I just want to cut it off: the weight-loss patients who no longer fit their skin

Bariatric surgery is a highly cost-effective way to lose life-changing amounts of weight but the NHS rarely removes the excess skin that is left behind. Desperate patients are now crowdfunding their operations while struggling with anxiety, depression and identity issues

When Haze Atkin passed the 32kg (5st) mark on her weight-loss programme, something strange began happening to her skin. First it grew softer. Then it grew emptier. By the time she had shed her 64th kilo, her body had shrunk so much that her loose skin needed to be folded into her clothes. Now, when Haze sits, a hovercraft of skin skirts her seat. When she takes a bath, her spare skin floats. In bed, her husband Chris accidentally rests an elbow on it; he cant always be sure where Haze ends. The edges of her have become mistakable.

To her childrens delight, Haze can wobble her skin and make it talk like a puppet. Sometimes her daughter holds out her hands like a set of scales and Haze places her stomach skin on them. She thinks it weighs a stone. It has become oddly plastic, so that Haze can gather it in her hands and stretch and shake it, fold and mould it. But the one thing she can never do with her skin is forget it.

Like many people with excess skin, Haze lost a lot of weight after bariatric surgery. In the 10 months after her gastric bypass an operation the NHS has come to see as highly cost-effective she shrank from 149kg (23.5st) to 70kg (11st). She met all her targets. Her surgeons called her a model patient. And yet, just when Haze should have felt she had achieved her goal, her skin held her back. The scales said she had reached the end of her journey, but the mirror told a different story.

Haze is one of the 9,325 UK patients who in 2013 underwent bariatric surgery on the NHS, according to statistics held by NHS Digital. The same year, NHS England reported that the price of keyhole bariatric surgery for diabetes patients with a BMI of 35, for instance, is recoverable in just 26 months. According to projections from the Department of Health, the cost to society and the economy of people being overweight and obese could increase to almost 50bn in 2050, so it is easy to see why bariatric procedures make financial sense. But is the surgery causing a different kind of health crisis? Is such massive weight loss MWL, as healthcare professionals call it solving one problem only to create a new one, a generation of weight-loss survivors tormented by anxiety and depression because they no longer fit their skin?

Haze has a simple message to the NHS. You dont just leave people half-done. Finish it.

The NHS does perform some skin removal operations. But the only mention of skin removal in all Nices recommendations is that a multidisciplinary bariatric team provide information on, or access to, plastic surgery (such as apronectomy) when appropriate (an apronectomy is a mini tummy tuck to remove the apron of skin that hangs over the pubic area). This provision varies hugely by region. In theory, a patient needs to show that skin removal surgery is a health rather than a cosmetic intervention.

In practice, the local clinical commissioning groups, which commission NHS healthcare, rarely approve such applications which is why crowdfunding websites are full of people who have lost massive amounts of weight and are desperate to remove their skin, even if it means posting explicit, naked or near-naked photographs that play to a sort of pornography of excess skin. Hazes page has raised 332 of the 6,600 she needs for surgery. She applied to the NHS she suffers from skin infections, anxiety and depression, and believes the extra weight exacerbates her fibromyalgia (she is registered disabled). But she was rejected.

Lisa
Lisa Riley, who had skin surgery. Photograph: Ken McKay/ITV/Rex/Shutterstock

So each week for the past four years she and Chris have laid aside 20 every spare penny towards the cost of the fleur de lis abdominoplasty on which Haze has set her heart. This double incision runs vertically and horizontally, and was part of the suite of operations carried out on the actor and TV presenter Lisa Riley in her documentary Lisa Rileys Baggy Body Club. The fleur de lis leaves a wound so severe that Rob Winterton, the cosmetic surgeon who performed it on Riley, says it is comparable to a 20 or 30% burn.

But for Haze, the surgery is the only way out of an unbearable predicament. At 30, she finds her skin so invasive, so mentally hard to deal with, every day I just want to cut it off myself. It invades my thoughts, my feelings, all the time. Every time I get dressed.

If you catch yourself in the mirror, Chris interjects. If I touch you wrong. If I roll on you. If I see you getting dressed.

Hazes skin is always on her mind which is not, of course, where skin is meant to be. Her daily life has evolved to make dozens of minute accommodations. She must wash carefully, lying down and stretching her skin out in order to clean and dry it thoroughly. Where the skin is folded, bacteria grows, she says. Dressing is a military operation. Everything is tucked away. And her relationship, the way she and Chris interact, has changed too.

Haze has gone from one kind of person to another, and the speed of her transformation has caught both her and Chris by surprise. You went from having a plus-size, curvy, full wife which you never had a problem with to suddenly this petite woman with hanging sacks of skin, Haze says to Chris, who is seated at her side. And it really threw you.

