But What Do You Know?

As regular readers already know, I’m a major Buffy The Vampire Slayer fan.  There is a scene where she is teaching how to kill vampires and she says “It’s not what do you think, it’s always what do you know.”  That flashed into my mind today during a panel discussion that I was involved in.

One of the panelists was a dietician and 90% of what she said was information that was accurate based on my research and she had a really positive attitude.  She made a really interesting point that we are being told to eat more closely to nature but we judge our results by the completely artificial standard of modern beauty – she asked the group how we would eat if there were no mirrors.  Great question!  But then someone asked about weight loss and she said that the reason that 95% of people gain weight back after diets is because they lose weight too fast.  That caused me to raise an eyebrow because I don’t know of research that supports that.  Then she said that people who lose weight very slowly keep it off long-term.  Note that she didn’t say that these were her ideas or opinions.  As the only professional dietician on the panel she said these things as if they were true.

So I asked if there was any research to support that and she admitted that there was not.  I later pointed about that there isn’t any research that shows any method of weight loss that works, and the rest of the panel nodded their heads in agreement.  The effects of this were amplified by the fact that I was at CalTech where most, if not all, students are trained to make decisions based on evidence. Several audience members came up afterwards to thank me for taking an evidence-based approach.

People who are looked upon as healthcare experts need to realize that there is a vast chasm between what they think and what they know, and it can only be crossed through disciplined research. That doesn’t mean that it’s not ok to give theories, talk about what evidence might suggest (without mistaking that for being ” sure proof”), or make their own choices based on what they think is right.  But they still need to have the intellectual humility to realize that they cannot ethically and responsibly state their opinions or pet theories as fact when they are speaking in a professional capacity, regardless of how good their intentions might be.

If we were making health decisions based on evidence we would have long ago suspended the practice of recommending dieting on the basis that there is no evidence that would lead us to believe that it is possible for most people and there is evidence to suggest that it may be dangerous. One of the reasons that dieting continues to be recommended by healthcare “professionals” who should know better is that they are confusing what they think for what they know.  That’s dangerous, and for those who get paid to sell weight loss it borders on perpetrating a fraud.

We may not be able to stop them from doing it, but as consumers we can educate ourselves to know the difference, and we can demand that our healthcare professionals provide us with evidence to back up their interventions and treatment plans.  You are the boss of your healthcare underpants, don’t trust them to just anyone!

I wrote a piece for iVillage about the dangers of villifying a certain food (fat, sugar, carbs, gluten).  You can find it here. As always if the mood strikes you, it’s awesome if you want to read and comment!

This blog is supported by its readers rather than corporate ads.  If you feel that you get value out of the blog, can afford it, and want to support my work and activism, please consider a paid subscription or a one-time contribution.  The regular e-mail subscription (available at the top right hand side of this page) is still completely free.   Thanks for reading! ~Ragen

23 thoughts on “But What Do You Know?

  1. My husband is a fatty like me, but we’ve had arguments about a lot of things. Talking about people’s bodies, doctors, that sort of thing. I don’t want to get too specific, because it’s a bit triggering for me, so I can only imagine it would be for others. Getting upset doesn’t help, so I’ve had to try to stay calm and make parallels. “Why are fat people always eating stuff that’s bad for them in pictures?” “For the same reason any group is presented living up to stereotypes about them.” That sort of thing. One thing that he has trouble hearing me about is doctors. They went to school for a million years, after all, so they must know more than any lay person. I tell him that doctors are people, too, and that in order to make a diagnosis they have to feel sure of themselves; this can lead to hubris, which, just like you’ve said here, can make them say what they think as though it were what they know. He’s coming around. He’ll never be a fat activist, but at least he’s more careful about what he says to me.

