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Over the years, Martin has tried many times to become thin. And many times she has succeeded. About eight years ago, however, Martin decided it wasn’t worth it anymore, so she stopped dieting.
Upon diagnosis, she had an A1C of 13.9%. Her doctor’s prescription: Lose weight!
Over the next few months, Martin started exercising more and eating better. Her A1C showed progress—dropping to 7.9% and then to 5.8%.
However, her weight did not go down. When she returned to her doctor a few months later, carrying food logs and records proving the downward trend of her blood glucose, he was not pleased.
“The first thing he said was, ‘You obviously don’t care about your health since you haven’t lost any weight.’ I was so disheartened. I said, ‘That’s not true—I’ve been working very hard.’ He then replied, ‘You are obviously not working hard enough. Weight loss is the most important thing, and that should be your focus.’”
Martin’s experience is not unusual among type 2s. About 80 percent of type 2s are considered overweight or obese, and weight is often the source of blame for having type 2.
Is Weight Loss the Wrong Prescription?
Walter Willett, MD, of the Harvard School of Public Health, says that upon diagnosis for type 2, weight loss should be pursued.
“Where the primary problem is insulin resistance, the most natural and physiological way to deal with hyperglycemia is to reduce insulin resistance,” he says. “The most effective way to do that is through losing weight.”
There are a growing group of researchers, clinicians, activists and medical doctors, however, who say that weight loss should not be prescribed to—or pursued by—people with diabetes.
Or anyone else, for that matter.
This group, which calls itself “Health at Every Size” (HAES), believes that people who are fat should simply try to eat healthfully and become fit at whatever size they happen to be. They base their position primarily on one simple fact: Dieting for weight loss does not work for the overwhelming majority of people who try it.
By most accounts, the failure rate of diets is somewhere around 90 to 95 percent, though these numbers are constantly debated. To the “Health at Every Size” faction, it is a disturbing phenomenon that the medical industry continues to prescribe a practice that has so little proven success.
“The enormous failure rate of diets does not seem to affect the medical industry in urging people to diet,” says Paul Campos, a law professor at the University of Colorado, and author of “The Obesity Myth: Why America’s Obsession With Weight Is Hazardous to Your Health.”
Campos, who is an outspoken supporter of the HAES cause, represents something of an extremist position in the debate. He contends that obesity has not been proven to be particularly unhealthy.
“The diet industry has just about the best scam in the history of the world going,”says Campos.
Like Campos, many others in the HAES movement believe that not only is dieting generally unsuccessful, it is also damaging to both mind and body.
“The medical community doesn’t see the fallout from the process of trying to attain weight loss—they are not there,” says Deb Burgard, a clinical psychologist and eating disorder specialist in Los Altos, California.
Burgard, who uses the HAES approach in her practice, says that aside from the overwhelming sense of failure of many dieters, they are often prone to having unhealthy relationships with food and with their bodies.
“Dieting makes you and your body enemies,” she says.
For people with diabetes, Burgard adds, this can be a dangerous and painful situation.
“The last thing you want to do is to develop an adversarial relationship with your body. You want to go in the direction of loving and nurturing your body, feeling like you are partners and allies, letting your body tell you what it needs, and being able to respond to it. Dieting is the complete antithesis of that. It is all about your brain or an external authority figure dictating what and when you will eat. It is all about trying to ignore your body.”
William Polonsky, PhD, CDE, a clinical psychologist and certified diabetes educator at the University of San Diego, stands somewhere in the middle of the debate.
“When people are told that they have diabetes, they are usually told to go home and lose weight,” says Polonsky. “For a small number of people, that is enough. For many people, we unnecessarily focus on weight loss.”
Polonsky adds that it is not a bad thing to encourage people to lose weight, but that we shouldn’t make it the priority in diabetes when there are so many other things that take precedence.
“Before weight loss comes normalization of blood sugar, blood lipids and blood pressure,” he says. “There are a lot of really good diabetes physicians and specialists that say, ‘We don’t talk to our patients about weight loss. That is not our priority. Our priority is to get metabolic numbers in line.’ ”
Polonsky says the way to do that, of course, is through healthy eating and exercise.
‘It Is Better to Be Leaner’
To the more mainstream medical community, it is alarming that the HAES movement preaches something that, they say, studies show is patently unhealthy to the public.
“No matter how physically active you are, it is better to be leaner,” says Willett. “Every 10 years or so, someone comes up with the idea that is it okay to be overweight. This is not true.”
Kelly Brownell, author of “Food Fight,” and director of the Yale Center for Eating and Weight Disorders, does not like the message HAES is sending.