It was trying to remember who she is, Chris replies. Not mentally but physically. Its like, are you sure its you?

The pair have been married for 13 years. But the surgery, so hyper-efficient and cost-effective, has not given their emotions, their instincts, their bodies, time to adjust. Ill get there in the end, Chris says. Its because the process is so quick. Very shocking.

They had a small amount of savings, which Haze spent on a breast augmentation to save my sanity because she was so depressed by her new paper bag breasts. Even so, in their most intimate moments, Hazes skin still comes between them. If Im on top and I lean forward, she says, my stomach gets there first. She turns to Chris. You literally hold it back, she says, putting her hands at her narrow waist to demonstrate. To try and make you feel better, he nods, and they reach for each others hands.

Two further years of saving lie between Haze and Chris Atkin and the promised land of an operation so extensive that Winterton says it puts two and a half feet of scar on a patient. Providing, of course, that inflation does not outstrip them. But Paul Watling, 34, from Manchester, has barely a week to wait. Like Haze, he was rejected for the operation on the NHS after months of psycho-evaluation. He was trying to get along with his skin, to live with it, until last summer when he picked up a friend from hospital after body lift surgery.

The sight of his friend in his new skin made Paul see himself with unexpected clarity. At lunch with his mother and his girlfriend, Charlotte, I turned around and said: I need it. I just felt the time had come to put this part of my life to bed.

We are talking in a breakout area of Manchester Metropolitan University where Paul works as a night-time duty manager for halls of residence. While students amble down the corridor, Pauls voice quickens. This is it! Something that has been a negative aspect of my life for all my life is banished for ever.

Paul
Paul Watling: I feel great. But I dont look it. I look awful. Photograph: Christopher Thomond for the Guardian

The negative aspect of Pauls life began as a child with a tendency to overeat. At 22, he weighed 191kg (30st). He was offered a gastric bypass after doctors discovered a lung tumour (he was too fat to operate on) and this was in 2005 was promised that his excess skin would be removed on the NHS. However, by the time his weight had stabilised, he was turned down for the skin surgery. Depressed by what he saw in the mirror, the nipples that sagged far below his chest, the reams of spare stomach and undereye sacks that made him look permanently tired, Paul began to eat and drink heavily.

I thought: If Im going to look this bad, I may as well fill it out and just be the fat guy again, he says.

Over the next 10 years his weight rose as he ate to fill up his skin; a gastric bypass is only a tool to help with weight loss, and depends on adjustments to diet and exercise to work. While his stomach expanded, Paul kept telling himself: Im nowhere near as bad as I was. Then, last Christmas, he woke up after a binge and needed the bathroom. Looking down at the toilet bowl, he realised he couldnt see what he was doing; his stomach was too large. I thought, thats not normal. I dont remember that.

He was staying at a friends house, and his friends bathroom contained a set of scales, something Paul hadnt seen in a long time. He stepped on. I was like: Wow! This is insane! The scales said he weighed 162kg (25.5st). He found his friend in the kitchen. I took my shirt off and said: Take a photo. And I could see, in that photo, the 21-year-old me. I said: This has to stop.

He researched nutrition and exercise plans and began to adjust his diet and lift weights. After 11 months, in an entirely self-directed effort, he had lost 64kg (10st).

I feel better than I have ever felt in my life, Paul says. I feel great. But I dont look it. I look awful. While we talk, Pauls right arm disappears beneath the table to shield his stomach from passersby.

Im happier now with the way people treat me and it is a world of difference. But when I was bigger, I was happier with the way I looked. I was just a fat guy. Thats all I was. Yeah, people take the piss and are cruel but its there for everyone to see. This, he says, looking down to where he can feel his skin pulling over his belt line, is a hidden shame. Even the fat guys in the gym hang around in the dressing room. But Im ashamed. I sneak into the family room and lock the door.

Paul is troubled not only by his skin but also by the fact that it troubles him. Its a constant internal struggle for me. Why are you spending 10 grand on this? Its just appearance. Come on! You can rise above this. Of course, how you look shouldnt matter, he says, but it does matter, because of the experiences you had when you were younger, the years of verbal and physical abuse. He is a heavy metal fanand has always identified as an outsider, found comfort in it. But his skin has made him feel more privately misplaced, estranged in a way that is unfamiliar he has become an outsider in his own body.

I know I should be proud of my excess skin. It should be a battle scar But the flip side, which is the stronger side that always wins, is: Look at the state of you, youre gross, youre disgusting, you cant let anyone see you I dont want to fit in with society, I want to fit in with myself.

