Q&A with Yoni Freedhoff M.D. on The Diet Fix: Why Diets Fail and How to Make Yours Work
What misconception about dieting do you think causes the most damage?
The most damaging misconception about dieting is that our weights should all be “ideal” and that scales not only measure pounds, but also possess the ability to measure the presence or absence of health. It’s those messages that lead dieters to undertake wholly nonsensical approaches to weight management, and they also serve to help fuel society’s hateful weight biases.
What is Post Traumatic Dieting Disorder?
Post-traumatic dieting disorder or PTDD is the frequent consequence of years of recurrent traumatic dieting efforts. It’s a shared constellation of symptoms that often extends far beyond a dieter’s relationship with food and may include feelings of ineffectiveness, shame, hopelessness, loss of healthy body image, feeling permanently damaged, social withdrawal, and, at times, can even impact upon interpersonal relationships. Another very common symptom of PTDD is the belief that traumatic diets are required for weight management success; oftentimes folks with PTDD spend huge portions of their lives yo-yo’ing from one traumatic diet to the next. This leads to a vicious cycle of suffering, binge dieting, and feelings of inadequacy that sets people up for failure.
What is the most important factor in sustaining your weight?
The most important factor in sustaining your weight is not just tolerating, but actually liking your life and being both consistent, and, believe it or not, imperfect. Truly, your job in regard to both weight and health is to live the healthiest life that you can enjoy - in other words, to do your best. That said, it’s important to note that the best you can do over say, Christmas or a vacation, is very different than the best you can do during a plain, old, boring week, but that also doesn’t mean you shouldn’t still be thinking about things. Given our modern day Willy Wonkian food environment, not paying attention, for many, leads to easy gains, and given it’s so much easier to gain than it is to lose, remaining thoughtful, but not blindly strict, and doing so consistently, is crucial. Putting this another way - the healthiest life you can enjoy still needs to include chocolate, but that amount of chocolate needs to be the smallest amount that you need in order to be happy, and that amount changes day by day.
Why is the label of obesity misleading?
Unfortunately the label “obesity” carries with it a huge amount of societal stigma, stereotype and frankly ugly judgment whereby people who are described as “being” obese are regularly perceived and portrayed as lazy and gluttonous. Yet the presence or absence of weight really doesn’t define anyone. There are healthy people with weight to lose, and unhealthy skinny ones, and I certainly know plenty of beanpole gluttons. While there’s no doubt that medical risk rises with weight, risks are certainly not guarantees, and more importantly, weight does not and cannot be used to judge a person’s lifestyle. So if you’re ever writing about obesity, remember that a person cannot “be” labeled as obese, they can only have obesity, and that given the negative stereotypes and implications surrounding the word obesity, that distinction matters.
What is the biggest misconception you wish people could shake off about dieting?
The biggest misconception that I wish people could shake off about dieting is that suffering and sacrifice are dieting’s true determinants of success. Unfortunately, as a species, we just aren’t built to suffer in perpetuity. Consequently, weight that’s lost through suffering, through some combination of under-eating and/or over-exercising, is bound to come back.
What’s the best diet?
There really is no one “best” diet - if there were, there wouldn’t be tens of thousands of different diet books available, and weight struggles would be rare to non-existent. Ultimately a person’s “best” diet is the healthiest diet that they can enjoy, as diets that are merely tolerable, given food’s star billing as one of life’s most seminal pleasures, simply don’t last. Real life does, and frankly must, still include chocolate.
About the Author
Dr. Yoni Freedhoff, MD, CCFP, is widely considered to be Canada's most outspoken obesity expert. His weekly column in U.S. News & World Report's online Eat + Run edition is regularly the most read on the site, and he writes periodically on issues of health, weight management, and fitness for a variety of publications including Psychology Today and The Huffington Post, and daily on his award winning blog Weighty Matters. He is also an Assistant Professor in the Faculty of Medicine at the University of Ottawa and a sought after international speaker. Dr. Freedhoff graduated with honors from the University of Toronto Faculty of Medicine, where he received the Betty Stewart Sisam Award as the graduating student who "has shown the greatest human understanding and care for the welfare and health of patients."
Excerpt. © Reprinted by permission. All rights reserved.