    1. Doctors do know more than the average lay person about medicine, however, we are also human and make mistakes. I see weightloss being prescribed with care and a true desire to help. Naturopaths are really good about trying to focus on eating a balanced whole food diet and if they would stop there, I think it would be very beneficial to patients. They always add the “to lose weight” or “need to lose x amount of weight” though, which is where things get messed up. I think what they see is people start eating well and moving who DO lose weight and keep it off, but don’t become thin. I think the docs see the massive improvement in health and wrongly attribute it to the weight loss and not the improved habits. They then think,”if we just tween this and that, the patient will lose more weight and become even healthier!!!” when that is not necessarily the case. When I see someone improve their habits and lose weight as well as feel better, I am glad they are feeling better and assume that they were over (or under if they gain) what their body had as their set point and the loss/gain is a rebalancing, not something I need to push.

      So give the doctors slack, but don’t let them bully you with all of their “knowledge”! Heck many docs still prescribe antibiotics for viral infections. *headdesk*

    2. Most US medical schools, at least, have maybe one class on nutrition. I don’t mean “one class over a semester”—I mean one class meeting/lecture devoted to discussing nutrition.

      1. I’m in naturopathic medical school. We had 4 full terms, so if available, NDs can provide amazing medical care. Supporting legislation can help make them more available to more people. I should have been more clear about the angle I was coming from.

        You are right about MDs’ education in nutrition. In that case, I would hope they have the wherewithal to enlist the help of a nutritionist and we can work on making HAES the approach most nutritionists use!

  2. Coming from one who has suffered at the hands of misinformation on dieting and weight loss my whole life, ( my mother had my doctor prescribe amphetamines for me when I was 8, can you imagine what that does to an 8 year old? and that was in the late 60’s) I have learned that I have to allow my mother to have her beliefs… and she buys into every theory that comes down the media influenced pike and when I was a child she inflicted each and every one of them on me. I tell people all the time I dieted myself into morbid obesity and it almost killed me.

  3. The media reviewer in Esquire (this was ages ago–don’t remember his name) was comparing Buffy and X-Files and said (brilliantly, I thought at the time) that X-Files appeared to be about profound and important stuff, but was actually fairly shallow (he wasn’t saying this was negative, per se–he was talking about how things are often mis-read) and that Buffy appeared to be lightweight and silly, but was actually about many of the most profound questions. Your reference here is a nice case in point.

    I have often wondered about the slow-loss issue. It would be nice if someone would actually take a look at it. But it’s probably not shiny enough for people to pay that kind of attention to. erg.

    1. Wow, apparently I have a lot to say today. I hope you all don’t get bored!

      The following is my theory (it isn’t bunnies) about why slow weightloss “works” better.

      I think the “slow loss leads to permanent loss” idea comes from what I mentioned above. Many people who have not been eating well or moving much or too much or are under a great deal of stress begin to make changes in those things for the better. While they were engaging in the less healthy behaviors, their bodies may have added or subtracted pounds they normally would not to maintain a balance. When they begin to change their habits, their bodies may at first not do much, but as the habits begin to be more established, the body decides it is ok to go back to where it wants to be. This would likely cause weight loss or gain, slowly, and if the habits are continued, the body would level out at some point.

      This sounds amazing until someone’s body changes weight by 10-30 lbs and stops, but they are still not at their “ideal” weight. Because they have been told that getting there is very important, they may change those habits to further change their body, which starts the whole crisis cycle of their body anew. I think maybe this is why set points change. The body can’t relax so it gives itself more wiggle room.

  4. I have been taking issue with “evidence based” medicine lately. As a naturopathic medical student, I see our medicine being poorly researched then vilified as “quackery” while many conventional approaches continue unchecked despite their lack of research evidence and ample practice based evidence that they are not helpful. I have “evidence” of the benefits of dieting and the “proof” of the “obesity epidemic” spouted off in my classes weekly, even as I have “evidence” that counters it. (evidence is getting the quotes regardless today) I feel like I am caught in a biblical discussion where the same passages are being used to argue effectively for both sides.

    On top of the many many poor research studies out there (my school is doing a lot to better the naturopathic studies at our research institute, Helfgott) it seems we rarely have an opportunity to actually SEE all of the research. Why were some people actually cut from the study? What happened to those who quit (if that info is available)? What does “eating a healthy diet and exercise” actually mean to the researchers? What preparation and dosing were used for herbs and nutritional supplements?(that does not always make it to methods) Why is a sweeping conclusion made from an N of 10?? How can we even trust any study funded by someone who stands to make money from a positive result? What neutral parties are going to have the money or desire to fund these studies?

