About two years ago I was interviewed for Darryl Robert’s film “America the Beautiful 2: The Thin Commandments” That film is now available on Netflix Streaming (yay!). The part of the film that I’m in goes back and forth with Dr. Howard Shapiro. Dr. Shapiro is one of those people who helps me remember that Democracy is about someone shouting at the top of their lungs that which I would spend a lifetime opposing at the top of mine. (20 points if you can identify the movie reference.)
You may know him as the doctor who marketed the cookie diet (which was invented by a different doctor – 6 cookies and one meal a day for about 1,000 calories), and the “Picture Perfect” diet which is a book that shows, in pictures, that you can have a hell of a lot of vegetable soup for the same calories as a giant cookie. Thanks dude, I had no idea!
Anyway, the back and forth in the movie is comprised of alternating bits of each of our individual interviews. I thought that I would offer direct responses to what he said in the film since he did a good job of stating a lot of the mistakes and erroneous assumptions that people, including doctors – and perhaps especially doctors whose paychecks depend on them – make about weight and health.
Before I get started, I want to clarify: Dr. Shapiro confuses the concepts of Health at Every Size and Size Acceptance. HAES is an optional, evidence-based, health practice where the focus is on healthy behaviors rather than weight loss as a path to health. Just like everyone else, people who choose to practice HAES can prioritize their health however they choose and pick and choose the health practices in which they want to engage with the understanding that health is not an obligation, barometer of worthiness, completely within our control, or guaranteed under any circumstances, and that many of our choices can be affected by outside circumstances. Size Acceptance is an entirely different thing. SA is a civil rights declaration that states that the rights to life, liberty and the pursuit of happiness are not size dependent – nor are they health or healthy habit dependent. These rights are for everyone, not just the people who act like you think they should act, or look how you think they should look.
For the record, I met Dr. Shapiro at the LA premiere and we had a short debate during the Q&A in which he reiterated most of what he said in the movie and offered no evidence to support his claims. Dr. Shapiro has picture books, a bunch of diet cookies and an active practice as a weight loss specialist. What he doesn’t appear to have is any evidence that his interventions do any better than lack of long- term success that every study on long-term dieting has shown for intentional weight loss attempts. But that didn’t stop him from toeing the caloric restriction party line.
His first quote:
You can’t tell me that being heavy is better than being thin. Being fat causes you to have diseases… strokes, cancer, diabetes, we know those for sure, heart disease, we know all of that.
Fascinating. First of all – nobody is saying being heavy is better than being thin. We are saying that bodies come in lots of different sizes for lots of different reasons, that one body size is not inherently better than another, and that health and weight are two different things (which you can tell since there are healthy and unhealthy people of every size.) I am also saying that, as a doctor, you should probably learn the difference between correlation and causation. While being fat is correlated with many diseases, causality is not proven. The stress of constant stigma is also correlated to all the same diseases as obesity (see Peter Muennig’s work from Columbia University.) Further, there are no diseases that just fat people get – thin people also get strokes, cancer, diabetes, heart disease etc. and many fat people do not get these diseases so being thin cannot be a sure preventative or a sure cure. As I’ll discuss in a moment, a great deal of research shows that fitness is a much better indicator of hazard ratio than is weight.
You can be healthy without losing weight for part of your life, it depends. If you’re 40, uh, ummmm, if you’re 28 years old, if you’re 35 years old you can carry a lot of extra weight without any medical problems, but if you carry that weight until you’re 60 you’re going to have some medical problems. Guaranteed. Guaranteed. [yes, he said it twice.]
I know it seems from this quote like he was choosing ages by throwing darts but if you watch the film you’ll see that there’s no dartboard in sight, so this was more of a general rectal pull sort of situation. I’ll give him credit for finding a great way to hedge his bets – choosing diseases for which age is also a risk factor and then trying to blame them all on fat. Also, I personally know a number of fat people over sixty who don’t have health issues so, like his promises of weight loss, it seems that his guarantees also can’t be believed.
You gotta tell me if you’re heavy you’ve got problems. You’re not comfortable. you can’t be comfortable. you can get used to it you can accept it, but you’re not comfortable. So why would you want to live like that – because you’re too lazy to make the difference to work at it. It takes work.
