Elemental: Soon after you turned your focus to obesity and bariatric medicine, you began amassing an extensive collection of historical weight-loss memorabilia, including books and gadgets. Did you learn anything from it?
Yoni Freedhoff: As a species, we want very simple solutions to very complex problems. We want magic diets. We want to deify foods and demonize foods because it’s a lot easier if all you have to do is avoid this food or food group, and eat that food and that food group and suddenly all your medical woes and weight melts away.
The appetite for this idea — that there is an easy quick solution — is what fuels the modern-day diet industry, and the zeitgeist around what’s involved. In turn, the thesis of my book is that the commonality among all these different diets failing is that we have been taught to look to suffering as a solution.
We’re talking about one of life’s most seminal pleasures: food. It is the world’s oldest social network. There is nothing, there is no event — no matter how small — that doesn’t revolve around it. And yet we’ve created this Willy Wonka food environment where you have to go out of your way to make healthy choices. Unhealthy choices, they’re the ones that are in front of us constantly.
I gave a talk yesterday for an employee benefits organization. As I do many times, I took a picture of the food at the conference to put into my slide deck. At 9:30 in the morning, they were being offered Cinnabons and soda pop. We’ve got this world that pushes junk food on us constantly.
“The research would support the notion that you can lose weight on any diet, and you can also gain weight on any diet. Physicians who are stuck in the “one right way” world need to get over themselves.”
So we’re getting very mixed messages then.
We’ve got a world that is full of indulgence and temptation, and the message is that success involves denying yourself all those things that are constantly being offered to you. No wonder we don’t succeed long-term. There is no “eat as much as you want, whatever you want” weight-loss program. Obviously, there’s going to be compromise and effort involved. The idea that people will be able, in this food environment, to say no forevermore is flawed yet commonplace.
I don’t think that anybody can claim that [their position] is absolutely and universally right. In weight management, there is no gold standard. But I do think that it’s fair to say that most people will not suffer in perpetuity with food, but that different people perceive different diets as suffering. Some person’s horrible, God awful, just-until-I-get-into-my-clothes diet is somebody else’s happy healthy lifestyle.
You can see the appeal of one-size-fits-all solutions to weight-loss.
I wish I had them. I’d share them.
As the saying goes, if something seems too good to be true, it usually is. Are experts that peddle a single, universal fix being predatory?
Without hesitation, yes. From physicians specifically. We are taught that there are multiple treatments for most problems, right? I think about blood pressure, and there are literally dozens of drugs that I could choose from. Some people don’t respond as expected to particular drugs. Some people don’t tolerate particular drugs, and then they try other drugs. We don’t get caught up in the fact that our favorite drug didn’t work for that patient. We just offer them the next one.
The research on weight loss would suggest there is no one diet that is best for everyone. The research would also support the notion that you can lose lots of weight on any diet, and you can also gain weight on any diet. Physicians who are stuck in the “one right way” world need to get over themselves. I do wonder in some cases whether it’s predatory and financial. Doctors should know better.
In title and style — though not substance — your book, “The Diet Fix — Why Diets Fail and How to Make Yours Work,” resembles predatory diet books. Was a conscious approach to reach the people desperate for a diet miracle?
I will tell you, the title that I had chosen for the book was not The Diet Fix. Had I been given my choice, it would have been A Prescription for Chocolate, The End of Traumatic Dieting. It would have been positioned and marketed more as a thinking book than a diet book per se. But you’re right. My book is marketed and packaged to appeal to that same group of people who’ve been choosing other diet books. I don’t think that’s a bad thing.
There’s a term you use a lot: traumatic dieting. You also describe something called “post-traumatic dieting disorder.” People define trauma differently, but does dieting rise to the level?
It does. I meet people where, not only are they disappointed with their lack of success with dieting, but the impact of their lack of success is far more [intense] than simple disappointment. They are deeply traumatized by the experience, especially when they repeat the cycle over time.
The term post-traumatic dieting disorder alludes to the fact that there is real trauma. This is a real condition, but not a DSM-5 [the American Psychiatric Association’s diagnostic manual] recognized condition. It’s when the impact of people’s lack of success with weight management leads to sometimes quite extreme emotional dysregulation, depression, social isolation, thoughts of loss of self-efficacy, loss of self-worth, loss of self-esteem. For some people, it can have incredibly negative effects, especially people who undertake approaches that lead to large, rapid losses that are regained. The loss is dramatic and the regain is dramatic. Mentally that is really challenging.
Now, it’s not something that everybody has. There are plenty of people who don’t succeed in maintaining weight loss and don’t lose much sleep over it, but it really is this constellation of failure, shame, hopelessness, insecurity, and depression that accompanies people’s lack of success with weight loss — and can impact their lifestyles, their marriages, their health, their personalities. I think it is what fuels, to some degree, these recurrent diets. The person who’s suffering this much emotionally from regain might be more likely to want to take on another magical approach, or another extreme approach, because they are blaming themselves, and not their diets.
Plenty of cultural forces either reinforce or amplify those feelings. I know I’m not the first to bring up “The Biggest Loser” in that context. But it is coming back to TV next year.
Yeah, it is unavoidable. The Biggest Loser is the modern-day Roman gladiators. We watch people suffer for our own entertainment. There is no show, I think, that’s done more damage to society’s understanding and approach to weight management. The Biggest Loser very explicitly and clearly teaches people that scales measure more than gravity. That they measure success, effort, self-worth, and happiness, that if the scale doesn’t move, a person themselves is the failure.
“This message — suffer, suffer, suffer and you will get where you want to go, and if you stop suffering, you’re a failure — is problematic.”
I can’t believe it’s coming back. It was a horror show, and very destructive. Especially the season that had children on it. At such a young age, I don’t feel they could have properly provided informed consent. They couldn’t possibly have known what they were getting themselves into.
