Episode 225: As part of the episode, we chat about Fiona’s background and the thesis for her PhD. We talk about Fiona’s history with an eating disorder and how recovery from this helped her move from a weight loss focus to one that’s weight neutral. We also talk about The Look Ahead Study, Malnutrition at every size, overeating, cravings and bingeing and how blood biomarkers are impacted upon restriction.
Fiona Willer is an Advanced Accredited Practising Dietitian who combines academic research, university lecturing and public speaking with creating professional development resources and training for health professionals through her business, Health, Not Diets. Her research areas are dietetic private practice benchmarking, inter-professional learning, health consciousness and dietary quality and the integration of weight neutral lifestyle approaches (including Health at Every Size® and the Non-Diet Approach) into the practice of health professionals, particularly dietitians. Fiona has served on the boards of international and domestic organisations including HAES Australia, the Association for Size Diversity and Health and now Dietitians Australia. Creator of the innovative Unpacking Weight Science professional development podcast, Fiona has great enthusiasm for both interrogating weight research and overusing food and eating metaphors in everyday life.
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Chris Sandel: Welcome to Episode 225 of Real Health Radio. You can find the show notes and the links talked about as part of this episode at seven-health.com/225.
Hey, everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel.
One tiny piece of housekeeping before I get started with this. During the week commencing the 15th of February, so a bit over a week after this episode comes out, I’m going to be opening up my practice again to new clients. I’ll be doing more of a push then and be talking about it and putting out more content starting that week. I’m just getting everything set up for that now. But if you’re interested and want to find out more, you can head over to seven-health.com/help. That’s all I’m going to be saying on it right now, but if you’re interested in finding out more about working together, then you can check it out.
On with today’s show. Today it is a guest interview, and my guest is Fiona Willer. Fiona is an Advanced Accredited Practising Dietitian who combines academic research, university lecturing, and public speaking with creating professional development resources and training for health professionals through her business, Health, Not Diets. Her research areas are dietetic private practice benchmarking, interpersonal learning, health conscientiousness and dietary quality, and integration of weight-neutral lifestyle approaches, including Health at Every Size and the non-diet approach, into the practice of health professionals, particularly dietitians.
Fiona has served on the boards of international and domestic organisations, including Heath At Every Size Australia, the Association of Size Diversity and Health, and now Dietitians Australia. A creator of innovative Unpacking Weight Science professional development podcast, Fiona has great enthusiasm for both interrogating weight research and overusing food and eating metaphors in everyday life.
I’ve been aware of Fiona Willer for a number of years now. I’ve known that she had a podcast called Unpacking Weight Science for a while, but truthfully I just kept listening to other things instead. But towards the end of last year, this changed and I went back through and have now listened to the vast majority of the episodes. Fiona really knows her stuff and is incredible as a researcher, so I wanted to have her on the show to demonstrate those skills.
As part of this episode, we chat about Fiona’s background and her thesis for her PhD, which is fascinating, and what it finds about the importance of body appreciation is something everyone should hear about. We talk about Fiona’s history with an eating disorder and how recovery for her helped her move from a weight loss focus to a more weight-neutral practice.
And then really the bulk of the episode is spent going through topics that Fiona’s show, Unpacking Weight Science, has touched on and things that I loved and wanted to get a chance to discuss with her and flesh out. We discuss the Look Ahead study, we discuss malnutrition at every size. Overeating, craving, and binging was another episode, and then finally how blood test markers are impacted upon by restriction.
One thing I want to mention is there’s a couple of terms that we use a lot. One is weight inclusive and one is weight centric. These are terms that are used a lot during the conversation, especially weight centric, and we do cover what they are, but not properly at the start. So I wanted just to mention here so you’re not confused at first, and if you’ve just not heard of these descriptors before.
Weight centric means weight focused, so the outcome that is being prioritised or focused on is weight loss. Centric meaning central, so weight loss is central to the whole approach. So that’s what weight centric means. Then weight inclusive means the opposite; the goal is to improve health, but all weights are included without the goal of weight loss. If weights change unintentionally, whether up or down, that is okay, but the goal of weight inclusive approach is not focused on weight changes as an outcome. Those are those two terms. I just wanted to mention it up front because they do get used a lot.
Fiona is a fantastic guest, and I loved getting a chance to chat with her. The two hours just really flew by. I’ll be back at the end with a couple recommendations, but for now, let’s get on with the show. Here is my conversation with Fiona Willer.
Hey, Fiona. Thanks for joining me on the show today.
Fiona Willer: Hi.
Chris Sandel: I’m a huge fan of your podcast, Unpacking Weight Science. I’ve been doing this work for a long time and feel fairly well-versed in it, but I still learn something new or many things new with every episode I listen to, and I love your research and scientific approach and would like to share a lot of that on the show today. I thought we could use some of your episodes as a jumping off point for discussions. But I’d also like to find out about you and your background and your practice and how you’ve become so passionate about Health at Every Size and its integration into dietetics. So that’s what I want to cover.
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To start off with, do you want to give listeners a bit of background on yourself? Who you are, what you do, what training you’ve done, that kind of thing?
Fiona Willer: Sure. Chris, thank you so much for having me. It’s a real pleasure to hear how interested you are in my work, too, which is lovely.
I am a dietitian. I’m now an Advanced Accredited Practising Dietitian in Australia, which is basically Australia’s registered dietitian equivalent with an advanced practice credential on top of that, basically. I’ve just about wrapped up my PhD. The thesis is written; it’s under examination. My thesis was in the integration of Health at Every Size interventions in dietetics.
A PhD is a lot of research, so I looked at whether it’s evidence-based practice within dietetics, and I also extended it to look at when people in the community take a health consciousness focus rather than a weight control focus, whether there’s any difference between how physically active they are, their dietary qualities, or how broad and varied their usual dietary pattern is, and also mental health factors like their self-compassion, their body appreciation, that kind of stuff.
I was very pleased to find that there is a relationship there. The more health focused and less weight focused people are, they tend to have a spontaneously broader, more health supporting dietary pattern, which is kind of cool I thought. It was not the hypothesis. The hypothesis was that they were going to be the same. The finding was that they weren’t, and even more satisfying, I guess, for somebody who’s quite passionate in this field, it was actually that the health focus won out. So that’s cool.
What else? My day job is as a lecturer in nutrition and dietetics at a big university in Australia, and also providing courses and professional development and podcasts in unpacking weight science, particularly getting to the bottom of where the weight bias is in the research that we read and how to look beyond that to interpret beyond just the impact of starvation, I guess, in these studies.
Chris Sandel: Do you also have a practice of your own? Are you practising as a dietitian and seeing clients, or not anymore?
Fiona Willer: I did for a long time. I had a private practice for about seven years, straight out of uni. I bought a private practice that was long established and continued that on until my family moved areas. My private practice was face-to-face, back in the time when we actually did that and we didn’t do any virtual practice. [laughs] At that point I decided that I would sell the private practice and focus on the PhD and the business side of things for a while. Doing a lot of things ends up being quite exhausting, so I wanted to focus on that stuff. But I am considering going back to private practice. It’s now back in my horizons for years later.
Chris Sandel: I imagine the busyness with having three kids is also a struggle with that.
Fiona Willer: It’s a lot, yeah. We moved away and then we had another baby outside of our family support network. [laughs] Yeah, that was interesting. But we’re back now in Big Smoke. Got my life back a bit.
Chris Sandel: For me, I like that mix where a researcher is also a practitioner because I think sometimes when it is just someone who’s always been a researcher, you can miss some of the nuance or what it’s really like to be with someone. I’ve had Josie Geller on the podcast before, and I think she’s another person who’s similar like that. I do think it’s a really big strength.
Fiona Willer: I agree. I’ve always identified myself as a pracademic, and my research – private practice is an unresearched area because of the nature of it. University based researchers tend to research populations that are relatively easy to access, and private practice patients and clients are not necessarily those. But the focus in my research field has always been on those as well, wanting to make life better for private practitioners and for their clients.
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Chris Sandel: Your thesis sounds really interesting. Was it focused in Australia as part of the research?
Fiona Willer: Yes. You’ve got to narrow down your research question so that you can really decide to explore an area deeply rather than a broad area more shallowly in a PhD. The population I was interested in was Australian adults – I didn’t look at teenagers or kids – and their outcomes, and Australian practising dietitians as well, particularly dietitians working with larger bodied humans and those outcomes.
Chris Sandel: And it was survey based?
Fiona Willer: It was. I had three studies. The first study was a survey of dietitians, both weight centric dietitians and weight neutral dietitians, and I looked at their knowledge about Health at Every Size and weight inclusive practice and their beliefs about what it’s for and how effective it is for X, Y, Z, and their attitudes towards weight inclusive practice versus weight centric practice as well.
I also looked at their psychological characteristics, too. I’ve interestingly found that people who are more towards the Health at Every Size side of the weight focus spectrum happen to also have high levels of self-compassion themselves, high levels of body appreciation, more flexible eating style. They’ve tended to mirror the characteristics that they were more prizing in their clients as well. So that was interesting. And the weight loss dietitians tended to be more uptight, more judgmental about themselves, more rigid in their eating styles. It’s fascinating.
Chris Sandel: Which actually makes a lot of sense.
Fiona Willer: It does, but when it pans out… [laughs]
Chris Sandel: It’s easy to teach people I guess what you already know from a lived experience, and if you’re always restricting and always dieting and focused on weight loss as an individual, it must be very difficult to then be talking about satisfaction and hunger and fullness and all of the other components.
Fiona Willer: You can’t mask for that long. If you’re a weight centric in that kind of mindset, you can’t really mask as a Health at Every Size person for very long before getting unmasked unceremoniously. But it’s also very difficult to describe to someone who’s in that weight centric mindset what the difference is, because it’s so different. Just about on every metric, it’s quite opposite to their comfort zone and their beliefs around how people should eat and how they should eat and that kind of stuff.