    I’ve also go a bit of a beef with access. I have access to PunMed and many other sites through my school where I can get full articles, but when I started looking up the obesity references for a recent lecture, I could not gain access to most of them without paying. So frustrating! I find this often actually.

    I know this ran long, but I have so much more skepticism when it comes to “evidence based” medicine than I used to have. Not that there isn’t a place for it, I just think we need more accessibility, neutrality in funding, and transparency in reporting.

  5. DeAun, I appreciate your comments about the strengths and weaknesses of evidence-based medicine. As the old saying goes, “Garbage in, garbage out.” If the study itself is flawed (as so many are), then any meta-analysis based on the results of that study is flawed also. I’ve seen some pretty appalling stuff in obstetrics research along those lines.

    And the question of funding/researching by people who stand to profit from the research’s conclusions or products is an extremely important one in obesity research, where conflicts of interest taint nearly everything. Why the primary reporters of results on WLS are weight loss surgeons (who stand to profit greatly from positive results) is beyond me.

    We really need studies done by independent researchers with no possible ulterior motive about WLS, no point to prove about weight loss in general, and no ties to any obesity foundation, weight-loss company or center, drug company shilling wt loss drugs, etc. Sadly, those folks are few and far between.

  6. I just had to pop in here and say I’m a huge Buffy fan, too. And I always come away from this blog brimming over with smelly knowledge that would make Giles swoon with delight.

    So there.

  7. I think the idea that there are people who make big permanent weight losing changes in their life style is urban legend. Great post!

  8. I’m sure a lot of them do, but allow themselves far more license in this area due to the suspension of basic standards of intellectual rigour.

    Those that do will continue until they meet more like yourself willing to take a no nonsense attitude about it.

  9. So I know I am a childbirth info freak, but I have come to distrust modern medicine and doctors because of the unsafe practices they continue to promote. And I think its parallel to fighting HAES

    Take cutting the infants cord right away. This practice started just out of pure convenience even though now we know its dangerous to the baby – they experience a 30% blood loss when their cord is immediately clamped/cut. But now that the practice is so profoundly imbedded in obstetrics they seem to want to refuse to listen to science that says its wrong to do.

    sooo… no studies to start the practice and ignore studies to say you should stop.

    Seems the same with weight loss.

    “I’ve believed it to be “X” for so long everything else is just fringe info from rabid groups”

    when that is blatantly not true.

    Intellectual humility….

    Its what’s for breakfast.

    1. The science is certainly not conclusive, as to whether the practice of early cord clamping is dangerous to babies. There has not been conclusive evidence yet to suggest that your statement is any sort of scientific truth. The WHO recommends:

      “WHO has recently recommended that “the cord should not
      be clamped earlier than is necessary” and notes that this would
      normally take around three minutes. They have graded this recommendation as “weak recommendation, low quality evidence”

      Click to access WHO_MPS_07.06_eng.pdf

      This is from 2007, reprinted in 2009. The Cochrane Collaboration is well respected.

      You’ll find in the following paper, the quote that I made above. Additionally, it is not clear if the increase in iron and blood cell levels yield significant beneficial health outcomes in the long term, and the study calls for more study regarding the long term effects. The study did find that jaundice was significantly increased in babies who had their cords delayed in clamping, and the study notes that this is an issue that may vary in severity and the significance is usually mitigated by access to photo-therapy.

      So I don’t know, I think intellectual humility is warranted on your part, when you go and pretend as if an issue is case closed, when the science doesn’t say that yet at all. To pretend as if all doctors who disagree with you have their fingers in their ears and don’t care. To spout one statistic, and ignore the rest of the information out there is cherry-picking. There is obviously merit in the delayed cord clamping argument, and it quite obviously requires a closer look at, but please don’t claim negligence on the part of all doctors when the WHO isn’t even yet able to make a strong recommendation on the topic.

      1. I persist in my comment. The science is not 100% there to prove that the practice is inherently dangerous to babies. The long term effects haven’t been studied hardly at all.

