Tuesday, September 8, 2009

Weight Stability

A while back, I attended a tutorial where we discussed a fictional patient case. In the introduction, the patient is described as having gained 45 lbs over the past three years. Most students seem to believe that this is a reasonable amount for someone to gain simply based on becoming more sedentary and adopting a worse eating style.

I strongly disagreed. I think that the vast majority of the time when someone has a stable weight for years and then suddenly gains a significant amount of weight (175 to 225 lbs, in this case) it's almost always going to have a medical cause. Our bodies cling to our setpoints quite voraciously. It's HARD to gain that much weight from a stable beginning. Of course, there are exceptions: chronic dieters, psychiatric illnesses such as depression, and individuals who happen to be unusual weight gainers or losers.

It took me a while to figure out why this was making me so angry. I think that this attitude that it's so easy to just gain 50 lbs if you 'let yourself go' is behind this idea that somebody who is thin is actively doing something right to maintain their weight. So if somebody is thin it follows that they are maintaining a 'good' lifestyle. If they adopted a 'bad' lifestyle, they would become fat. That is, naturally thin folks have a vested interest in believing that it is easy to gain weight because the conclusion drawn is that they have a good, virtuous lifestyle that has earned them the right to be thin.

Of course, if somebody unintentionally LOSES any weight (even 10 lbs lets say) we'd be all over a medical cause for it!

15 comments:

Bill Fabrey said...

Very well said. I am afraid that med students probably have whatever biases they had before coming in, reinforced before they graduate. It's great that this blog exists, and I'd like to keep an eye on it! I found it on an automatic daily Google search on "HAES".

Bill Fabrey
Council on Size & Weight Discrimination
www.cswd.org
Mt. Marion, NY

Anonymous said...

I don't know, speaking from personal experience I've gained about 30 pounds over the past 3 years, and so far as I know I'm as healthy as the proverbial horse. I eat a healthy and balanced diet, exercise regularly, and only drink socially. However, I was previously a classic chronic dieter.

About 12 years ago, when I was out of college and living on my own, and when I started doing intensive physical work during the summer, I dropped somewhere ~50 pounds over the span of a couple years. Since then, my pattern has been to drop 10-15 pounds every summer (when doing intense hiking) and regain 15-20 pounds every winter. Over time that's led to a gradual gain. Then, in the last few years (conveniently in my early 30s) I've stopped losing much, if any, weight over the summers, yet still gaining weight during the winters (despite going to the gym and eating a 1500-2000 calorie diet).

One could argue that I'm approaching my original setpoint from my early 20s. But I don't think so. First off, I managed to maintain at a setpoint 20-25lbs below my current weight for ~5 years (though admittedly through HEAVY effort: 1200-1400cal low-carb diets, 8-10 strenuous hours/week at the gym. Of course, despite this effort, my BMI still hovered at 30 +/- 1, natch), until I adopted more of a HAES approach. Secondly, the rest of my family - none of whom are chronic yo-yo dieters - have steadily gained weight throughout their lives, despite maintaining consistent diet and exercise habits. I think it's quite possible that our genes don't code for a setpoint, at least one that can be maintained without heavy effort.

Collie said...

I think the age of your fictional patient would be an important factor wouldn't? People's metabolism do slow with age, so if this woman is maybe hitting menopause then it seems like it COULD be normal.

the fat nutritionist said...

This is an interesting point to make, and one I hadn't thought of in those terms.

By that same token, however, sometimes doctors are under-concerned when someone loses weight (especially if they were fat to begin with) because it's so often seen as a desirable thing -- even if that weight loss is actually unintentional and could be a warning of something going on.

I do really agree, though, that it's common to overlook potential medical causes of weight gain, and to instead assume it's entirely lifestyle-mediated. That's part of the reason fat people don't get the care they need -- they're assumed to be lazy and gluttonous before there's any question about what's going on with them medically. But lots of medical issues could be behind weight gain, like hypothyroidism.

Kipper said...

I gained almost exactly that much weight -- actually a bit more (from 170lb to 230lb) -- over about 4 years after moving to California. I was slightly less active in that I bought a car, but otherwise I have no explanation for the change. In the most recent 4-5 years I've lost a little over half of that gain without any consistent or strenuous effort...I actually feel like my "set point" has simply been ratcheting down bit by bit over the years (225 -> 211 -> 207 -> 202 -> 197). Again, I have no real explanation for the change.

First Year Med Student said...

I just want to thank you for starting this blog. I'm a first year medical student in the US, and after three weeks of classes I've already sat through several lectures on obesity and "nutrition" which were full of "comic relief" consisting of every tired fat stereotype in existence, the ultra-educational bags of fat, pictures of enormous burgers (which obviously all fat people eat for every meal), and more. The rage I feel as I watch my classmates snicker and whisper during the mock case videos we've seen (gasping at reported food choices, "wowing" at BMIs, and etc) is almost more than I can bear. I also fear for the generations of chubby kids who'll see the future pediatricians in my class, or for the scores of women with PCOS that will spend years in undiagnosed misery due to physician bias and ignorance, or the patients who'll be belittled for med-related weight gain instead of offered practical guidance, or the teens who lose tons of weight due to ED or disordered eating and are praised by their doctors. In short, it's been really rough to sit through, especially when no one else seems to see the horrible skew in the info we're "learning."
Reading your entries, and all the other HAES and FA literature out there has truly helped, so thank you again. Your blog gives me hope for the future of HAES concepts, and an emphasis on achievable health goals instead of size, in medicine.

chartreuse said...

