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Why I won’t tell you to lose weight during your TBI recovery

Read to me!!

I respect your desire to lose weight.

I respect your choice if you chose to attempt weight loss.

It just saddens and frustrates me how much you are forced to focus on this.


So many things change in your life after a TBI — maybe it’s your job, your hobbies, your activities, your relationships, your goals, your future plans, and even the way your body works, looks, and feels.

There are so many aspects about the brain injury that are invisible. People can’t really see on the outside your headaches, dizziness, fatigue, confusion, sensory sensitivities… And neither can you, really. We sometimes wish these challenges could be visible. So that others would not judge us.

Yet, changes to body shape and size ARE visible. And these changes are often unjustly judged.

Man in Blue Button Up Shirt and Black Shorts Standing Beside Green Car

Have you ever wished you could go back to being your old self again? Get back the life you had? I’ve wished this and I know many other survivors have as well.

I remember a couple of years into my own concussion recovery, my psychologist challenged me on this saying “You can never go back. Because no one can every go backwards. Even if you never had the injury, you would have still changed as a person. Maybe no brain injury, but a different set of experiences would have changed you in some way.”

I know other survivors who have arrived at this realization too — that our lives, brain injury or not, would be different regardless. In this context, I think we can accept this change. Yet when it comes to weight, we have a hard time accepting that our bodies over the years will change as well. And even though it is completely justifiable for you and I and everyone to feel this way, a major reason we do is unjust.

Woman Holding Baby Near Window

People in the TBI community often approach me wanting nutrition for weight loss. Post TBI, with such a limited ability to enjoy or even just participate in physical activity, survivors might move and exercise far less than they used to (especially if they used to be athletes, recreational or pro!). On top of that, as pain and mental health issues can become major obstacles in a survivor’s recovery, medications become such important allies in their management. Sometimes a side effect of these may also contribute to weight gain.

I want to be clear. Weight loss is something everyone thinks I do as a dietitian. But in fact, weight loss interventions are NOT something I promote. Rarely do I weigh or measure my clients. And NEVER do I tell someone they HAVE TO lose weight. I do not feel it is right to force someone’s body into shape & size standards that are wrongly upheld by medical & wellness communities.

That’s right. I said WRONGLY.

Doctor, Security, Office, Hospital, Injection, Analysis

I entered into my nutrition studies at university having already seen how dieting for weight loss had harmed people close to me. But I was still taught the way of Body Mass Index (BMI) and weight loss under the guise of helping those with certain chronic conditions.

I graduated and went out into the world as a young dietitian. I felt I had to work under that guise, so I gave into BMI & weight loss in certain situations, but always with much discomfort. My clients would come back to me after failed weight loss attempts saying “it’s just me… I’m just lazy… I just have to be better at it…”

These “I just” statements were repeated at each session until finally my clients stopped coming to see me. Because who wants to tell a dietitian over and over again that they “just” can’t stick to a meal plan, and somehow still fail to keep the weight off??

But I knew whole-heartedly that those clients didn’t “fail.” I knew instead that I and the wellness world of weight loss had FAILED THEM.

I have never seen weight loss work.

And when I say “work,” I mean I’ve never seen forced food restriction in the name of health lead to long lasting weight loss, a healthy relationship with food, and a happy person.

Nope. Haven’t seen it.

Instead I’ve seen people shamed for being in a body that’s not coveted by society. I’ve seen restriction inevitably lead to emotional eating, binging, a serious condition in sport known as  RED-S, disordered eating or diagnosed eating disorders. I’ve seen diets lead to fear of food, sadness, stress, and self-hatred.

Could you imagine if weight loss programs and diets came with the above hazards listed “on the bottle”??

Sign, Stop, Warning, Stop Sign, Symbol, Safety, Danger

So. Early in my dietitian career, I stopped. I stopped working under that guise of “maybe weight loss is ok to promote in some circumstances…” and switched to a more compassionate, inclusive approach.

And do you know what I found?

A person’s shape & size doesn’t indicate how healthy they are. People in smaller bodies can have the same illnesses as those thought to only affect people in larger bodies (yes, skinny people get diabetes, heart disease, and have strokes too). 

