On sacrificing our health to focus on our weight

In September, the media in New Zealand sank their teeth into the idea that obesity (always a problem) is caused by food addiction (finally a reason). “Food like meth to addicts,” Obese need help to kick addiction,” Third of Kiwis ‘need to kick food addition’”. These stories were generated from a press release that suggested that obese people in New Zealand are addicted to food and should be given treatment to combat their addiction. As you probably expect, my eyebrows raised when I began seeing these headlines. As the known fat [spokes]person in New Zealand, I waited for my phone to ring. I did not have to wait long.

I was not the only one who questioned the voracity of this claim. Andrew Dickson suggested that the problem was one of confusing metaphors and falling victim to metonymy.  John Pickering astutely noted that when the only tool you have is a hammer, everything looks like a nail. The academic at the centre of the press release is Professor Sellman, the Director of the National Addiction Centre (University of Otago), and a scientist with an impressive record of scholarship. A glance at the research projects listed on the NAC website does not reveal any studies however, past or present, into food addiction and its relationship to body size. One current study ‘Problem Food’, is exploring the relationship between obesity and what the researchers identify as ‘problem foods’. According to the project blurb on the website,

People become obese by eating more than they need, but assisting people to eat a little less and exercise a little more with standard psychosocial treatment has produced limited results. I am always struck by the language learned individuals use to acknowledge the 95% failure rate of lifestyle changes to produce meaningful, permanent, weight loss. In addition, some foods (what we call ‘problem foods’) encourage overeating, especially in people with obesity, although this varies amongst individuals. A nod to acknowledge that most fat people do not engage in overeating, and that many that overeat are not fat.

Despite knowing that ‘problem foods’ play a role in maintaining obesity, we do not yet know what the best advice is to give people about how they should handle their problem foods. This means that we do not know whether it is best to tell people to stop eating their problem foods altogether (abstinence) or whether we should tell them to cut down on the amount of their problem foods that they eat (moderation). At this point I am wondering the purpose of this project. If the problem is obesity, and weight loss is impossible, then why do these problem foods matter? Wouldn’t it make more sense if this kind of work was framed in a health narrative, rather than a weight narrative? May I suggest this as an alternative: Independent of weight loss, we want to encourage people (of all sizes) to make nutritious food choices.

I cannot help but wonder whether the weight narrative is due to the funding available to those engaged in research around obesity.

In the ‘Problem Food’ Study, headed by Professor Doug Sellman, we are investigating which advice is best to give to people with obesity to help them lose weight and maintain that weight loss. All other studies across the last 70 years, have failed to do this – but we’re going to give it a try! This is a randomised controlled trial of 250 obese participants (BMI 30-40) who are randomised to one of three conditions i) abstinence from problem foods, ii) moderation of problem foods or iii) wait list (receive no treatment for six months before being randomised to moderation or abstinence for six months). The length of study is important – six months is enough time for participants to lose a meaningful amount of weight, but not enough time for them to gain most of it back.

All participants receive six months of active treatment focusing on lifestyle change with support from a personal health coach. In addition, during that six months those in the abstinence group will attend Overeaters Anonymous groups and those in the moderation group will attend Weight Watchers. Again, the false assumption that the fat people in their study are addicted to food and would therefore benefit from attending OA meetings.Four key outcomes sought are loss of body fat, increased physical fitness, improved nutrient intake and increased well-being. Recruitment will commence in 2009.

It is possible that the theoretical foundation and hypotheses of this project arose from this research. It explored the emergent themes from reports filed by 72 fifth year medical students who had attended a single meeting of Overeaters Anonymous each. Two of the themes that emerged revolved around addiction: conceptualising food as addictive, and the experience of being addicted to food. OA embraces the addiction model. It is modelled upon Alcoholics Anonymous, promoting the use of Twelve Steps among members. It should not be surprising that individuals who attend these meetings identify as addicted to food – nor should it be surprising that an observer to the meeting would identify members as suffering from an addiction as well.