Paul is right that not everyone with excess skin feels as he does. Krystina Wright, 31, from Grendon in Warwickshire, lost 44kg (7st) with the help of Slimming World, and has a pouch at her stomach.

She knows she has undergone a transformation, and that her skin tells the story of it. Last year she was shortlisted for Slimming Worlds woman of the year. Out dress shopping, she stood in the fitting room in her underwear, and her mum remarked, You can see youve lost weight. But I never see that in the mirror, Krystina says. When Im walking, [the skin] around my legs is obviously looser than somebody who hasnt lost weight but I just ignore it. Im so happy with my journey that everything negative about my old self doesnt seem to matter.

Even in her contentment, however, Krystina still associates the experience of being fat with an old self, and it is this sense of disjuncture between an old self and a new self, a fat self and a thin self, that challenges people who have lost a transformative amount of weight.

Skin is a boundary between ourselves and the outside world. But for Haze Atkin, her skin, in its looseness, provides an untrue border; her skin seems to stop beyond her true edges. Instead, she strongly demarcates the line between old and new selves. When she was fat, she was Hayley. Two years ago, after weight loss, she changed her name legally. Its weird to see pictures of me before, she says. You cant I cant tie those two people together.

Im very proud of Hayley. But thats not me. Theres a real separation. She picks up her stomach. The thing thats hanging on is this. Hayleys skin.

Elna Baker can relate to Hazes divided self. The American writer and performer, 35, has documented her weight loss and skin removal surgery in blogs and podcasts such as This American Life. Between losing weight (nearly 50kg/8st) and losing the skin, she lived in the same sort of limbo as Haze she thinks of it now as a transitional place between fat and this idea of thin.

Elna
Elna Baker: I feel like Im wearing a disguise. Photograph: PR

But Baker also says she has travelled further along the timeline I dont know how to explain it. But theres, like, a core thing that youre still running from, she says, speaking on the phone from New York. And not to sound ungrateful for the means and the experience of getting to transform, but I also feel its more complicated than I expected, because its about identity and gender and worth. The thing that still saddens me is that I lived too long in the world as a fat woman to forget the way the world exists when youre fat. So now I feel like Im wearing a disguise, which allows me not to have to experience on a daily basis judgment, shame and hatred. But I also have all this muscle memory of that. So I sometimes feel confused like Im still experiencing a side-effect of a thing I no longer am.

Baker had implants to return her breasts to their former size, a body lift, a thigh lift and a circumferential body lift a cut around the circumference of the body. The scar draws a line between her top half and bottom half and has left her feeling, literally, a little divided.

Despite complications afterwards that meant that she had to pack her wounds with gauze, pushing wads into the holes left by burst stitches as if she were stuffing a soft toy, Baker is glad that she had the operations. But she has spent the past year using therapy, meditation and self-help to address the boundary between old Elna and new Elna. She hopes the division is an illusion and it is possible to reach into the depths of me and meet the person [I was] and integrate it.

Haze, meanwhile, hopes for the opposite, that surgery will not only make her proud of her body but sever her from the past. And Paul, only a week away from his operation, sometimes has to quiet the small voice that asks: What if I go through this and Im still not happy? He reminds himself: Ive set this up in my mind. This is closure of a lifetime of not being happy in my body.

All he, and Haze and anyone, really want is to be comfortable in their own skin.

Read more: https://www.theguardian.com/lifeandstyle/2018/jan/02/i-want-to-cut-it-off-weight-loss-patients-excess-skin

Health mutt: proposal to put shelter dogs on vegan diet divides Los Angeles

A possible plan to move the citys dogs onto a plant-based diet has the backing of prominent vegans such as Moby, but others warn it could get messy

Proponents say it will make Los Angeles the worlds progressive capital. Sceptics say it will mean diarrhea, lots of diarrhea.

The proposal, which has divided scientists and animal rights groups and inflamed social media, is to put dogs in the citys public shelters on a vegan diet.

The Los Angeles animal services commission is considering the idea after lobbying by prominent vegans, including Moby, the dance music pioneer.

The commission unanimously voted earlier this month for a feasability study and analysis of the benefits and risks. A report detailing pilot project options is expected in February.

Roger Wolfson, a commissioner and television screenwriter who is driving the initiative, cites ethical, environmental and health reasons to switch dogs to plant-based food.

Currently more than 20,000 chickens, 10,000 turkeys and 1,000 lambs die each year in order to be churned into food for the 33,000 dogs in LAs public shelters, he said.

