Dispelling nutrition myths, ranting, and occasionally, raving


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A dietitian’s take on the new Canadian Adult Obesity Clinical Practice Guidelines

Here are my thoughts on the new Canadian Adult Obesity Clinical Practice Guidelines (written as I read each chapter):

Reducing Weight Bias in Obesity Management, Practice and Policy

I was really pleased that they put this chapter first and I really didn’t find anything to object to in it. I was especially pleased to see the recommendation that weight not be a target for behaviour change, both on a population and individual level, and that other indicators be selected for assessing the effectiveness of population health interventions.

Epidemiology of Adult Obesity

This chapter discusses the prevalence of obesity in Canada among different age groups and changes in obesity rates over the past ten years. A definition for obesity is also finally provided:

Obesity is a chronic disease characterized by the presence of excessive and/or dysfunctional adipose tissue that impairs health and wellbeing. Obesity is a complex disease in both its etiology and pathophysiology.12 In epidemiological research, obesity is often determined using the body mass index (BMI), calculated as weight in kilograms divided by height in metres squared (kg/m2).

One thing that bothers me about this framing is the assumption that obesity is a disease in and of itself. I also don’t feel that enough emphasis was placed on the fact that BMI is not intended to be used at an individual level. This despite the fact that nearly every doctor (and many other healthcare professionals) uses it as such. There is disappointingly no mention of the significant limitations to BMI; i.e. that it is not appropriate to use with populations other than white adult men up to about the age of 50.

Essentially, what I get from this chapter is that “obesity” is a major “problem” in Canada but there is no real accurate way to measure it. So, call me crazy, but perhaps if there’s no good way to measure it “obesity” in and of itself is not a true disease or health concern. Perhaps instead, we should be focusing on tangible issues.

The Science of Obesity

A little bit more about BMI at the start of this chapter: “BMI is a fairly reliable anthropometric measurement to stratify obesity-related health risks at the population level.” I think this statement is debatable given the significant limitations of BMI. I truly think that we need to just let go of BMI altogether. Just throw it away. BMI is like the partner who constantly mistreats and gaslights you but because you’ve been together for so long you don’t want to “waste” all that time and energy you invested in the relationship so you stay with them even though that’s only going to prolong your misery. Just dump it already. Just because you don’t have a better option lined-up doesn’t mean you should forge ahead with this complete dumpster fire.

Then there’s this: “The increased availability of processed, affordable and effectively marketed food, abundance of sugar-sweetened beverages, economic growth, behavioural changes and rapid urbanization in low- and middle-income countries are some of the key drivers that promote overconsumption of food.” Sorry, what? Didn’t we just establish that “obesity” is complicated? And yet here we are boiling it down to people eating too much “junk” food. Sigh.

The chapter then goes on to discuss the biology and physiology of “obesity”. Even though previously establishing that BMI is only appropriate at a population level, there is still use of it for individual classification. There is also mention of a percentage of individuals “with obesity” who are metabolically healthy. Another problem, in my mind, of assuming “obesity” is a disease in and of itself. Essentially, you have people who have no health concerns but are labelling them as diseased solely on the basis of the size of their bodies. Didn’t we just talk about the harm of stigma? How is it not stigmatizing to say someone has a disease just because their body is classified as a certain size (based on a flawed measurement)? Why can’t we just focus on known health concerns (such as heart disease) and leave “obesity” out of the discussion entirely.

The chapter concludes by saying that, “Obesity, or excess adiposity, is the result of an imbalance between energy consumption and energy expenditure by an individual.” Boiling the “complex” “disease” of “obesity” (sorry for all the quotation marks!) down to eating more calories than you burn off which is an oversimplification and just further encourages the belief that fat people simply need to get more exercise, which I hope was not the intended message of the authors but nevertheless is what’s implied.

Prevention and Harm Reduction of Obesity (Clinical Prevention)

Don’t be fooled by the title of this chapter. It is not about reducing the harm caused by healthcare professionals when treating “obesity”. It is about preventing “obesity” in patients. I found this statement particularly alarming: “pregnancy and the postnatal period may be particularly important periods for targeted primary weight gain prevention.” People’s bodies go through HUGE changes during pregnancy, and postpartum and it’s NORMAL for bodies to be permanently altered by the process. There is already enough stress and pressure on someone during pregnancy and as a new parent. We absolutely do not need to be adding to the pressure during that time by shaming people for gaining too much weight during a pregnancy or pushing them to lose weight rapidly after giving birth.