People who are considered “overweight” are poorly treated by the medical system and wellness community. Those in larger bodies most often are not offered the same level of healthcare or treatment options as those in thinner bodies. (Miller et al., 2018; Tomiyama et al., 2015 & 2018)

And importantly, when the focus shifts away from weight loss and towards developing positive experiences with food & movement, no matter what your size, you become happier & healthier. And your body finds its own unique shape & size that reflects that. (Bacon et al., 2005; Bacon & Aphramor, 2011; Mensinger & Meadows, 2017)

Happy black plump woman in stylish hat smiling brightly

If no one has ever introduced you to this shift in perspective, then it might be puzzling. There are after all many pervasive myths about weight & health. So why don’t we look at some of these myths together 🙂

5 weight & health myths to challenge in your every day life so that you can be happier & healthier

MYTH #1: BMI is a good measure of health.

BMI is the measure used today to categorize people into “normal weight,” “overweight,” and “obese” based on their weight & height measurements. BMI = weight in kilograms divided by height in meters squared.

This measure is bunk when it comes to health. In fact, the idea of comparing measurements of weight & height wasn’t originally made popular by healthcare professionals… it was made popular by life insurance companies.

Starting in the 1900s, insurers used just basic calculations of weight & height to decide premiums. Even though these calculations weren’t based on any medical science, doctors started to use them with their patients. But there were problems with these basic calculations. And so, a better equation was sought and found by looking back in history (Nuttall, 2015; Your Fat Friend, Oct 2019).

In the 1800s a dude named Quetelet wanted to create a math equation that could quantify “the average [white] man,” and then plot a population on a smooth & symmetric bell curve. The equation he found was known as the “Quetelet Index” and is the kg/m2 we have today. This equation was forgotten until the late 1900s when it was adopted under the name BMI and embraced by the World Health Organization (Nuttall, 2015; Your Fat Friend, Oct 2019).

Since then BMI has repeatedly been shown to be a crummy predictor of our wellbeing. After all, it wasn’t created to measure body fat, build, nor health! BMI doesn’t differentiate between muscle and fat. It doesn’t take into account the natural differences in body shapes & sizes of different genders, cultures, and age groups. It’s based on old numbers that don’t reflect our current society, which wrongly labels more people as “overweight” who are otherwise healthy in the body they are in (Nuttall, 2015; Your Fat Friend, Oct 2019).

MYTH #2: Everyone can achieve long term weight loss.

There are no research studies that show weight loss programs work over the long term for most people. But there are a number that show problems with weight loss research and the harm of recurrent weight loss attempts. Did you know repeated use of weight loss diets is related to heart disease, lower bone mass, and can cause more weight gain over time? (Rothblum, 2018)

Remember that show The Biggest Loser? A study followed all the participants years after the show ended and found they had regained most of the weight (Fothergill et al., 20 16). Why? Because when your body senses calorie restriction and weight loss, it slows down your metabolism, and can even make you hungrier. Your body is trying to protect you from starvation! This however makes it easier for you to gain weight, and harder for you to lose it again. This is why dieting on and off (aka yo-yo dieting) causes big weight fluctuations, and as time goes on can make it harder and harder to lose that weight with each attempt. (Mann, 2018, May; Nordmo et al., 2020; Ochner et al., 2013)

Unlike what the weight loss industry will have us all believe, the probability of maintaining weight loss is very very VERY low (1 in 124 for women and 1 in 210 for men in this study: Fildes et al., 2015).

MYTH #3: Eating disorders only happen in skinny people.

TBI and eating disorders. There’s a link.

Something I’m concerned about is the amount of nutrition talk in brain injury that supports disordered eating. There’s no shortage of diets, food eliminations, and restrictions offered up to people recovering from TBI, despite the serious lack of any good evidence for these recommendations. Disordered eating is something I have seen with my clients, whether that came before or after the injury.

Indeed, if you do a quick google search of “eating disorders brain injury,” you will find case studies of people who have developed eating disorders post TBI (Damlouji & Ferguson, 1985; Das et al., 2017; Castaño & Capdevila, 2010; Uher & Treasure, 2005). You’ll also find that not enough studies or clinics screen for eating disorders in their brain injury patients, even though this can be one of a number of psychiatric disorders that follows a TBI.

And the consequences are severe. I remember one of the first eating disorder trainings I attended. The lead doctor pleaded for a call to action saying the estimates of deaths caused by eating disorders could be compared to deaths from cancer…

So it’s absolutely crucial that we take down the myth that eating disorders only look like that image of a frail skinny woman with bones sticking out. In fact, eating disorders may be dismissed in people in larger bodies, which leads to worse outcomes (Lebow et al., 2015; Rastogi & Rome, 2020).