We are the department of animal services, not the department of animal companion services, he told the Guardian this week. So we need to start from a place of avoiding unnecessary killing of animals. We already shelter pigs and chickens and turkeys and we wouldnt think about killing them unnecessarily. So if dogs can get their needs met without killing animals we owe it to the citizens of Los Angeles to try.

Wolfson, who was a political speechwriter in Washington DC before moving to LA and writing for shows such as Fairly Legal and Law & Order: Special Victims Unit, also cited the impact of meat and dairy consumption on deforestation, greenhouse gases and ocean dead zones.

Several high-profile allies endorsed Wolfsons proposal at a public hearing in November, including the musician and DJ Moby, who owns a vegan restaurant in LA. If we adopt this, its just one more thing that proves to the world that Los Angeles really is the progressive capital of the world, he said, according to meeting minutes, which used his real name, Richard Hall.

Musician
Musician and vegan restaurant owner Moby is a supporter of the plan. Photograph: Kris Connor/WireImage

However, the citys chief veterinarian, Jeremy Prupas, cited clinical nutritionists, a veterinary toxicologist and other experts who advised against a vegan diet. In addition to health questions, workers at the understaffed shelter would confront canine diarrhea, a big issue, Prupas said.

Armaiti May, an LA-based veterinarian who supports the proposal, told the Guardian that abrupt changes in diet can lead to looser stools but that a gradual transition would avoid major problems. Its a small issue in the grand scheme of things. May believes meat-based kibbles have fuelled a cancer and allergy epidemic in dogs.

Tracy Reiman, executive vice-president of the animal rights group Peta, said a vegan diet was healthier and more ethical than feeding dogs factory farmed animals who have endured miserable lives and gruesome deaths and whose dead, dying, diseased, or disabled carcasses are found in most commercial dog foods.

Other voices urge caution. Lisa Freeman, a veterinary nutritionist and Tufts university professor, told the New York Times earlier this year there were no long-term studies on the effects of veganism in dogs. We know a lot about dog nutrition, but there are unknowns as well it isnt easy to formulate a high-quality diet for dogs, and its particularly difficult with a vegan diet.

Social media has bristled with arguments for and against, the latter insisting dogs need meat.

Owners who have put their dogs on vegan diets say diarrhea fears are overblown and that health benefits are tangible. Winky had been plagued with recurring ear infections which disappeared permanently after I phased the meat-based food out of his diet, Karen Dawn, an author and activist, wrote in an LA Times op-ed.

Read more: https://www.theguardian.com/us-news/2017/dec/29/los-angeles-vegan-dog-diet-animal-shelters-moby

Introducing Halo Top: the ‘healthy’ ice-cream taking over America

Marketed as the low-calorie, high-protein and low-sugar alternative to ice-cream it is now outselling tubs from Ben & Jerrys and Hagen-Dazs

Everyone you love is gone. There is only ice-cream is the darkly humorous sign off used in a recent ad for fast-growing American ice-cream brand Halo Top.

The Black Mirror-style commercial, which ran in US cinemas before films including the horror flick It, features an elderly woman being force-fed ice-cream by a robot in some dystopian future.

It was directed by Mike Diva, who has built a YouTube following with his advertising parodies, and who typifies the offbeat digital marketing aimed at millennials that has helped turn Halo Top into serious competition for bestselling brands such as Magnum, Ben & Jerrys and Hagen-Dazs.

The somewhat noir US TV ad for Halo Top ice-cream.

The Los Angeles-based company was founded at the start of the decade by Justin Woolverton, a former lawyer who suffered hypoglycemic episodes when he indulged his sweet tooth. So he bought a $20 ice-cream maker on Amazon and began trying to create healthier alternatives. It was just something that I was making in my kitchen because I didnt like sugar, he told one interviewer about his Eureka moment.

While most ice-creams are a sugar and fat-laden treat, Halo Top bills itself as a low-calorie, high-protein and low-sugar alternative to mainstream brands, with flavours such as mochi green tea and rainbow swirls. Its recipe uses sugar substitute Stevia, which means a scoop of its Vanilla Ice contains 60 calories versus 250 in a similar sized dollop of Hagen-Dazs.

Reports in the US media have begun to question whether Halo Top is really as healthy as the marketing makes out, with some dieticians raising concerns about the use of artificial sweeteners.

Halo Top is now stocked in supermarkets across America, with the company shifting nearly $50m (38m) worth of ice-cream in the US last year. Its sales accelerated in 2016 after GQ writer Shane Snow lived on Halo Top ice-cream for 10 days and the resulting article went viral.

The brands rise has been propelled by social media: it has 590,000 followers on Instagram and more than 700,000 on Facebook.

