1.  A bodily ailment or weakness, especially one brought on by old age.

2.  A failing or defect in a person’s character.

After the laughter subsides, I ask everyone who has “the absence of disease or infirmity” to remain standing. In a group of 2 or 3 hundred typically 10 to 20 people remain standing. I next ask this group to remain standing if they have “complete physical, mental and social well-being.”  Usually everyone but one or two sit down. I then remind them that telling the truth is a sign of mental health and everyone has a good laugh as the remaining folks seat themselves.

Traditionally, even when health is defined as more than just the absence or opposite of disease it is still most often envisioned as some “optimal state” that can be achieved if we just try hard enough. A trip to the local bookstore will reveal a seemingly endless barrage of books by health experts claiming to provide the steps needed to reach this proposed state of perfection.  The problem is, of course, that as human beings we all live with varying amounts of physical, emotional, and spiritual baggage.  How many people have ever experienced or ever known anyone in “optimal health?  What does “optimal health” even look like?  As medical writer David B. Morris suggests in his insightful book Illness and Culture in the Postmodern Age:

Complete well-being is a fantasy.  Health, whatever else it might be is something that happens not so much in the absence of illness as in its presence.

It helps me to think about the difficulties surrounding the concept of “optimal health” in this way:

If you can start the day without caffeine,

If you can be cheerful, ignoring aches and pains,

If you can resist complaining and boring people with your troubles,

If you can eat the same food everyday and be grateful for it,

If you can understand when loved ones are too busy to give you time,

If you can overlook when people take things out on you when, through no fault of yours something goes wrong,

If you can take criticism and blame without resentment,

If you can face the world without lies and deceit,

If you can conquer tension without medical help,

If you can relax without liquor,

If you can sleep without the aid of drugs –

If you can do all these things …

Then you are probably the family dog!

Dogs and especially golden retrievers (this was ours before she passed a few years ago) just seem to be at peace with the universe and everything in it. The WHO definition is not a bad one; it just doesn’t fit our species. Living skillfully and compassionately with our inevitable, struggles, rather than perpetually searching for the latest “holy grail” of “optimal health” may come closer to what it truly means to be healthy. Furthermore, the constant pressure to strive for this unreachable perfection; the quest for the perfect body, the perfect diet, the perfect exercise program, the perfect risk factors, behaviors, etc. set us up for almost inevitable frustration and failure. In his often cited 1975 article Medical Nemesis, philosopher Ivan Illich addresses this issue head on saying:

“Health is not freedom from the inevitability of death, disease, unhappiness, and stress, but rather the ability to cope with them in a competent way.”

My friend and colleague Laura McKibbin has developed an amazingly creative graphic that she calls the Food For Thought Pyramid (below) as a way of displaying what a truly holistic description of health might look like. It is structured like the food pyramid used to be, with the most important foundations of health at the bottom of the pyramid.

As you can see, the base of the pyramid has little to do with personal strivings for biometric or behavioral perfection, though the issues therein can certainly impact those parameters, and everything to do with the context of our existence and the circumstances we have been dealt. Without the life sustaining foundation represented by the bottom of the pyramid; fruits and vegetables, exercise and low cholesterol will likely have minimal impact on personal health. Genetics, luck and a range of cultural factors provide the critical platform on which a healthful existence is built and remind us about the complexities and importance of context to understanding the true meaning of human health.

So, what are the practical, life applications of this information? In their groundbreaking book Healthy Pleasures, Sobel and Ornstein nail down a prescription for the pursuit of health, saying:

“We need to restore some sensibility to the pursuit of health. Many of us increasingly view ourselves as fragile and vulnerable, ready to develop cancer, heart disease or some other dreaded disease at the slightest provocation. In the name of health we give up many of our enjoyments. The important point is that worrying too much about anything – be it calories, salt, cancer or cholesterol – is bad for you, and living optimistically with pleasure, zest and commitment, is good. Medical terrorism shouldn’t attack life’s pleasures.”

Making peace with our bodies and our foods—the hallmark of the Health at Every Size philosophy—seems like a perfect starting point for this prescription.

In part III of this series I outlined 3 major disconnects between traditional worksite health promotion and employee and organizational health. The third and perhaps most important disconnect was the use of extrinsic motivational techniques which can result in decreased employee engagement. In the final part of this series I want to explore this issue further.

Scores of studies over the previous 2 decades have clearly demonstrated that in the vast majority of circumstances extrinsic incentives are ineffective for producing long-term behavior change. Furthermore, their use can retard learning, suppress creativity, inhibit productivity and reduce intrinsic motivation. As Daniel Pink says in his groundbreaking book, Drive: The Surprising Truth about What Motivates Us: “This is one of the most robust findings in social science, and also one of the most ignored.”

The literature with respect to the use of extrinsic rewards at the workplace is no less daunting. Below are The Top 11 Reasons Not to Use Incentives at the Workplace; 25 years of research all coming to the same conclusion.

There are a myriad of proposed explanations for why these approaches do not work, (see Kohn, Punished By Rewards) but thanks to advances in Neuroscience technology we are beginning to get a glimpse of what is actually going on in the brain.