This message — suffer, suffer, suffer and you will get where you want to go, and if you stop suffering, you’re a failure — is problematic. Then the other huge problem with the Biggest Loser is that it taught viewers that exercise was the ticket to the weight loss express, and it is not. I mean, even on the Biggest Loser, the bulk of their weight loss is consequences of their quite extreme caloric restriction during that show. There are studies about the show that looked at the impact of watching the show on a person’s desire to exercise. Not surprisingly, viewers watching people exercise to the point of throwing up, which is a common theme on the show, were less inclined to exercise. There was one study that suggested that watching even a single episode increased weight bias in the viewer, and that’s just awful.
Do you feel we’re collectively suffering from a sort of national, or since you’re working in Canada, international, eating disorder?
I definitely believe our constant focus on weight as something that measures health is problematic, for sure. Weight doesn’t measure health in any way, shape or form. But that is how it’s presented to the public and in many cases by health professionals.
The term that I coined a long time ago was “best weight,” which is whatever weight you reach when you’re living the healthiest life you actually enjoy. There really does come a point where a person cannot happily eat less, and cannot happily exercise more. We’re trying to aim people at the best [point] they can enjoy. A person’s best changes day by day and circumstance by circumstance, but there’s still a best a person can enjoyably live with — and that’s the goal.
There are now some decent medications for weight management. Surgery is a terrific resort for some people. It’s the most durable and effective program we have for weight management.
All this is to say that we need to approach weight management in a nonjudgmental way — where we respect our personal best, where clinicians respect their patient’s personal best, and where we also respect the fact that it takes a tremendous amount of privilege to intentionally change your behavior in the name of weight or health. People forget that all the time. I would venture that maybe it’s only 5%, or 10% of the population at most whose lives are sufficiently privileged to make this their priority in life.
And yet many people view medication — and in particular bariatric surgery — which you say is a very good option, as capitulation, giving in to failure and a lack of personal responsibility. It’s framed in moral terms.
We don’t moralize around any other chronic disease. Obesity is the only chronic disease where we suggest, “Oh well, theoretically you can do this with your forks and your feet.” Therefore doing anything other than using your forks and your feet is a failure. Forks and feet, they treat 80% to 85% of chronic diseases to some degree. Some completely, some partially.
We don’t say boo at somebody who decides to take blood pressure medication rather than go on a low-sodium diet, exercise, lose weight, improve sleep, and meditate. We don’t get mad at somebody with diabetes, who needs cardiac surgery to open up arteries, because they weren’t terrific at remembering to take their medications or check their blood sugars. Medicine is without blame, except with obesity. That is a societal problem, and doctors being part of society, they fall into that category as well.
My belief is that for clinicians, and myself included, our job is to provide patients with information about their options, and then support whichever option they choose. When it comes to obesity, those options would include medications and surgery.
One of the things you really have prescribed is chocolate — it was in the working title for your book — but you’ve also had patients walk out of your office with prescriptions for cookies, ice cream, and pizza, and foods that bring them joy. Is that good for patients or just to prove a point?
I don’t think abstinence is the solution. So, if people think they will live forevermore without their favorite foods, there will be some who succeed with that. Again, there are some people who succeed on every approach. But for the majority of people, their favorite foods never let them down — our most beloved members of our family will [let us down], but not our favorite foods. They’re literally comforting, changing stress hormone levels. I meet a lot of people who are stuck in a very diet-centric view of the world, where they feel that to succeed they are not allowed to have these foods they love and enjoy. Because of their weight, they’re not allowed to live normally with food. But normal life includes celebratory food and indulgent food.
So, we teach people to ask themselves two questions. First, is it worth it? In certain circumstances, it’s going to be obviously worth it, like on someone’s birthday for instance. Sometimes the “why” will be less obvious, but we’re human beings, and we’re allowed to decide if something’s worth it. We had a rough day, whatever. Then the follow-up question is what is the smallest amount that they feel will satisfy them? That’s the way we want people to approach indulgences as a whole.
You work in conjunction with the Canadian government. Does defining obesity as a chronic disease help activate the public health apparatus in dealing with weight issues?
Certainly, it does. There’s now preliminary research to suggest that using the definition of chronic disease for obesity actually improves weight bias attitudes amongst clinicians, which is a good thing.
In Canada, we have socialized medicine. If something is not considered a medical condition, it would be much more difficult to get coverage for it through socialized health care. Having obesity defined as a chronic disease in Canada is important in that regard. It’s still not completely recognized as such. The Canadian Medical Association recognizes obesity as a disease. I believe there is still a hold up with the Public Health Agency of Canada, who have not formally defined obesity as a disease. I think part of the rationale for not doing so is weight bias, where again there’s this erroneous belief that this is a disease of real power and personal responsibility,
That attitude is pretty widespread and there’s a lot of ingrained resistance to your view of obesity. Have people come after you with proverbial pitchforks?
No doubt. There are angry people who are happy with approaches that I might suggest leads many to be unhappy. I get why that upsets them, but really they’re so narrow in their scope of vision to believe that, “this works for me, therefore, it’s the only way to go.” That’s an attitude that needs to disappear.
It’s relative, right? We all can tolerate different degrees of suffering or unhappiness, but we also all have limits. Respecting those limits is sort of the cornerstone of my practice. I would want and hope that to be the cornerstone of others as well. I’m not personalizing it on a basis of DNA, or other tests, but actually exploring the individual — what’s worked for them in the past, what hasn’t, and being realistic with them. It’s important to be compassionate and not have the rigidity that leads them to feel like if they aren’t perfect then they’re abject failures. Embracing imperfection is hugely important for someone to succeed in the long run.