A (Very) Brief History of Dieting
Diets are anything but new. The first popular diet was a lowcarb diet written by a British coffin maker in 1863. His name was William Banting, and the diet he championed and detailed in his Letter on Corpulence, Addressed to the Public was of the lowcarb variety with an emphasis on eating meat, greens, and fruit while avoiding sugar, starches, dairy, and beer. His book was so incredibly popular that at the time, the word banting was used in conversation in place of dieting. Believe it or not, the book is still in print and you can even buy it in Kindle format. But it’s been over the past 50 or so years, not coincidentally the time period in which obesity rates have nearly quadrupled, that the number of diets has grown by multiple orders of magnitude. At the time I’m writing this paragraph, over on Amazon there are over 37,000 books in their “diets and weight loss” racks.
Their strategies may all vary wildly, but ultimately we can subdivide all diet books and programs into seven broad categories:
1. Good/bad diets: These are among the simplest to follow. They have very clear rules that either cut out entire categories of foods or provide very specific meal plans. People on these types of diets are told that they don’t need to track intake in terms of calories; instead they’re told to avoid virtually an entire food group and they’ll do fine. The most obvious examples of these are the ultralowfat diet of Dr. Dean Ornish and the ultralowcarb diet of Dr. Robert Atkins.
2. Scientific and pseudoscientific diets: Rather than vilify an entire food group, these diets tend to focus only on specific foods within the group. Beans are good, carrots are bad. Oatmeal is good, rice is bad, and so on. Some, like the GI diet and the various surging paleo diets, are built on true scientific principles; others, like the blood type diet, and Suzanne Somers’ food combination diet, tend to lapse into what might be described as common sense or intuitive, but are not in fact rooted in a rigorous, scientifically defensible evidence base.
3. Counting diets and programs: Food gets assigned points (or calories) and you’re allotted a certain number with the aim of not going over. Perhaps the first counting diet was that of Dr. Lulu Hunt Peters, whose 1918 book, Diet and Health, with the Key to the Calories, was the first to recommend tracking calories. At the time, no one had heard of calories, and early on in the book Dr. Peters had to explain to readers how to pronounce the word. Of course, as far as counting diets go, there’s no doubt that the grand champion is Weight Watchers, which in 50 years has enrolled tens of millions of people in more than 30 countries.
4. Crash diets: From the get‑go, this type of diet is meant to be temporary. These diets aren’t meant to be a “for good” solution but rather just a “for now” solution. Often they’re undertaken as a way to lose weight before a particular event--a wedding, a trip, a high school reunion. They’re usually massively restrictive, and the aim is to lose the weight to get to the event and then start eating again. Generally, they just involve eating very little of anything and sometimes as much as you want of just one very specific thing. The cabbage soup diet, the grapefruit diet, and the so‑called master cleanse (that modified juice fast based on lemon juice and cayenne pepper) are this category’s most obvious examples.
5. Exercise diets: These aren’t necessarily diets so much as they are aggressive exercise programs undertaken with the expectation of weight loss. Invariably, the exercise is either highly intense (like boot camps, for instance) or exceedingly lengthy, sometimes even involving hours of daily activity.
6. Magic diets: Simply pop a magic pill or potion, or sidle up to some newfangled exercise contraption, and presto chango, with zero effort and zero dietary change, the weight will just melt off. While I’m guessing magic diets aren’t going to help melt weight, I’m positive they’ll help melt bank accounts.
And then, of course, there’s the most common and the most popular diet in history. The one diet that virtually anyone who has ever been unhappy or concerned about their weight has tried on at least one occasion. There’s no book to read, or guru to follow. I call it the “Eat Smarter diet.”
7. Eat Smarter diet: Honestly, who hasn’t tried this one at least once? Even folks who aren’t concerned about their weight have likely tried to “watch what they eat,” “eat smarter,” “be more aware,” “be more thoughtful”--with the dual aims of “eating less” and “being more healthy.” No books to purchase. No programs to consult. Just “eat less and exercise more” and “be smarter.” And while it certainly makes sense and reflects the truism of energy balance, our bodies and our environment conspire to make this approach almost invariably useless.
“DOC, WHICH DIET SHOULD I GO ON?”
