Two years ago, at a small cabin in the San Juan Islands, I put a ladder on a slippery deck and stepped on it, and something happened that will surprise nobody but a woman utterly intent on fixing a rain gutter: it slipped off. I landed on one leg, fragmenting the knee joint. My husband hauled me to the beach and onto a boat and into a car, and ultimately I ended up at the best trauma center in the region, Harborview Hospital in Seattle.
During the aftermath of surgeries and narcotics, I got skinny, and then, over time, I gained back my normal weight, which put me at the low end of obese. Through the first year after the repair, my knee gradually felt better and better, but as I gained, it started hurting more. I talked to the doctor. “You did quite a job on that joint,” he said in a matter of fact tone. “At some point you’ll have to replace it.”
“But what about all of the metal?” I asked, gesturing toward my upper calf, where scars mark the steel plates that run down the top three or four inches of my tibia. “What about all of the screw holes?”
“Oh, we’ll just cut the bone off below all of that.” he said.
I had the same visceral reaction you’re probably having right now.
That isn’t happening, I thought. Two months later I elected an alternative procedure that I hoped would buy me an extra decade on the knee, a bariatric surgery that removed part of my stomach.
Any surgery has risks that have to be weighed against possible benefits, and for many heavy people the risks of stomach surgery would outweigh the benefits. But for a number of reasons, I chose to make the gamble. I’ve been “sturdy” all of my life: early maturing, strong and stout. Even at 5’4” I think of myself as a big person because in the second grade I was big—proud to outweigh and outrun most of the boys in the class, proud to have the largest feet. By age 16, though, I felt like a cow and had developed a sense of body-loathing that kicked off a four year struggle with bulimia. I recovered, but becoming a mentally healthy adult has required a truce with myself that involves relentlessly fending off the beauty myth and refusing to diet. To this day, dieting just makes me compulsive about eating, which is why, when I wanted to save my knee, I turned to the kind of people who had saved it in the first place, surgeons.
Over the next nine months, I lost about forty-five pounds, and my knee stopped hurting, which turned out to be an especially good thing when I injured the other knee and my bad leg had to function as my only leg for a while. Today I can walk and even run a little without pain thanks to remarkable people who spend their lives figuring out how our bodies work and how to repair them.
My surgeries changed me. The knee surgeries were, essentially, highly sophisticated carpentry–mechanical repairs, if you will. I feel a certain kinship with the antique chair in my basement that sports a metal hose clamp as a permanent part of one repaired leg. But the bariatric surgery was a different thing altogether, and it changed how I think about weight.
Most Americans believe that weight loss is a matter of will power. We hear it all the time—in the words of doctors who advise middle aged people to lose a few pounds; on sit coms where fat people play out stereotypes; in advertisements where buff means lean; and in the sometimes subtle but ever present denigration of fat people. People who are fat are lazy or weak, sloppy or indifferent. Implicitly, they deserve knees that hurt and blood sugar problems, even poverty, early death, and worse: rejection.
This sort of thinking is a product of American culture, which teaches that with enough determination you can become anything. Self-made men are created ex nihilo by sheer force of will. Ordinary people can and should bootstrap their way to success even if they were born into families that couldn’t afford boots (or education). Addicts should have the fortitude to quit shooting up. Fat people should have the fortitude to quit eating.
As a budding adult who felt at times like a whale, this was the sea I swam in. By the time I was offered psychotherapy at age 19, I felt too hopeless to take it. If I couldn’t stop my compulsive eating with a combination of prayer and will power, then I was a wretched excuse for a human being. It would be years before I understood clearly why the combination didn’t work.
Like most powerful falsehoods, America’s cult of will power is built on a foundation of truth. Determination is powerful, and we tend not to get far in life without it. Some people do bootstrap themselves out of poverty—with a little help from their friends and public infrastructure. People sometimes can convince themselves to believe things that serve their self-interest, evidence be damned. (In technical parlance it’s called motivated reasoning.) Dieters do lose weight while they are restricting their food intake. Our choices do matter.
But as the Yiddish proverb says, a half truth is a whole lie.