The social media buzz helped Halo Top chalk up another milestone in the summer when industry data showed its pint pots were outselling Unilevers Ben & Jerrys and Nestls Hagen-Dazs in US grocery stores for the first time. Halo Tops parent company, LA-based Eden Creamery, is seizing the day with one recent report suggesting it is exploring a sale that could value the company at up to $2bn.

Read more: https://www.theguardian.com/lifeandstyle/2017/oct/20/introducing-halo-top-the-healthy-ice-cream-taking-over-america

Poor diet is a factor in one in five deaths, global disease study reveals

Study compiling data from every country finds people are living longer but millions are eating wrong foods for their health

Poor diet is a factor in one in five deaths around the world, according to the most comprehensive study ever carried out on the subject.

Millions of people are eating the wrong sorts of food for good health. Eating a diet that is low in whole grains, fruit, nuts and seeds and fish oils and high in salt raises the risk of an early death, according to the huge and ongoing study Global Burden of Disease.

The study, based at the Institute of Health Metrics and Evaluation at the University of Washington, compiles data from every country in the world and makes informed estimates where there are gaps. Five papers on life expectancy and the causes and risk factors of death and ill health have been published by the Lancet medical journal.

It finds that people are living longer. Life expectancy in 2016 worldwide was 75.3 years for women and 69.8 for men. Japan has the highest life expectancy at 84 years and the Central African Republic has the lowest at just over 50. In the UK, life expectancy for a man born in 2016 is 79, and for a woman 82.9.

Diet is the second highest risk factor for early death after smoking. Other high risks are high blood glucose which can lead to diabetes, high blood pressure, high body mass index (BMI) which is a measure of obesity, and high total cholesterol. All of these can be related to eating the wrong foods, although there are also other causes.

causes of death graphic

This is really large, Dr Christopher Murray, IHMEs director, told the Guardian. It is amongst the really big problems in the world. It is a cluster that is getting worse. While obesity gets attention, he was not sure policymakers were as focused on the area of diet and health as they needed to be. That constellation is a really, really big challenge for health and health systems, he said.

The problem is often seen as the spread of western diets, taking over from traditional foods in the developing world. But it is not that simple, says Murray. Take fruit. It has lots of health benefits but only very wealthy people eat a lot of fruit, with some exceptions.

Sugary drinks are harmful to health but eating a lot of red meat, the study finds, is not as big a risk to health as failing to eat whole grains. We need to look really carefully at what are the healthy compounds in diets that provide protection, he said.

undernourishment graphic

Prof John Newton, director of health improvement at Public Health England, said the studies show how quickly diet and obesity-related disease is spreading around the world. I dont think people realise how quickly the focus is shifting towards non-communicable disease [such as cancer, heart disease and stroke] and diseases that come with development, in particular related to poor diet. The numbers are quite shocking in my view, he said.

The UK tracks childhood obesity through the school measurement programme and has brought in measures to try to tackle it. But no country in the world has been able to solve the problem and it is a concern that we really need to think about tackling globally, he said.

Today, 72% of deaths are from non-communicable diseases for which obesity and diet are among the risk factors, with ischaemic heart disease as the leading cause worldwide of early deaths, including in the UK. Lung cancer, stroke, lung disease (chronic obstructive pulmonary disorder) and Alzheimers are the other main causes in the UK.

The success story is children under five. In 2016, for the first time in modern history, fewer than 5 million children under five died in one year a significant fall compared with 1990, when 11 million died. Increased education for women, less poverty, having fewer children, vaccinations, anti-malaria bed-nets, improved water and sanitation are among the changes in low-income countries that have brought the death rate down, thanks to development aid.

People are living longer but spending more years in ill health. Obesity is one of the major reasons. More than a billion people worldwide are living with mental health and substance misuse disorders. Depression features in the top 10 causes of ill health in all but four countries.

Our findings indicate people are living longer and, over the past decade, we identified substantial progress in driving down death rates from some of the worlds most pernicious diseases and conditions, such as under age-five mortality and malaria, said Murray Yet, despite this progress, we are facing a triad of trouble holding back many nations and communities obesity, conflict, and mental illness, including substance use disorders.

In the UK, the concern is particularly about the increase in ill-health that prevents people from working or having a fulfilling life, said Newton. A man in the UK born in 2016 can expect only 69 years in good health and a woman 71 years.

This is yet another reminder that while were living longer, much of that extra time is spent in ill-health. It underlines the importance of preventing the conditions that keep people out of work and put their long term health in jeopardy, like musculoskeletal problems, poor hearing and mental ill health. Our priority is to help people, including during the crucial early years of life and in middle age, to give them the best chance of a long and healthy later life, he said.

