking a lesson from autism

An article in my local paper got me thinking yesterday. If the autism parents can get their shit together to push for more comprehensive insurance coverage of their kids' illness, why can't we?

Jim Lock himself, one of the gurus of the Maudsley method here in the U.S., once told me that eating disorders parents should model ourselves on the autism parents. As a group they've dedicated themselves to not just supporting their children but to advocacy on all levels--especially, now, with regard to insurance coverage.

The article quotes an autism professional as saying "Most of the major autism organizations, both providers and support groups, have come together in agreement that insurance coverage for all individuals with autism is a positive and important need."

Same goes for anorexia and bulimia, as well we know.

Like anorexia, autism is often not covered, or covered poorly, because it's classified as an emotional disorder rather than a brain disorder. But I say, if your brain isn't considered part of your biological body, then what is it--a disembodied organ floating in space?

One of the autism advocates is quoted as saying "We're continuing to work together in the hope legislators take notice that the need is not going to go away and we're not going to go away."

Hey, what about us? What about those of us who have watched our children waste away or go through hell, only to be told that insurance doesn't cover therapy, or IP treatment or whatever the doctors are recommending at that moment?

What about people like Anna Westin, whose smart, articulate parents fought like hell to get her well, only to be turned down by insurance eventually? Anna committed suicide, and her parents took her experiences to the state insurance commissioner and to the courts and won not just money but also changed the way insurers in Minnesota cover anorexia.

We could do this, state by state. That's what it's going to take, probably, unless we can get the federal mental health parity bill passed.

I'm sick of "steps forward," though, and "making progress." We aren't making progress when it comes eating disorders. What will it take?

Good food, bad food

Sound familiar? I've often wondered where the good food/bad food dichtomy originates. Why is it that carrot sticks carry with them an aura of smug virtue, while chocolate cake bears the stigma of sin?

Of course I know the answer: It's all about the calories, stupid. But there's got to be attitude behind those calories. And there is. Turns out reseachers from Yale and elsewhere did a study several years ago (which I just came across) looking at the stigma associated with obesity. Get this: They quizzed obesity specialists--doctors, researchers, psychologists--and discovered that even people who have devoted their lives to the subject associate "blameworthy behvioral characteristics" with obesity.

These are folks who understand the genetic and environmental factors implicated in obesity. Who know that fat people aren't fat because they watch TV and eat bon-bons all day.

Geez, if you can't trust these people to understand, who can you trust?

This sense of judgment extends beyond food to any part of our lives that our related to fat and overweight. We fatties are told that we bring all kinds of bad things on ourselves, from diabetes to lower pay to heart disease.

If your heart were, I don't know, a sewage pump (which in some ways isn't such a bad comparison), and it got clogged, would you feel a sense of moral failure? Or would you just call the plumber to have the pipes cleaned out? So why the strong sense of self-blame and guilt over being fat?

Stigma equals shame. Shame equals a sense of moral dichotomy, good and bad. People with anorexia take this good/bad food thing to obsessive extremes. But I bet most of us do it on some level.

Pay attention to your feelings about the next plate of food you sit down to. See if it's true for you. Then practice moral blindness when it comes to food. Repeat after me: There is no such thing as bad food, only badly cooked, badly prepared, or bad-tasting food.

Bon appetit.

A Big Fat Bad Idea

I don't watch reality TV. Even if I did, I would not be tempted by this recent offering from TLC. The show reportedly follows a father-and-son team who perform bariatric surgery on "obese people who have opted to undergo weight-loss surgery in an attempt to regain their lives."

And here I thought obese people had lives, even without undergoing the risky-but-oh-so-profitable procedures performed by these butchers--I mean surgeons.

The producers would have you believe that this father and son are dedicated do-gooders out to make the lives of Fat People better by surgical mutilation, we know better.

We know, for instance, that nearly 40 percent of those who underwent such surgery last year had complications within 6 months, including vomiting, diarrhea, difficulty swallowing, reflux, abdominal hernia, leaking at the surgical site between stomach and intestine, and infections of one sort or another.

We know that 7 percent of those who had the surgery had to go back to the hospital within 6 months to treat complications of the surgery.

The producers of this incredibly offensive show describe the father and son as "passionate" people "who have dedicated their professional lives to raising awareness about obesity."

Raising awareness? Um, did we need our awareness raised on this issue? Do those of us whose BMI qualifies us as overweight or obese just not realize it? Is there anyone living in America--heck, in the world--who hasn't been inundated with anti-fat propaganda and prejudice?

Captain Kirk was wrong; fat is the final frontier. And this show is one big fat bad idea.