I’ve written about it before, but it bears mentioning again that we as a society (and especially as healthcare professionals) do people, especially women, a huge disservice by promoting the message that we should remain one weight throughout adulthood. It is actually normal and perfectly healthy to gain weight as we age, particularly during menopause, and this weight may actually be protective against illness in older adults.

One more thing that I am horrified by in this chapter is the suggestion of encouraging adolescents to self-weigh in an effort to prevent obesity. This is a recipe for creating eating disorders. We should not be pushing this narrative of measuring self-worth on a scale to youth. Rather we should be promoting self-confidence and encouraging them to embrace and respect differences in body shapes and sizes. Promote healthy choices to youth, not bathroom scales.

Enabling Participation in Activities of Daily Living for People Living with Obesity

This chapter is all about how doctors should provide advice to patients classified as having “obesity” on how to perform activities of daily living, cleaning skin folds, and avoiding falls. Which I find a little presumptuous and cringeworthy. I know that I would be offended if a doctor told me, unprompted, how to wash my own body.

The authors even state: “There are significant gaps in knowledge about what it is like to live with obesity in the context of participating in day to day activities including self-care, leisure and life roles.” Here’s a novel idea: how about we allow patients to state their concerns to their doctors and then let doctors provide solicited advice.

Assessment of People Living with Obesity

All the recommendations for healthcare providers in this section (save for one) are graded level D. I don’t know about others, but I am not comfortable moving forward with such low quality evidence.

I appreciate the author’s emphasis on avoiding stigmatizing patients. However, I question whether it is possible to do this when labelling individuals as having a disease on the basis of the size of their bodies. Also, I once again question the recommendation that healthcare providers assess BMI when it was earlier established that this is not an appropriate measure on an individual basis. Do we really want to continue to use a deeply flawed tool just because we don’t have something better? Perhaps we should focus on actual lab work and patient concerns rather than something we know is potentially harmful.

The Role of Mental Health in Obesity Management 

I do think that it’s vitally important to discuss mental health when we’re discussing “obesity”. However, I’m disappointed that this chapter implies that people classified as having “obesity” may have binge eating disorder. It is possible for people with larger bodies to suffer from anorexia and bulimia, and really all types of eating disorders. They are not the sole domain of people with smaller bodies and failure to recognize this increases the risk of harm. I would have also liked to see more connection between this chapter and the chapter on weight stigma. Many of the ill-effects of “obesity” may actually be attributable to weight stigma.

Medical Nutrition Therapy in Obesity Management

I don’t have much to say about this chapter. I might also just be getting tired of reading. I appreciate that the authors state that there is little evidence of calorie restricted diets being beneficial and mentioning that dietitians can provide support for patients.

Physical Activity in Obesity Management

I’m actually surprised that there is supposedly high quality evidence to support exercise for achieving “reductions in abdominal visceral fat” (Grade A!) and losing small amounts of weight and maintaining weight loss (Grade B). The vast majority of research that I’ve seen has shown that exercise is not effective at producing long-term weight loss in most people. Of course, the authors of this chapter also state that physical activity can be helpful in managing a number of health conditions and is beneficial even when not accompanied by weight loss. This is the messaging that I think is best. We should be focussing on being physically active for overall well-being. Otherwise people see it as “work” and a means to an end and it all too often is abandoned.

Weight Management over the Reproductive Years for Adult Women Living with Obesity 

I wasn’t going to bother with the remaining sections (and this is out of order) because they address management of “obesity” and I feel like it’s kind of pointless for me to pass judgement on them when I’ve already established that I don’t believe “obesity” is a disease to be treated. However, as a relatively new mom I couldn’t resist taking a peek at the chapter on reproductive years. And I had a bit of a wtf moment when I read the following: “Primary care providers should offer behaviour change interventions, including both nutrition and physical activity, to adult women with obesity who are considering a pregnancy (Level 3, Grade C),7,8 who are pregnant (Level 2a, Grade B)915 and who are postpartum (Level 1a, Grade A)16 in order to achieve weight targets.” I mean, given that we’ve already determined that these are ineffective means for achieving weight loss why would they be recommended for that purpose? Also, can we please stop obsessing over women’s weight?? Why isn’t there a chapter on managing men’s weight through the reproductive years? Fuck the patriarchy.