It’s really interesting work intellectually, but I think it’s incredibly important work for the profession and in fact for anyone who does nutrition counselling, not just dietitians. There’s lots of people out there talking to people about food and their bodies. But really important to show people there is another way, because we’ve got to meet clients where they are as well.
Chris Sandel: Definitely. Maybe you can’t answer this because it wasn’t part of your research, but how does Australia stack up with Health at Every Size versus other places around the world? Is it something that is well filtered out to the masses, or at least within dietetics? Is there quite a sizable movement?
Fiona Willer: There is here. My perspective on this is really built not so much by my PhD research but just because I’ve served on the board of the Association for Size Diversity and Health in the US as their Vice President International for a few years, and I was one of the founding members of HAES Australia here in Australia, which is a similar non-profit organisation for health professionals to help educate and support health professionals and other interested people in bringing HAES into the health care system here. Obviously my PhD did talk about the integration of these things as well.
My perspective is, my feel of it is, that the world leader is Canada in terms of the development of HAES-based approaches in dietetics. Certainly over there they have done for a lot longer and a lot deeper work unpacking – in dietetics we have this whole performative element. People have this idea of what a dietitian looks like and what kind of advice one might get from a dietitian. So we’ve got all of those societal roles that a dietitian might play, and we’re unpacking that stuff as well as beliefs about food and about body and about science and about the way that we’ve done ourselves a disservice in the interpretation of weight-related research.
So Canada is really leading the field in my mind. There are more dietitians in Canada than there are in Australia just by population numbers. Then I think Australia and New Zealand are probably next. We have a smaller profession here; there’s 7,000 dietitians. I campaigned to be on the Board of Directors here in our National Association and my campaign was a HAES promotion type of campaign that I led to get on the board, and I was elected on the board.
So that’s part of my mandate while I’m on the board, to make sure that there is a voice for people who don’t want weight centric treatment in Australia and to make sure that we dampen down any weight bias that might be creeping into the way that we respond to media and the way that we have our position statements and the way we interact with government and other policymakers here.
Then maybe the US, and I’m afraid to say I think the UK is trailing behind in terms of the larger dietetics/dietitian professional body countries. Sorry.
Chris Sandel: No, no.
Fiona Willer: There are some absolute superstars in the UK, but I think the way the NHS is organised means that it’s less able to propagate through those systems because they’re a lot more hierarchical and a lot more solid in framework.
Chris Sandel: Yeah. It’s interesting when I think about Australia because whenever I go over there – and I get back there when there’s not a pandemic roughly every year or every other year. I’m from Sydney, so I go there. Obviously, there’s this strong HAES aspect, but there’s also a really strong aspect of the other end of the spectrum.
Fiona Willer: Yeah, the Body Beautiful stuff is really…
Chris Sandel: I go to restaurants and there’s just so much of a focus on – the last couple of times it’s been on paleo or keto, to a degree that I definitely don’t see over here. It’s kind of like schizophrenic in terms of these two things that are trying to live next to each other that really don’t belong.
Fiona Willer: I hate using the word trouble. I’m not really going to use it. In terms of nutrition information, I think it’s just a normal offshoot of the fact that there’s so much information. You’re going to find something that feels right at the time. People are really led by their gut feelings, led by truthiness and dreams rather than maybe a more balanced view in terms of the experience of people with eating disorders and disordered eating and the science as well.
There are far more people giving nutrition advice in Australia than are licenced to do so. [laughs] That is the static behind the work that we both do. People talk about food all the time, and they should, but the fact that the narrative about food is usually so disparaging, just as part of the cultural milieu – it’s depressing how negative food talk is normal.
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Chris Sandel: Yeah. Getting back to your research, one of the things you’d said was that if there is a focus on health, the outcomes can be just as good. Is there a threshold where that changes? And the reason I’m asking this is I have a lot of clients who focus excessively on health, and it is not even about health, but to them it feels about health. Did you find that in your research, that past some point it’s actually not healthy?
Fiona Willer: The community study I did was a cross-sectional study, so a whole heap of people but only at one time. I had more than 3,000 participants, and more than a third of them were people who identified as male, as men. So that’s amazing. [laughs] It was difficult to get so many men, but it was great that we actually ended up with heaps in there.
What I found when I looked at the characteristics that I assessed for and I controlled for things we usually control for – things like socioeconomic status and age and education status – I didn’t control for BMI because it’s not really a valid thing to control for because it loads up on top of a whole heap of other things and messes up what you’re actually looking at. When I put all that into multiple regression analysis, that basically means that it can weed out what’s doing the work. Like, when one point changes, it changes more of the other things, basically. That’s what multiple regression does. I love stats, but it’s a bit difficult to explain them. [laughs]
But anyway, basically you put it all in there and it figures out what is behind the things, what’s the prime factor that’s moving these factors, the outcomes. I was predominantly looking at dietary quality and physical activity level as well, and I found that it was body appreciation that was doing the most work. The people who got the highest dietary quality scores were those who tended to have the highest level of body appreciation.
I used the Body Appreciation Scale too, which basically asks around unconditional body acceptance. So, “Yes, I accept my body with everything that it is, whether it can move well, maybe not as well as other people” – all that kind of stuff that somebody absolutely, unconditionally accepts it, and they also accept diversity in body shape in themselves and in others, and that they treat their bodies well and they have pride in themselves as a separate thing from their bodies. It’s a really nice neat little scale.
Those scores were so closely related to the dietary quality scores. When you took weight out of the picture, so you removed the people who either wanted to lose weight, so they had a goal of achieving a healthy weight, that was the statement, or they were actively trying to diet – remove those, then the dietary quality scores got a huge boost. So just leaving the people who were focused on achieving healthy habits and who didn’t have any of this weight consciousness going on – and there were more than 1,000 of those people in the study. It was actually, again, surprising that I managed to capture so many.
They had lovely dietary quality to the point where I could pin it on longitudinal studies of dietary quality, and the difference in the dietary quality scores was certainly enough to be able to compare against mortality stats with the dietary quality score. Basically, eating that way is related to a lower chance of various types of early death. That was a pretty cool thing to find as well, I thought.
It’s as if when you drop in weight centrism, it’s like contaminating the well. You’re really cutting people off at the knees to be able to eat a varied diet and have a high level of self-compassion and body appreciation and all those other things that we know are really good for you.
Chris Sandel: Wow, that’s really huge.
Fiona Willer: It is. I’m writing it up at the moment. I wish I could point you to a paper, but as I said, the thesis is under examination and the paper is almost ready to submit. But they’re the findings. I’m hoping it’ll be well-read.
Chris Sandel: Yeah. It just points towards how backwards we are with so many things and how often you’re trying to treat the symptoms as opposed to the root cause while making the root cause even worse. Whereas if you can help people feel good about themselves, feel positive in their choices, all of that, the other stuff will take care of itself. But we’re doing the opposite. In a sense, you’re trying to make people feel bad about themselves as a way of motivating better choices, which just invariably never works.
Fiona Willer: It’s so topsy-turvy. That belief that the behaviours are really anything to do with the BMI – it’s horrible. It means that people get gaslit at their doctors’ offices, and they get gaslit at home. “How can you be trying if your weight’s not changing?”, blah, blah, blah.
I know this research back to front, and the correlation between BMI and dietary quality and even energy intake is so small. You get a statistically significant difference when you break the entirety of humanity into three BMI classes and then pit them against each other. [laughs] You can get a statistical difference out of that, but actually at an individual level, there’s no predictability. You could take 10 people with the same BMI; you wouldn’t be able to predict what their dietary pattern was like, their energy intake, their physical activity. It’s completely nonpredictive. It’s an absolutely absurd metric. [laughs]
Chris Sandel: Yeah. I know on the podcast you’ve mentioned a number of times the fact that at every BMI category, there’s roughly 10% of that category who are following the dietary guidelines and that’s whether we’re at normal or at overweight or obese or whatever the category is. It’s pretty much the same.
Fiona Willer: Yeah, you’ve got your range of different patterns of eating in each of the BMI categories. The difference is enough to get a significant stats outcome, but it actually is not useful at an individual level at all.
Chris Sandel: Cool. Well, whenever your thesis is done and ready to be read, I would love to read it.
Fiona Willer: I cannot wait until the embargo is offered, because you’re not allowed to share it until it’s done, out there, assessed. I passed my defence. We do things a bit differently down here, but I have passed my verbal defence. It’s just the thesis bit that’s the last bit now. It’s a long, protracted process. I really, really am very jealous of the PhD programmes where you literally do an oral defence and they say “Yes, you’ve done it” and then you can go out and go, boom, I’ve done it. It’s done. [laughs] Our process takes months. It’s really horrible.
Chris Sandel: Yeah, a lot of waiting.
Fiona Willer: Yes.
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Chris Sandel: If we go back a little bit in terms of your history, how did you get into being a dietitian or wanting to do that as a job?
Fiona Willer: Well, my first degree is in archaeology and film production.
Chris Sandel: So naturally it just goes from there.
Fiona Willer: [laughs] But I had an eating disorder while I was a teenager and I studied to be a naturopath. I did half of a naturopath’s degree, as it is done here. Did a lot of travelling. Anyway, my eating disorder was grumbling away in the background as a young adult.
I had a final straw moment in my naturopath’s course when I got a high distinction for the subject where you read irises in your eye to diagnose disease, and I got a high distinction for doing that subject by correspondence, and I thought, this kind of feels like crap. [laughs] I feel like I don’t want to spend the rest of my life trying to defend my whole profession – which is ironic now that I’m a dietitian. But anyway, the choice at that time was to go back to uni and do dietetics rather than continue in that complementary and alternative health field. My parents are academics, so there was pressure there.
