The consequences of weight bias: beyond making you feel bad.

Debra came to me frustrated about her climbing weight, now about 20 pounds out of her normal range. This is nothing unusual for me—plenty of women and many men reach this point, desperate for answers and guidance to help them take charge of their weight. Others present for help managing symptoms or medical outcomes—like high blood pressure or cholesterol or GERD that have more to do with the quality of their diet than with their weight.

Debra was an active woman in her 50s, a non-emotional eater—yes, they do exist—who felt like she was doing most things right. She ate regular meals and snacks; she had to, as she started to feel really low energy, and fuzzy headed if she didn’t. And she’d start to get the sweats, too. She had a history of very high cholesterol, and a family history of Type 2 diabetes as well. And the weight she had previously maintained, her normal weight, was nothing crazy, nor did it require heroic measures to achieve it. Her goals were quite realistic.

After reviewing Debra’s intake and activity, I made modest recommendations to ensure she was doing whatever was reasonable in terms of change. Was she still getting the workout that she thought she was, or does she need to evaluate her intensity or duration? Perhaps with better conditioning she could prevent further weight gain. Was she inadvertently influenced by the halo effect—having more of those foods she believed to be healthy, such as lean protein sources or nuts—without an awareness of just how much was enough? (http://dropitandeat.blogspot.com/2011/05/halo-effect-your-thoughts-about-healthy.html) Fullness was challenging to observe, she had stated. Perhaps she needed to evaluate just how much she needed as opposed to portioning her food on autopilot, without much attention to her need http://dropitandeat.blogspot.com/2010/08/size-matters-but-not-how-you-think.html or http://dropitandeat.blogspot.com/2011/02/who-or-what-decides-how-much-you-eat.html While these recommendations were helpful—and prevented further weight gain—it was clear to me that another explanation was responsible. She had many markers for polycystic ovarian syndrome (PCOS) or hyperinsulinemia, a condition where high circulating levels of insulin result in symptoms of low blood sugar (including the sweats, fuzzy headedness, irritability and immediate need for food). (For more on hyperinsulinemia http://www.diabetes.co.uk/hyperinsulinemia.html)

At my suggestion, she went to see an endocrinologist—an MD appropriate for evaluating such conditions. From Debra’s report she shared her sense of despair about her climbing weight and belly fat, yet the doctor began to dismiss her, like all the overweight women who presented before her, with a simplistic, patronizing “Eat less and exercise more”. Yes, judgment was decreed without even listening to how high her activity already was and how appropriate her eating has consistently been. 

But once she added the comment about the symptoms between eating—those low blood sugar-type symptoms—he got it. He finally recognized that it was unfair to put the blame on her—to simply tell her she needs to exercise more or eat less because after all, weight management is about energy balance. He put her on metformin, which addresses the underlying issue—it’s an insulin sensitizer, so it helps prevent excess levels of circulating insulin.

The outcome? Most importantly, her symptoms stopped and she felt so much better. No more shakiness in between meals, and the sweats ceased, too. And, her weight dropped about 9 pounds over the past year, in contrast to the weight climb the preceding year that felt so out of her hands.

Weight bias in reverse

Another active woman—at a normal and stable weight, recently had a physical. She’s a 51 year old who enjoys food and eats a healthy diet. By healthy, I mean rich in healthy fats, whole grains, fruits and vegetables, with a reasonable intake of desserts and chocolate and wine. She’s not vegetarian—but her intake of meat is minimal—nor gluten free, nor dairy free, nor carb free. She’s a reliable reporter.  I know, because she is me! For the first time in her/my history, my cholesterol was high! The good cholesterol was high too—likely the result of my activity (I’d attribute it to genetics except neither parent had a high HDL)—but the bad, the LDL was out of any lab’s range of acceptable. Add that to my high blood pressure and that places me at further risk.

And what did my doctor do? Nothing. Other than telling me to continue to ‘watch my diet’ and maintain my activity (about which he knew little), that is. Yet the variables that I can control are already in order. My diet and exercise aren’t going to change for better so I don’t suspect there will be any astounding improvement. Most likely, my hormone status was likely the greatest factor increasing my levels—LDL can increase 15-25% with menopause! But heart disease risk similarly increases with postmenopausal elevations in cholesterol. 

Me (in Robin's hand-me-downs) and my slim father who had type 2 DM,
high blood pressure and high cholesterol.