Read more: https://www.theguardian.com/society/2017/sep/14/poor-diet-is-a-factor-in-one-in-five-deaths-global-disease-study-reveals

Hunger by Roxane Gay review how the world treats fat people

A catalogue of horrors and public humiliations, Gays memoir responds to societys condescension and disgust about her body size

This is a book its author Roxane Gay has, over many years, earned the right not to publish. Even though she has found great success as an essayist, writer of fiction and university teacher, and attracted a large, passionate online following, its clear from her account that her weight is still the first thing strangers notice about her, and that she must spend much of her time dealing with their unsolicited responses to it. These range from rude to abusive, encompassing all sorts of casual mockery, faux concern and outright aggression along the way.

Shopping for clothes or food, visiting a restaurant or getting on a plane frequently involve a humiliating ordeal. Doctors not only patronise her but routinely refuse her basic care. Simply leaving the house means navigating a physical and emotional obstacle course. No doubt Gay is thoroughly sick of being reduced to her body and of enduring constant inquiries, prejudices and criticism, and she has evidently worked hard to make space for herself to talk and write about other things. People asking those kinds of questions dont deserve an answer, and yet here Gay has decided to give them one.

Hunger comprises at least two stories: a partial but more or less linear telling of Gays life so far, and a more halting, spiralling description of her everyday experience as a fat woman. The first of these hinges on the horrifying rape visited on her as a 12-year-old by her boyfriend and several of his friends. Gay blames herself, and her suffering is compounded when the boys report their version of events to their peers at school; she keeps hers quiet, unable to say anything about it to her family. The brief evocation of her childhood before this point conjures an almost fairytale-like atmosphere of love and optimism, peopled with adoring parents and siblings. I fell asleep most nights, Gay writes, flush with the joy of knowing I belonged to these people and they belonged to me.

Afterwards, everything changes: she begins to overeat and her weight gain is swift and dramatic, to her familys dismay. Various attempts to reverse it, some undertaken willingly, others under parental pressure, never last long, and both the traumatic event and her highly visible response to it overshadow everything else that happens to her. Gays mother and father are well-to-do Haitian Americans who clearly have high expectations of their children. Gay, who attends an elite boarding school followed by Yale, drops out and moves to another state without letting anyone know where she is. She eventually completes a PhD and garners acclaim as a writer, but this book is still a catalogue of horrors large and small: there are abusive relationships and public humiliations. Particularly striking are the depictions of what its like for Gay to go to the gym or on a date. Unable to fit on a restaurant chair and denied a more comfortable booth, she spends an entire meal holding herself up in an excruciating squat. At the supermarket, random people entitle themselves to remove foods they deem unsuitable from her cart.

Gays tone shifts between a breezy, conversational style and something harsher, and she recounts painful events in short, almost incantatory sentences: There was a boy. I loved him. His name was Christopher. Thats not really his name. You know that. She occasionally makes light of the cliches that surround public discussion of weight loss (though she herself cant avoid some of these). Scoffing at Oprah Winfreys metaphor of the cheerful, skinny alter ego lurking inside every fat person, she notes, I ate that thin woman, and she was delicious but unsatisfying.

But in general theres not much to laugh about. Gay alludes to or summarises difficult conversations, but rarely recounts them in full, and the overall effect is often one of claustrophobic intensity, as if the reader is trapped inside her head much the way she describes feeling caged in her flesh. Some of the books repetitions may be due to its origin in shorter pieces written for various publications, but most reflect the near-constant frustrations of living in a body the world both fixates on and refuses to accommodate. One of the few scenes rendered in detail is the gruesome early description of her father taking her to a group consultation with a doctor who performs gastric bypass surgeries. They must watch a video of patients steamy red and pink and yellow insides being carved up in an exorbitantly expensive and devastating procedure that even in the best case scenario will leave them permanently malnourished.

Though Gay does not owe anyone a single explanation of her size, she gives her readers an abundance of them. If some can seem a little too neat and familiar, that effect is complicated by how many accumulate, often directly contradicting each other. She characterises her initial weight gain as an attempt to take up more space, growing bigger and more powerful, but also as an effort to disappear and avoid ever attracting male attention again. She deliberately eats to create a protective shield of flesh, or simply cannot resist using food to soothe unbearable emotions. Gays mixed feelings often feel inevitable, though, in a culture that gives fat women no safe place to stand: you must feel bad about your size, but not enough to make anyone else uncomfortable; you must feel good about yourself as you are, but not too good. I am a product of my environment, she writes, explaining why her feminist convictions cant protect her from the cycle of selfblame, from longing to be thinner and accusing herself of weakness or lack of discipline when her body doesnt change.