“They are telling people to accept their weight and not worry about it—which is like telling people who have hypertension not to worry about it.”
Brownell points out that there is no evidence that the HAES approach works any better than the diet approach.
“People who say that you just need to eat right and exercise have no data that that works better than telling people to go and diet.”
Frank Hu, MD, PhD, of the Harvard School of Public Health recently told CNN that it is “very misleading” to suggest that if you are particularly active, you don’t have to worry about your body weight and diet.
Little Individuals Can Do to Lose Weight
To many in the HAES movement, the good or bad health effects of being overweight are beside the point. They suggest that outside of bariatic surgery—which has unknown long-term consequences—there is very little an individual can do to lose weight.
“You can quite successfully address people’s health risks without necessarily making them lighter,” Campos says. “This is very good news, actually, because we don’t know how to turn obese people into nonobese people.”
HAES advocates are not against weight loss as a byproduct of healthful living, but they do not think it is necessary for health.
Not Enough Long-Term Weight-Loss Success Stories
“The cornerstone of treatment for diabetes is weight loss, but we don’t really know if it is even particularly beneficial, because we don’t have any controlled trials of long-term successful weight loss,” says Paul Ernsberger, a professor at the Case Western School of Medicine and a nutrition researcher.
Lack of evidence for the benefits of long-term weight loss on health is not a failure on the part of scientists, Ernsberger says, but of dieting itself.
There simply have not been enough long-term weightloss successes to study.
Ernsberger adds that most of the studies showing the health benefits of weight loss for type 2s involve not simply weight loss but overall lifestyle changes, such as exercise and more healthful eating. It is possible, he says, that the benefits attributed to weight loss could come from the lifestyle changes rather than the weight loss itself.
“The problem, when it comes to studying diabetes, is that even skipping a meal will result in lower blood sugars,” he says. “Does that mean that skipping meals is a cure for diabetes? I don’t think so. If people alternate between going hungry and bingeing— as most dieters do—that’s not healthy.”
Many in the HAES camp take the anti-dieting argument to an even deeper level, saying that “weight cycling” or “yo-yo” dieting is actually worse than simply staying fat. “There are no studies that show a beneficial correlation between weight cycling and health,” Campos says. “The ‘do no harm’ motto would not recommend a strategy that is certainly not helpful and may be harmful.”
Willett admits that there is little evidence that weight loss in people with type 2 lessens the risk of complications.
Giving Type 2s the Benefit of the Doubt
So, should the medical community simply agree that no two cases of type 2 are alike? In addition, are blanket prescriptions for type 2s wrong and should they be abandoned—particularly when it comes to an issue as emotionally charged and medically complex as diabetes management and weight loss?
“Some obesity researchers seem to think ignorance is the cause of obesity, and it isn’t,” Ernsberger says. “[Diabetics] don’t want another lecture. They don’t want to be patronized.”
Ensberger adds that obese people and diabetics know a lot about nutrition—more than the average person.
“They have read all of the books and articles,” he says.
Polonsky says that healthcare professionals should presume that patients are well motivated and want to live a long, healthy life.
“We must find ways to support our patients in making changes to improve their health and lives,” says Polonsky. “We also have to recognize that making and maintaining health and behavior changes is really hard. Not impossible, but very hard.”
Does Dieting Make You Obese?
“Dieting may contribute to obesity,” says Glenn Gaesser, professor and director of the Kinesiology Program at the University of Virginia, and author of “Big Fat Lies: The Truth About Your Weight and Your Life.”
Gaesser says that a history of dieting is a significant predictor of subsequent future weight gain in both children and adults.
‘A blanket prescription for heavy people to lose weight runs the risk of doing harm to people and may be violating the Hippocratic oath. I am waiting for someone to sue their doctor for telling them to diet.’ — Glenn Gaesser
‘I focus on things I can do something about.’
Is being told to eat healthfully and exercise for health the same as being told to eat right and exercise for weight loss?
Not for Stacey Martin.
She keeps her blood glucose under tight control, swims three times a week and works out on a treadmill and with weights twice a week.
“I cut out most refined carbs and focus on healthful things— lean meats and fish and food like that.”
However, Martin has continued to gain weight since her diagnosis.
“If I focused on weight loss, I certainly would be disappointed, because I haven’t been able to lose any. And I might think, why bother with the other things? Instead, I focus on things that I can do something about—such as my blood glucose and exercising.”
Martin, who believes in the HAES paradigm, admits that emotionally, accepting her size remains a challenge, but she remains committed to improving her health.
“I think I am in pretty good health. My triglycerides are in the normal range, my blood glucose readings are good—though they could be a little better. My blood pressure is normal.”
Mar 1, 2005