Is there one right diet for you? Is there some test you could take where you’d plug in your lifestyle, personality, and dietary preferences and out would come your perfect answer? If only it were that simple.
There are just so many variables. Some may be modifiable, but others simply aren’t. It would be no easier to give yourself a palate that loves spinach and hates chocolate than it would be to swap out your genes. And don’t kid yourself into thinking those things don’t matter--they do. As the father of three beautiful little girls, I can tell you I sure had a great deal more free time to cook, sleep, and exercise before they came into my life. And although I know I’d probably be healthier if my favorite guilty pleasures were organic vegetables, I just can’t seem to convince my mouth not to adore pizza, wings, burgers, and potato chips.
At the end of the day, all diets work, every last one. Even diets with nonsensical approaches can help people lose weight. But losing, of course, isn’t the issue. I hear it all the time in my office and it’s absolutely true: “Losing weight is easy; it’s keeping it off that’s hard.”
So is there a common theme that makes keeping lost weight off difficult? Absolutely, and putting it simply, the common theme that makes longterm success difficult is the notion that suffering is a prerequisite to success.
TRAUMATIC DIETING
The questions people ask themselves when failing any given diet may sound familiar to you: Why can’t I just stick with it? What’s wrong with me? What’s my problem? Why am I such a failure? It’s the “it’s not you, it’s me” speech we give when we break up with someone, only unlike our breakups, where the statement’s usually a sugarcoated lie, with weight management, we believe it. We failed, not our approach. It’s not the diet, it’s me.
If that’s really true--that it’s not the diet but rather us--how is it that failure is the norm? Can it really be that the past 50 years have seen a global pandemic loss of willpower? That somehow as a species we’ve become powerless to resist weight gain? That as individuals we simply can’t control ourselves?
Maybe it’s not you.
I’d be willing to wager that if you’ve been battling your weight for a while, you’ve invested more willpower in weight loss than in virtually any other area of your life. You’ve probably undertaken various whiteknuckle diets, have set your alarm clock for 5:00 a.m. so that you can hit the treadmill downstairs, and you’ve likely eaten more salads and grilled boneless, skinless chicken breasts than you’d care to admit. You might have been on your first diet before you even made it to high school, and you may well have a veritable library of contradictory diet books filling shelves of your bookcase. Clearly, you’ve got willpower. So what is your problem? Why can’t you “just stick with it”?
Human nature. We’re just not built to needlessly suffer forever. Yes, we’re an exceedingly adaptable species, but if the need to suffer isn’t there, and if the alternative to suffering is easily accessible, like water seeking its own level, that’s where your human nature and actual physiology will take you.
While there are those who will argue the scientific merits of one dietary approach over another until they’re blue in the face, at the end of the day if you don’t like the life you’re living while you’re losing weight, you’re virtually certain to gain it back. Putting dietary theory aside, what we choose to put on our plates reflects a sort of personal homeostasis--meaning that while we put as much food on our plates as we feel we need to be satisfied, satisfaction isn’t simply meeting some sort of stomachfilling need. Yes, there are our physiologically driven needs to satisfy our bodies’ fuel requirements, but there are many other needs at work: our psychologically driven need to satisfy pleasurerelated desires; our medical need for food to help us cope with stress or depression through its impact on cortisol; our hedonic need, in which food plays a genuinely celebratory role such as on vacations, birthdays, and holidays. So while one particular dietary regime may do a fabulous job on one area of need, if another need is left lacking, human nature being what it is, we’re not likely to stay on program. It just isn’t meeting our needs.
If you were to take a straw poll of your friends, family, and self, I’d bet that their answer to the question of what’s required for longterm success is some variation on suffering, sticktoitiveness, or willpower, that success is therefore the by‑product of willfully denying ourselves enjoyment and satisfaction from food. I disagree. To succeed in the long term, to actually keep the weight you lose off, I think you need to genuinely like your life with fewer calories.
Indeed, since time immemorial, dieting has been steeped and forged in suffering. Diets have been designed to be traumatic. They’re about denial and sacrifice. They’re about suffering and restriction. They’re “die” with a “t.”
And people wonder why they fail?