Went to do dietetics and met some more senior dietetic students while I was in my first year because I was part of the Dietitian Students Association, of course, because I’m addicted to being in committees, I think. [laughs] Anyway, I got handed a book called If Not Dieting, Then What? by one of those more senior students, and that was my first introduction to the Health at Every Size flavoured approach. It got me on the road.
I finished dietetics, bought that private practice as I mentioned before, got some therapy for my eating disorder and unpacked that stuff, as much as you can at that early phase. It coincided with starting to do some lecturing and tutoring at uni. Again, I gravitate toward those roles. I had hassled my old lecturers to see whether they needed any tutors, and it turned out that they did, which was great. But you can’t go anywhere in academia without the PhD, so I thought, right, this is it. It’s changed my life. I can see it changing my patients’ lives as well, because I had a private practice then. So I thought, I’m going to do my PhD in this and I’m going to pick at it and see if it’s got legs in dietetics in Australia.
That was way back. I’m in my ninth year of this PhD. [laughs] “Do it part time, have babies,” they say. I have had three children, gotten married, all the rest of the things. Life has happened. So it’s nine years and can’t wait to be rid of it. [laughs]
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Chris Sandel: You talked then about having the eating disorder. How was your treatment for that, all throughout the years?
Fiona Willer: I had one set of group therapy. I had binge eating disorder, but of course, like most people with binge eating disorder, it actually waxed and waned between more restrictive phases when dieting – long history of weight cycling. But I’m well recovered now, more than a decade recovered now.
It was mindfulness therapy, and it was for binge eating disorder specifically and it was weight neutral. It wasn’t what I do now, and it wasn’t what we do in dietetics either, but it was the psychological version of weight neutral, body positive coping mechanisms for people with binge eating disorder. It was great. Got me on my way.
Chris Sandel: Did you just luck out that you got that as the treatment method, or that’s pretty much the standard method over there?
Fiona Willer: No, it’s definitely not the standard. In fact, it was part of the psychologist’s PhD programme that I got in. [laughs] That was the call for participants. It was good timing. I already had an interest in this stuff from during my time at uni, but it was just what I needed at that moment to boost my own stuff and to really get me into proper recovery. It was good.
But you can’t really tell with any person when that moment’s going to be. You can’t predict. It has to come from inside. It has to be just the right time for them to get it and be on their way. All we can do is support people until they find that spark, that moment, and continue to support them through the wobbles.
Chris Sandel: I agree.
Fiona Willer: My story is not necessarily going to be helpful for others, but I guess my message is recovery is possible for everyone, I believe, with the right support and the right time, if all the constellations align.
Chris Sandel: I would agree with that. Did that mean that when you started practising as a dietitian, you were straight into the weight neutral approach?
Fiona Willer: No, I already had my private practice when I was receiving treatment. So I did weight loss dietetics for a number of years first. That was part of the light bulb moments to really get it. To have one success story out of a whole heap of weight loss clients – it’s like, “Oh yeah, this is the textbook one. Just one. And I’ve seen so many hundreds of people for this kind of thing. Just one. Hmm, what’s going on?” The cogs working. [laughs] Like, “This is clearly not typical.” I’m reading the research and I’m like, “Yeah, it’s not typical in there either. What the hell are we doing, really?”
Chris Sandel: I think to start with there’s an “It must be me. I’m fresh as a practitioner. Maybe I don’t know what I’m doing well enough here.”
Fiona Willer: I had life experience. I knew I was quite a good dietitian. Good information retention, good rapport, all the rest of the stuff. Confident in my ability as a dietitian. Not the best dietitian in the world, but certainly not terrible enough to reflect the poor results I was seeing from my weight loss clients. I’m like, “This doesn’t make sense. I don’t think it’s me and I don’t think that’s just ego talking.” So there were a number of nails in the coffin for weight centrism for me.
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Chris Sandel: How was it for you then making that shift? Did it feel like “Now I’m going to lose a big chunk of this practice” or “This is going to feel quite strange to be going in this very different direction”?
Fiona Willer: No, I was being tugged there. My heart was tugging to do weight neutral stuff. A lot of the weight centric counselling I was doing was pretty body positive. I didn’t identify as being a really strict weight loss dietitian, but that was still in the agreed goals for the clients. But I was clearly picking at the edges of it as I was going along as well.
When I finally made the decision, it was a massive relief and it was incredibly exciting and incredibly energising to finally be free of those kinds of expectations and be able to help myself and my clients look through their health picture with a different lens that was much more around their autonomy and around them defining their outcomes and being really honest about how crappy weight loss goals are in the long run.
So I had no tears about doing it. I was absolutely ready. It was just that last little thread of tension and then bang. It was a really exciting time of my life. So much energy.
Chris Sandel: That’s awesome. What about with the lecturing? Are the other lecturers at the university all in alignment with you? Are you the one ostracised person because you have these beliefs? How is it?
Fiona Willer: Well, you’d have to ask my colleagues, I guess. I’ve been teaching at this university now for more than a decade, 12 years or something. I think this is my 13th year teaching there, on and off. So everybody does know mad ne my stuff. I’ve put them all through their paces. The course is quite different in terms of the way that we teach the relationship between body weight and health outcomes, and we’re really very clear about what is a risk factor versus what is a disease and where those processes are and what’s an association versus what’s a disease process.
We’re actually very good at showing the students how to understand research, like what can this type of study tell us? What can it not tell us? Where are the public health guidelines located in the constellation of things that we think about with health? Where do they live in relation to an individual person we might see? All that kind of stuff.
My area of lecturing at the moment is in a huge first year unit, so I get hundreds of students every semester. Sometimes future dietitians at one time of the year, but also exercise physiologists, people who are taking a food and nutrition course because they’re doing another degree and they need to fill their electives. I get a whole heap of people. And future nutritionists as well, not just dietitians. We teach both the clinical side and the non-clinical, more public health nutrition side too.
So lots of people that will go off and talk to people about food and others that might not, but are there for interest. It’s a really great opportunity. I love first years so much because they come in with the massive ideas that are out there in humanity about food, and they’re men and women – just all of these ideas, and to help them unpack those beliefs and interpret research studies and read qualitative research as well and watch out for people with lived experience and all that kind of stuff. It’s not an easy task. Alongside what is a carb and how digestion works and all that. [laughs] It’s a responsibility and an honour I really love. I love teaching that stuff.
Chris Sandel: I guess even if people are coming in with their prior beliefs and what they’ve read and all of that, the fact that they’re first year and they’re exposed to that I think would make such a difference as opposed to you trying to talk to them in fourth year and you’re now having to undo three years of academic studies.
Fiona Willer: It’s a house of cards, weight loss focus. It doesn’t take that much picking to go, “Oh yeah, right, okay.” When I teach medical doctors as well, it’s fantastic. I say, “Get out your phone. Get out Google Scholar. Search for a weight loss trial that goes for more than two years.” You get them to do that and I’m like, “Look at the first graph that you’ve got in that paper. Can you see the shape of that graph? Does it look like this Nike tick?” It’s not like I’ve got this really neat research that this is specialised and blah, blah, blah, there’s only a few subjects. No, no, no.
It is in all the weight loss research. This is just widening our view of the effectiveness of the way that we’ve been doing things, and also shining a light on the harms associated with that way of doing things, because for a long time we did not look for eating disorder harms in weight loss studies at all. Those researchers are completely separately siloed from psychology and eating disorder research. Completely different fields. Never the two shall meet.
It’s not a difficult task to start framing edges. The hard stuff is getting to those beliefs. It’s our conditioned beliefs around how a body looks if it eats a certain way, that kind of stuff, that’s harder. The research is clear, but it’s those beliefs that we have. It’s a kind of faith-based system. When you put stuff in your mouth, you feel like you know what happens afterwards. [laughs] But we’re wrong a lot.
00:42:18
Chris Sandel: I think it’d be good to sharpen that up a little bit by looking at the Look Ahead study, because I think this is something that is nice because of how long term it is. It was quite detailed, and there is so much information that’s come out about it. If I just tee this up for you, could you start off with what was the Look Ahead study?
Fiona Willer: Firstly, when we do research, we can’t do it for decades on end if we actually want to be a successful scientist. The timeframes have to be sensible, usually. What that means when we’re doing weight loss studies usually is we use biomarkers like your cholesterol levels or your blood sugar levels to act as proxies for the longer term things that we’re worried about like heart attacks, strokes, getting diabetes or getting diabetes complications like losing toes and that kind of stuff.
In the short term we measure these surrogate markers, but in the long term we’re actually interested in those other things. We’re not interested in cholesterol levels. You can’t feel your cholesterol levels. Cholesterol is only relevant because of its risk relationship with heart attacks. So that’s the first. These are the rules of the game.
Now, the Look Ahead study was fantastic because rather than saying, “We’re going to put people on a long-term weight loss trial” – there were people with diabetes and it was a huge trial, thousands of people – rather than just saying “We’re going to get them to lose weight and see what happens to their cholesterol levels,” they said, “We’re going to get them to lose weight. We’re going to make them maintain it as much as you can, and we’re going to see if they actually do have those heart attacks that we think they’ll avoid because they’ve lost weight.” The hypothesis is the weight loss will not just result in reduced blood cholesterol levels, but will also result in reduced heart attack rate – because the proof is in the pudding at the end, not the ingredients.
Look Ahead had a long timeline. It was funded to 14 years, I think. Thousands of people in each arm. They split them in half, randomly selected. Half of them were just normal; they took their diabetes drugs, they went about their normal day, they got one or two sessions on how to eat well and how to move well at the beginning of this decade-long trial. The other group was their weight loss arm. They got three meal replacement shakes. Certainly for the first couple of years they got a lot of meals replaced there, and then extended on, they could continue to have those. Those who weren’t losing enough weight got weight loss drugs. They really tried to get the weight loss to happen. It was older adults as well, so 45+, that were in the study.