The picture above identifies four areas of the brain involved in the story. The prefrontal cortex is the newest part of the brain. The neurons (nerve cells) here are responsible for the creativity and decision making that makes us uniquely human. No other creature has such a well-developed cortex and this part of the brain probably does not exist at all below the higher primates. When we receive input from the outside world, the working memory of the prefrontal cortex takes in the new information and matches it to what is already known. It is a very energy intensive area that fatigues quite easily.

The basal ganglia are clusters of neurons that represent a much older area of the brain. Any activity that is practiced repetitively becomes a habit and is stored in the basal ganglia to be called upon whenever it is needed. Once we learn how to ride a bike, we no longer have to think about it because the neural patterns it requires are stored in the basal ganglia and called up unconsciously whenever we need them. In fact, thinking is likely to take away from the performance of these stored activity patterns. The baseball pitcher who consciously thinks about the motions he goes through to throw a curve ball will perform poorly, because the stored patterns are too complicated to be thought of consciously.

The limbic system is one of the oldest parts of the mammalian brain. It is the seat of emotions. When we are challenged or frightened, the limbic system kicks in and the result is the body prepares to fight or to flee.

Finally, the nucleus accumbens is a group of neurons that is often referred to as the pleasure center of the brain. Pleasurable experiences of all kinds stimulate these neurons to release chemicals that make us feel good.

Thanks to the miracles of PET scans and Functional MRI’s we are now able to see what happens in the brain in response to extrinsic and intrinsic motivation. The picture below represents what happens in the brain when people are pushed or prodded to do something they probably would not do otherwise (remember this as the stated purpose of incentives in health promotion). Extrinsic motivation stimulates the basal ganglia because what is being suggested goes against the established patterns stored there. The error detection that occurs alerts the limbic system and the result is fear and anxiety as the body prepares to fight or flee. In addition, as shown below, the basal ganglia send inhibitory signals to the pre-frontal cortex, telling it that now is not the time for cognition and creativity. The bottom line is that when people are pushed, prodded and coerced to do something, they respond by shutting down their creative capacities and becoming anxious, fearful and sometimes even combative.

When people are intrinsically motivated however; when they are immersed in and enjoying what they are doing – just for the doing – the story (below) is quite different. Specialized cells called mirror neurons actually minimize input to the limbic system and stimulate the prefrontal cortex. – Again, the bottom line – this time cognition, creativity and productivity are maximized.

Furthermore, when people are intrinsically motivated the nucleus accumbens is stimulated to release dopamine – the feel good chemical. Fascinatingly, the dopamine is released not when the goals of a task are reached, but rather when we are engaged in the work that leads to the accomplishment of the goals. As management expert Charles Jacobs says in his book Management Rewired, “It is the work itself that is rewarding.”

So, what does this all mean for worksite health promotion? Based on the four parts of this blog, the bullets below suggest a vastly different approach from the traditional.

• Re-conceptualize health as a dynamic dance between the inevitable frailties & imperfections of being human and the desire for well-being and happiness, rather than a never-ending quest for reaching some “optimal” holy grail of biomedical, physical and behavioral perfection.

• Re-conceptualize health promotion as helping people to decide for themselves what they want their lives to be rather than trying to impose ever-changing (and often arbitrary) sets of rules and guidelines about what they should or should not be doing to be “healthy.”

• Accept that the foundation of a “healthy work culture” begins with and ultimately rests on the quality of the relationships among its people rather than on what they eat, how much they exercise and whether or not they practice stress management techniques.

• Fully embrace Shared Responsibility: If organizations want employees to feel valued they have to really value them. Exercise nutrition and stress management can have only limited impact on the bottom line in a dysfunctional environment.

• Fully embrace Authentic Intention: If economics are the prime reason for worksite health promotion interventions; employees will know it, the programs will show it and they will ultimately fail.

In Finding Our Way, Leadership for an Uncertain Time, renowned professor of management and organizational consultant Margaret Wheatley captures the essence of this approach to promoting health at the workplace, saying that the more we try to cultivate healthy behaviors through coercion, measurement and reward:

“The more damage we do to the quality of our relationships, the more we trivialize the meaning of work, and the more disengaged people become.”

In Part II of this series I summarized the traditional approach to promoting health, based on a Mechanistic Worldview and a Biomedical Model of health as:

1. Reducing, measuring and quantifying health (mostly physiological risk factors);
2. Scaring, cajoling, pressuring and persuading (and shaming when deemed necessary);
3. Employing behavior modification techniques
4. Getting people to change.

The problems with this approach are rooted in the fact that both the worldview and medical paradigm on which they are based are outdated. The 17th century was a long time ago, and our scientific understanding of health, illness, and the process of change has evolved dramatically since then.

From quantum physics and chaos theory we have learned that the Universe is in reality more akin to a dynamic, living thing than it is a machine. Even a rudimentary understanding of its immense complexity demands a holistic approach whereby the whole is much more than the sum of its parts. Psychoneuroimmunology (mind-body science) has taught us that human beings are complex systems in which everything (mind, body and spirit) is interconnected and mechanistic predictability and controllability are simply not possible. Together, these new understandings lead us to a more scientifically appropriate framework for considering the process of promoting health.

With this new framework in hand, I would like to suggest 3 problems with traditional worksite health promotion approaches.

DISCONNECT #1 – The major foci for worksite health promotion initiatives are not the ones that have the greatest bearing on the health costs and productivity of employees.