        You seem to think that I’m some sort of enemy, because I disagreed with the absolutism in your statement. I wouldn’t be surprised if the evidence eventually shows irrefutably that delayed cord clamping has positive effects associated with it for a large portion of the population in the longer term. However, the area is still an open research question, and is still being studied. For example, the results from studies looking at the potential negative effects of delayed cord clamping have been conflicting and inconclusive.

        I’m not going to sit here, without a medical degree, and criticize doctors as if I know what they do behind their own doors regarding how they evaluate new clinical information. I wouldn’t feel comfortable making assumptions. You however, feel very comfortable doing so. There are many incompetent doctors, but also tons of perfectly competent doctors. I don’t make generalizations about all of them.

        Let’s also note that the type of delayed cord clamping we’re talking about here, that is being studied, is cord clamping after 5 minutes or less (I think the WHO recommendation was 3 minutes). The standard in the NBC community (which I disagree with highly) is to leave the cord intact for longer than that, sometimes far longer. This type of extended delayed cord clamping is positively associated with a longer length of the third stage of labor, which increases the risk for maternal hemorrhage.

  10. you prove my point exactly… no research to start a practice but its demanded it to stop it.

    sounds just like dieting in my opinion – no research to show if all this dieting even helps and then consistently ignore research against it because it doesn’t fit in the current paradigm so it must be inconclusive?

    I don’t think you are an enemy but supporting the medical community harmful practices is not ok.

    Same as for healthcare providers who prescribe weight loss.

    And all the statements in your last paragraph delayed cord clamping and PPH? I think not.

    Now overly managed third stage… and cord traction – purple pushing. all not natural procedures… that causes PPH.

    I am fine making generalizations about the state of maternity care. Just compare your local hospital’s stats to that of midwifery care. I don’t need to look any further than that. But I can. I can compare my own deliveries at a hospital to that with a midwife.

    forceps… episiotomy, threatened un-needed csections every intervention and indencency

    vs. a safe respected environment (where as a matter of fact my baby’s cord was not cut until AFTER the placenta was delivered and I had no PPH like I had at the hospital.

    and my baby did not have jaundice. (like my other induced babies did.)

    common sense has been lost in healthcare.

    1. Practices are not started for no reason.

      They can be started because it’s believed it’s better for the patient. But also they can started because it’s believed that they speed up hospital procedures and make staff more efficient. If there’s not significant harm done because of an efficiency modification, I’m not personally going to be too torn up about it. Until something drastically changes about our health care system, doctors and hospitals are going to be continually pressured to cut as many corners as reasonably possible.

      Additionally I don’t think you can compare cord clamping to describing diets, those issues only seem similar on the surface, especially when you’re coming from the whole doctors don’t do things for good reasons or any reasons at all perspective. One is a small procedure done in the path of a larger procedure, with the desired outcome being a healthy baby and a healthy mother. The second is a prescribed procedure with the desired outcome of weight loss and health gains. If the procedure doesn’t produce the desired outcome, then it’s wise to not do it. The research isn’t uniformly clear whether or not the cord clamping procedure affects the desired outcome of the birthing experience in a significant way.

      It is a farce to think that medical professionals should not be allowed to attempt anything, without a full understanding of everything involved, tested in both the short and long term. Many aspects of health and human wellness are as of yet barely understood, and most medicine does the best that it can. What they can do is have a judicious review of the outcomes of different procedures. If something, like prescription dieting, doesn’t prove to be effective, I think it’s in the best interest to stop that practice. But if a practice proves to make no difference in their outcomes, and research isn’t yet clear that the procedure is good or bad or neither, then I don’t see the point in wasting the time and energy to replace it.

      But I see now from the rest of your comment, that you’re full on the NCB train. Your anecdotal evidence doesn’t prove or disprove anything. You are free to make your own decisions, but practices like homebirth, even with CNMs, have been show to be less safe than hospital birth. That’s not to say that hospital practices are perfect, but even with that error rate in hospitals, home birth is still worse.