They did manage to have an average weight loss in that weight loss intervention group of about 5% to 7%. Again, we’re not talking Bigger Loser numbers here. There’s nothing that’s on TV. This is not entertainment TV numbers here. You might not even be able to visually see it on someone, that kind of weight loss percentage. But because it was really intensive for that whole time – and those people also had to be really physically active, so it was an exercise and weight loss trial.
Chris Sandel: Would they have taken biggest number losses and that was what they were hoping for, but it just didn’t occur? Or the goal was let’s get people to lose 10% or 15% or there was some lower goal that they were aiming for?
Fiona Willer: They set their goals individually in that study, which was interesting in itself. Usually weight loss trials are ‘lose as much weight as you possibly can’, so you’ve got your super responders in there, which are usually your middle aged white men who have never been on a diet before. It’s their first rodeo and they’re in there with huge numbers, and they drag the average down. Then it’s like, 5% weight loss. Great. But it’s mostly being dragged down by these guys who’ve lost heaps, with most people not losing very much at all.
Statistics are – it’s difficult to describe 1,000 participants. Statistically there’s a whole heap of different decisions you have to make as to how to render that information. And then you’ve got the element of time in there as well. But anyway, that’s a whole other thing.
I think with Look Ahead they did say 7% weight loss was the goal, and if people were re-gaining weight, the research team was on them pretty quickly and gave them more meal replacements again and made them do more physical activity and gave them these mostly ineffective weight loss drugs. They really were on them.
Chris Sandel: On them for the first year or two years, or the whole time of the study?
Fiona Willer: The whole time. Officially everyone was ridden pretty hard in the first couple of years, but for the extended period of time, that weight loss – they were offered, “You can have this weight loss drug. If the weight’s starting to come back you can have more shakes.” They went beyond their initial study plan to try to white-knuckle the weight loss maintenance in the intervention group in Look Ahead. Which ordinarily I’d be rolling my eyes for days, but we do want to know about these heart attacks. The interesting information, the bottom line, is around death, right? We’re interested in the deathy things.
What they found at about Year 9 was they’d had enough normal passage of time for heart attacks to start happening in their population. They noticed firstly that heart attacks were not happening as frequently as they had predicted. They used a population cardiovascular event rate to base the numbers on how many they would need to be able to detect something that was real in the population. They first noticed that neither group was having a lot of heart attacks. They were having lower than the general population of heart attacks.
Then they noticed that there was no difference between those who’d been given that very short nutrition and physical activity information at Year 1 and those who they’d ridden so hard about that weight loss for the last almost 10 years. There was no difference in the rate that people were having heart attacks and having strokes.
So they discontinued the study. They couldn’t justify it financially going on. I mean, the intervention group was getting a lot of attention from the research team. It’s expensive. They couldn’t justify continuing on because there was no benefit to the intervention group. That’s what happens in medication trials as well. If they find that there’s no benefit, the trial is abandoned for futility.
00:50:05
What we can find from Look Ahead is that while the hypothesis that because larger bodied people have heart attacks at a slightly higher rate than smaller bodied people, so we if made those larger bodied people smaller bodied, then surely they would have fewer heart attacks, similar to the smaller bodied crowd – that’s the assumption that all weight loss advice is based on, virtually. When tested in the long term, long enough to properly see what happens to real people in real living circumstances with their cardiovascular events, there was no difference.
So that hypothesis, that assumption, is incorrect. But it’s very hard to convince people of that despite this amazing trial. That’s Look Ahead in a nutshell.
Chris Sandel: It was interesting when I heard you do the podcast and then went and googled it.
Fiona Willer: I didn’t want to admit it. [laughs]
Chris Sandel: However many articles I found on it were giving the research trial gushing praise for what it found by doing these interventions. I was like, this doesn’t seem to match up with what I’ve heard on this podcast.
Fiona Willer: I know. If you read the papers that they produced at the two year mark and the five year mark and even at the seven year mark, they’re still really optimistic that there’s going to be a difference between their intervention group and their control group. They looked at the biomarkers and they found the differences. They did report pretty regularly while the trial was going. Part of their funding was to continue to do that.
But yeah, when it came to the crux, the stuff that is used in the fear-based campaigns about ‘you should try to lose weight’, that stuff, the really deathy stuff – ‘you’re going to lose your family, you’ll drop dead and you won’t be alive the next decade’ – that really scary, fear-based rhetoric around high body weight – when it got to that end of the trial, it was kind of, “Oh, whoops.”
To read the paper, the mood in the paper – academic writing is a style unto itself. [laughs] I read a lot of academic papers and I write them too. There’s still definite moods within papers, and there were no ‘gotchas’ in those final papers around the reason that the trial was discontinued.
It hasn’t stopped them publishing a whole heap of papers like “Maybe heart attacks didn’t change, but these one or two other things stayed all right in the intervention group.” Like, okay guys. Yeah. [laughs]
Chris Sandel: Was there any explanation that they theorised or gave for why there were less deaths and incidents than what they had expected?
Fiona Willer: Predicted, yeah.
Chris Sandel: Is it that the kind of population that puts their hand up for a trial is not average?
Fiona Willer: You’re hit it on the head there. The kind of people that are able to volunteer for a decade plus long trial tend to be people whose lives are stable. They’re not going to be those people who are financially disadvantaged necessarily. They’re going to be people who’ve got access to their health care team because that was part of the trial, that they continue on with their usual care. So they’ve got relationships with their health care providers that go on for years and years and years.
It weeds out those population groups that are high risk for chronic diseases as well. But saying that, all of the participants did have Type 2 diabetes already, but it was a healthier population of people with Type 2 diabetes to start with, if that makes sense.
Chris Sandel: Yeah. One of the other things you mentioned on the podcast as well is that those who were in the weight loss group actually did end up doing more physical activity, they did end up having more fruits and vegetables, things that would typically be associated with better health outcomes and do come up across lots of different research. But in this instance, it didn’t make a difference.
Fiona Willer: I wondered then, on balance, whether that energy restriction had a negative impact, so it’s undone any benefits that eating well and moving regularly had for that group. But who knows? The data that we have – and most of these big trials do release their datasets. I can’t remember from memory whether this group did. But it’s difficult to reverse engineer that kind of exploration of the data. It would need another study. But it’s hypothesis building.
Chris Sandel: It would definitely make sense in connection with so many of the clients that I work with. So many of them on paper are doing everything that they’ve been told they should be doing and everything that this culture is saying is healthy, and yet they’ve lost their period, and yet they’re having osteoporosis or osteopenia in their thirties. There’s all of these negative outcomes that are occurring because of the restriction. It doesn’t matter how many fruits and vegetables you eat. If you’re in a calorie deficit and you’re getting less than the body needs, you’re missing the most important thing.
Fiona Willer: That’s it. We’re just so topsy-turvy about that aspect of it. It makes me angry and then disappointed. [laughs] But no one is in this field, and certainly in Health at Every Size, in terms of trying to help the more weight centric providers understand where the approach may be falling down. Rage gets you a long way in this work. [laughs]
Chris Sandel: Even for all of the outcomes that occurred, in some ways it’s great to have something that went on this long. As you said, most trials last two years. To have something that was 9 years or 11 years or however long it went on, that is so not the norm. And it was well controlled. They were making sure people were keeping up the weight loss so you couldn’t then argue it was because they re-gained the weight and that was what was happening. They did all of the things that could potentially be considered ‘there’s this compounding variable’.
Fiona Willer: Yeah, exactly. I am glad. I’m sad for those participants who spent almost 10 years on a diet. That is awful. In terms of the scientific research body, it’s really good. It’s going to save a lot of treatment burden of humans having that information, that phenomenon captured in the academic literature. But I do feel for those people.
Chris Sandel: Definitely. I’m reading a book on the Minnesota Starvation Experiment. I’ve done a lot of reading around it, but I’m reading a book on it at the moment.
Fiona Willer: Those poor guys.
Chris Sandel: Those poor guys. Just brutal to be suffering like that for such an extended amount of time.
Fiona Willer: And they did not suffer from doing it because of body image issues or because of societal stigma that was hitting them every day. Certainly there was societal stigma about being a conscientious objector amongst some people, but you don’t walk around with that label on your forehead. Yeah, but I still feel for them. It’s terrible. It’s so interesting how many eating disorder cognitions develop on the background of insufficient energy intake, that spontaneously appear in humans that are part of the neuroticism of humans. It’s really ‘turn off this food tap, this is how human brains start to work’. It’s fascinating.
Chris Sandel: It is, and it’s sad that there is some level of that that is going on all the time for most people. There is some level of restriction, there is some level of energy insufficiency. And maybe it’s happening in moments and then it stops again for a couple months or whatever, but it is an epidemic.
Fiona Willer: Yeah. The lived experience of it, too. You tend to think, that’s me, my neuroticism or blah, blah, blah. But you can see clearly, when you step away and actually look at the patterns, it’s a predictable part of energy restriction in a human.
So we’ve got a lot of messages to spread, don’t we? Weight centrism is dangerous for a great many people and completely ineffective for the rest. And those people who are struggling. They’re not the first people to have struggled, they’re not the only people to be struggling right now, and there is hope.
Chris Sandel: I think the comment you made where whatever state you’re in, it feels like that is the normal way of being, and it just feels like this is the self, this is who I am – that’s the thing that I experience so much with clients. When they recover, there’s this realisation of “Wow, I didn’t know how much this was affecting my cognition. I didn’t know how much this was affecting my preference for spending so much time thinking about food” or whatever it may be. I think it’s when you can have that change occur that you notice the distance and you notice how much it was having an impact.