The typical employee wellness initiative centers on programs like weight loss, smoking cessation and exercise or as it is often suggested by program promoters, “the top three lifestyle choices that contribute to a company’s bottom line,” or “the things that matter most.” While they may be intuitively appealing, these statements are actually erroneous. The research with respect to healthcare costs and productivity at the work place is quite clear – “what matters most” are psychosocial issues like stress, depression, life and work satisfaction, etc. These issues are unlikely to be properly addressed by aerobics in the south lobby or healthier choices in the cafeteria – as well meaning as these approaches might be.

DISCONNECT # 2 – Traditional approaches to worksite health promotion do not directly address the issues that “matter most” to organizational health.

When speaking about the health of an organization, the research again is quite unambiguous. The most important element in the equation is employee engagement defined as:

“The positive emotion a person attaches to the organization, their job and their colleagues. When a person is engaged, they are attracted to, inspired by, committed to and even fascinated by their work or their input to the work relationship.”*

Employees who are fully engaged in their work:

1) Know what is expected of them

2) Feel valued – that their opinions count

3) Are able to leverage their strengths

4) Have quality relationships at work

5) Are cognitively stimulated

When employees are engaged, the result is increased productivity, profitability, loyalty, organizational commitment and retention and reduced absenteeism and turnover: in other words, organizational health.

It is not difficult to see the problem here. Traditional approaches to employee health promotion perceive wellness as:

But when employees feel “unwell” they say they feel:

While some of these concerns may be impacted by improvements in traditional wellness parameters, the issues are clearly much more complex.

Finally, we move on to the third disconnect which may be the most serious of all.

DISCONNECT # 3 – Traditional approaches to worksite health promotion can negatively impact engagement and organizational health.

In the 2nd part of this blog series, I talked briefly about the extrinsic behavior modification techniques of reward and punishment that are so ubiquitous in our culture, and how decades of research clearly demonstrate that these approaches do not foster long-term behavior change and in fact actually undermine it by reducing intrinsic motivation. Unfortunately, extrinsic motivation techniques in the form of rewards, incentives, competitions, contests and risk-rated insurance continue to be mainstays of worksite health promotion initiatives. And those involved in using these tools are quite clear about their intentions. As a leading national worksite wellness organization put it:

“Let’s face it…incentives are about getting people to do things they would otherwise not do.”**

We have known for a long time that these approaches don’t result in sustained behavior change for the majority of people, but now the latest discoveries in brain research are helping us to understand why. In the 4th and final part of this blog series, I will briefly review what we are learning and suggest some potential solutions to the problems raised above.

In the first part of this 4-part series, we traced the roots of our traditional approach to health promotion and health promotion at the workplace as they evolved out of the 17^th century worldview of the Scientific Revolution according to which: 1) the Universe and everything in it are conceptualized as machines; 2) understanding these machines can only be accomplished by analyzing them (reducing them to their constituent parts); and 3) a biomedical (fix the machine) model explains what we need to know about health. We also mentioned that this worldview held the values of competition, aggression and especially control in very high regard.

Accordingly, traditional approaches to promoting health have generally been about:

1. Reducing, measuring and quantifying health (using mostly physiological risk factors);
2. Scaring, cajoling, pressuring and persuading (and shaming when deemed necessary);
3. Employing behavior modification techniques; and
4. Getting people to change.

I have bolded the term getting above because the desire for control and manipulation has unfortunately become a mainstay of traditional approaches to promoting health.  As a widely utilized Health Education Textbook of the 1990’s described it:

“As science and technology advance, the least conquered force of nature remains the human being and his actions.”

It is important to understand that it makes perfect sense that this is the approach to health promotion that emerged from The Mechanistic worldview and the Biomedical Model. The problem is that this 400 plus-year-old worldview is outdated, leaving us with an understanding and an approach to health that is similarly lacking.

For instance, we now know that the two separate universes envisioned in the Mechanistic Worldview are, in fact, one; what happens in the mind is inextricably interconnected with what happens in the body and vice versa. We only have to examine the rich literature on placebo and nocebo phenomenon to know this to be true. (See Part I, Part II, and Part III of my series of blog posts on placebo and nocebo.) Furthermore, the idea that we can make people healthier by scaring and shaming them is simply not supported by the literature – certainly the dismal failure of weight loss interventions is the ultimate testament to that.

Then there is the use of externally applied behavior change techniques to coerce people into doing what they don’t necessarily want to do. I mentioned the originator of these techniques—B.F. Skinner—in a previous post. The application of Skinnerian behavior modification in the form of contingent incentives to get people to change is ubiquitous in our culture; from grades in school, to bribing kids to eat their broccoli by promising them ice cream, to rewarding productivity at the work site. As for health promotion; rewards, incentives, contracts, contests and competitions continue to be at the core of the vast majority of programs. Ironically, though the Skinnerian approach to motivation is rarely questioned, decades of research substantiates that rewarding people in this manner retards learning, suppresses creativity, inhibits productivity and reduces internal motivation. (see Alfie Kohn, Punished by Rewards).

Finally, there is the ultimate goal of “getting people to change.” Make no mistake about it. Health promotion experts are clear about their intentions. Incentives are about:

“…getting people to do things they would not otherwise do. Like it or not, people frequently don’t do what will help them stay healthy and live longer. Changing this situation is what wellness is fundamentally about.”