Forty five million Americans report being on diets at any given time, yet according to the Centers for Disease Control, 36 percent of American adults are obese (BMI 30+) and another 33 percent are overweight. In case you’re not counting, that’s sixty nine percent of us who are fatter than we should be, fatter than we want to be. The medical establishment and diet industry have responded with a proliferation of products and with a broad vocabulary that blames faulty diets and dieters for our inability to weigh less. Crash diets are bad, but proper diets work. People who regain weight need to exercise more and eat more vegetables or try the next new magic bullet: Atkins, Big Breakfast, Caveman (Paleo), Detox, Eat-Clean, Five Factor, Grapefruit . . . I won’t go all the way through the alphabet. The bottom line is, if you didn’t lose weight and keep it off, you chose the wrong one or did it wrong.
Some of the diet offerings are transparently silly, but the reality is that even the most sensible diets rarely work well or for long. One analysis reviewed 25 years of weight loss research. Dieters who persisted for three to four months in a structured program lost an average of almost 25 pounds. By the end of a year, this had dwindled to 18 pounds. Only a few programs kept track for three years, and by then the few participants still weighing in had maintained about 14 pounds of weight loss—significant but far less that the loss most obese people are seeking.
In reality, lasting weight loss was probably much lower than these published averages. Around half of dieters drop out before their chosen program is completed. Pleased customers are more likely to stick with a program for three months or answer questions three years later. Successful programs are more likely to be included in the published research. Thus, published results likely overestimate the effectiveness of weight loss programs.
Weight Watchers has built a multimillion dollar company based on slow, healthy weight loss bolstered by social support. It is thought to be one of the more sensible and comprehensive programs available for weight management. Even so, it has been the focus of significant controversy in recent years, and not just because of questionable employee practices. Three randomized controlled trials that studied Weight Watchers programs found a weight loss of merely three percent after two years. That’s six or seven pounds for a person who started out at two hundred, and again, people who dropped out of the study likely had poorer experiences than those who stuck with it. Biology’s a bitch.
I first got an inkling of the power of biology in my own weight struggle about a decade ago when I suffered a bout of low grade depression. My doctor put me on a drug called Wellbutrin. Within a few weeks I noticed that the sun was brighter and I was humming in the car. More surprisingly, my migraines were gone, as was my lifelong tendency to fret about the health of our pet rabbit or chickens when there was nothing bigger to worry about. Most unexpectedly, my appetite changed.
Normally, when my blood sugar drops, it crashes, and in the absence of food I turn into a wild-eyed witch. My husband always carries snacks when we are traveling. Even in the absence of a crash, hunger doesn’t just call to me, it bugs me like a whiny dog until I do something about it. On the medication, I found myself thinking I’m kind of hungry, but I’m busy and I’ll get at that later. It was an alien thought, and it led to a very un-Valerie eating pattern. Plain and simple, I felt like I had more of a choice about what foods I ate, and which to ignore, and I ignored more. Consequently, my weight dropped back to what it had been during my twenties. Six months later, the headaches started to return, followed by the nattering anxiety, then hunger and weight. My body had found a way to fend off the medication. Fortunately, my mood had lifted, and so I went back to my regular rhythm of life. But not without marveling that so many aspects of my experience could be altered by a single set of neurotransmitters!
So, last spring, when I started trying to figure out what to do about my knee, there was a reason I decided to have part of my stomach removed rather than, for example, merely having it banded like New Jersey Governor Chris Christy did. Any bariatric surgery would have reduced how much room I had for food. But from what I read, removing part of the stomach would change the way my body regulated appetite by decreasing a hunger hormone called ghrelin that signals the appetite regulation neurons in the hypothalamus. My brief experience a decade earlier had convinced me that those hormones are powerful.
Sure enough, once I had healed from the surgery itself, it was clear that something was different in my brain. I could go four hours without thinking about food. I didn’t crash when my blood sugar got low. I could finish a task and eat when I got around to it. When I actually felt hungry, I had no more self-discipline than I’ve ever had, but I was making different choices, and so my body changed too. Where I used to have soft, smooth extra chins, I had soft wrinkles. My daughters missed my lap. My husband lamented my Italian ass. But it was a fair trade, I think, for knees that could hang in there with me from sun up till bedtime.
Perhaps the biggest gift was the freedom I got from the constant chatter in my head that used to interrupt me while I was trying to think (often while I was trying to write). It might sound odd, but back when I was eating more, I also was saying no thanks to food way, way more than I am now. A person can say no to a bowl of chocolate espresso ice cream twenty times and give in the twenty-first, and that counts as failure rather than a feat of resistance. That was my life story. I said that I have no more self-discipline now than then, but the reality is probably that I have less. Temptation simply doesn’t come calling the way it did.