Fiona Willer: Weight centrism makes you really cynical about anything that’s not weight centric. It’s built into the nature of it that anything that suggests that accepting yourself might be a good idea is very easily dismissed. There’s a lot of motivated reasoning to keep you in diet culture, to keep you weight focused.
01:01:10
Chris Sandel: Totally. This moves on nicely to another topic that you covered on the podcast, which is malnutrition at every size. I think it would be great to spend some time on. I think you said it’s often referred to as undernutrition as well?
Fiona Willer: Yeah. The thing about malnutrition is that we’ve got a lot of information about malnutrition from various famines that have occurred, and in that state you’ve got your typical – what you might think of with someone as being undernourished, malnourished. Very emaciated looking humans who have no reserves whatsoever left. That’s our frame of reference for malnutrition and the way the public usually thinks about it.
But when we’ve got a population where there’s a lot of diversity of BMIs, of body weight in the population to start with, and lots of dieting behaviour, you can pretty quickly end up malnourished. The clinical guidelines for the assessment of malnutrition vary from country to country. Some of them still have BMI in there.
I think I talked about it on the podcast as well; usually that’s a guideline that’s been developed using expert consensus rather than data derived assessment. It’s what the experts think, and that’s much more likely to be driven by their confirmation bias around malnutrition. So it’s much less likely to be more scientifically valid – which is frustrating because we’ve got a lot of malnutrition out there, but whatever.
The guidelines that use data to develop the algorithms to decide when malnutrition is being experienced by a person tend to have things like a percentage weight loss over a period of time as well as some biochemical markers. If you do a physical exam, you can tell when people’s muscle stores are wasted, and particularly in the face. When somebody’s suffering from malnutrition, no matter what their weight is, you can feel it. The temples are hollowed out. No matter how big somebody is, you still see that in a face. The face is really a very useful place to assess malnutrition.
But if that goes under the radar – when somebody comes into a hospital for whatever reason, if they’re in a larger body size, they get ignored in terms of malnutrition screening in a lot of places. I’ve got to say that in Australia, we’re not bad at screening for malnutrition, but that is all dietitian driven because we know we’d rather feed people while they’re in there because then they get out more quickly. It reduces bed days in hospital when we feed people enough.
But malnutrition screening doesn’t happen widely for larger bodied people in a lot of places in the world, and it can obviously impact really negatively on the other stuff that they’re in hospital for as well.
On top of that just purely medical aspect of it, we’ve got the attitudes of people who are involved with feeding people, and that includes doctors. “Oh, a little bit of weight loss during a hospital stay has got to be a good thing. We’re helping them along.” That drives me utterly, utterly to distraction. It’s completely appalling. I’ve got an episode on starving in the intensive care unit, which is kind of timely given our current situation in intensive care units.
Chris Sandel: If you’re thinking about how you could properly improve repair – especially if someone’s in hospital, it’s typically because they’ve had surgery, they’ve got an infection. There’s some disease process going on.
Fiona Willer: Sick already.
Chris Sandel: And in all of those situations, having adequate energy come in is going to be helpful. And one of the things you talked about as part of this that I found really useful to think about is that there’s often this phase of like “Look at the size of their body. They obviously have so many energy stores on their body” – which is incorrect. But the storage capacity for so many vitamins and minerals and different components of food is so small within the body. So even if someone supposedly has all of this energy hanging around in their body, they don’t have all of the vitamins and minerals.
Fiona Willer: Yeah, it’s not a doomsday locker. This is not that. [laughs] Exactly. Particularly now we’re living in a post bariatric surgery world where not even just somebody in a larger body who’s malnourished at the moment, but if they’ve got heart failure and they need X, Y, and Z treatment done and their digestive system is completely replumbed to literally avoid absorbing nutrients, it’s incredibly difficult for dietitians to do our job. We need to nourish that person so that they can overcome or manage whatever they’re in for. We want them to live.
But bariatric surgery, particularly the bypass type surgeries, take that away. It’s like being in space without oxygen supply and no hope of getting home. It is absolutely terrifying as a clinician, and it’s got to be worse as the patient who’s done all these things because they were told they’d be good for them, and they end up with one of the conditions that happens quite frequently to people who are older. Nothing to do with their weight. And they’re basically nutrition resistant. It’s a coming wave. That’s my hot prediction. We’re going to be watching in horror as a lot of people are unable to overcome things that we’re usually okay with dealing with nutritionally.
Chris Sandel: Yeah. But I guess the problem with that is it won’t be blamed on the bariatric surgery; it’ll be blamed on “These people were obviously not very healthy. They weren’t looking after themselves, because otherwise they wouldn’t be in that size of a body.”
Fiona Willer: I think that would be the take that maybe family and friends and other people in their social circles may take. But dietitians are pretty good at sticking it in that situation, because it is really clearly what’s going on.
I did work in a hospital for a number of years as a dietitian as well – I’ve always done a lot of things. [laughs] We didn’t even talk about that, but whatever. I was a clinical dietitian for three years in addition to lecturing, in addition to having a private practice for a while. This is before kids. Just watching a patient starve when I’m surrounded by food and I can’t get it into them – even the TPN, the vein feeds, the storage capacity of the liver was resistant to even TPN nourishment at that point because they were so malnourished for so long.
It was just horrible, totally horrible. Really traumatising. Many patients died. Really traumatising for me as a clinician to not be able to do anything. You feel completely helpless to help them. Horrible.
Sorry about the low note. [laughs] This is why it’s so important, isn’t it? This is what keeps me going.
Chris Sandel: The thing I was going to say was the times where people are told that it’s a good idea for them to lose weight, given this whole idea around malnutrition, makes completely no sense in terms of when someone is coming in for surgery.
Fiona Willer: Yeah, “Let’s get you malnourished before that major surgery. Let’s decondition you so that you don’t have those ready stores of X, Y, and Z in your recovery after this.” Even knee replacements. You do recover faster if you’re well nourished going into it. But there’s a whole heap of stuff around orthopaedic surgeons’ attitudes towards heavy people plus the skills and the equipment.
It needs a lot of champions within that profession to come in and call out discriminatory practices and to push for better prostheses. The knee replacement devices, the hip replacement devices, better techniques, all that kind of stuff. And the appetite, unfortunately, for that is lower than it should be.
But as non-surgeons, we can help to nudge them and remind them that doctors and surgeons are able to operate on neonates and foetuses in the womb. We do hard things, and people in that profession who do hard things are usually heroes. We need some heroes in medicine for larger bodies and surgery for larger bodies, because there’s at least a third of the population who would be triumphing along with that.
Chris Sandel: Definitely. The same with fertility. People are told to lose weight before you’re about to embark on this thing that is going to suck the best part of 50,000 calories out of you, and then whatever is needed, 1,000 odd for every day breastfeeding. To then be starving yourself before that because it’s supposedly better for fertility also makes no sense.
Fiona Willer: That is really another case of – we’ve got insulin resistance driving some of the issues people would have with the frequency of ovulation and the fulfilment of ovulation. Then if you put somebody on a weight loss plan, that tends to reduce their insulin resistance. You tend to get ovulation happening more regularly, so people do tend to fall pregnant a bit.
But it’s actually not the weight loss. It’s the higher levels of physical activity, perhaps some changes to food. It’s not the weight loss doing the thing. But they’ve conflated that process. You can get those kinds of changes – and of course, we do with people with PCOS all the time – to change lifestyle elements in a weight neutral way that does help with ovulation and it helps with insulin resistance or helps increase insulin sensitivity. They’re the things that are driving that increased chance of successful ovulation and successful conception. But it’s dumbed down to the lowest common denominator when it’s weight loss that’s getting the damn credit for it.
Chris Sandel: The indicator of malnutrition was I think 5% to 10% of weight lost over a 3 to 6 month period.
Fiona Willer: Yeah does that sound familiar? [laughs]
Chris Sandel: That’s what every diet is hoping to achieve.
Fiona Willer: It’s like the claim lines on every weight loss product. Ugh, it’s utterly maddening.
Chris Sandel: When I read that, I was like, that seems to make no sense in comparison to what is pretty much recommended at every doctor’s visit if someone is in a larger body.
Fiona Willer: Yep, exactly. I think a lot of what drives that – I got this sense many years ago, and it hasn’t really changed. People always confirm this belief that someone with a larger body must be overeating to stay larger. This is the natural understanding of what must be going on. But in fact, whether their BMI is 22 or 42 or 62, if the body weight is stable, then they’re eating to meet their nutritional needs at that time, their energy needs. They’re not overeating. You cannot read somebody’s eating pattern off their body.
So many of the traps we fall into around weight centrism are because of that naturalistic belief about what a body size says about somebody’s lifestyle.
01:14:25
Chris Sandel: You’ve done a whole podcast on overeating and craving and binging, which I want to touch on. The final thing I just wanted to say in that malnutrition piece – and I don’t know if this came up in that podcast, or it might’ve been in another one – but you talked about during adolescence and there being this three years where you have this change in growth, which I think is really useful to know. Can you talk a bit about that?
Fiona Willer: Yeah. This is just amazing. As a parent of children who are coming into that phase now, it’s even more cool to know about. But anyway, the thing about puberty is that those growth changes can happen anywhere between – well, it depends on the sex, but between the age of 11 and 17. The magic happens during an intense three year period. All the sex characteristic changes, all that stuff. It’s really, really intense in a three year period.
But you never know when you’re in that. Once somebody gets to about 17 or 18 years old, you can look back at their growth pattern and go, oh yeah, that’s the three years for me. But when you’re in it, you can’t confirm that you’re in it, if that makes sense.
Some people will have their height spurt first, and some will have their weight spurt first, followed eventually by whichever the other one is. Some people have them at the same time as well, so they remain relatively proportional. Of course, you always get taller during the main growth spurt years.
