Why Weight Loss Methods DON’T Help Deal with Self Loathing

Tom Rifai, MD, FACP
We have a weight problem in the USA. But it’s not the type of which you may be thinking at first thought. Please allow me to explain why de-emphasizing (while not ignoring) the scale is the best way to achieve metabolic health – including, but not limited to – weight management success.
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I’ve been blessed to have over 20,000 hours of clinical experience in multidisciplinary intensive lifestyle intervention program leadership and design in some of the nation’s top institutions, working with amazing patients. My Bachelor of Science major was in psychology and I’m a recovering binge eater who at barely 5’7” tipped the scale at over 200 lbs by 19 years of age. I hit my record high notably after bingeing 40 lbs onto my 162-lb bodybuilding competition-torn body in just one month back in 1989.

That summer I remember feeling like I was going to die of heart failure from the combination of massive salt and processed calorie intake. And in 2007 I actually did almost die after a night binge on pizza (2 large with ham) so severe that I vomited a large volume while sleeping on my stuffed belly.

I woke up to what seemed a nightmare, unable to breathe and realizing quickly that I was self-asphyxiating, alone in an apartment and unable to dislodge the vomitus in my airway. That was until, right at the brink of losing consciousness, I jolted backwards rapidly slamming my back into a wall to try and dislodge enough cheese, ham, refined flour and tomato sauce to gasp my way back from the precipice. It was a harrowing teeter to the threshold between this and the afterlife. Afterwards, the shame was immense, until I finally opened up and went public about my binge eating disorder in 2017.

Binge Eating Leads to Tragic Death

My youngest brother Basil never got over the shame about his bingeing nor what was at one point his 380 lb beautiful body and soul. Even with a weight loss surgery (sleeve gastrectomy), he only felt a temporary, surgically derived “bandaid” of relief, lacking being able to cut to the core issues (what I call our Mind Matters).

Basil is no longer with us. On one January 2017 early morning after bingeing on pizza – just like me in a sad romantic irony – he severely vomited while sleeping. He clearly struggled for air based on how we found his body. But he did not stop at death’s threshold. I miss him dearly and daily. May God rest his soul.

Scale Weight, BMI, and Human Self-Valuation

With that blend of personal and professional background, you can imagine I have a keen sensitivity to anything that might even unintentionally lead to a human valuing themselves whatsoever based on their scale weight or any of its derivatives, like BMI (body mass index).

BMI is a “fancy” sounding weight assessment tool best applied to large population (especially phone-call based) surveys where all that can be practically asked of and collected from a participant is their height and weight. BMI is not intimately correlated with body composition, a much more accurate assessment for metabolic health risk. Particularly over short periods of time (and considering many people are “obsessed” with “quick weight loss”), weight and BMI have only a fairly crude relationship to calorie intake versus short-term sodium or carbohydrate intake or even retention of fecal matter, for that matter.

Now please, don’t get me wrong. I am a practitioner of science. I know better than most what health risks are associated with metabolic obesity (by “Metabolic Obesity” I mean to reinforce that better methods exist for body composition – aka “weight” – assessment like DEXA body composition analysis, among others). And while we could dive deeper into what better ways there are to assess “weight,” particularly body composition analysis, the point I wish to make here is different.

What We Don’t See: Serious Metabolic Risks versus ‘The Scale’

My point here is the fact is that serious metabolic risks associated with our high-risk Western lifestyles are often not seen on the scale or visibly. In fact, the vast (and I mean vast – see below) majority of the “thin” also have issues related to suboptimal cardiometabolic health. But “weight” is what we “see” in our public eye.

We are obsessed with body shapes and sizes. I’m not criticizing that necessarily. It’s a human tendency we have to contend with. But how we value varieties of body shapes and sizes and so often ascribe a human value to them is not only disheartening. It may be sabotaging our odds of successfully managing the “obesity epidemic.”

