What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (31 page)

In one study, the “lucky” 10 percent of formerly fat people who dieted and stayed thin ate an average of 1,298 calories a day to stay at their new weight, whereas normal controls ate 1,950 calories to stay at that same weight. This demonstrates that dieters may never again be able to eat normal amounts of food if they want to stay thin. Yo-yo dieting—taking weight off, putting it all on again, and then trying to take it off once more—is a Sisyphean battle. The second time obese patients go on a VLCD, they lose weight more slowly, yet they take in exactly the same number of calories as the first time.
¹⁵

This makes biological sense. Imagine a species only recently emerged from 100,000 years of famine. During this epoch, weeks or even a whole season go by with almost nothing to eat. Then there is a big kill or a bumper crop. Everyone gorges and then rations what is left until the next big kill. An epoch of famine and feast produces strong evolutionary pressure for a creature who gorges and stores up a lot of fat during periods of plenty, but releases fat’s life-sustaining energy with reluctance during shortages. The more the creature goes through the feast-famine cycle, the better it gets at storing fat and conserving energy.

Now imagine that this epoch suddenly ends and food is abundant. This creature eats a great deal and gets fat. Someone conceives a scheme to limit fat, and the creature voluntarily undereats. But its body can’t tell the difference between self-imposed starvation and actual famine. So the hoary survival defenses kick in: The body defends its weight by refusing to release fat, by lowering its metabolism, and by insistently demanding food. The harder the creature tries not to eat, the more vigorous these defenses become.
¹⁶

This creature is
Homo sapiens
, the departed epoch is the Pleistocene, the time is now, and the doomed scheme is dieting.

Bulimia and Natural Weight

A concept that makes sense of your body’s vigorous defense against weight loss is
natural weight
. When your body screams “I’m hungry,” slows its metabolism, makes you lethargic, stores fat, craves sweets and renders them more delicious than ever, and makes you obsessed with food, what it is defending is your natural weight. It is signaling that you have dropped into a range it will not accept. Natural weight prevents you from gaining too much weight or losing too much. When you eat too much for too long, the opposite defenses are activated and make long-term weight gain difficult. A group of prisoners was paid to add 25 percent to their body weight by eating twice their usual calories for six months. The first few pounds came on easily, but then there was no weight gain.
¹⁷

There is also a strong genetic contribution to your natural weight. Identical twins reared apart weigh almost the same throughout their lives. When identical twins are overfed, they gain weight and add fat in lockstep and in the same places. The fatness or thinness of adopted children resembles their biological parents—particularly their mother—very closely, but does not at all resemble their adoptive parents. This suggests that you have a genetically given natural weight that your body wants to maintain. I don’t know a formula for assigning a number to your natural weight, but it is probably considerably higher than your “ideal” weight. The average middle-aged American man, for example, weighs 16 percent more than his “ideal” weight.
¹⁸

The idea of natural weight may help cure the new disorder that is sweeping young America. Hundreds of thousands of young women have contracted it. More than 5 percent of the young women to whom I teach Abnormal Psychology every fall complain of it. Two percent of adult women may have it in severe form.
¹⁹
It consists of bouts of binge eating and purging alternating with days of undereating. These young women are universally concerned with their body image. They are usually normal in weight or a bit on the thin side, but they are terrified of becoming fat. So they diet. They exercise. They take laxatives by the cup. Twice a week they find themselves at a buffet or in an ice-cream parlor. They gorge: four hot-fudge sundaes topped off with a banana split. Then they vomit and take more laxatives. This malady is called
bulimia nervosa
(“bulimia” for short).

Therapists are puzzled by bulimia, its causes and treatment. Debate rages about whether it is an equivalent of depression, or an expression of a thwarted desire for control, or a symbolic rejection of the feminine role. Almost every psychotherapy has been tried. Antidepressants and other drugs have been administered with some effect, but—with one exception, which I’ll discuss shortly—little success has been reported.
²⁰

I don’t think that bulimia is mysterious, and I think that it will be curable. I believe that bulimia is caused by dieting. The bulimic goes on a diet, and her body attempts to defend its natural weight. With repeated dieting, this defense becomes more vigorous. Her body is in massive revolt—insistently demanding food, storing fat, craving sweets, and lowering metabolism. Periodically, these biological defenses will overcome her extraordinary willpower (and extraordinary it must be even to approach an “ideal” weight, say, twenty pounds lighter than her natural weight). She will then binge. Horrified by what this will do to her figure, she vomits and takes laxatives to purge calories. Thus bulimia is a natural consequence of self-starvation to lose weight in the midst of abundant food.
²¹

Every bulimic I have met is dieting. Systematic surveys of bulimics show that at least 80 percent are on diets immediately before bulimia starts. The epidemic is sweeping America right now because the thin ideal has become thinner and thinner over time as the average female body has gotten heavier and heavier. The ideal has so far outstripped the capacity to achieve it that the discrepancy between natural weight and “ideal” weight is so great as to produce binge eating on a massive scale. Women whose natural weights are most discrepant from their “ideal” weights will be most vulnerable.