Elna
Elna Bakers 2016 account of her own extreme weight loss sheds light on Hunger.

Most of what Gay endures is neither her fault nor within her control, but since she believes society will not change fast enough, if at all, she makes no apology for yearning to adjust herself to it. And of course, much of the more or less veiled fear and disgust expressed by others is a self-fulfilling reaction to their own conditioning: People know how they see and treat and think about fat people and dont want such a fate to befall them. The book is crammed with agonising ironies, some more strongly emphasised than others. Gay gains weight as an outward expression of her unhappiness, but those around her dont get the message, and only make her more miserable in their reactions to her changing body. In trying to develop a defence mechanism after her rape, she inadvertently invites half a lifetime of invasive threats to her physical autonomy and violations of her consent. When her parents want her to go on a liquid diet or to a fat camp, she agrees because I had learned that saying no meant nothing.

As she has before, in her hit essay collection Bad Feminist, Gay proclaims her refusal to represent anyone but herself. Among other things, that means she isnt interested in trying to make anyone feel better including other people of size who would rather not hear that she hates her body and blames herself for her inability to change it. This is not, as she notes repeatedly, a story of triumph neither of triumphant weight loss nor triumphant self-acceptance.

Stories that skirt those two possibilities are far rarer than they should be, and the exceptions, whatever their individual failings, stick in the mind. Reading Hunger reminded me of radio producer Elna Bakers 2016 account of her own extreme weight loss and its aftermath, which in some ways holds up a funhouse mirror to Gays experience. Its only after losing a huge amount of weight that Baker fully discovers the miseries the world inflicts on fat people. As a thin woman, she finds her love life, job prospects and everyday existence suddenly transformed. And she encounters head-on the stubborn denial that enables other people to enforce sadistic norms: when Baker insists to her husband that hed never have fallen for her at her previous weight, he tries to weasel out of it, suggesting that all the benefits Baker derives from being thin are simply due to how much happier and more confident she must now feel. But that isnt true, she says she was fine before, whereas now she must live with the knowledge that her new life and relationship require her to keep up an unnatural (and unhealthy) struggle with her weight for ever. Bakers story helps shed light on one of the most intractable knots in Hunger. Gay knows that losing the weight would not solve everything or grant her happiness, and yet she longs for the entirely different, less painful life she imagines she could have had without it.

Early in the book, Gay characterises it as a confession, that term so often flung as an insult at women who write about themselves. These, she writes, are the ugliest, weakest, barest parts of me. Its more a provocation than a promise. There are certainly flashes of confession, passages in which Gay lays out, say, the precise effects her rape has had on the formation of her sexual desires. But mostly she is not prepared to be so bare and weak as all that. Its the world around her that comes off as out of control in its appetites hate-filled, obsessed with womens body parts, eager to punish what it helps create.

Hunger is published by Harper. To order a copy for 11.89 (RRP 13.99) go to bookshop.theguardian.com or call 0330 333 6846. Free UK p&p over 10, online orders only. Phone orders min p&p of 1.99.

Read more: https://www.theguardian.com/books/2017/jul/19/hunger-by-roxane-gay-review

Gluten-free diet carries increased obesity risk, warn experts

Food adapted for those with coeliac disease often has more fat and less protein, and no benefits to non-sufferers, finds research

Substituting everyday staples with gluten-free foods could increase the risk of obesity, experts have warned, after finding that such products often contain higher levels of fats than the food they aim to replace.

A gluten-free diet is essential to those with coeliac disease an auto-immune condition that is thought to affect 1% of Europeans while the regime is also proving increasingly popular among those without the disease. But while a host of gluten-free products are on the market, researchers have said they have a very different nutritional make-up to conventional staples.

There is very little [consumers] can do about it, said Joaquim Calvo Lerma of the Instituto de Investigacin Sanitaria La Fe in Spain and co-author of the research. Unfortunately consumers can [only] eat what is available on the market.

Calvo Lermas warning comes after he and his and colleagues compared 655 conventional food products to 654 gluten-free alternatives across 14 food groups including breads, pasta, breakfast cereals, biscuits and even ready meals, covering a range of brands.

The results presented at the annual meeting of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition reveal that, overall, gluten-free products were more energy-dense than their conventional counterparts.

The team found that, on average, gluten-free bread loaves had more than twice the fat of conventional loaves, while gluten-free breads in general had two to three times less protein than conventional products. Gluten-free biscuits were also found to be lower in protein but higher in fat, while gluten-free pasta had lower levels of sugar and just half of the protein of standard pasta.

Calvo Lerma warned that gluten-free foods could be contributing to an increased risk of obesity, particularly among children who are more likely to eat products like biscuits and breakfast cereals. He urged consumers to compare gluten-free products across brands to find those with the lowest fat content.