And by using incentives, practitioners can:

“Jar the attention of someone in precontemplation and force them to at least think about improving their health.”

How has this approach to  “helping people” manifested itself at the workplace? Here is a short list of really, really creepy things organizations are doing in the name of wellness.

Clarion Health Partners – docking pay up to $30 every 2 weeks unless employees meet cholesterol and blood pressure guidelines

United Healthcare – $5,000 v. $1,000 deductibles for smoking or obese individuals

Wal-Mart – $2,500 v. $500 deductible if height/weight standards are not met

LL Bean – “twinkie tax” on fatty foods

Weyco – tobacco use testing for all employees and spouses

WellPoint, Inc. – 5% of bonus pay linked to a 20-point health index

Oh yes, and there is Dr. Delos Cosgrove, Chief Executive Officer of the Cleveland Clinic, who won accolades a few years ago for his decision not to hire smokers, who stated that “if it were up to him, if there weren’t legal issues, he would not only stop hiring smokers, he would also stop hiring obese people.”

Seems like a slippery slope as organizations get more and more into the business of “getting” people to be healthy. Not a pretty picture indeed.

In the 3^rd part of this series, I will examine in more detail the consequences created by this approach to promoting health at the workplace

Like many people in this country, I have a chronic “pre-existing condition” which has me paying exorbitant rates for mediocre health insurance and prohibits me from looking around for a better option. As a health professional I have also, over the past two decades, been involved with worksite health promotion as a creating partner of a unique, holistic, HAES-based employee wellness program entitled KAILO that has won awards in both the United States and Canada.  Additionally, I regularly speak at Employee Health Conferences throughout North America. For all of these reasons, I have been watching the controversies over “Obamacare” with great interest.

On the one hand, I am excited (and mildly hopeful) that I may qualify for more reasonable and effective health insurance in the not too distant future. With respect to employee wellness, you would think I would also be excited by the prospect of millions of dollars for workplace health – certainly many of my colleagues are. But I have issues with what is happening in the workplace around health and I am worried that this health care reform may actually make things worse.

Coincidentally, I had a recent email conversation with a colleague regarding weight loss programs at the worksite. He said that there was no need for me to harp on the failures of traditional to weight loss programs because every health professional was already well aware of the complete lack of efficacy of these approaches.  I realized that this statement might actually not be too far from the truth. As Dr. Dee Edington from the University of Michigan, one of the most seasoned and well respected names in worksite health for as long as I can remember put it a few years ago:

“Weight loss money is money down the toilet.”

I thought a bit more about this and asked my colleague this question. “If health professionals all know about the failure of these programs; why are they all still promoting and implementing them at the workplace?  Why are weight loss programs, contests and competitions still a mainstay of worksite health initiatives?”  Perhaps not surprisingly, I never got an answer back from him on this one.   

Our traditional approach to promoting health is based on a paradigm that developed some 400 years ago during the time of the Scientific Revolution in Europe. Often referred to as “The Mechanistic Worldview” it sees everything within the universe, including living things as machines.  Understanding any of these “machines” is accomplished through a “reductionist approach” which entails taking the thing apart and fixing or replacing the broken part. The entire universe of things is actually divided into two; one universe includes everything that can be measured and quantified and the other contains all those things that cannot be. So blood pressure cholesterol and weight, etc. would be included in the first universe and feelings, thoughts, emotions and spirituality would be relegated to the latter. According to this worldview, nothing in the second universe (mind/spirit) can impact anything in the first (body) and therefore the former should not be considered appropriate topics for scientific study. Here we have the original separation of the body from the mind and the spirit.  Finally, this worldview is decidedly patriarchal, valuing highly the masculine characteristics of aggression, competition and control.

For the health professions, the result of this worldview is our traditional  biomedical model which views human beings as complicated machines whose diseases (diagnosed mostly using physical determinants) are caused by biological malfunctions that can be cured (fixed) by physicians (mostly male).  Of course, we have moved off this worldview to varying degrees, but it still underlies much of what we do in the health fields. For instance, the idea that we can calculate how much someone needs to eat to lose a certain amount of weight, the use of BMI as a proxy for health, and the stubborn reliance on calories in calories out calculations are clearly throwbacks to the “human being as machine” assumption. After all, these kinds of mechanistic calculations work pretty well with lawnmowers!

Our traditional approach to health promotion and health promotion at the workplace evolved directly out of this biomedical perspective. I will explore the approach and examine the associated problems in my next blog.

On The ASDAH (Association for Size Diversity and Health)  list serve for which I regularly blog there was recently some discussion of a couple year-old published  article entitled Financial Incentives for Extended Weight Loss: A Randomized, Controlled Trial. There was simply no way I could pass this one up. Here was a chance to put to rest (again) two of the most pervasive oxymorons of traditional health promotion: incentives for behavior change and extended weight loss. No one could have published research that lends itself to this task better if they had set out to do so.

Before discussing the details of the study, a few comments about these two concepts are in order. The easier concept to grasp of the two is clearly extended weight loss. We are all quite aware of the lack of significant evidence that weight loss programs result in long-term weight loss for all but a small minority of participants. The authors of the article acknowledge this in their opening paragraph, saying:

Weight loss interventions have generally been unsuccessful in achieving sustained weight loss.