Back in grad school I had a friend, let’s call her Cara, who was a marvel to me. Cara could buy a cookie at the lunch room in the basement and then carry half around for the rest of the day. I would buy a cookie, finish it on the way up the stairs, and then go get another. The thought of carrying half of a cookie for hours was inconceivable. I wouldn’t have been able to think, uninterrupted, about anything else until it was gone.
Recent research suggests that I’m not a rare mutant in this regard. Resisting a cookie takes mental energy—executive function, it is called—and when people are putting energy into resisting temptation they do less well on other cognitive tasks. Furthermore, people who are fatigued from hard mental work have a harder time resisting temptation. Cara is an outlier, and so am I for the time being. (For about fifteen percent of people with my surgery, their body finds a work-around and they get their old hunger back and regain the weight.)
I have some friends who have real self-discipline yet who are, by CDC standards, obese. They are strong, smart, determined women who have charted the courses of their own lives, including high powered careers. They have lost weight the old fashioned way—and gained it back. One friend did an expensive, extended diet and exercise program that took off a hundred pounds. Another clamped down on her food intake and trained for a marathon. Another has spent weeks and thousands of dollars at retreats where she devotes the full formidable power of her mind and body to getting fit and healthy. Still another can ride a bicycle from Seattle to Portland no matter how much she weighs. If I can be accused of taking an easy way out, the opposite is true for them. These women are Amazons. They are forces of nature, fit and beautiful, and they are fat.
Here is what incredible, strong obese friends and my own history have taught me: Fat isn’t about being weak or lazy or sloppy or indifferent. It’s mostly about biology. And the fact that we humans are getting fatter en masse says there’s a misfit between modern culture, economics, technologies, and food supply and the average human body. As of 2006 there were more overweight people in the world than hungry ones. Obesity has become a global norm. Our bodies are optimized for survival under conditions of scarcity. We are programmed to want fat and sugar, carbs and salt, and to eat them when we can get them. The same can be said for our dogs and cats, and many farm animals.
Like any other evolved characteristic, of course, the intensity of this call and response varies. Variety is what makes evolution work. Some of us are like Cara, meaning it takes relatively little effort to tune out the call and make healthy food choices. But for some of us at the other end of the spectrum resistance is a full time second- or third-shift job for which we simply don’t have the energy—or a hope in hell of succeeding.
Together we know more than enough to challenge fat-shaming as a last bastion of bigotry. As J.K. Rowling put it, “Is fat really the worst thing a human being can be? Is fat worse than vindictive, jealous, shallow, vain, boring, evil or cruel? Not to me.” Not to me either. Not even close.
It’s time to get over it.
It’s also time to tell any doctor who suggests dropping a simple twenty pounds Go drop it yourself. Cut the pep talks. Cut the A-Z diet list. We already know we’d be better off health-wise if we lost weight. We already know we’d have better odds in romance and job interviews and getting smiles from passersby. You don’t need to convince us to care. For many of us, it’s not a matter of where there’s a will there’s a way; it’s a matter of where there’s a way there’s a will. If doctors and other public health advocates want people to be less fat, they need to get real and find better alternatives. Promoting diets is about as sophisticated and effective as promoting sexual abstinence for teens.
Just beneath the surface, many fat people are caught in endless cycles of self-scrutiny and utterly baseless self-blame about their weight: Was it my childhood? Is it my birth control? Is it my conflict avoidance? Am I staying up too late? Am I going to bed too early? The recriminations are not only baseless they are useless and worse. They can lead to depression and despair. They can suck the pleasure out of sports or create a vicious cycle of overeating as a form of self-punishment for overeating. They can draw energy away from big dreams and projects or small wonders and beauties, or the creativity and passion a person would otherwise put into making our world a little better.
So, the next time you see someone you think is fat, or the next time you hate on yourself for weighing more than you wish, try a little kindness. With all of the relentless social and health pressures you can rest assured that most fat people have tried, are trying and—whenever they can muster the energy–will spend their lives trying to eat less and weigh less.
Lastly, please remember this: Most fat people exercise more will power every day than the cookie carriers of the world can possibly imagine.
Valerie Tarico is a psychologist and writer in Seattle, Washington. She is the author of Trusting Doubt: A Former Evangelical Looks at Old Beliefs in a New Light and Deas and Other Imaginings, and the founder of www.WisdomCommons.org. Subscribe to her articles at Awaypoint.Wordpress.com