It’s an irony that may be lost on those who’ve not seen what I have. But to be sure, there’s definitely a general growing acknowledgment that focusing on psychology and healthy behaviors while leaving the healthy ramifications (i.e., “side effects“) of such happen as a consequence is better than focusing on superficial (in terms of human spirit) component manifestations of behaviors (e.g., blood sugar, blood pressure, cholesterol, fatty liver and weight, for instance, among others).

Let’s please consider this: We don’t “see:” hypertension (appropriately and often referred to as “the silent killer”). We don’t “see” most dyslipidemia (sure, there are occasionally clinical signs with a trained eye of dyslipidemia, but the main point is defensible). We don’t “see” most insulin resistance (with fairly rare exception, like dyslipidemia).

And it’s worthy to note here that often clinicians may feel they do “see insulin resistance ” (or, more accurately, assume it) in patients defined as overweight or obese by BMI when it doesn’t exist, or at the least is far milder in some individuals with the same BMI as others due to individual variations (sometimes termed ’metabolically healthy obesity’ in which risk of high grade obesity does exist, but is notably delayed and lesser risk than others at same BMI).

So it is clear that not everyone at any particular level of obesity-defined BMI has notable insulin resistance. But here and in so many other areas of health, our tendency to judge a book by its cover is strong. And as you will see, this judgment notably goes both ways vis à vis people who are “thin” being often assumed to be healthier than a sober analysis of good data would reveal.

Even if we were to combine everyone in the US who has BMI of 25 or higher (so-called overweight, until a BMI of 30 which is the beginning threshold of BMI defined “obesity”), we will still only have approximately 70% of the population accounted for.

Reality Check: Why Weight Loss Methods DON’T Help Deal with Self Loathing

I hope I’ve had your attention this far because this is where I will give you this article’s “reveal:”  I said “only 70% are overweight or obese” above because, among other population assessments, a recent analysis of 14,000 Americans found only one in 2000 met all 7 of American Heart Association’s “Life‘s Simple Seven for a Healthy Heart“ (see list below). No, that was not a typographical error. I didn’t say one in 20, not even one in 200. I said one in 2000!

  1. don’t smoke
  2. maintain a healthy weight
  3. engage in regular physical activity
  4. eat a healthy diet
  5. manage blood pressure
  6. take charge of cholesterol
  7. keep blood sugar, or glucose, at healthy levels

What does that mean? It means that there’s virtually no American who couldn’t benefit from improving their lifestyles and metabolic health status irrespective of weight. Based on that alone we can easily argue that we should stop looking through only one “window” (ie obesity) of our national “metabolic house” (including suboptimal disease risk in almost everyone who is of “normal weight” as well), which is on fire.

Being judgmental of someone’s weight without taking all of this into account (and I would say even if you did), or even unintentionally seeming to be, promotes stigmatization, shame and therein only worsens the quality of life for those of excess weight without any known benefit from the shame. It is ironic that smoking is still leading, or at least virtually tied with, severe obesity as the leading cause(s) of preventable death. Yet we do not term chronic smokers as “morbid” (e.g., the antiquated and outdated, but still commonly used term, “morbid obesity”). Why do we do so with people suffering from high grade obesity? In fact, several years ago a plea was written in the opinion section of the Mayo Clinic Journal Proceedings to retire the term “morbid obesity” precisely because of such frank and obvious judgment intertwined in the term.

So I offer you this plea: whatever your or my weight, please remember almost all of us probably have a behavior, habit or lifestyle issue we could improve upon (unless you’re the 1 in 2000). Acting as a national, compassionate – though respectfully honest – family by shifting our main focus to therapeutic behaviors will offer many benefits. It will, as a “side effect”, help address all of the following: elevated insulin and blood sugar, blood pressure, cholesterol, and weight as well as a slew of other “metabolic health windows” (eg fatty liver, obstructive sleep apnea), through which we can look into our “metabolic house.” In so doing, I believe we will get our “health house in order” more effectively, compassionately and as a non-judgmental, unified family.

And what could it hurt? We would at least stop hurting feelings as the approaches we have been taking certainly haven’t been effective so far. Please then, won’t you consider my plea?

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