Obesity Management and Indigenous Peoples

As a white person, I am uncomfortable commenting on this chapter. I don’t know the backgrounds of the authors but I hope that they are Indigenous. I was pleased to see the recommendation that healthcare providers educate themselves about Indigenous cultures. Also, that they recognize that health inequities exist. However, I’m question why this particular population was singled out and the discussion about Indigenous Peoples being disempowered felt a little condescending. I don’t think that we, as healthcare providers (or humans in general) should be making assumptions about people. Perhaps it would have been better to put a discussion about systemic oppression up-front with weight bias as there are many people who have been harmed by our white patriarchal systems. Perhaps it would be better to listen to patients about their experiences and concerns rather than making assumptions not matter how well-intended.

Final thoughts (aka TL;DR):

I get that the authors have devoted careers to working on treating and preventing obesity so it must be incredibly difficult to let that go. But we need to stop and ask who it’s serving to pathologize obesity, and as well-meaning as it may be if it is not actually causing more harm than good. We need to stop talking about “obesity” altogether and start focussing our time and energy on creating healthy supportive environments and systems. Let’s get a national school food policy, let’s dismantle the patriarchy, let’s implement a universal basic income, let’s eliminate poverty, let’s teach food literacy in schools, let’s create walkable communities, let’s encourage work-life balance.


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What bothered me about Lizzo’s red bikini

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An article I kept seeing popping up in my Twitter feed over the past few days was titled “Lizzo rocks tiny red bikini while on vacation in Brazil” and was accompanied by a couple of photos of Lizzo on a beach wearing a red bikini. And while part of me was like, “good for her” and was pleasantly surprised to see a positive headline there was another part of me that felt really uncomfortable about the whole thing. I spent altogether too much time trying to figure out exactly what about it made me uncomfortable. No, it wasn’t that she was wearing a bikini, I wear a bikini when I go to the beach and I have no problem with other people wearing bikinis, I’m not a total prude.

My problem with it is, that I don’t think it’s cool for us to be publicly judging people’s bodies, regardless of their size, and regardless of whether or not that judgement is positive or negative. I hate seeing those magazines at the grocery store checkouts that are plastered with paparazzi shots of famous people on beaches and are either commenting on their cellulite or their hotness. Just because someone is famous that doesn’t mean their bodies belong to the public domain. It doesn’t mean that they’ve granted us permission to share photos of them during their personal time and pass judgement on them. And just because those judgements happen to be fat-positive it doesn’t make them any more acceptable. Yes, it’s great that Lizzo is confident and is a positive role model but that doesn’t make it okay for us to intrude on her personal vacation and it doesn’t make it okay for us to comment on her body. Frankly, other people’s bodies are none of our business.


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How pregnancy has made me confront my own weight bias

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Two months to go! Photo credit: Randall Andrews

I have a confession to make and I’ve gone back and forth about whether or not to write about it because I’m not proud of this. However, I’m taking a deep breath and going for it because I think that it’s important to acknowledge these things.

During the first trimester as I started to gain weight but wasn’t yet obviously pregnant I found myself struggling with the thought that people might think I was *gasp* fat. As someone who has always had a small body I have lived a life rich in thin privilege. Despite my support of HAES and firm belief that people should not be judged by their weight I realized that I wasn’t comfortable extending this mindset to my own body. My body is small, my body has always been small, and therefore, my body should remain small. It’s great for other people to accept their own larger bodies but I, I am ashamed to admit, am not willing to accept that my own body could be anything other than small.

When I would go running at the local indoor track, as my clothes became a little tighter around my belly, I imagined people thinking “good for her, trying to lose weight”. I also imagined people who knew me thinking “looks like she’s not running as much these days”. or passing other judgements on my physique. I was pissed at these people for judging my body. I wanted to wear a sign to tell the world that my imperceptible weight gain was due to the fetus growing inside of me, not because I’m incapable of taming my unruly body. And then I was ashamed and disappointed in myself for not extending the courtesy of body acceptance to my own body as it changed. I was also ashamed because this was how I envisioned others thinking about strangers bodies. Do people really pass these judgements on each other? On themselves? Why did I care what people were (or weren’t) thinking about my body? How have I allowed so much of my identity to be tied to my size? And how self-absorbed of me to presume that others are spending any time judging my body – given the number of people who expressed surprise upon learning I was pregnant when I thought it was pretty obvious people are not nearly as attuned to my body as I imagined. 