But if you’ve got somebody, particularly a girl – if she’s having her weight spurt first, that is going to track on our growth charts as if she’s jumping percentile lines because the percentiles for height and for weight are these smooth lines representing a whole heap of group characteristics. They don’t capture effectively the amazing velocity of changes that happen during those three years.
So we’ve got this situation where we’ve got a girl who’s having a weight spurt before a height spurt, but everyone is freaking out because she seems to be jumping lines upwards into what might be classed as more risky categories – which I don’t agree with, but whatever. Then that person is over-pathologized. She might get dragged to the dietitian, who tries to give her healthy eating advice, very well meaningly, but ending up tipping off the first stages of disordered eating that might spiral into something much more serious.
And all because we’re panicked about weight gain, even on the background of puberty, which is such an amazing metamorphosis time for humans.
My take-home message there is we need to calm down and recognise that they’re changing from bugs into butterflies, and what happens in between is not something that we need to white-knuckle, basically.
Chris Sandel: Definitely. I think you made the comment that if at the time, say someone is having their weight spurt before their growth spurt, and then you try to intervene by restricting or other methods –
Fiona Willer: Their height spurt will get stunted if they’re not eating enough. Insufficient energy intake during adolescence will stunt height. Once there’s enough food going around in there, the weight will restore to whatever their weight would’ve been in general, but the height’s never going to catch up. You don’t really get catch-up height growth properly if there’s been extended energy restriction during puberty. Not that we’re heightist, but that’s a pretty serious intervention into what somebody’s natural history would otherwise have been throughout their lifespan.
Chris Sandel: I think the issue as well with it is often as humans, especially around weight, we are good at looking at the outcome and then trying to come up with a possible explanation for why this is occurring. If someone is having a weight spurt first and you’re then trying to work out why that is occurring, you’re like, “We had McDonald’s now a little more frequently than we used to” or “I noticed I’ve got more of a sweet tooth.” You build up all of the –
Fiona Willer: You’re pathologizing those normal things which aren’t necessarily the drivers. You’re absolutely right.
Chris Sandel: Exactly. And then for someone who is getting leaner and more muscular and taller, maybe the height’s there, their explanation is “I’m keeping up the sports quite a bit.” Yeah, you find a narrative to fit whatever is actually going on, but that doesn’t mean that it’s true.
Fiona Willer: Yeah, we are not in charge. [laughs] We’re definitely not in charge. And when we do try to be in charge, we mess it up, basically. Health professionals and humans.
Chris Sandel: Totally. The reason I wanted to bring that up is I think dieting at any point and restriction at any point is a problem, but at that particular time, it is so much more likely to be a problem for reasons in terms of impacting on physiology at a really important moment, but also someone is so much more sensitive and going through this process of turning into an adult and separation from their parents and understanding who they are as an individual and all of those processes that are going on. Even for someone who’s well adjusted and isn’t dieting, that’s a difficult time of life.
Fiona Willer: Yeah, tumultuous.
Chris Sandel: To then throw this extra thing into the mix makes it so much worse.
Fiona Willer: Yeah, it’s like, here are a few more bricks to carry despite the load you’re already under because being a teenager is something else.
01:21:23
Chris Sandel: Yeah. Let’s talk about your podcast on overeating and craving and binging. It’s interesting with this. Part of the reason I want to talk about this as well is I haven’t actually done a lot of writing around this or a lot of podcasts around this as a topic. I was recently, at the end of last year, working with someone who’s helping on SEO and looking at the things that people are searching for versus the things I’ve written an article on or matches up with a title.
What became acutely obvious at that point is there’s one or two search terms that people are looking for in terms of anorexia. It might be ‘anorexia’ or ‘anorexia recovery’ and that’s kind of it. But if you put in ‘binging’, ‘craving’, ‘overeating’ – all of those search terms, you have 30, 40, 50 different combinations of those things that people are searching for on a really, really regular basis.
I think I fell into the trap of like I understand that restriction is at the heart of all of this, but the majority of people who are searching are not that way of understanding things. They think their problem isn’t the restriction. The restriction was when things were working really, really well, and their problem is the binging or the craving or the overeating or however they are using those different terms. That is now the problem.
Fiona Willer: Yes. It’s where the problem is located. Researchers and people, if they say, “This eating behaviour is problematic because look at my body. Here’s the evidence that it is,” that is all shades of fatphobic, usually. And even eating disorder researchers and therapists will say quite openly that binging is the issue because it causes fatness. “This is why I’m working with people to help them stop binging, because there’s nothing worse than being fat.” That’s the narrative for the work they do. That is where they’re putting the meaning. “I help people with binge eating disorder because binging is terrible because fatness.”
As somebody who is also in the eating disorder field and with lived experience, if you think about how eating disorders are defined and about how eating disorders are experienced, it’s actually about distress. We’re quite happy to problematise distress. This is actually what we’re trying to help our clients with and support them through so that they experience less distress. That is the bit that ruins your life, the distress. [laughs] Not the binging.
But these two types of clinician will both call themselves eating disorder clinicians, and one will locate the problem in the body and the other will look at the problem in the distress and the emotional experience of it. That divide has not helped.
So we get these terms. We demonise binging when really, that is a coping mechanism that follows very predictably from restriction, and restriction itself is a coping mechanism as well. It’s all around body distress or the perceived body distress. A lot of the body distress is what we as a society has decided is a problem. Nothing to do with the actual body itself.
So we’ve got all these onion layers of where the issue lies. If you’re finishing thinking about the issue when you’ve come to the body bit, you’re not really doing deep work. These people are not going to be properly in recovery. You’re not really doing your job as an eating disorder therapist if you are deciding that you’re in league with binging being the bad thing. Binging is a very adaptive strategy and a very predictable result of restriction.
Chris Sandel: Totally. I also think there’s the other layer of, for a lot of people, they have underlying anxiety or depression or other mental health issues or other uncomfortableness that actually has nothing to do with their body and their body shape, and it predates any of this going on. But that kind of gets forgotten about because then the binging becomes the problem and everything gets seen through that lens. So at any point when I feel uncomfortable, at any time that I feel anxious, it must be because of something I did or didn’t do with food.
Fiona Willer: Our bodies are with us all the time. They’re a really concrete thing that we can count on to be there in a physical sense. So they’re really an obvious thing to blame for anxiety, for feeling bad. The body is seen as something that can take the heat that might otherwise be unbearable to deal with if we acknowledge that it was really beyond our control.
When I explain this to health professionals and people that I’m working with, it’s a process of transference of something that is big in their life that goes beyond what they can deal with. It might be a problem in their key relationship where the other person isn’t coming to the party. There’s no resolution in sight and it’s very distressing for the person. All of that frustration very quickly can be transferred to the body being ‘wrong’.
The body is a natural place for this to go as well because we have this perceived idea that we can fix it through our own volitional means. So I’m going to make this big problem; that frustration is going to transfer itself onto my body. That happens subconsciously. It makes us feel immediately better that we can then deal with it. I’m going to deal with it by going on a diet. I’m going to do this diet, that diet, lose whatever amount of weight, decide to do something that feels heroic, and I can do that, and suddenly I’ve got a plan. That plan’s going to relieve me of some of that stress that I’m feeling. But really, we haven’t deal with the actual issue. The body’s taking the brunt of it.
Chris Sandel: Totally. You’re grasping for a sense of control, and if you narrow your focus enough, you can find something that feels really controllable.
Fiona Willer: That’s it. And because we’re with our bodies all the time, they’re there. They will take the fall for us, unfortunately.
01:28:52
Chris Sandel: With binging – I don’t know if you will remember this from the podcast, but what is the definition for it, or how is something defined as a binge versus ‘that wasn’t a binge’?
Fiona Willer: Usually it’s defined by a sense of loss of control. The sense of being out of control with eating, and eating more than was planned or more than they would usually eat. That’s one of the broadest definitions.
Then it depends on who’s doing the assessment. If it’s a psychologist doing the assessment, there’s also room for that psychologist to decide whether it was a legitimately large amount of food or whether it was just perceived as a large amount of food by the person experiencing it. Huge dodgy loophole. Huge.
The main crux of it, though, is the sense of loss of control and distress related with that. So if you’re just at a party and you end up feeling uncomfortably full at the end of it, that’s not a binge – although a layperson might call it that. ‘Binge’ has become such a big part of our vernacular, too. We binge TV all the time, but it really doesn’t have much to do with the way that we use the word in eating behaviour terms. But that loss of control and distress, that’s the key. And that’s got nothing to do with body size.
Chris Sandel: No. I do think, though, there is some subjectivity to that as well because when someone – and this is something I’ve experienced with clients – talks about losing control, that loss of control is often because they’ve gone over some threshold that they deem appropriate. So for someone, loss of control was “I ate a whole pizza and a thing of ice cream” and for someone else it’s “I ate half a chocolate bar and I said I was going to eat a third.”
Fiona Willer: Yeah. You know what, I don’t even think it matters much. If we say that it does, we are falling into the trap of being interested in the food intake itself in a broad sense at that moment.
Chris Sandel: Oh sure. I guess my reason for mentioning it is a way for feeling like you didn’t lose control is broadening the parameters more and more for what it means of like ‘I crossed the line’.
Fiona Willer: Yes. You mean when you’re unpacking it with the person, yeah, “Is that real?”
But again, use with caution, because we can end up colluding with that sense of eating a lot at once is bad. But actually, eating a lot at once for a human is – we have bodies that will totally deal with that. We have stomachs that stretch a damn lot. We have digestive systems that just take their time. They will get through it. They’re amazing, and they will get all of what they can out of it. They very rarely really object in a completely spectacular sense. Human bodies are incredible. So we can’t actually label eating till feeling quite stuffed as pathological in itself. We would only do that if we’ve got this weight centric lens that we’re worried about what that might mean weight-wise.