As for the use of incentives for behavior change, it turns out that the situation is surprisingly similar. Like weight loss programs, incentives often result in short term change, and like weight loss programs, incentives rarely result in long term success. This is true for a wide variety of applications and is certainly true in the area of health behavior change.

The use of incentives for behavior change has its roots in the mid 20^th century work of B.F Skinner. Skinner believed that all human actions were merely “repertoires of behaviors” that could be fully explained by the environmental consequences that followed them. He saw humans as brainless machines responding to their environment claiming that:

There is no place in the scientific analysis of behavior for a mind or a self. (American Psychologist, 1990)

We answer the telephone after it rings because someone on the other end (hopefully not a telemarketer) answers. Theoretically, if we responded to the ringing phone enough times without someone answering, we would eventually stop doing so. While this makes intuitive sense, Skinner went way beyond this by concluding that all human behaviors were so determined.  His take on love, for example, is that when two people meet:

One of them is nice to the other and predisposes the other to be nice to him, and that makes him even more likely to be nice. It goes back and forth, and it may reach the point at which they are very highly disposed to do nice things to the other and not to hurt. And I suppose that is what would be called being in love. (Walden II).

Pretty romantic, don’t you think? Anyway, to make a long story short, the behavioral approach to motivation (external rewards and punishments) is ubiquitous in our culture and rarely questioned in spite of the fact that decades of studies have convincingly demonstrated that it does not work for most people in most situations. Furthermore, the research strongly suggests a number of significant iatrogenic consequences, not the least of which is a reduction in internal motivation  associated with its use. (see Punished By Rewards, Alfie Kohn) This conclusion holds true in a wide variety of applications and certainly for health behavior change – as multiple studies with weight loss, smoking cessation, seat belt use, etc. have demonstrated (see Robison, To Reward?…Or Not To Reward?: Questioning the Wisdom of Using External Reinforcement in Health Promotion Programs, and Kohn, Incentives and Health Promotion: What Do the Data Really Say?).

So, the research in this article incorporates not one, but two supposed health promoting approaches that result in short term change, rarely succeed in the long run and engender iatrogenic consequences – a 32-week, randomized, controlled trial of the use of financial incentives for extended weight loss.

Three groups of men between the ages of 30 and 70, with BMIs between 30-40 from a VA Hospital were assigned to one of three groups (n=22 each group). Subjects in the two experimental groups met with a dietitian and put up money (matched by the program) which they could then win or lose based on their self-report of whether or not they met their weight loss goals (1 pound per week) over the course of the next 24 weeks. One of the experimental groups was told that weeks 24 through 32 constituted a maintenance period, while the other was not. The control group met with a dietitian and then received no incentives, but was followed for the same period of time. The main measure was weight loss at 32 weeks. As a secondary measure, weight loss was again assessed 36 weeks after the initial 32 weeks.

Subjects in the two experimental groups lost an average of about 8 or 9 pounds, as compared to the control group’s 1 pound average loss over the course of the first 32 weeks. At the end of the “maintenance period” (additional 36 weeks), “participants regained weight post-intervention” and there was no difference between the incentive and control groups. The results are not overly surprising given the decades of research and scores of studies which have reached the same conclusions. Of course iatrogenic consequences were not assessed in either case.

So, what lessons can we take from this study and decades of similar findings? Weight loss interventions work in the short term for many and in the long term for very few. And financial incentives do about the same. Do we really need one more study to tell us this? Apparently we did and we still do. Here are the authors’ conclusions.

This is the first study to demonstrate that deposit contact incentives can successfully help keep off weight for 32 weeks.

and

Future research is needed to devise techniques that promote sustained weight loss over longer periods of time.

Amazing – no?

From time to time I overhear or read about people discussing whether obesity should be considered an Eating Disorder (ED). I have even seen obesity listed along with anorexia and bulimia as if it were just common knowledge that it belonged there. This is just wrong on so many levels that it almost seems like it is not worth acknowledging the discussion. On the other hand, it is so often promulgated both in the lay media and in scientific circles that perhaps it is important to elucidate the ways in which the classification of obesity as an ED makes no sense.

To begin with, Eating Disorder Reviews defines EDs as:

Extreme expressions of a range of weight and food issues…serious emotional problems that can have life threatening consequences.

Obesity, on the other hand, is defined as a Body Mass Index (BMI) equal to or greater than 30. It is a measure of height and weight (kg/m2). Just as there are different eating disorders, there are other measures of height and weight; The Ponderal Index, The Body Mass Prime and The Body Volume Index to name a few. An ED is a serious emotional problem/illness and obesity is a measure of height and weight. So, on the most basic level comparing obesity and eating disorders is somewhat like comparing apples and oranges.

Actually, the comparison is really a good deal more obtuse than that because apples and oranges are at least both fruits. The comparison between obesity and eating disorders is really more akin to comparing an apple with a chair. You can’t sit in an apple and you can’t eat a chair!

Actually, on a somewhat lighter note, I have seen a chair shaped like an apple, but you still can’t eat it.

It is important to remember (as I discussed in a previous blog post) that this BMI measure (1) was never meant to be a measure of health and (2) is a population statistic not meant to be used on individuals. So, making connections between this measure of obesity and the serious emotional health issue of EDs is scientifically unjustified and inappropriate.

