Last year, Stacey Martin, a 41-year-old realestate agent from East Hampton, New York,was diagnosed with type 2 diabetes. At 270pounds, the medical community consideredher “morbidly obese.”
Over the years, Martin has tried many times tobecome thin. And many times she has succeeded.About eight years ago, however, Martin decided itwasn’t worth it anymore, so she stopped dieting.
Upon diagnosis, she had an A1C of 13.9%. Herdoctor’s prescription: Lose weight!
Over the next few months, Martin startedexercising more and eating better. Her A1Cshowed progress—dropping to 7.9% and thento 5.8%.
However, her weight did not go down. When shereturned to her doctor a few months later, carryingfood logs and records proving the downward trendof her blood glucose, he was not pleased.
“The first thing he said was, ‘You obviously don’tcare about your health since you haven’t lost anyweight.’ I was so disheartened. I said, ‘That’s nottrue—I’ve been working very hard.’ He thenreplied, ‘You are obviously not working hardenough. Weight loss is the most important thing,and that should be your focus.’”
Martin’s experience is not unusual among type2s. About 80 percent of type 2s are consideredoverweight or obese, and weight is often thesource of blame for having type 2.
Is Weight Loss the Wrong Prescription?
Walter Willett, MD, of the Harvard School ofPublic 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 todeal with hyperglycemia is to reduce insulinresistance,” he says. “The most effective way to dothat 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 prescribedto—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 shouldsimply try to eat healthfully and become fit atwhatever size they happen to be. They base theirposition primarily on one simple fact: Dieting forweight loss does not work for the overwhelmingmajority of people who try it.
By most accounts, the failurerate of diets is somewherearound 90 to 95 percent, thoughthese numbers are constantlydebated. To the “Health at EverySize” faction, it is a disturbingphenomenon that the medicalindustry continues to prescribe apractice that has so little provensuccess.
“The enormous failure rate ofdiets does not seem to affect themedical industry in urging peopleto diet,” says Paul Campos, a law professor at theUniversity of Colorado, and author of “The ObesityMyth: Why America’s Obsession With Weight IsHazardous to Your Health.”
Campos, who is an outspoken supporter of the HAEScause, represents something of an extremist positionin the debate. He contends that obesity has not beenproven to be particularly unhealthy.
“The diet industry has just about the best scam in thehistory of the world going,”says Campos.
Like Campos, many others inthe HAES movement believethat not only is dietinggenerally unsuccessful, it isalso damaging to both mindand body.
“The medical communitydoesn’t see the fallout fromthe process of trying to attainweight loss—they are notthere,” says Deb Burgard,a clinical psychologist andeating disorder specialist inLos Altos, California.
Burgard, who uses the HAES approach in herpractice, says that aside from the overwhelming senseof failure of many dieters, they are often prone to having unhealthy relationships with food and withtheir bodies.
“Dieting makes you and your body enemies,” she says.
For people with diabetes, Burgard adds, this can be adangerous and painful situation.
“The last thing you want to do is to develop anadversarial relationship with your body. You want togo in the direction of loving and nurturing your body,feeling like you are partners and allies, letting yourbody tell you what it needs, and being able to respondto it. Dieting is the complete antithesis of that. It isall about your brain or an external authority figuredictating what and when you will eat. It is all abouttrying to ignore your body.”
William Polonsky, PhD, CDE, a clinical psychologistand certified diabetes educator at the University ofSan Diego, stands somewhere in the middle of thedebate.
“When people are told that they have diabetes, theyare usually told to go home and lose weight,” saysPolonsky. “For a small number of people, that isenough. For many people, we unnecessarily focus onweight loss.”
Polonsky adds that it is not a bad thing to encouragepeople to lose weight, butthat we shouldn’t make it thepriority in diabetes when thereare so many other things thattake precedence.
“Before weight loss comesnormalization of bloodsugar, blood lipids and bloodpressure,” he says. “There area lot of really good diabetesphysicians and specialiststhat say, ‘We don’t talk to ourpatients about weight loss.That is not our priority. Ourpriority is to get metabolicnumbers in line.’ ”
Polonsky says the way to dothat, of course, is throughhealthy eating and exercise.
‘It Is Better to Be Leaner’
To the more mainstream medical community, itis alarming that the HAES movement preachessomething that, they say, studies show is patentlyunhealthy to the public.
“No matter how physically active you are, it is better tobe leaner,” says Willett. “Every 10 years or so, someonecomes up with the idea that is it okay to be overweight.This is not true.”
Kelly Brownell, author of “Food Fight,” and director ofthe Yale Center for Eating and Weight Disorders, doesnot like the message HAES is sending.