Chris Sandel: Sure. Just to clarify, I’m not trying to create a line that says if you have that amount of food, that definitely is a binge. It’s more of a thought experiment and trying to be like, if you thought about this differently and the line was a different place, how would that experience have been different for you? Because basically I’m like, there is no amount of food that is off limits; it’s just when you’re creating some level of demarcation, that’s when you start to trip up.
Fiona Willer: That’s it. I agree with that. It’s so easy for clinicians who aren’t as solid in their weight inclusive work to slip into it, though. That’s why I’ve really got to be very clear about what I’m saying here, and that there is no limit.
I have been argued with in protracted, very animated manners by psychologists trying to argue the opposite of that because of their ideas around nutrition. I’m like, that’s not your lane. [laughs]
Chris Sandel: Yeah. But I also think about it, even in my own experience – and I have never had an eating disorder; I’m very lucky. I’ve always had a good relationship with food. But there are times that I eat in a way that I know lots of people would identify as a binge. I finish a meal and then I’m spending the next five minutes eating, with the spatula from the pan, more food. I’m doing things that for many people they would say, “I lost control. I wasn’t present there,” etc. I don’t know. I think depending on how someone frames it has a really big impact on what that experience means.
Fiona Willer: Yeah, absolutely. And that person’s food story, what they learned about eating from their family, what they learned about eating from their social groups – it’s so important to understand that context. So important.
01:34:45
Chris Sandel: You’ve talked about as well – we’ve just touched on it there – the impact of the cognitive dietary restraint and how that affects disinhibition. Do you want to talk a little about that?
Fiona Willer: We’ve kind of touched on it before, that restriction. Cognitive dietary restraint is around how rigid somebody’s eating behaviours are, so inflexible eating. It may be that they only allow themselves a certain amount of food or certain types of food. Eating might be regimented to particular times of the day. Basically it’s dieting behaviour, and in psychological terms it’s inflexibility that’s ruling the day there. It’s rules and regulations, external, rather than internally led eating behaviour.
The opposite of it is flexible dietary restraint. In more lay terms, it’s the intuitive eating style, flexible eating style, eating to hunger and fullness cues. So we use measures that have those two things, one at one end and the other at the other end, to try to unpack how tightly wound a person is about their eating behaviour. And certainly the way that they’ve grown up and the kind of messages they received from their caregivers, particularly the mothers – but if the fathers are around, that impacts on the kid’s eating behaviour as well. It’s just who they’re mostly with.
If the message are “No, you can’t have seconds,” “No, you shouldn’t be eating that,” “No, don’t eat that because you’ll get fat” – those kind of really weight centric messages – then the person is going to be more likely to be up on that restraint end. It takes more work for us to tap them down towards more flexible, calm eating. Because of course, once you break a rule, you’ve got an element of shame around that, and the perception is that there’s going to be some sort of consequence body shape-wise and you’re going to feel anticipatory shame as well. It’s just a big shame breadbasket, basically, eating rigidly.
Chris Sandel: Yeah. As you said, once you break that rule, often you then have the impact of like “Oh, what the hell, new diet starts tomorrow.” Once you go over some threshold, rather than it being more likely that you’re going to stop, it becomes more likely that you’re not going to stop.
Fiona Willer: Yeah. It’s so shame-driven as well. That disinhibition is quite powerfully – particularly if somebody is overall hungry, like they’re energy restricted overall, you’ve got the dual power of the fact that you’ve got shame driving eating at that moment plus you’re legitimately underfed. All of your hormones are screaming “Feed me please!” So tipping over that waterfall into eating, your body’s behind the wheel, but your mind is totally there thinking it’s the one doing the driving.
It’s a very fascinating, complicated, amazing process. There’s a reason we’re such a successful species, and part of that is that we don’t go hungry willingly.
01:38:33
Chris Sandel: Definitely. The final area I want to cover, which again, you did a really great podcast on, was blood test results and how these are impacted on by weight loss or restriction. As a starter, when were the ranges for a lot of these blood tests created, and how were they updated? What populations were used? Do you know all of those details?
Fiona Willer: The cardiovascular ones, so the things like cholesterol levels, the first time we had a handle on those as risk markers was in the Framingham study. That’s a big, long-term, multigenerational study of the people living in a town in the US that started during the ’50s. They enrolled many thousands of people and then they enrolled the children of those families in the study, and their children. I think they are up to about third or fourth generation now.
So we have a long-term dataset looking at, as I said before, if we’ve got these factors on Day 1 and we figure out how long it goes from that age with those factors until they’ve died, and of what, we can then develop up a risk profile for that deathy event – heart attack, stroke, whatever.
That’s really where we connected blood pressure with strokes and cholesterol levels with heart attacks and the type of stroke that has a similar origin to heart attacks. The reference ranges originally were based on those populations. I think mostly, particularly for heart attacks, they haven’t changed very much.
Other reference ranges, like your diabetes diagnostic ones, are different from country to country, and they’re usually dictated by the professional body most interested in that disease, which is also interesting. It’s not epidemiologists who set the reference ranges; it’s the cardiovascular health associations, medical associations. It’s interesting. There’s an amazing amount of literature about how we’re over-medicalising what’s normal human variation within biochem results and so forth. But that’s basically where the reference ranges come from.
Chris Sandel: As a place, Framingham, is it an affluent place, a middle of the road?
Fiona Willer: It was picked because it was gloriously average. [laughs] And close to a university. I’m pretty sure it was those two things. The researchers didn’t have to come too far to do the interviews, and it was not special in any particular way. But of course, it’s very special now. It does hold a great place in the scientific record, basically. It’s good that we did it. But that’s where the references are from.
If we think about the people and their lives and their biochem measures, those people were not people who were dieting at the time. Particularly our cardiovascular disease markers. They’re set with people who do not live today; they’re set with people who lived decades and decades ago and died decades and decades ago now. So it’s a different world that they were in, basically, is the take-home. They’re certainly not people who were energy restricted.
Apart from Look Ahead – and we found that there was no difference in biochem – we don’t really have a good handle on chronic disease risk in energy restricted populations. What we know is that energy restriction can drag down our chronic disease biomarkers. It drags down cholesterol. Unless somebody is really chronically, severely malnourished, in which case cholesterol levels tend to go up. But your usual dieter type person, it’ll drag down cholesterol. It will drag down your glycosylated haemoglobin, which is basically a test of how much exposure your red blood cells have had to higher glucose levels in the blood. It will increase your insulin sensitivity, as we were speaking about before.
So it does change the risk markers. It makes them look like lower risk markers, so it’s more similar to risk markers in the populations with a lower cardiovascular risk who aren’t dieting. But it is kind of like a party trick. It’s a body hack. It’s not a real thing. That dragging down of the cholesterol because you haven’t eaten enough over the prior few weeks is not necessarily going to result in you having less likelihood of a heart attack in 30 years’ time.
When you think about it that way, it’s kind of absurd. But it’s an invalid comparative population, to talk about it in scientific terms. It would have to be a whole different energy restricted population to be able to make that statement that there’s a relationship.
Chris Sandel: And as you said, that was basically what they did with the Look Ahead study, and it didn’t really pan out and make any significant improvement. But it is so sad that that then becomes the yardstick for are you becoming healthier? There’s a difference between markers moving to a better range because you’re genuinely doing things that are supporting your health versus basically hacking the numbers.
Fiona Willer: Yeah. We’ve got a number of things that we can do – if we’ve got access and we’ve got availability and we’ve got the financial situation where we can buy more fruit and veg, change the way that we eat, if we’ve got those things available to us – and not everyone does, but if we do and we make those dietary changes, that in some people does have an impact on their cholesterol levels. And we know that both the dietary patterns and the cholesterol levels in that context can be related to decreased mortality risk. It’s more likely to be a real thing because it’s extended.
This is basically what we do for everyone who’s got a BMI of less than 25 anyway. Normal care for someone with a BMI of less than 25, if they come in with high cholesterol levels or other biomarkers that are a bit worrisome, “Okay, well, let’s work on some dietary changes, maybe get you a bit more physically active” – if that’s an issue for them. We can see what happens.
So we do know how to do weight neutral care. It’s literally what people with a BMI of less than 25 get now. Humans are still human when they flip over that BMI threshold to the heavier BMI categories. They don’t stop receiving benefit from things that help smaller bodied people with a chronic disease risk at that point. But for some reason the blinders come out and it’s ‘weight, weight, weight’. It doesn’t make any sense. There are so many logical gaps when it comes to our weight centrism.
Chris Sandel: I think Ragen Chastain has a thing of asking the question, “What would you do in this situation for a smaller bodied person? Let’s start there.”
Fiona Willer: Yeah. Or “I’ve tried dieting before and it didn’t work, and I don’t want to do it now. What else have you got for me?” Make them squirm.
The other thing – I have touched on it in the podcast a bit, but it is a huge issue, and that is research that involves larger bodied people very rarely is non-weight loss research. We need to know how medications work for people, particularly for people in much larger bodies, much higher on the BMI scale beyond the clinical trial characteristics. We need to know how effective chemo is. We need to know how effective birth control is. We need to know how effective basically all of the drugs we prescribe to people are across the different body sizes.
We don’t trial it, we don’t know how it works except in the context of someone who’s not having enough energy to get by. It’s a huge, huge gaping hole in our knowledge.
Chris Sandel: Do you know if people are starting to do that research?
Fiona Willer: There have been a few, particularly interventional studies on the Mediterranean diet. There’ve been a few good ones where they used a broader range of body sizes as their trial participants, and they randomised them into Mediterranean style pattern versus non, or they fiddled with the different styles, and they haven’t wanted to also piggyback weight loss outcomes on there. Particularly for cholesterol, actually. Hot tip. [laughs] There’s some good statistically significant results coming out of those kind of studies, and they’re properly weight neutral studies.