On the next most basic level, it is certainly true that body weight and eating disorders both have something to do with food. Yet, the evidence that people labeled as obese eat more than other people is inconclusive at best, with some recent research even suggesting that just the opposite may be the case.  So, the very common suggestion that you can know whether someone is eating the “proper amount” of food (or the “right kind” of food for that matter) by looking at them is not supported by the evidence and therefore, doing so can best be defined as prejudice (pre-judging).

Of course, the lack of supportive evidence for this conclusion does not stop people from continually making it. In fact, the word obesity itself comes from the Latin obesus, whose primary definition, “one who has become plump through eating,” confirms the misconception.  Instructively but perhaps not surprisingly, the secondary definition for obesity usually includes the words coarse and vulgar.

From a phenotypical perspective, the concept of obesity as an ED also makes no sense. Most patients with anorexia nervosa and bulimia nervosa have always been thin and “normal weight” people.  However, everyone knows that the vast majority of people in these weight categories do not have an ED. With the acknowledgement of Binge Eating Disorder (BED), many therapists are now seeing fat people who have an eating disorder. As is true with people of any size, of course, the vast majority of fat people also do not have BED. Research suggests that somewhere between 4% and 8% of people labeled as obese may suffer from BED which means that the overwhelming majority, 92% to 96%, do not!

In conclusion, here is what we can now say about the relationship between obesity and ED. They are about as related as the chair and the apple. Suggesting that someone has an ED simply by virtue of their BMI is prejudicial, unscientific and unethical. As fat activist and author of Fat!So? Marilyn Wann puts so eloquently:

The only thing anyone can diagnose by looking at a fat person is their own level of prejudice toward fat people.

“ Good nutrition is getting a bad name — one that smacks of rigidity, guilt-making and extremism… Worse still, some eight out of ten (Americans) think foods are inherently good or bad… every single bite they take represents an all-or-nothing choice either for or against good health.”

Unfortunately, this two-decade-old pronouncement from the Tufts University Diet and Nutrition Letter still rings true today. Americans live in a constant state of anxiety and confusion when it comes to food. We have been warned of the need for constant vigilance to protect ourselves from the dangers lurking in a wide variety of foods.

As a famous diet doctor cautioned:

“You must treat food as if it were a drug. You must eat food in a controlled fashion and in the proper proportions – as if it were an intravenous drip.”

For many, if not most adults, a longing glance at a desired food is sure to elicit the following inner dialogue:

“I wonder how many calories, fat grams, carbohydrates, etc. are in that food. I don’t know if I should eat it…Will it give me heart disease, diabetes, cancer?…Will it make me fat?”

If the desire to eat ends up winning out over the fear, which it usually does, the anxiety, now intensified by the guilt of not having resisted returns:

“ I’ve really blown it now…how many miles am I going to have to walk, run, bike, etc. to get rid of those calories…”

And in response to the possible eventuality of acquiring some affliction in the future:

“Now I’ve gone and given myself a heart attack, stroke or cancer. That never would have happened if I hadn’t eaten this or that food.”

Over the years the ongoing barrage of proclamations from the government and health organizations about the “badness” (unhealthiness) of various foods has managed to wrench from many of us the natural pleasures of eating while turning food selection into an intellectual activity, replete with mathematical calculations, “shoulds” and “shouldn’ts” and dire warnings of dreaded consequences.

It started in the 1970’s and 80’s with the fear of fat – lipo-phobia. According to the experts, all fat was bad and we should eat as little of it as possible. But wait! Scientists soon discovered that only saturated fat was bad for the heart, while other fats were not. Then they discovered that only some saturated fats were bad while others were not. Then they said that polyunsaturated fats were good. Then they told us that, although polyunsaturated fat helped with the bad cholesterol it also lowered the good cholesterol, so what we really should be eating was monounsaturated fat.  Then research suggested that a low fat diet might actually be unhealthful for a significant portion of the population.

Confusing as all this was, most experts agreed about what should make up the bulk of our diet!  – Lots and lots of carbohydrates! Hold the burger, eat the pasta! Then came Gary Taube’s fateful 1991 New York Times editorial entitled: What if it has all been a Big Fat Lie?  Seemingly overnight we traded in our nearly quarter-century-long lipo-phobia for a new fear – the fear of carbohydrates – carbo-phobia – Hold the pasta, eat the burger (without the bun of course!).

To make matters worse, special interest groups have promulgated a host of other food phobias that continue to haunt people as they try to decipher what might be left that is still safe to eat. With little or at best contradictory scientific evidence for the claims, we have been told that meat is bad for the kidneys, that milk should not be consumed past childhood, that the cholesterol in eggs causes heart attacks, that sugar makes children hyperactive, that HFCS is a major cause of “the obesity epidemic” and so on.

Is it any wonder that in a 2001 survey in the Journal of The American Dietetic Association, 43% of those polled said they were tired of hearing about what foods they should or should not eat and 70% said that the government should get out of the business of telling people what to eat? Perhaps not surprisingly, the media headlines recently heralded a study in the Journal of Nutrition that concluded “Nearly everyone fails to meet Dietary Guidelines.”