      Also, PPH can be caused by any number of factors, but the research that I spoke of did reach the conclusion that not leaving the cord intact for significant periods of time did reduce the length of the third stage of labor and thus lowered the PPH risk associated with that particular variable (length of the third stage of labor). Thus your comparison of when you did and didn’t have a PPH means nada given the topic of the discussion.

      I am checking out of this conversation, because with all due respect, I don’t think you even clearly understand what I am saying, your last comment about the PPH makes that pretty obvious. Your opinions on NCB seem steadfast and unshakeable, and I have no interest in changing them. I hope that if you do continue to advocate for your views, you in the least do the world a favor and don’t encourage the use of DEMs.

  11. Hi there,

    Great post, thank you. I just have a couple of comments – I should give my credentials. I am a biomedical scientist, science writer and editor, certified personal trainer (in a previous existence) and currently a HAES advocate promoting a no-diet approach to health and wellbeing.

    First, just a semantic point: while I agree with all of the sentiments expressed in the post, it is not correct to state “…it’s not ok to … talk about what evidence might suggest (without mistaking that for what it actually proves)…” Evidence never proves anything. It is technically impossible to PROVE something scientifically. You can only DISPROVE something with evidence. This is because you can accumulate evidence in favour of a theory until the cows come home, but as soon as somebody shows evidence to the contrary, that theory is then disproved. No matter how strong the evidence base for a theory, it is correct to say that the evidence ‘suggests’…. and not to say that evidence ‘proves’. The usual example of this is the white swan story – you can see 1000 white swans, which suggests that all swans are white, but you only then need to see one black swan…. you get the idea.

    Second, re: the slow/fast weight loss discussion. The myth that slow weight loss is permanent is a result of faulty extrapolation from the science that fast weight loss almost never is. When you lose more than a couple of kilos in a week (if that), a much larger proportion of the weight lost is made up of lean body tissue, i.e. muscle, in addition to the fat tissue you were aiming for. Because muscle tissue is much more metabolically active than fat, the resultant changes in body composition have a negative impact of basal metabolism (i.e. slowing it down), so you need fewer calories than you did before to stay at the same weight. When you eventually get sick of the diet (as our intelligent bodies are biologically designed to do) and start eating again, you will not only gain back the initial weight lost, but more, as the calories you consumed at your starting weight are now in excess of what would be needed to maintain that weight. Hence, fast weight loss is generally discourages in order to maintain lean body mass. This does not mean that weight lost slowly, which would be expected to consist of a greater proportion of fat mass, will not go straight back on if you go back to eating the same way you did before. This is where people get confused.

    1. Thanks for the comment. To your first point, I think I wasn’t clear – I was trying to say that instead of discussing what evidence suggests, people mistakenly think that it’s irrefutable proof of something. I’ve gone back and changed the language to make it more clear. Interestingly, a couple years ago I blogged about the same black swam example that you used.

      To your second point, the idea that people regain weight simply because they return to their old eating patterns is another place where people get confused. The idea that people regain their weight because they “went back to the way of eating that made them fat” (which may not be what you are saying at all but is frequently speculated upon) is vastly over-simplified and not supported by evidence. Many people who maintain their diet behaviors still regain weight (as their bodies drop their base metabolic rate through a variety of physiological mechanisms that happen regardless of the composition of the mass that is lost or the speed of weight loss), and those who are able to maintain weight-loss often have eating patterns that more closely resemble people with eating disorders rather than what would be considered “normal eating”.


  12. I see no problem with vilifying or cutting out carbs totally. The scientific fact is that the carbs cause the insulin rise which makes the fat storable instead of usable. This is not really controversial, it’s hormonal processes. I don’t agree with perfect strangers telling you what you need in the grocery aisle and I would not have been as kind as I’m sure you were. I also don’t agree with trying to replace one set of carbs with another as the gluten free crowd does. But the fact of the matter is that carbs are not needed for body processes, there is no minimum you must have. Get them in forms your ancestors would have recognized and you’ll be a lot healthier. There is no reason to throw out the baby with the bath water and say that the demonizing of the food is the issue when really the issue is the chemical replacement. We don’t need to replace these dietary elements at all.

    Kudos for calling this “expert” out!

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