It is also important to acknowledge the role of social mores in a study such as this. Take OA, for example. I have never identified as someone who overeats, and I have never attended a meeting of OA. I would hope that it provides help for those who desire it. Those who attend OA would do so because they believed they (may) are addicted to food. And perhaps some who attend OA do so at the advice or instruction of concerned doctors, family members, or friends. And the *recognition* of overeating is probably strongly tied to an individual’s body size. I would imagine that the majority of those who attend OA have a similar body size.

This provides the illusion that only fat people overeat, and this is a dangerous assumption to make; a false one as well. How many non-fat people are identified by others as overeaters? How often do doctors assess their non-fat patients for overeating?

Let me be clear that I do not have a viewpoint on whether food addiction is real. The literature I have read suggests that those engaging with this topic have mixed feelings about this concept. One review article notes the problem in the lack of validated measures to establish food addiction in research. Others have noted that only a small amount of obese individuals demonstrate qualities that meet the diagnosis of food addiction.

When I read the criteria for food addiction – including (1) a persistent desire or unsuccessful attempts to cut down on food, (2) consuming larger amounts of food than intended, and (3) the continued use of food despite physical or psychological problems – all I can think about are the dynamics between dieting (especially yo-yo dieting) and our relationship with food.

When I used to wage war with my body, I often found myself obsessing about food. What I ate. When I ate. When I could eat again. How much I could eat of what and when, and what it would mean for the rest of my consumption for the day/week/month/etc. As many have written before me, engaging in dieting behaviour often leads to preoccupation with food. And it often leads to consuming more than intended – and dieting definitely leads to physical and psychological problems. It makes me wonder how much of what is classified as food addiction is really just an environment created by the dieting culture?

Much of the research on food addiction and body size may be biased by the assumption that food addiction is only present in fat individuals. As one study noted, “Healthy, normal weight individuals, by definition, do not suffer from food addiction; however, overweight and obese individuals could meet clinical criteria”. Assuming that an individual’s body size tells you their likelihood for an addiction is dangerous and unhelpful. Just as assuming that an individual’s body size tells you their likelihood for an eating disorder is dangerous and unhelpful. But alas, both falsehoods are all around us. And much of the research is based on the clinical overlap between BED and [drug] addiction – which is different from a clinical overlap between obesity and addiction – but that is only a problem if you are unwilling to conflate body size/obesity with BED.

Overall, what I have read indicates that body size is not a reliable predictor of food addiction. Whether or not food addiction exists, we do a disservice to everyone who is affected by it when we suggest that only fat people may be food addicts, and that all fat people must be food addicts.

Going back to the ‘Problem Food’ study, it is possible that these foods are the same ones identified by Sellman and colleagues in the NEEDNT Food List. This list is comprised of foods identified by the team as non-essential, energy-dense, nutritionally-deficient foods. Items ranging from alcohol, chocolate, cream, honey, jam, museli, sour cream, and whole milk all make this list of ‘problem foods’. The presentation of the NEEDNT list has been couched within an obesity epidemic narrative. The press release and subsequent news stories about the list all suggest that obese people need to be warned away from these foods. I’ve written about this before, but it is worth repeating here,

This is the usual discourse of the obesity epidemic and it shows how the authors fail to recognise that if foods are lacking in nutrition then all individuals – regardless of size – should be told to avoid them. Why is the focus, understood as prioritising health, directed only at fat people, who are assumed to be unhealthy based on their weight?

When I engage with the media, I am often admonished by media personalities with something like this, ‘But you can’t be saying that being fat isn’t unhealthy?’ ‘You must agree that being fat is unhealthy!’ And when I do refute the idea that being fat is unhealthy, then they always go in for what they see as the common sense-no brain-kill question – ‘But surely it isn’t okay that kids drink nothing but fizzy drinks?!’  (or some version of the ‘But who will think of the children!’)

My response is always the same: If we want to have a public health conversation about the health of kids, then let’s have one. Let’s talk about the health of all kids, regardless of size. If we want to talk about whether kids should be drinking fizzy drinks, then let’s have that conversation. But why is it only a problem when fat kids drink fizzy drinks? Why do only obese people need to be educated about the foods identified on the NEEDNT list?

Allow me to answer my own questions: We have allowed ourselves to conflate weight with health so many times that we fail to realise when we are sacrificing our health in order to focus on weight.