We are in desperate need of a serious serving of common sense when it comes to eating. With the possible exception of the recent “pink slime” (ammonia treated by-products in ground beef) nightmare, viewing foods as weapons of mass destruction is scientifically unsound and psychologically destabilizing. In fact, our burgeoning fear of foods has actually spawned a new eating disorder – orthorexia nervosa – the obsession with eating only “healthy” food.

With all of the admonitions to avoid this food, eat less of that food, and be sure not to get more than this percentage of calories from this food, maybe it is time to get back to basics. Wasn’t it grandma who said many years ago – drink your milk, eat your fruits and vegetables and go out and play? Maybe we need to reevaluate our alimentary recommendations. In this regard, perhaps we could follow the lead of our mother country across the sea, whose enlightened number one dietary guideline is – Enjoy Your Food!

Sadly, the committee responsible for the 1995 Dietary Guidelines for Americans came one vote short of including “Enjoy a Variety of Foods” in their recommendations for fear that such wording “would unleash unlimited license” for people to eat “whatever.” The rest, as they say, is history.

Gary Taubes was at it again recently, responding to “The Fat Trap” by Tara Parker-Pope spouting the same old rhetoric about how carbohydrates are poison and how the “obesity epidemic” is the result of too many carbs. As usual, his response was short on confirming evidence for his claims other than mentioning several clinical studies (no names or references) and the fact that severely restricting carbs has evidently helped him to lose weight.

The latest round of sugar bashing probably traces its origin back to an article by the lawyer (not nutritionist) Jon Banzhaf in the New Scientist in 2003 in which he argued that “fats and sugars can act on the brain in the same way as nicotine and heroin.” In a piece in The New York Times in 2011, Dr. Robert Lustig summed up the latest attack on the sweet tasting white powder from the health professionals perspective saying:

“Sugar is not just an empty calorie…It’s not about calories. It has nothing to do with calories. It’s a poison by itself.”

Of course the sugar as “empty calorie” concept makes no sense at all. A calorie is a measure of energy and carbohydrates are a nutrient – sugar has both. But that aside, the supposed dangers of sugar have certainly become legendary. Its damaging effects have been compared to those of another white powder and an entire industry – non-sugar sweeteners – has grown up around the fear produced by the legend. Experts have claimed that “most Americans are addicted to sugar” and a quick Google of sugar addiction will bring up almost 11 and a half million hits, more than 5 times the number for cocaine addiction!

What is it about this wonderful tasting stuff that inspires such trepidation? Well, the argument by the naysayers goes something like this. When people ingest sugar, it lights up the same nerve pathways in the brain that get lit up when people take cocaine. Therefore sugar must be addictive just like cocaine. In fact, the effect of virtually all drugs of abuse is largely dependent on activation of the body’s reward circuit or pleasure center – the mesolimbic dopamine system. While there are undoubtedly other mechanisms involved as well, all of these drugs exert their influence primarily by increasing the release of dopamine, which makes us feel good. So, what about sugar? Actually, it is true that eating sugar and sugary foods also increases the release of dopamine through these pathways and makes us feel good. Does this mean we are addicted to sugar? The biggest clue to the answer for this question is that sugar is only one of many factors besides addictive drugs that lights up these pathways. Here are a few others:

Music

Humor

Winning a prize

Expecting to win a prize

A mother recognizing her child

Attractive Faces

Smiling Faces

Oh yes, and being in love!

Are we to claim a pathological undercurrent for the enjoyment of all of these? Writing in 2010 in a review article in The Journal of Clinical Nutrition, Dr. David Benton, professor of psychology at the University of Swansea, Wales summed up the reality this way:

“That such a wide range of pleasant phenomena activate these mechanisms suggests that rather than seeing the stimulation of these pathways as something unusual or worrying, it can be viewed as one of a wide range of positive experiences that routinely stimulate a common circuitry.”

Interestingly, a closer look at the details unearths other discrepancies in the comparison between sugar and drugs of abuse when it comes to mechanisms of action. In fact, although these substances all do share some common pathways, sugar actually influences different populations of nerves in the brain, causes different patterns of firing, and induces different timings of the release of dopamine. As Benton explains: “reward response is highly dependent on the substances tested, demonstrating that multiple reward mechanisms operate that can encode for different stimuli.”

In spite of the evidence, the sugar as evil mantra is not likely to disappear anytime soon. You only have to go to the bookstore to see that – Beat Sugar Addiction Now, Break Out of The Sugar Prison, Lick The Sugar Habit, The Sugar Addict’s Total Recovery Program, How To Break Your Sugar Addiction Today, Little Sugar Addicts, Suicide By Sugar and of course Freedom from Obesity and Sugar Addiction – to name only a few titles. Even more unfortunately, many so-called experts are stuck in the food as addiction paradigm, leading to outrageous recommendations to an already confused and anxious population. In his recent book, The End of Overeating: Taking Control of the Insatiable American Appetite, physician and former Food and Drug Administration Commissioner David Kessler focuses on the alleged addictive qualities of highly palatable ( sugary and/or fatty) foods. He claims that the only way to deal with these foods is to banish them. He suggests that “the enduring ability to eat differently depends on coming to view these foods as enemies, not friends.” The solution according to Kessler is to retrain the brain to think “I’ll hate myself if I eat that.”

