Put Health First, Not Weight Loss- Lessons From Body of Truth

Harriet Brown wrote an excellent Book, Body of Truth: How Science, History, and Culture Drive Our Obsession with Weight–and What We Can Do about It, in 2015, but I’ve only just read it now, when I found out about it in a comment from a fellow blogger. This is a very important book, in my opinion. The main takeaway I got from it is we have to stop being preoccupied about weight and instead focus on health. I’ll go over her ideas, which I find totally convincing, in this post, then go into detail about the evidence in a followup.

I personally very much dislike the notion of feeling superior to other people or “shaming” them, and certainly not because I think I’m closer to my “ideal body weight” than they are. But this is not just about being politically correct or “fat acceptance”. My overriding concern in this blog is healthy aging, both mental and physical. And I have an engineer’s mentality of wanting to solve problems the most effective way. Two of the most effective tools for healthy aging are being physically active (both through exercise and activities of daily living) and eating healthier (such as eating more fruits and vegetables and cutting back on junk food). As soon as you start using those tools you become healthier, regardless of your weight. Motivating yourself to do these things for good health is simply more effective than doing so because you want to lose weight. That’s not just my opinion, there is plenty of science to back it up, well-illustrated in Harriet’s book. Here’s how I summarize it:

1. If you focus on health you are more likely to do the right long term behaviors like being physically active and eating healthy food till pleasantly satisfied. If you focus on weight loss you’re more likely to go for short term quick fixes, like yoyo dieting, and if you do exercise, possibly doing it to excess
2. Focusing on weight loss is more likely to lead to eating disorders
3. There is evidence that being sedentary and overweight are both risk factors for disease. But sedentary is the stronger of the two. An overweight fit person is healthier than a normal weight sedentary person. Further, I haven’t seen studies to prove it, but I suspect any risk factor for being overweight will be reduced substantially by eating healthy.
4. The evidence for overweight being a risk factor is weaker than normally thought. In fact, it does not become a significant risk factor for mortality until you are very overweight (officially “grade 2 obese”).
5. A final reason I want to throw in, since we’re “healthy aging” specialists here, is that some extra weight can be protective for older adults, who are more at risk for frailty. This point was made forcefully by Dr. David Lipchutz, a noted geriatric specialist, in his book Breaking the Rules of Aging. In an entire chapter of his book, he goes so far as to say older adults should not even try to lose weight, it can do more harm than good. You might finally achieve your “ideal body shape” but have weaker bones.

Points 3 and 4 are likely to be more controversial but there’s plenty of evidence to back them up. Many experts in the health and nutrition fields do not like any message that might be interpreted as “it’s ok to be overweight”. As Harriett puts it, they think it means we will all “sit on the couch and eat bon-bons all day”. But that’s not the message. It’s be active, eat well, and you’ll be a lot healthier, regardless of your weight. Weight loss may gradually come with time as a result of there behaviors, but it should not be your main focus.

This was the missing piece of the puzzle in my own thinking. I already knew about the benefits of physical activity going way beyond weight loss. And I understood ideas like avoid junk so you can connect back up to your body’s internal wisdom on how much to eat till satisfied. But I did not get the overall message that the focus should not be on weight loss. I’d exercise and eat well for a week and then not lose weight and feel like a failure. Sound familiar?

Here’s an  example. Suppose you are five feet 4 (162 cm) and weigh 200 lbs (90.9 kg). That makes you officially “grade I obese” by current medical standards, and your weight would have to be below 145 lb (66 kg) to be considered “normal weight”. So you think you need to lose 55 lbs (25 kg) to be “normal”, or more than 25% of your body weight. That is a daunting challenge. How likely are you to be satisfied with “taking the long view” and just being satisfied with eating healthier and getting more activity? Aren’t you more likely to go a more extreme route, exercising like crazy and thinking “it doesn’t count” if you just go a walk, or trying more extreme short term diet options?

The same is true for people who have to lose 20 or 25 lbs. Despite the fact that the weight may be “middle aged spread” that accumulated gradually over many years, we suddenly want to lose it right now.

But lets go back to the person that thinks they need to lose 55 pounds. You might be thinking, yes but being obese is unhealthy and that person really needs to lose a significant amount of weight to be healthy. But as we’ll see below, actually the science does not show that. At 200 pounds, active, and eating better, that person has less health risks than someone that weighs 145 and is sedentary and eating poorly.

If you take your mindset off the and scale place it on health where it belongs, then at the end of a week you feel great about yourself because you went on several walks this week and maybe did a strength training session or two, you got up and moved around once in a while instead of sitting in a chair for long periods of time, and you had a side salad instead of fries a few times. If instead you focussed on the scale, you might instead feel discouraged at the end of the week because you didn’t lose any weight, even though you did all that good work. Emphasizing health keeps you on the process, which is under your control, rather than the outcome, weight, which is often much less under your control because of external factors.