If you’re a health care provider and you have clients coming to you for weight loss, or you’re telling your clients to lose weight, then I am 100% sure that you have clients with disordered eating. No matter their shape or size.

MYTH #4: Thin people live longer.

Some people will say things like “but people who are overweight live shorter lives!” I’m here to burst your bubble — that just isn’t held up by the actual data.

For example one study (Reis et al., 2009) showed that a higher BMI in older age women and men was associated with longer lives. A large review of 97 studies (which in total looked at 2.88 million people!) also found lower mortality rates in those considered by BMI as overweight & moderately obese (Flegal et al., 2013).

All this to say larger bodies may actually be protective.

MYTH #5 Eliminating a bunch of food during your TBI recovery will help you heal faster.

Listen. If you believe that “food is medicine,” then let’s focus on EATING FOOD. Not cutting it out.

I don’t have any fancy research to back this one up. Not yet. But I have over a decade of experience as a dietitian. I can also pull from all the years my profession has been working in rehab. And I can give a shoutout to all the hospital RDs out there who are fighting malnutrition, because we know not getting enough energy through food leads to longer hospital stays and longer recovery times in many illnesses… Taking all this together, I think it stands to reason that focusing on cutting out a bunch of foods is NOT going to help you heal.

How could restricting food and eliminating more from your life truly heal your brain, body, and soul? This isn’t what nutrition is about.

If your brain is buzzing with overwhelm, I’m sorry. This shift in perspective is very mind boggling in our weight-focused society of today.

But if you take away anything, maybe try this:

Weight loss does NOT have to be the focus of your brain injury recovery.

Measuring body weight may still be a part of your medical assessment — it does have a role. A person’s weight can help determine medication dosing. In children and youth it helps us look at their growth curve.

With my clients, I still ask about weight history. Because unintentional weight loss or big shifts up or down in weight make us wonder whether something in the body might not be working so well.

Calculating a weight goal is not for most people.

Restricting to lose weight is mostly harmful.

When we shift away from weight loss and towards positive experiences with food & movement, your body finds its own unique shape & size that reflects that.

At the end of the day, I respect whatever decision you make. It’s your body, your choice. I may not promote weight loss, but whatever you choose, I will support you in the most compassionate & safest way possible. Whether it’s talking about weight or shifting focus more towards health & wellbeing, my role is to help guide you to the decision that’s most in line with what’s important to you in life.

Because you deserve to be seen, accepted, and heard as a whole person. Not just a number on the scale.

And you deserve to eat.

Calling for compassionate care in brain injury when it comes to weight,

Krystal Merrells, RD


Further exploration into this topic

HAES Curriculum: videos you can listen to on the topic of weight & health, plus developing a healthy relationship with food & exercise: https://haescurriculum.com/videos/

Your Fat Friend: Essays on life as a very fat person: https://www.yourfatfriend.com/

Food Psych® podcast about intuitive eating, Health at Every Size®, and body liberation: https://christyharrison.com/foodpsych

Jessica Wilson, RD, Centering those most marginalized in conversations about body liberation: https://www.jessicawilsonmsrd.com/


References

Bacon, L., & Aphramor, L. (2011). Weight Science: Evaluating the evidence for a paradigm shift. Nutrition Journal, 10, 69. https://doi.org/10.1186/1475-2891-10-69

Bacon, L., Stern, J. S., Van Loan, M. D., & Keim, N. L. (2005). Size acceptance and intuitive eating improve health for obese, female chronic dieters. Journal of the American Dietetic Association, 105(6), 929–936. https://doi.org/10.1016/j.jada.2005.03.011

Castaño, B., & Capdevila, E. (2010). Eating disorders in patients with traumatic brain injury: a report of four cases. NeuroRehabilitation, 27(2), 113–116. https://doi.org/10.3233/NRE-2010-0586

Damlouji, N. F., & Ferguson, J. M. (1985). Three cases of posttraumatic anorexia nervosa. The American Journal of Psychiatry, 142(3), 362–363. https://doi.org/10.1176/ajp.142.3.362