Collie -- this amount of weight gain would be quite unusual even for someone during menopause. In this case the patient was male, I think. Still, thinking about menopause is a good example of trying to come up with a medical reason for weight gain outside of just saying that someone is 'letting themselves go'.

chartreuse said...

Kipper -- At the point where you had gained that weight, personally I would consider that to be a medically significant weight gain that deserves investigation.

chartreuse said...

Anonymous -- sounds like you've had a long and difficult journey around eating and weight. I hope things are getting better for you. It sounds like you had some significantly eating disordered behaviours for quite some time, and, to me, that changes the whole story in terms of identifying set points and explaining the meaning of weight changes.

chartreuse said...

First Year -- I encourage you to speak to your professors or dean about what's going on, they may be more supportive than you think. It helps to take detailed notes of exact phrases that are said in class. Things look worse and are taken more seriously when they're documented in detail.

Orodemniades said...

Could you talk more about setpoints? If I have a setpoint, it appears to ramp up as time passes with no particular change of behavior on my part. I don't lose weight through exercise and quite frankly, have a bit of trouble actually believing in the concept of the setpoint...

...however, I also have PCOS, so maybe that makes a difference?

Mantis said...

About a few months back I went to see my doctor and I am a size 14. I regularly refuse to be weighed in doctor's offices because I feel that the humiliation and suffering at never being a "nomral" weight far outweighs whatever health information they may glean from my weight.

I went in to review a general blood test because of some headaches Ive been having. Everything NORMAL. (Except triglycerides which I expected due to wine party night before:) blood pressure everything normal.

My doctor could stand in for dr. phil with a paunch and his assistant must be a size 20. They saw me refuse the scale as I walked into t he office.

He comes in and after talking about what I came there for proceeds to tell me that I could stand to lose some weight and that weight is attributed to all kinds of health risk behaviors.

WTF... seriously???

I proceed to tell him that all the data shows that my weight is not tied to health when in an active lifestyle, that I am a vegetarian (he had the teremity to look suprised) that no diets work and when he has personally found a weight loss procedure which is actually sucessful more than 5% of the time (like all diet plans now) then I would be more than happy to hear about it but until then how dare he point out a "problem" for which there is no "cure".

And to me... the hubris in having a fat man and a fatter assistance tell me to lose weight...are you kidding me?

anyways this is a vent but I will not be back to see that dr. I wish more than anything I could find a HAES supporting doctor. :( I think that a lot of the data we are seeing where there are correlations between weight and illness may have a lot to do with heavier people being so abused and made to feel like the modern day leper that they do not seek treatment for issues until it is so acute they have no choice but to seek out help.

I hear that once medicine was polite to people... when did that go away?

Anonymous said...

About a few months back I went to see my doctor and I am a size 14. I regularly refuse to be weighed in doctor's offices because I feel that the humiliation and suffering at never being a "nomral" weight far outweighs whatever health information they may glean from my weight.

I went in to review a general blood test because of some headaches Ive been having. Everything NORMAL. (Except triglycerides which I expected due to wine party night before:) blood pressure everything normal.

My doctor could stand in for dr. phil with a paunch and his assistant must be a size 20. They saw me refuse the scale as I walked into t he office.

He comes in and after talking about what I came there for proceeds to tell me that I could stand to lose some weight and that weight is attributed to all kinds of health risk behaviors.

WTF... seriously???

I proceed to tell him that all the data shows that my weight is not tied to health when in an active lifestyle, that I am a vegetarian (he had the teremity to look suprised) that no diets work and when he has personally found a weight loss procedure which is actually sucessful more than 5% of the time (like all diet plans now) then I would be more than happy to hear about it but until then how dare he point out a "problem" for which there is no "cure".

And to me... the hubris in having a fat man and a fatter assistance tell me to lose weight...are you kidding me?

anyways this is a vent but I will not be back to see that dr. I wish more than anything I could find a HAES supporting doctor. :( I think that a lot of the data we are seeing where there are correlations between weight and illness may have a lot to do with heavier people being so abused and made to feel like the modern day leper that they do not seek treatment for issues until it is so acute they have no choice but to seek out help.

I hear that once medicine was polite to people... when did that go away?

Five Hundred Pound Peep said...

what I want to know is why the hyperthyroid people are told they have lost massive amounts of weight and it's medically caused [like my sister] but the hypothyroids and others are told all the weight is their fault?

I had a massive weight gain in the late 90s that was found to have medical cause, I still think they never got to the full root even now, but at least got some help and if I had not been able to stop the 30lb weight gain per month I would have been dead.

http://fivehundredpoundpeeps.blogspot.com/2010/07/my-350-400-pound-weight-gain.html


Why is the medical establishment ignoring the concept of people having different metabolisms?

Cathy Addams said...
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