This is my favorite (favorite here having the meaning of “quote that most activates my throat punch reflex”) First he tells me how I feel, implying that he is a better witness to my experience than I am. Then he tells me all about me and how lazy I am. During the Q&A I told him that I didn’t appreciate this. He said that he didn’t say it, and that it was editing. You can watch the film and decide for yourself but if this is editing it deserves some kind of editing Emmy award. Calling people lazy is just an outstanding way to encourage them to take care of themselves – that’s some good doctorin’ right there.
If you had a door, that door, and you could walk out (one of these fat acceptance people) and be 40 pounds thinner or this door walk out and be the same – no work involved, walk out on the other side of the door 40 pounds thinner, or you’re the same, I’ll be you a good portion of them would go out the door where you’re 40 pounds thinner.
I wouldn’t walk through the “40 pounds less door” because that would be suggesting that the best way to cure the social stigma that I deal with is to change myself, and I am vehemently against that. I have never suffered from obesity, but I have suffered from the stigma that people like Dr. Shapiro like to put on me because of my obesity, and the cure for that is for them to stop stigmatizing me – it is not for me to try to bend and twist myself until I fit into their narrow minds.
The fat acceptance people and I have a big problem. If they want to be heavy, that’s fine with me, I don’t want to make anyone thin if they don’t want to be thin it’s up to them. But you gotta say, it’s ok to be heavy but your risk factors for many many diseases, many many many many many diseases are increased. I don’t care what they’re telling you. If they can prove to me and show me some legitimate studies that say it’s better to be fat than thin, I’ll buy it but I see studies that say it’s better to be thin and you will live longer.
Speaking for this fat acceptance person, we don’t have a big problem. We don’t have a problem at all. I think he’s full of crap and therefore I’ll never go to him for healthcare. Other people can make whatever choice they want to make. No problem. Based on all the research that exists, he rarely succeeds at making people thin long-term no matter how badly they want to be thin, so though I don’t require his permission, I’m relieved to hear that he doesn’t want to work with me. Now, seven “many’s” seems like a lot, but I’m not so worried because I have actually read the research (which, it seems, makes one of us) so I’m aware that fat is a risk factor because it is correlated with a number of diseases (not because it’s causally related,) and that simple healthy habits (movement, 5 servings of vegetables, moderate drinking and not smoking) have been shown in studies to give fat people the same health hazard ratio as thin people who participate in those habits, and a dramatically better hazard ratio than thin people who don’t if that’s something that interests you. Again, nobody is saying that one body size is better than another, but we are saying that if people are interested in prioritizing health (and they are under absolutely no obligation to do so) healthy habits, not weight loss, are our best chance for our healthiest body. Here’s some of that evidence he has suddenly found himself interested in:
“Healthy lifestyle habits are associated with a significant decrease in mortality regardless of baseline body mass index.”
“We’ve studied this from many perspectives in women and in men, and we get the same answer: It’s not the obesity, it’s the fitness.”
“no measure of body weight or body fat was related to the degree of coronary vessel disease. The obesity-heart disease link is just not well supported by the scientific and medical literature”
“With or without consideration of …extremes or gains in body weight…alumni mortality rates were significantly lower among the physically active.”
Your turn Dr. Shapiro, let’s see some evidence that your interventions work long term. I won’t hold my breath.The thing is, it doesn’t matter how many diseases are correlated or even causally related to weight, since we have no evidence that suggests that we know how to help people lose weight long term. People with joint pain would be much better off if they could fly (as flying takes the pressure right off the joints.) But we don’t know how to make people fly so we don’t prescribe jumping off a roof with homemade wings. But doctors like Dr. Shapiro continue to prescribe weight loss, even though the chances of losing weight are only 5% better than the chances that the roof jump will lead to successful flying, and the other 95% of the time people gain back all their weight and often more.
I will say the good thing about him is that I know what I’m getting. As a fat person, so often I go to a doctor for an actual health issue and they decide to be a “weight loss specialist” instead. At least I won’t waste an appointment on Dr. Shapiro.
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