I think people fail because most diets promote an almost religious experience, whereby adherents are taught to all but shout, “Hear O world! There are no other diets before mine.” Dieters are expected to stick to a strict set of commandments, from “Thou shall not consume carbs” to “Thou shall honor thy treadmill and free weights.” Transgressions against the diet are framed as being almost sinful, leaving dieters with a real sense of guilt over a plate of pasta. I hear about this guilt and regret all the time from my patients, so much so that I’ve come to think of the rules they are trying to follow as the deadly sins of dieting. I count seven most common misbeliefs, seven deadly dieting sins that have been championed by society as the necessary evils of success, and that while challenging and unpleasant, by society’s misguided definition of success, need to be willfully endured forevermore. They’re continually nurtured as necessities by popular culture, diet books, the entertainment and media industry, and even by allied health professionals. And while society believes them to be essential to success, I believe them to be integral to failure. In the next chapter, I’ll tell you what they are.
Dieting’s Seven Deadly Sins
Have you ever succumbed to the allure of dietary zealotry and felt so constrained by the rules of your regime that transgressions felt akin to sinning? While there may well be tens of thousands of different diets out there, dieting’s seven deadly sins span their gamut, and though they may not all be present in each and every diet, I’m guessing that if you’ve battled with diets over the years, you’re all too familiar with this motley collection, whereby your job was to endure and cultivate one or more of these and where failing to do so was a dietary sin.
1. HUNGER
“If I’m not hungry, my diet’s not working.”
Now, in my mind, the word hungry means a couple of different things. I use the word to describe not only the physical pitofyourstomach sensation of hunger (stomach hunger), but also simple cravings (head hunger). Purists and researchers might well disagree with my combination of what they in turn would refer to as appetite and hunger, but given that my experience has been that both head and stomach hunger respond identically to treatment, I think they’re simply flip sides of the same coin. I’ve also met hundreds and hundreds of individuals who tell me that while they never experience stomach hunger, head hunger’s a common and unwelcome visitor that manifests itself either as incredible cravings or as compulsive can’tstoponcestarted eating.
Eating and drinking are second only to breathing in the hierarchy of survival needs, and after 100 million years of evolution, hunger is an extremely powerful physiologic drive. If you don’t eat, you die. Taking one step further back in time, if your cavedwelling ancestors weren’t great about eating as voluminously as possible when they were hungry and food was available, they might have had difficulty living long enough to pass on their genetic materials. Hunger is evolutionarily protective, and satisfying hunger when food is available has allowed our species to thrive.
However, over the course of the past hundred or so years, we’ve seen incredible changes to our food supply. There’s no longer any dietary whim that can’t be satisfied in a matter of moments, and where we once had to physically hunt for our food, now we simply have to dial for it. I think what we’re seeing today in terms of societal weight struggle is reflective of the fact that our genes and physiology, honed over thousands of years of extreme dietary insecurity, still function as if the next meal might never come. While a thorough discussion of how our ancient physiology responds to hunger isn’t necessary, it’s worth a brief visit given its role in getting in the way of our best intentions.
From neuropeptides, to hormones produced by our actual fat cells, to proteins produced by our intestines, there are pathways and backup pathways whose jobs are to ensure that we eat enough to survive. There’s leptin, produced by our own fat cells; its job is to act on the hunger center of our brains, the hypothalamus, where it inhibits appetite by signaling the brain that the body has had enough to eat. There’s ghrelin, produced by our stomachs; it works in our hypothalamus too, but its job is to tell us to eat. There’s neuropeptide Y, produced by the hypothalamus itself; its job is to decrease the expression of a gene that encodes for the production of proopiomelanocortin, a polypeptide that plays a role in appetite. It also decreases the synthesis of the pituitary hormone that signals the thyroid to make its hormone. There’s peptide YY, produced by our small intestines, which decreases gut movement and the production of ghrelin, and acts in our brain’s hunger center. And these are just the tip of our body’s hunger system iceberg. It’s a very complicated place and the problem is, those peptides, hormones, and proteins? They’re still cave dwellers, and what once was a protective behavior--eating highly caloric foods in large quantities in response to hunger--has become in our modern day a kidinacandystore environment, and, at least in terms of weight, a liability.