But Harriet didn’t just talk about the science, the culture part is vital too. We have a cultural image of a rail thin supermodel as the ideal woman, and a buff basketball player as the ideal man. The male ideal is not as bad because it’s healthy, the female one is worse because it’s based on an overly thin ideal, who would be considered medically underweight (and supermodels use unhealthy tactics to look that way). That is changing some now that we also have athletic female role models. Trying to look like Serena Williams is a lot better goal than a supermodel. But even then, the average woman is going to have a heck of a time getting her body to look like Serena Williams, just like I’m not likely to get mine to look like LeBron James. Having these unrealistic ideals can make us dissatisfied with ourselves, and more likely to try extreme measures or develop eating disorders.

Harriet relates the poignant story of when her daughter developed anorexia. In a miracle of loving parenting, she prepared the kind of higher calorie foods their daughter needed to get well, and she and her husband ate them right along with her daughter to encourage her. Harriet already felt herself to be overweight and would normally recoil at eating like this, but could not in the slightest show that to her daughter, so for as long as it took she made the sacrifice of eating like that even though it caused her to gain weight. That’s what good Moms do.

But the sad part of the story was how others reacted. When her daughter was ill and overly thin, people on the street would compliment her on how beautiful she was. When she was recovering and gaining back to a healthier weight, the compliments stopped. That’s a really bad sign of a messed up societal norm.

I consider myself fortunate that my own problems with weight have been milder. My only body image problems were being a skinny runt when I was a kid (which was no fun at the time and yes I did get bullied), but I outgrew that. I have always enjoyed physical activity so weight-wise things were kept somewhat in check despite poor eating habits. The worst it ever got was when my weight crept up to 200 lbs (91 kg). To be normal weight for my height (6’0” or 183 cm), I should weigh less than 184. So only 16 lbs to lose from a medical standpoint, that’s not bad. But I wanted a flat belly like LeBron (actually my role model at the time would probably have been more Michael Jordan). I’ve never had that all my adult life, even when training for marathons. I’ve always been able to “pinch more than an inch”. So I wanted to get to 165. That’s a little more challenging. Fortunately I never “went on a diet”, the closest I came was to follow Weight Watchers, who to their credit do try to emphasize a long term way of eating. And they did teach the concept of “non-scale victories”, or remembering things you did right, so you could pat yourself on the back even if you didn’t lose weight. But when you show up once a week to get weighed at a meeting, it’s hard for it not to be about the scale. One week I worked out, hard, for 10 ½ hours, and stayed within my “points budget”, which should have caused a significant caloric deficit, and was disappointed when I only lost 2 ½ lbs. Sometimes a couple of days before weigh-ins I’d start to read up on tricks that athletes in weight classes like wrestlers used to “make weight”. I’m glad I never tried any extreme ones like laxatives or diurectics, but I was tempted.

On weigh day I’d schedule my hardest workout of the week. Once about 15 years ago, I worked out, hard, for almost 3 hours on a pretty hot day. I excitedly ran upstairs so I could weigh myself but fainted before I had a chance. I’ve kept a “training log” for close to 20 years. It shows how much I’ve been working out, has comments on my eating, and once a week shows my weight. When things aren’t going well I would periodically save the old log (as say “training log pre 09 01 12”) and start a new one so I can “restart” my effort. I can’t tell you how many times I’ve put a comment in the new log like “forget the crazy stuff, I’m going into long term mode and gradually lose the weight sensibly”. So far so good. But then I’d often write “but first! Lets do two weeks of lots of training to kickstart my weight loss!” and I’d be off on the wrong foot again. If my wife ever finds the folder on my computer where those old logs are stored she’d have the evidence to commit me, because as the saying goes “the definition of insanity is doing the same thing repeatedly and expecting a different result”.

It changed for me in 2017 when I got nudged by my doc to clean up my triglycerides and cholesterol. For the first time I focused on health, not weight, and didn’t worry that I wasn’t losing weight but focused on enough exercise to be healthy and eating better. I had my heart issue at the time, so could not exercise more than moderately. To keep myself from exercising too hard to “make weight” I had to weigh myself before exercising. It was like events conspired to force me to stop worrying about weight and focus on health. And my health, or at least my bloodwork, improved dramatically. Fortunately this had the byproduct of reducing my cravings dramatically so it was easy and enjoyable to keep eating healthy. I’m lucky enough to be able to maintain my weight in the “normal” range without focusing on weight. I still don’t have a flat belly, I think I’ll always have  a little paunch, but I’m ok with it now. So now I kind of knew the “focus on health, not weight” idea instinctively, but it didn’t crystallize in my mind until I read Harriett’s book.

For Harriett, things finally changed during a session with her therapist. After her daughter was ok she went back to the cycle of losing weight, gaining it back, and feeling badly about herself. Until her therapist looked her in the eye and said “What if you were ok with your current weight”? She thought the therapist was nuts and left the session feeling dissatisfied. But that planted the seed that caused her to do the mountain of research leading to the book. And now she, finally, after all these years, is ok with her weight, even though medically it’s considered above “normal” and her body shape does not match the ideal. Does that mean she “sits on the couch and eats bon-bons all day”?. No. She gets plenty of physical activity doing things she enjoys like walking and biking. She works on eating better. But the goal is health, not a number on the scale.