In spite of my high cholesterol, my doctor didn’t suggest that I have it rechecked in 3 months or that I start a statin to lower the levels. He didn't explore my exercise frequency, intensity or duration. While the updated 2014 cardiac risk calculator concludes statins for cholesterol lowering aren't necessary for me, (and doesn't include weight in the assessment) he didn't plug the numbers into this risk analyzer (I did later though.) No, I did not look like a high cholesterol patient so my cardiac risk was minimized.

I share this for those of you still blaming yourself—for your health, and for your weight. That is not to say that there aren’t things you can do to take charge of your health. Physical activity in moderate levels can improve insulin sensitivity, lower cholesterol, improve blood sugar and assist in energy balance. Oh, and it certainly may help mood and sleep, too. And eating portions appropriate for your need can help everything from reflux to fatigue to your weight climbing out of your normal, healthy range. Eating more home prepped meals can give you more control of portions and meal content. Even for you non-cooks, there are plenty of easy-to-prepare, yummy dishes you can make, with practical strategies for pulling it all together. And avoiding long periods without food certainly will improve your energy level and your control of eating when you finally take the time to eat.

But if you’re already doing what’s in your hands to do, don’t let others burden you with blame. And start to advocate for the care you deserve.

When I see my new doctor, you can bet I’ll be discussing my labs and inquiring about any treatments that might lower my risk. Because truly, my high cholesterol is not my fault.

thanks for reading!

Fat enough. Coming to terms with weight when it’s less than ideal.

I don’t know which made me saddest—her sense of vindication when reporting the oncologist’s orders: “I don’t want to see any more weight loss”, or her distress that her weight was up 5 pounds. Or perhaps it was her pride in getting down to the lowest adult weight she has seen in many decades. Ahh, the perks of esophageal cancer!

She’s lived so tormented by her weight, berated by doctors and non-supportive family members to reach for something unattainable, to get thin, from the time she was a pretty, young, school-age girl. “You’re beautiful”, they’d say, “if only you could lose some weight.” Perfect labs and low normal blood pressure were not good enough. No, she didn’t look fat on paper.

And yet her obesity just might have been the source of her potentially fatal illness. There. I’ve said it. Admittedly, GERD, gastroesophageal reflux, is linked with many factors, and obesity is just one of them.  But after a decade living on antacids, popping Rolaids like LifeSavers—no pun intended—with a blood sugar approaching diabetic levels, she had gastric bypass. The GERD? Finished! Antacids were no longer a fixture like Kleenex and lipstick in her purse. Yes, she was free of heartburn and indigestion—and her blood sugars dropped to normal. With her 90 pound weight loss came a reversal in symptoms and the promise of a better life.

So it came as a quite a shock last year to learn that she had esophageal cancer. And hers, located at the very bottom of the esophagus near the stomach, was not a result of alcohol or smoking but from many years of damage from acid reflux.

GERD can lead to changes in the cells of the esophagus—between 5 and 10 % with GERD get Barrett’s.  And Barrett’s Esophagus can develop into cancer, with an overall lifetime risk of 5%. 

Could it have been prevented in her case?

Sure, earlier screening by endoscopy to evaluate progression to Barrett’s sooner could’ve helped. And being more proactive with a procedure called ablation to wipe out the changed “Barrett’s” cells would have helped too. 

As for weight loss?

It’s not that she didn’t try. Perhaps she was genetically meant to be a large woman with a high BMI. Still, she could have worked in more activity, walks at least, something, setting realistic, achievable goals. And stress reduction to prevent emotional overeating and anxiety-driven overeating.

Yes, those might have helped her weight and subsequent chronic reflux and possibly prevented her cancer. But in our society it would never have been enough. She would still be viewed as obese, with the stigma we project on that label. Doctors would still say her weight was too high, falsely envisioning the fast food drive-ins she never frequents. (Actually, her meals have been quite healthy and balanced for as long as I could remember.)

In spite of her post cancer, post surgical weight loss of more than 40 or 50 pounds—honestly I don’t know how much exactly—following the doctor’s orders and not striving to lose more weight is quite a challenge. Self-acceptance doesn’t suddenly appear at age 75 when it has been long absent.

So please don’t wait until changing is a matter of life and death. Seek support for working on self-acceptance. And try to see your weight as just a number—not a reflection on your character, nor your motivation, nor your fitness level or your health.

Thanks for reading.

And yes, I've written about this before with a bit of a different focus.

Getting Personal: Lessons About GERD, Cancer, HAES, Bulima & Food Restriction

Read this if you are overweight. And read this if you purge through vomiting. Read this if you restrict your intake to less than you know your body needs. And read this if you've been told you have reflux, GERD or Barrett's esophagus.

Stomach--cow, not human, though!