We know only too well that far from moving us towards that End Of Overeating,  this approach is one that has led and will continue to lead to exactly the opposite – more confusion, more anxiety, more shame and more overeating. My friend and colleague Dr. Karin Kratina has been treating disordered eating for many years. She shared the following with me about her experiences with the concept of food as addiction. She asks her clients “if I gave you a bag of sugar and a spoon, how much would you eat?” She says they look at her like she is crazy! I’m guessing this would be an unlikely response from someone offered the other white powder.

We in the health professions (and lawyers as well, evidently) seem to be constantly in need of pathologizing some food or another. I hope to write more about this in my next blog. 

Decades of research on the placebo effect support that people’s perceptions and expectations about their health can positively influence physiological parameters as well as the course and outcome of treatment. But, is the opposite also true? Can negative expectations adversely affect our biology? The answer to this question is yes and the phenomenon is called the nocebo effect.

The word nocebo comes from the Latin nocere (to do harm) and is defined as “the causation of sickness or death by expectations of sickness and death and by associated emotional states.” People most commonly equate the nocebo effect with Voodoo, a concept well-documented in so-called “Traditional Societies” throughout the world. There is, however, substantial scientific evidence that the nocebo effect is alive and well in contemporary Western Cultures.  Here are a few examples from the research over the last 4 decades:

When individuals with asthma were told they were taking a drug that would make their breathing more difficult, airway resistance increased even though the drug was composed simply of saline solution.

People who were susceptible to poison ivy developed rashes when given a harmless look-alike plant and told it was the real thing

25% of people with food allergies developed symptoms when injected with a benign substance and told that it contained the foods to which they were allergic.

The suggestion that a mild electric current was being passed through the head of healthy volunteers caused headaches in about 2/3 of the people in spite of the fact that there was actually no electric current.

A recent study in the journal Pain clearly demonstrates the power that people’s perceptions can have on their physiology. The authors reviewed 73 clinical trials from 1988 through 2007 involving comparison of the efficacy of 2 different anti-migraine medications (non-steroidal anti-inflammatories, and anticonvulsants) vs. sugar pills (placebos).  Non-steroidal anti-inflammatory drugs are known to cause stomach problems. Side effects from anticonvulsants include paresthesia (burning, itching, and numbness) and memory loss. In each study, participants were told they were going to be taking either one of the two drugs or a placebo. In all cases, people who were taking the placebo had side effects that were related to the drugs they thought they might be taking. No one who thought they might be taking an NSAID reported tingling or memory problems, and only people who thought they might be taking NSAIDS reported experiencing stomach problems.

Negative thoughts, feelings and expectations on the part of health care professionals can translate into potentially dangerous and even life threatening consequences for the people they are trying to help. In his excellent book, The Placebo Response, Dr. Howard Brody says that anytime a patient “feels less listened to, without a good explanation, uncared for, and less in control, then we’d predict that a nocebo effect is possible.” He goes on to say: “in our complex and often too impersonal health care system, nocebo effects must be rather common.”

In fact, the literature is replete with stories of individuals who appear to have suffered serious untoward consequences as a result of nocebo effects or what Dr. Andrew Weil refers to as medical “hexing.” In Spontaneous Healing, Dr Weil relates the story of a woman in her early 40’s who came to see him from Finland after being diagnosed with multiple sclerosis. Although the symptoms to that point had been limited to muscle weakness in one leg, she was depressed and related her story almost without emotion, as if it was all happening to someone else. It turns out that, as can be the case with this type of disease, the initial diagnosis had taken a long time to make and involved many tests. After finally sitting her down in his office and delivering the bad news, her neurologist excused himself and left the room only to return a moment later with a wheelchair that he invited her to sit in to “practice” for when she was totally disabled.

In a study at Massachusetts General Hospital, patients about to undergo surgery were randomly assigned to control and experimental groups that were matched for age, gender, underlying disease, severity of disease and type of operation. Those in the control group were addressed by anesthesiologists in a cursory manner. The anesthesiologist gave them his name and told them that he would be giving them the anesthesia the next day and that everything would be fine. The same anesthesiologists spoke warmly and sympathetically to those in the experimental group, sitting on the bed, holding the patients hand and discussing exactly what they should expect in the way of pain and suffering. The operations were performed the next day by surgeons and nurses who were not aware of which patient belonged to which group. The patients who experienced that simple 5-minute act of compassion needed only half the pain killing medication and were released from the hospital 2.6 days sooner than those in the other group!

Contrary to the traditional dogma of the separation of the mind from the body and of psychology from physiology, the literature on placebo and nocebo clearly demonstrates that thoughts, beliefs and emotions can powerfully affect our physical health. In all therapeutic encounters, treatment is delivered within a psychosocial context based on the expectations of the patient which is strongly influenced by her/his relationship with the involved provider. Every interaction has the potential to detract from or promote the healing process. Furthermore, the beliefs that people hold prior to entering into the therapeutic process can influence the outcome in either direction.

For the work that we do around size acceptance and weight and health, this information has particular significance. It helps us to begin to understand the devastating damage that can result from oppression, weight stigma, discrimination, marginalization, labeling, bullying, etc. even when they are done in the name of health. With the accumulated knowledge of the powerful effects that perceptions and expectations can have on our physiology it is time to realize that it is not only sticks and stones that can hurt us.