One thing she covers in detail is: suppose you’ve been dieting for years before finally just deciding to focus on health, not weight? You may find you may no longer know how to just eat, without tracking your calories or following some sort of diet plan. That was the case for Harriet. She recommends resources like Evelyn Tribole’s book Intuitive Eating to address this.

I would add a tip of my own at this point. This is where I think cutting back on overly processed rules (“no junk”) will help a lot. You want to wake up your body’s mechanism that senses when you’ve eaten the right amount. But it will have trouble doing that if you eat a lot of food that was intentionally designed by scientists at commercial food companies to be hyperpalatable, throwing your body’s inner wisdom out of whack, as described in detail in Michael Moss’s book Salt Sugar Fat: How the Food Giants Hooked Us. As I’ve said, I don’t believe in forbidden foods, but overly processed commercial packaged foods are good candidates for the “special treat” category.

Such foods, especially refined carbs, are what makes our metabolisms dysfunctional in the first place and drives cravings, as discussed previously. It’s a lot easier for intuitive eating to kick back in without these foods interfering.

The Science

Now I’m going to summarize some of the science behind the claim that you are better off being “grade I obese”  (sometimes called “mildly obese”), physically active, and eating healthy, than someone of “normal” weight who is less active and doesn’t eat as well. I’ll go into a lot more evidence soon in another post. The evidence will show that by far the most important risk factors for health conditions like type II diabetes and heart disease are not enough physical activity, and sitting too much (or not enough NEAT). Another important risk factor is poor eating. If you fix those problems, there may be an additional risk factor for being overweight but it’s much weaker. And it’s important to keep in mind you still may lose weight gradually by focusing on health. But it you focus on losing weight it’s likely to do more harm than good. Yoyo dieting can leave your metabolism in worse shape, where you need to eat even fewer calories to maintain your weight [1,2]. And the stress the constant battle, and the self-loathing when you are unsuccessful, is causing you can’t be good for your health.

1. It is better to be overweight and active than sedentary and normal weight. Dr. Steven Blair has spent much of his career proving this. He himself is an enthusiastic exerciser but cannot maintain normal weight. In his own words he is “short and fat”. I first read of Dr. Blair’s work in Gina Kolata’s book The Quest for Ultimate Fitness back in 2003. Many of his earlier studies are referenced in that book. Harriett discusses his more recent work in her book. Dr. Blair is former director of of the Cooper Institute, now a professor at University of South Carolina, and is considered a leading expert on fitness and health.
2. Dr. Katherine Flegal’s work shows that the risk for all-cause mortality from being overweight is much weaker than normally thought. In fact, it appears that the risk of all-cause mortality from being overweight does not go up until you reach a body mass index of greater than 35, which is considered “grade 2 obese” [3]. There is no increased risk for overweight or grade 1 obese. Using the example from above, If you are 5 ft 4 in, your bmi is considered “overweight” if you weigh more than about 145 lb, “grade I obese” if you weigh more than about 174, but your risk doesn’t go up until you actually weigh about 204 lbs. Dr. Flegal first showed this in 2005 and again in 2013 using a meta-analysis of the latest studies. The 2005 paper also showed an increased risk of mortality for being underweight (bmi less then 18.5). This paper created a firestorm of controversy, not because her analysis was proven incorrect (although there was some nit-picking over the details) but because of the concern this would send the “ok to sit on the couch and eat bon-bons” message. The reaction was made a lot worse, because while Dr. Flegal’s conclusions were modestly stated, the media latched on to this with exaggerated claims like “It’s healthy to be fat!”. The actual headline in the San Jose Mercury News, the major paper in my area, was “Surprise: Death Risk Less For Fat People”. And the New York Times ran an editorial about it saying “after decades of listening to emaciated ascetics lecture us about fitness and exercise, it’s tempting to return the favor. We could turn into activists ourselves and stand in picket lines outside gyms with signs proclaiming ‘Stairmaster = Death’ ” [4]. I must admit the NYT has some entertaining writers. But this all was an exaggeration of Dr. Flegal’s results. The important takeaway from her work is that there’s no significant increase in risk of death until you are more than mildly obese. This is for all-cause mortality, which is, after all, the bottom line.

We’ll go over other evidence in more detail soon. In the meantime, take Harriet Brown’s, Dr. Blair’s, and Dr Flegal’s word for it (and mine, for what it’s worth). Focus on a healthy lifestyle instead of weight, and find ways to enjoy moving more and eating healthier food. If you want to give this a try, I’ll be joining you in it. For the first time ever my training log will not keep track of weight, because I put my scale in mothballs. I’ll keep you posted how it goes for me.

References

1. Martin, C, et al, “Effect of calorie restriction on resting metabolic rate and spontaneous physical activity”, Obesity, 2007.
2. Kiortsis, D, et al, “Effects of a low-calorie diet on resting metabolic rate and serum tri-iodothyronine levels in obese children”, Eur J Pedr, 1999.
3. Flegal, K, et al, “Association of All-Cause Mortality With Overweight and Obesity Using Standard Body Mass Index Categories. A Systematic Review and Meta-analysis”, JAMA, 2013
4. Tierney, J, “Fat and Happy”, The New York Times, April 23, 2005.