I was recently contacted by a blogger colleague, aware of my Health At Every Size (HAES) philosophy from my blog writings. She was interested in referring a client for Medical Nutrition Therapy for reflux, with a history of Barrett's esophagus. For those of you not in the know, reflux, GERD or gastroesophageal reflux disease, is a condition where acid from the stomach comes up into the esophagus—that tube connecting your throat and your stomach—where it's not meant to be. 

Over time, that stomach acid starts to change the lining of the esophagus and cause inflammation, heartburn and discomfort. For about 5-15% of sufferers, the cells lining the esophagus begin to change, resulting in a condition called Barrett's esophagus. Barrett's esophagus can be well controlled with diet and medication, but in some cases progresses to esophageal cancer. By the time cancer is diagnosed in those patients, the cancer has invaded the area making the prognosis far from great.

My mother was diagnosed with adenocarcinoma—a cancer of the esophagus.

Now, back to the referrer. She wanted to be sure that I wouldn't focus on the client’s weight; because that's what people tend to do—just focus on the weight. What my fellow blogger was unaware of was that I was in the midst of struggling with the horrific consequences of this very common symptom, reflux, which ultimately led to cancer of the esophagus, a potentially preventable disease. And I am painfully aware of all the risk factors that contribute to esophageal cancer—including obesity. 

For most of my years, my mother popped Rolaids and Tums, those chewable antacids, like they were candy. She didn't binge, but she ate compulsively. She wasn't a drinker or a smoker—alcohol and smoking also add to the risk—but she couldn't part with her coffee which like most things acidic make things worse. And she was obese, a major risk factor for reflux. In fact, after her gastric bypass surgery, her reflux disappeared. For 8 years, in fact, she experienced little or no reflux. But it was too late; the damage was done.

Now if you're thinking you're not the intended target for this post, don't stop reading! My story, unfortunately, impacts the purgers among you as well as those dreadfully afraid to eat. So please keep reading.

While the verdict isn't in yet, there appears to be an increased risk of reflux, Barrett's esophagus and cancer, based on a study of studies, a meta analysis, on bulimics. This should come as no surprise, as acid going where it's not meant to go is what causes the problem. Fear may not drive you to change your behavior. But perhaps you haven't considered your risk of getting a potentially fatal cancer, right up there with dental issues and of course, sudden death, all consequences that you can prevent.

So where do you restrictors fit into this article?

Let me enlighten you a bit more about the treatment for esophageal cancer. The best hope for survival is to have surgery, after aggressive chemo and radiation. If you're a candidate for surgery, you're in luck. Well, sort of. The surgery requires removal of most or all of your esophagus and creation of a new pseudo-esophagus from your stomach. It's a seriously risky surgery, but can be done well by top surgeons. We were fortunate, and in fact, her past gastric bypass likely aided the situation, making it easier to use her already bypassed stomach remnant.

If you've long struggled with your weight—like my mother did—being told you have to take in many hundreds of calories a day doesn't sit too well. So any opportunity to stop the tube feeding (from which the bulk of nourishment comes during the initial and very critical weeks of healing), is taken. 

Yes, she restricted. The lack of significant weight loss convinced her that there was no issue with her minimal nourishment. Never mind that she became lethargic, spending most of her days in bed, barely able to walk. Or that she became depressed, or that her thinking was far from clear. (Yes, sometimes it's difficult to see the damage from restricting as it's happening.)

That's the state she was in this weekend when I visited. She had convinced the doctors by telephone that she was eating fine, and they were even considering removing her feeding tube tomorrow. 

Except that now she was readmitted and has a blood clot in her lung. I can't say why, these things do happen, but laying in bed fatigued from poor intake no doubt didn't help.

Back to HAES and my fellow blogger.

I fully understand the experience of the obese, being told that their weight is the cause of all evils—even the common cold! As an RD, I would never just focus on weight loss for someone with GERD. Rather, I would address symptom management with volume changes, and reduce acidic foods that aggravate the inflammation. I'd guide the patient on foods and meal content that might be contributing to the reflux.

But would I avoid discussion of weight loss in an obese patient, if their eating were excessive for their need, if they had been gaining weight? Or for that matter, if portion adjustments could be made, reducing both calories and stomach volume that would improve acid reflux, and also result in weight loss? Studies show an association, and that's not to say that all obese people need to lose weight. I get it.

That said, for those with GERD, losing weight tends to improve symptoms, and gaining weight tends to worsen them in obese individuals, especially in those with intra-abdominal obesity.  

Thanks for reading. Please do me a favor and share this with someone you know whose's at risk. Tweet it, blog about it, Facebook 'like' it or simply talk about it.