Calvo Lerma also called on manufacturers to innovate. It is the responsibility of the food industry to produce these type of gluten-free products from other materials that are much healthier or have a [more] enhanced nutritional profile than the current raw materials being used, like cornflour or potato starch, he said, pointing out that healthier products could be made, for example, using grains such as buckwheat or amaranth.

He added that manufacturers should also add more complete and clearer labels to products to highlight their nutritional content, including levels of vitamins and minerals.

Benjamin Lebwohl, from the coeliac disease centre at Columbia University, who was not involved in the research, said that the study backs up previous evidence that gluten-free foods are nutritionally suboptimal. But while a gluten-free diet is essential for coeliacs, it is not intrinsically healthy or unhealthy, he added. It depends on the choices you make as part of the gluten-free diet, he said.

Sarah Sleet, chief executive of Coeliac UK, said the latest findings tie in with the charitys own research, adding that further development of lower-fat, gluten-free products would be welcomed.

David Sanders, professor of gastroenterology at the University of Sheffield, noted that other studies have found gluten-free and conventional foods to have similar nutritional value. The jury is out, he said.

But Sanders cautioned that there is no evidence a gluten-free diet has benefits for those without gluten sensitivity or coeliac disease. Once you go into the territory of dietary restrictions without medical symptoms then you are running the gauntlet of missing out on various vitamins or minerals without realising it, he said.

Read more: https://www.theguardian.com/lifeandstyle/2017/may/11/gluten-free-diet-carries-increased-obesity-risk-warn-experts

Fast or feast? Study shows alternate-day dieting too difficult to sustain

Participants in US study shown to even out calorie intakes beyond prescribed levels on alternating regime, leaving results barely more effective than daily calorie counting

From Beyonc to Benedict Cumberbatch, celebrities have flocked to diets based on intermittent fasting, but it turns out such regimes might be less effective than previously thought.

Among the diets experiencing a boom in popularity is the alternate-day fasting diet a regime many experts believed would be more palatable than daily calorie counting for those hoping to lose weight.

But a new study suggests it is tougher to stick to than expected, making it no better than a traditional diet in helping people to shed the pounds.

We thought that it would be easier to stick to alternate-day fasting, just because you get that day off every [other] day where you dont have to diet, said Krista Varady, co-author of the research from the University of Illinois at Chicago. We were really just expecting the traditional [daily diet] group to cheat a lot more.

Writing in the journal JAMA Internal Medicine, Varady and colleagues from four US institutions described how they recruited 100 overweight or obese participants, 86% of whom were women, and randomly allocated them to one of three regimes: eating as normal, daily calorie counting and an alternate-day fasting diet.

For the first month all participants ate as normal, after which they spent six months on their allocated diet. In the fasting diet, participants consumed 25% of their normal daily calorie intake on the fast day, and 125% the following feast day, while the calorie-restricted group consumed 75% of their normal calorie intake every day. The third group made no changes to their typical diet.

The results reveal that, compared to those who didnt change their diet, those on the fasting diet and those on the calorie-restricted diet had on average lost roughly the same amount of weight after six months. By the end of the study those who had fasted and those who undertook a daily diet were 6% and 5.3% lighter respectively than those who had not changed their diet. The results held when factors such as the sex and ethnicity were taken into account.

The team said the findings might be down to a greater than expected difficulty in sticking to the fasting diet, with data showing they typically ate more calories than designated on the fast days and fewer than designated on the feast days.

We found that around half the people in the alternate-day fasting group had a hard time sticking to it, said Varady.

But the authors admit that the study had limitations. The sample size was small and only 69% of participants completed the study, Varady warned, pointing out that participants in other regions might have fared better in sticking to the alternate-day fasting diet.

Michelle Harvie, a research dietitian from the Genesis Breast Cancer Prevention Centre at University Hospital South Manchester Trust, welcomed the study, saying that the ability of people to adhere to a regime is a crucial aspect of a diet.

But she stressed that the study only explored one type of intermittent fasting diet and that the results might not hold for other types, such as the 5:2 diet.

Harvie added that it was important to note that the fasting-based diet resulted in results at least as good as those from a traditional calorie-restricted diet, and that some people will be able to stick to the regime.

Varady agreed that there is no one-size fits all approach to dieting. Some people can stick to alternate-day fasting better, some people can probably stick to calorie-restriction way better, she said. People just need to figure out which one is better for them.

Read more: https://www.theguardian.com/lifeandstyle/2017/may/01/fast-or-feast-study-shows-alternate-day-dieting-too-difficult-to-sustain