One study observed twenty bulimics who binged an average of three times a week. Ten received a nutritionally adequate treatment diet for eight weeks consisting, unbeknownst to them, of at least 1,400 calories a day. All of them stopped binging. A control group of ten others ate a sham diet that was the equivalent of what they had been eating. They continued to binge, but when they were switched to the nutritionally adequate diet, all of them stopped binging completely. This suggests that dieting is a cause of bulimia and suggests a major strategy for therapy.
²²

The therapist’s task is to get the patient to stop dieting and become comfortable with her natural weight. He should first convince the patient that her binge eating is caused by her body’s reaction to her diet. Then he must confront her with a question: Which is more important, staying thin or getting rid of bulimia? By stopping the diet, he will tell her, she can get rid of the uncontrollable binge-purge cycle. Her body will now settle at her natural weight, and she need not worry that she will balloon beyond that point. For some patients, therapy will end there because they would rather be bulimic than “loathsomely fat.” For these patients, the central issue—ideal weight versus natural weight—can now at least become the focus of therapy. For others, defying the social and sexual pressure to be thin will be possible, dieting will be abandoned, weight will be gained, and bulimia should end quickly.

These are the central moves of the cognitive-behavioral treatment of bulimia. There are more than a dozen outcome studies of this approach, and the results are good. There is about 60 percent reduction in binging and purging (about the same as with antidepressant drugs). But unlike drugs, there is little relapse after treatment. Attitudes toward weight and shape relax, and dieting withers. Two studies explicitly compared drugs and cognitive-behavioral treatment, and in both studies, drugs were less effective.
²³

The dieting theory cannot fully explain bulimia. Many people who diet don’t become bulimic; some can avoid it because their natural weight is close to their “ideal” weight, and therefore the diet they adopt does not starve them.
²⁴
In addition, bulimics are often depressed, since binging-purging leads to self-loathing. Depression may worsen bulimia by making it easier to give in to temptation. Further, dieting may just be another symptom of bulimia, not a cause. Other factors aside, I can speculate that dieting below your natural weight is a necessary condition for bulimia, and that returning to your natural weight and accepting that weight will cure bulimia.

There is a new and disheartening development in “eating disorders.”Dr. Robert Spitzer, a New York City psychiatrist who organized the writing of that useful document the
Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-3
and
DSM-3-R)
, is now trying to have “binge-eating disorder” added to
DSM-4
. He discovers this new malady in as many as 30 percent of those dieting in hospital weight-loss programs. They binge occasionally, but they don’t purge, so they gain weight. From my point of view, many of these poor people are trying to slim down to weights far below their natural weight. Their bodies, like bulimics’, are screaming for food. Perhaps their disorder is not binge eating but inappropriate dieting.
²⁵

The Right Treatment

BULIMIA NERVOSA SUMMARY TABLE

In fact, we should consider a new category for
DSM-4
, “dieting disorder,” defined as being within 20 percent of your “ideal” weight and ruining your life and health by dieting.

The idea of natural weight has another huge practical implication. Right now I’m drinking my morning coffee with three packets of artificial sweetener in it. I love sweet coffee, but I hate the nearly 50 calories in a tablespoon of sugar in each cup. I have been assuming—until now—that for each dose of artificial sweetener I consume, I will take in that many fewer calories each day. I am also afraid that if I stop drinking artificially sweetened beverages, I will gain weight. This is the hidden logic of the army of consumers that supports the $10 billion diet-soft-drink industry. With artificial sweetener in three cups of coffee, the savings is about 150 calories; two diet soft drinks means another 400 or so calories saved: That’s around 550 calories a day I avoid; almost 4,000 calories a week, more than the equivalent of one pound of weight. But why haven’t I lost a pound a week since I started using artificial sweeteners? (I calculate that I should now weigh less than zero and go floating off like a helium balloon.)

The answer, I suspect, is natural weight. I probably eat an extra 550 calories elsewhere each day to make up for the sugar I avoid. Those calories aren’t in sugar, so my teeth aren’t rotting out, but they might be in fat. I don’t know if this is so, but I’m going to find out.
²⁶

Diet Pills

Diet pills suppress appetite, and they have one virtue: Unlike diets, taking pills requires no discipline. But pills create the same problem as dieting—rapid regaining of weight—and are more dangerous: In 1973, the Federal Drug Administration severely limited their use because the weight loss they produce (about two pounds per week) is small, and the health risks, including psychosis, addiction, heart attack, and death, are substantial.
²⁷

New drugs are developed every so often. The latest ones, fenfluramine and phentermine, show more promise. They produce substantial weight loss, and unlike their predecessors, they may readjust the “set point” of natural weight rather than just suppress appetite.

Michael Weintraub, an obesity researcher, coordinated a well-done study of these two drugs.
²⁸
One hundred twenty-one participants, mostly women, started the study at over two hundred pounds. The study lasted four years: Those women receiving the drugs (coupled with behavior therapy and exercise) lost an average of thirty pounds and kept the weight off for as long as they took the drugs. As soon as they ceased taking the drugs, however, the weight returned.

These two drugs have some side effects—dry mouth, nervousness, sedation, vivid dreams, and depression—which are milder than the early appetite-suppressing drugs. The side effects are not trivial, though, and because of them, more than one-third of the patients dropped out without much benefit. Overall, however, one-third of the patients lost a good bit of weight and kept it off—a much better result than any diet has achieved. Future research on these drugs should determine the long-term effects of taking them, and how to reduce the side effects and therefore the dropout rate. The development of these drugs is promising, but until more research is completed I regard them as experimental.