“They are telling people to accept their weight and notworry about it—which is like telling people who havehypertension not to worry about it.”
Brownell points out that there is no evidence thatthe HAES approach works any better than the dietapproach.
“People who say that you just need to eat right andexercise have no data that that works better than tellingpeople to go and diet.”
Frank Hu, MD, PhD, of the Harvard School of PublicHealth recently told CNN that it is “very misleading”to suggest that if you are particularly active, you don’thave to worry about your body weight and diet.
Little Individuals Can Do to Lose Weight
To many in the HAES movement, the good or badhealth effects of being overweight are beside the point.They suggest that outside of bariatic surgery—whichhas unknown long-term consequences—there is verylittle an individual can do to lose weight.
“You can quite successfully address people’s health riskswithout necessarily making them lighter,” Campossays. “This is very good news, actually, because wedon’t know how to turn obese people into nonobesepeople.”
HAES advocates are not against weight loss as a byproductof healthful living, but they do not think it isnecessary for health.
Not Enough Long-Term Weight-LossSuccess Stories
“The cornerstone of treatment for diabetes is weightloss, but we don’t really know if it is even particularlybeneficial, because we don’t have any controlledtrials of long-term successful weight loss,” says PaulErnsberger, a professor at the Case Western School ofMedicine and a nutrition researcher.
Lack of evidence for the benefits of long-term weightloss 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 weightlosssuccesses to study.
Ernsberger adds that most of the studies showing thehealth benefits of weight loss for type 2s involve notsimply weight loss but overall lifestyle changes, suchas exercise and more healthful eating. It is possible,he says, that the benefits attributed to weight losscould come from the lifestylechanges rather than theweight loss itself.
“The problem, when it comesto studying diabetes, is thateven skipping a meal willresult in lower blood sugars,”he says. “Does that mean thatskipping meals is a cure for diabetes? I don’t think so. Ifpeople alternate between going hungry and bingeing—as most dieters do—that’s not healthy.”
Many in the HAES camp take the anti-dietingargument to an even deeper level, saying that “weightcycling” or “yo-yo” dieting is actually worse than simplystaying fat. “There are no studies that show a beneficialcorrelation between weight cycling and health,” Campossays. “The ‘do no harm’ motto would not recommenda strategy that is certainly not helpful and may beharmful.”
Willett admits that there is little evidence thatweight loss in people with type 2 lessens the risk ofcomplications.
Giving Type 2s the Benefit of the Doubt
So, should the medical community simply agree that notwo cases of type 2 are alike? In addition, are blanketprescriptions for type 2s wrong and should they beabandoned—particularly when it comes to an issue asemotionally charged and medically complex as diabetesmanagement and weight loss?
“Some obesity researchers seem to think ignoranceis the cause of obesity, and it isn’t,” Ernsberger says.“[Diabetics] don’t want another lecture. They don’t wantto be patronized.”
Ensberger adds that obese people and diabetics know alot about nutrition—more than the average person.
“They have read all of the books and articles,” he says.
Polonsky says that healthcare professionals shouldpresume that patients are well motivated and want tolive a long, healthy life.
“We must find ways to support our patients in makingchanges to improve their health and lives,” saysPolonsky. “We also have to recognize that making andmaintaining health and behavior changes is really hard.Not impossible, but very hard.”
Does DietingMake You Obese?
“Dieting may contribute toobesity,” says Glenn Gaesser, professor anddirector of the Kinesiology Program at theUniversity of Virginia, and author of “Big Fat Lies:The Truth About Your Weight and Your Life.”
Gaesser says that a history of dieting is asignificant predictor of subsequent future weightgain in both children and adults.
‘A blanket prescription for heavy peopleto lose weight runs the risk of doing harmto people and may be violatingthe Hippocratic oath. I am waiting forsomeone to sue their doctorfor telling them to diet.’— Glenn Gaesser
‘I focus on things I can dosomething about.’
Is being told to eat healthfully and exercise for health thesame as being told to eat right and exercise for weight loss?
Not for Stacey Martin.
She keeps her blood glucose under tight control, swims threetimes a week and works out on a treadmill and with weightstwice 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 herdiagnosis.
“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 thingsthat I can do something about—such as my blood glucoseand exercising.”
Martin, who believes in the HAES paradigm, admits thatemotionally, accepting her size remains a challenge, but sheremains committed to improving her health.
“I think I am in pretty good health. My triglycerides are in thenormal range, my blood glucose readings are good—thoughthey could be a little better. My blood pressure is normal.”