Das, A., Elwadhi, D., & Gupta, M. (2017). Secondary Eating Disorder: A Reality? Case Report of Post Brain Injury Sequelae. Indian journal of psychological medicine, 39(2), 205–208. https://doi.org/10.4103/0253-7176.203112

Fildes, A., Charlton, J., Rudisill, C., Littlejohns, P., Prevost, A. T., & Gulliford, M. C. (2015). Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records. American journal of public health, 105(9), e54–e59. https://doi.org/10.2105/AJPH.2015.302773

Flegal, K. M., Kit, B. K., Orpana, H., & Graubard, B. I. (2013). Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA, 309(1), 71–82. https://doi.org/10.1001/jama.2012.113905

Fothergill, E., Guo, J., Howard, L., Kerns, J. C., Knuth, N. D., Brychta, R., Chen, K. Y., Skarulis, M. C., Walter, M., Walter, P. J., & Hall, K. D. (2016). Persistent metabolic adaptation 6 years after “The Biggest Loser” competition. Obesity (Silver Spring, Md.), 24(8), 1612–1619. https://doi.org/10.1002/oby.21538

Lebow, J., Sim, L. A., & Kransdorf, L. N. (2015). Prevalence of a history of overweight and obesity in adolescents with restrictive eating disorders. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 56(1), 19–24. https://doi.org/10.1016/j.jadohealth.2014.06.005

Mann, T. (2018, May). Why do dieters regain weight? Psychological Science Agenda. http://www.apa.org/science/about/psa/2018/05/calorie-deprivation

Mensinger, JL & Meadows, A (2017). Internalized weight stigma mediates and moderates physical activity outcomes during a healthy living program for women with high body mass index. Psychology of Sport and Exercise, vol. 30, pp. 64-72. https://doi.org/10.1016/j.psychsport.2017.01.010

Miller, M. M., Allison, A., Trost, Z., De Ruddere, L., Wheelis, T., Goubert, L., & Hirsh, A. T. (2018). Differential Effect of Patient Weight on Pain-Related Judgements About Male and Female Chronic Low Back Pain Patients. The journal of pain, 19(1), 57–66. https://doi.org/10.1016/j.jpain.2017.09.001

Nordmo, M., Danielsen, Y. S., & Nordmo, M. (2020). The challenge of keeping it off, a descriptive systematic review of high-quality, follow-up studies of obesity treatments. Obesity reviews : an official journal of the International Association for the Study of Obesity, 21(1), e12949. https://doi.org/10.1111/obr.12949

Nuttall F. Q. (2015). Body Mass Index: Obesity, BMI, and Health: A Critical Review. Nutrition today, 50(3), 117–128. https://doi.org/10.1097/NT.0000000000000092

Ochner, C. N., Barrios, D. M., Lee, C. D., & Pi-Sunyer, F. X. (2013). Biological mechanisms that promote weight regain following weight loss in obese humans. Physiology & behavior, 120, 106–113. https://doi.org/10.1016/j.physbeh.2013.07.009

Rastogi, R., Rome, ES. (2020). Restrictive eating disorders in previously overweight adolescents and young adults. Cleveland Clinic Journal of Medicine, 87 (3) 165-171; DOI: 10.3949/ccjm.87a.19034

Reis, J., Macera, C., Araneta, M., Lindsay, S., Marshall, S., & Wingard, D. (2009). Comparison of Overall Obesity and Body Fat Distribution in Predicting Risk of Mortality. Obesity, 17.

Rothblum, Esther. (2018). Slim Chance for Permanent Weight Loss. Archives of Scientific Psychology. 6. 63-69. 10.1037/arc0000043. 

Tomiyama, A. J., Finch, L. E., Belsky, A. C., Buss, J., Finley, C., Schwartz, M. B., & Daubenmier, J. (2015). Weight bias in 2001 versus 2013: contradictory attitudes among obesity researchers and health professionals. Obesity (Silver Spring, Md.), 23(1), 46–53. https://doi.org/10.1002/oby.20910

Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC medicine, 16(1), 123. https://doi.org/10.1186/s12916-018-1116-5

Uher R, Treasure J (2005). Brain lesions and eating disordersJournal of Neurology, Neurosurgery & Psychiatry;76:852-857.

Your Fat Friend (Oct 15 2019). The Bizarre and Racist History of the BMI. https://elemental.medium.com/the-bizarre-and-racist-history-of-the-bmi-7d8dc2aa33bb

Accessed Feb 4 2021.

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