But we’re still a long way from doctors and dietitians, even nutritionists, being able to say, “We know this way of eating works quite well for smaller bodied people, we know this way of eating works quite well for this condition for larger bodied people, and we know which is superior for your situation that doesn’t involve starving yourself.” We’re a long way from that. But the goal is figure it out and know what is the superior medication, superior intervention for somebody with a higher body weight versus a lower body weight to get the appropriate treatment for them, basically. At the moment they’re completely underserved.
01:49:40
Chris Sandel: Totally. I was wondering if you’ve come across this – I work a lot with people with eating disorders and then they’re in recovery – if there’s any good research around blood markers as part of that. I can find stuff around where someone is at at the start point or when they have an eating disorder for a long time, some of the things that are more likely to occur in terms of liver enzymes or whatever. But in terms of the messy middle bit, have they been looking at typical patterns that start to happen more often in this population?
Fiona Willer: I’m trying to chase that down now. It’s really difficult to find because with eating disorder recovery, it’s a bit of a secret. [laughs] We don’t tend to study the biochem because it’s less trial based, more therapy based. These are really vulnerable people. We don’t tend to mess with them too much when they’re in therapy. And when we’ve done trials, it tends to be trials of manualised therapy, group therapy, blah, blah, blah. It’s eating behaviour outcomes rather than biochem. It’s not well researched there.
But also, in regular weight loss trials, they tend to ignore what’s going on during weight re-gain phase because they don’t want to believe it’s really there. So the data for that is not signposted very clearly.
My reading of it is during weight re-gain after significant weight losses, it looks like fatty liver is something that can happen during that weight re-gain phase in a similar way to how it might happen without the original weight loss. It happens from an earlier point, though, which is horrifying. Not that fatty liver is a big deal actually anyway, but it’s another one of these things where that’s an unintended consequence of weight loss. Like, “You’ve got a higher chance of having more severe fatty liver in the weight re-gain phase that I’m not going to tell you about because you’ve still got to try to lose weight.”
In terms of inflammation, I’m having a look at that now for the current podcast I’m in development for. It looks like any positive energy balance, including the weight re-gain phase back up to settling point, does include that higher inflammation factor as well. Whether that’s significant in the whole context of somebody’s life, who knows?
It’s tricky to pin down and it’s likely to be quite complicated. When you’re trying to assess this stuff, what’s going on in the liver, what’s going on in the fat tissue, what’s going on in the muscle tissue, what’s going on in the blood markers, there’s a lot of different things you could look at to figure out what’s going on. It’s a very dynamic state.
Chris Sandel: For me, I’m less concerned in terms of if your blood glucose is going up or your HbA1c is going up or your cholesterol, it doesn’t matter. You’re in the middle of something going on.
Fiona Willer: Yeah, this is not normal life.
Chris Sandel: It’s not normal life. You’re going through this phase.
Fiona Willer: It’s convalescence from malnutrition.
Chris Sandel: Exactly. But my reason for asking was to be able to point those people to that research and say, look, this is just what happens during this phase and it is normal.
Fiona Willer: Yeah, I wish we had some really nice clear papers that said that. But there’s so much, even in mainstream eating disorder treatment sources of information – your eating disorder associations and stuff like that – like we were talking about earlier, it’s a completely different mindset when you’re inside an eating disorder. Any whispers that weight re-gain might have to happen, those suggestions will make people run to the hills, away from seeking help. It’s a tricky thing to put on there.
Obviously it would be, but we’re looking at it through the lenses of people who are not in a vulnerable state about what weight gain might mean to them personally. It’s just a bit awkward to try to focus on that stuff. I want to, but I think that’s why the information’s not so explored in the scientific research.
01:54:45
Chris Sandel: That makes sense. Fiona, this has been wonderful. As I said at the top, I really love your podcast, so it was nice to be able to go through this in detail and show people what you do as part of that. Is there anything we didn’t go through that you wanted to touch on?
Fiona Willer: We’ve covered a lot of stuff. I guess I did notice we have covered some quite negative things. [laughs] A take-home always is if your health provider is causing you distress around body and giving you a hard time around body, there are other people out here. Even if you have to source support from another country or another area, those people do exist. So I would really encourage you to reach out and try to find a health care team that is going to support you in working on supporting your health now without the weight focus. We’re out there.
Chris Sandel: I would definitely agree with that. I’ve also found that sometimes when people speak up, they actually get a much better level of care without having to change.
Fiona Willer: Yes. That simple question, Ragen Chastain’s question – she’s amazing – “What treatment would a smaller bodied person get? Can I have that now?” If you can practice that – take someone with you who can drop that line if in the moment you’re too frozen to be able to use the line. It can be really powerful and it can change the course of what they will be recommending to you as well.
Chris Sandel: Yeah. Where can people go if they want to find out more information about you?
Fiona Willer: I am on social media a fair bit, interacting with people. Twitter is currently my favourite. I go through stages. Twitter and Facebook. You can find me on Twitter under my name, Fiona Willer, and on Facebook as Health, Not Diets. If you’re looking for professional development, if you’re a clinician, dietitian, nutritionist, psychologist, researcher, medical professional, medical specialist – all of these are people who come to my courses and do my trainings – then www.healthnotdiets.com has got some course options there.
And also my podcast is called Unpacking Weight Science, and that’s sitting on www.unpackingweightscience.com. There’s a subscription model for the more recent episode, which is only $5 USD a month, which is pretty low cost, I think. But I’ve released a lot of the earlier episodes now for free. That’s on Spotify, all of your podcast apps. It’s easy to check it out and see if you’re into it.
Chris Sandel: Perfect. I will put all of those links in the show notes. Thank you so much for your time. This has been great.
Fiona Willer: Thanks. And thanks for having me. It’s been a pleasure.
Chris Sandel: That was my conversation with Fiona Willer. She is a lovely and compassionate human being who is equally science smart when it comes to myth-busting around weight loss research and knowing what is good for human health. If you like the nerdier side of science and weight science and everything connected to this stuff, then I would highly suggest checking out her podcast, Unpacking Weight Science.
01:58:25
I said at the start that I had a couple of recommendations for you of things to check out, and they actually both come from Tim Ferriss’s podcast.
The first is Episode 492 with Richard Schwartz. Richard Schwartz is a family therapist and is the creator of the Internal Family Systems or IFS. IFS is a form of psychotherapy that’s been used since the 1980’s and is especially helpful for dealing with trauma. Despite the name including ‘family’ in the title and Richard being a family therapist, this isn’t about doing therapy with your family; it’s about the internal families that you have in you, so all the different parts within you.
A number of years ago I read Bessel van der Kolk’s The Body Keeps the Score, which is a seminal book and really is incredible in looking at how trauma affects the body and the mind, and the second half of the book is all about the different modalities that are evidence-based for helping with trauma. IFS is one such practice. So it’s been something I’ve been interested in exploring but had just not got round to it. It just hadn’t happened yet.
What was so fantastic about this episode was that rather than just talk about what it is in theory, Tim and Richard do a live session. Tim last year opened up on his show about having a history of childhood sexual abuse when he was young and how this had been something he’s been working on in therapy for a number of years. This was what was working on as part of that session.
Tim really is phenomenal in being open and vulnerable to do this live. You just get this incredible sense from them being able to demonstrate what this style of therapy is like and how beneficial it can be. It’s not just about people who’ve suffered with big capital ‘T’ Trauma; it can be really helpful for anyone dealing with different aspects of who they are. There’s a lot of similarities in terms of the experience with IFS as with psychedelics, but without having to do the psychedelics as part of it.
So I really highly recommend checking out that episode. It’s Episode 492 of the Tim Ferriss Show.
The other recommendation, also a Tim Ferriss interview, is #485 with Jerry Seinfeld. Jerry Seinfeld probably needs no introduction, being the richest actor on the planet, just a little short of being a billionaire. Seinfeld the show is probably my favourite show of all time, or at least my favourite comedy of all time. I’ve watched all nine seasons of it multiple times, and it always has me in stitches. Unlike many comedy TV shows, especially shows that go on for a long time, it never went bad. It still finished on a high. I think it started getting really good from about Season 3 onwards, but yeah, it is all very, very good comedy.
I’ve listened to a number of interviews with Seinfeld before and I’ve always been disappointed. Seinfeld isn’t normally a great guest. He always feels annoyed or like he doesn’t want to be there or like every question the person is asking is a stupid question. You typically get short answers. He is like this black box where you don’t find out really anything about him or about his process or about what makes him tick, and I always left other interviews feeling like they’d been unenjoyable and I felt like Seinfeld was arrogant and grumpy.
And really, I still feel the same way about both of those things, but in this interview he is more open than I’ve heard in any other interview. Tim really does a great job here with making that so. I think Seinfeld have a lot of respect for Tim Ferriss, so I think that’s probably why he was more open and he was able to have a good interview with him. But it is definitely the best one I’ve heard.
If you are like me and you grew up with Seinfeld or even now, because he does the Comedians in Cars Getting Coffee, which is now on Netflix – if you’ve watched any of that and you want to find out more about him, then I would highly recommend checking out the podcast episode. It’s Episode 485 of the Tim Ferriss Show.
Hat tip goes to Meret for these recommendations, as she told me about both of them. I kind of got off the Tim Ferriss podcast train and very, very rarely check it, so I think I would’ve definitely missed both of these if it weren’t for her. Thank you, Meret.
That is it for this week. As I mentioned at the top, I’m going to start opening up the practice to new clients shortly, and we’ll start with a bigger push over the next couple of weeks and putting out more content. But if you’re interested in working together or finding out more, you can head over now to seven-health.com/help. I’ll catch you again next week. I’ll see you then.
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