As my belly grew and it became more obvious that it contained a tiny human and not just one too many cheeseburgers I became physically less comfortable but mentally more comfortable. People started to compliment me on my “adorable bump”. It feels good to have an acceptable larger body but I’m still carrying that extra guilt around too. It’s not right that women in larger bodies should be shamed while I’m praised for my belly. I truly have no more control over the shape and size of my “bump” as this fetus grows inside me than I have over my height or the size of my feet. 

I truly believe that we do people, particularly women, a disservice by not talking more about how our bodies change over time. It’s as though we all expect to reach a certain size and then remain there permanently. This is not realistic. Our sizes and shapes changes over time for myriad reasons. This is part of being a human in possession of a body. Some people may remain a similar size and shape for decades while others will evolve by the season (winterspeck anyone?). This is all natural.

As I previously wrote, women don’t need to “get their bodies back” after pregnancy. Our bodies have not gone anywhere, they have simply adapted to meet current demands. My new philosophy (during pregnancy and postpartum): my body is going to be the size it wants and needs to be right now.


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A bit about that working mums make kids fat study

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This article: The Impact of Maternal Employment on Children’s Weight: Evidence from the UK came out a couple of weeks ago and I was appalled. Essentially, the article is blaming working mothers for making their children fat. As if working mums don’t have enough guilt dished out to them already. As if there’s a simple causal relationship between obesity and maternal employment. And as if there isn’t already enough unhelpful fat-shaming going on in our society. I was going to blog about it but a number of other people already have so why reinvent the wheel. Instead, check-out these pieces:

Working Mothers Don’t Make Children Obese by Gid M-K; Health Nerd on Medium explains why the reporting on this study was all wrong.

Aiming the Obesity Blame Game at Working Moms by Ted Kyle on ConscienHealth reminds us that correlation is not causation.

A TL;DR thread from Sean Harrison breaking down the many limitations of the study.

If you’ve come across any other great criticisms of the research (and media surrounding it) please share in the comments. I would especially love to see some from a weight-neutral perspective as the majority of the criticism has been around the study methods and sexism but I think that sizeism is a major problem with the research as well.

 

 


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What obesity and homosexuality have in common

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A couple of weeks ago I was listening to an episode of Radiolab on which they shared an episode of the short podcast series Unerased titled: Dr Davison and the Gay Cure. They were talking about the former perception of homosexuality as a disorder and the rise of conversion therapy. As I was listening what they were saying really struck a chord with me. I found myself thinking “this is exactly how people are going to think about weight loss counselling one day”.

On the podcast, they were saying, essentially, it doesn’t matter if people come to us wanting to change. What does it actually mean to help them? “The problem that these people are asking us to solve is a problem we created. That we labeled as a problem.” Even if we could effect certain changes, there is the more important question as to whether we should… It makes no difference how successful the treatment is, it is immoral.” And I was like “YES, this exact same thing could be said about weight loss treatment!”

This belief in relation to homosexuality was considered to be fringe and most people weren’t in support of it initially. This parallels the Health at Every Size/body diversity/weight acceptance movement. There is a lot of push-back from people in the medical community and the general public when it’s suggested that weight is not a condition that needs to be treated. Just as with the acceptance of homosexuality as a normal state, there were a few outspoken pioneers leading the movement and with time, it became more accepted by the mainstream. I feel that this is beginning to happen now with weight. More of us RDs who were always taught that “overweight” and “obesity” are unhealthy are coming to realize that people can be healthy at many different sizes.

Of course, there are still hold-outs and there is still conversion therapy happening in some places. Similarly, there will likely continue to be hold-outs who believe that only thin people can be healthy and that BMI is indicative of health. However, I’m hopeful that we’re reaching a turning point and that one day the medical community will agree that weight is not a “problem” and that weight loss treatments are unethical.