Time to watch my weight?

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[Update: For the clinical perspective on today's topic, check out the accompanying article on Dr Yoni Freedhoff's blog Weighty Matters]

I had an interesting experience at my last physical exam, and I thought it would be worth sharing here on the blog.  Before the physical a nurse put me through an eye test, then took my blood pressure, height and weight.  She then calculated my BMI, and told me that I was in the “normal range” (it was around 24.5).  But, she continued, I was pretty close to the overweight cut-off of 25.0, so I should “watch my weight” moving forward.

I said “un-huh” and sort of laughed inside my head, given that I’m an obesity researcher and we have written the odd post about BMI here on Obesity Panacea.  But the more I talked about the episode with other people, the more ridiculous it seemed.  Here’s why.

BMI is only one aspect of health

As we have said before, weight ≠ health. BMI is moderately useful at estimating body fat, and therefore health risk (especially at the population level).  However, as Peter and I have argued many times, your behaviour matters as much (or more) than your weight when it comes to health.  If you are physically active and eat a healthy diet, you’re likely to be relatively healthy whether your BMI is 22 or 32.  It’s not that weight doesn’t matter at all, but it’s far from the only thing that matters.

(For more on the relationship between BMI and health, I suggest this excellent post by Peter while Obesity Panacea was hosted on Scienceblogs.  Or, for a review paper on the health-benefits of exercise regardless of body weight, click here.)

Context matters

My weight has been stable for several years.  I am (extremely) physically active. I try to limit the amount of time I spend sitting.  And thanks to my wife’s positive influence, I eat a reasonably healthy diet (mostly homemade vegetarian food for breakfast and supper, with leftovers and/or pizza for lunch).  My metabolic health is also fine although, ironically, I had to specifically ask before I was be told my HDL and triglyceride levels.

Why would you counsel a weight stable person with a BMI in the healthy range about their weight (as opposed to their behaviour) anyway?  I’m certainly not the only person to have this experience – here’s what colleague Atif Kukaswadia had to say on twitter:

My BMI is around 24.9. My doc told me to “not gain any more weight” for the same reason.

Yet, as our science blogging friend DrugMonkey pointed out on twitter, none of that means that we’re going to be weight stable forever. I’m in my late 20′s, cutting back on my participation in competitive sports, recently married, and nearing the end of grad school.  It wouldn’t be at all surprising if someone in my position were to begin putting on a few pounds over the next few years. In that context, the nurse’s advice seems to make perfect sense.

Except for one (very big) oversight.

How do you “watch your weight”, anyway?

This is really the crux of the problem.  Weight is an outcome, not a behaviour. When someone tells you to watch your weight, what do they really mean?

Obviously one would assume that the nurse meant that I should be physically active and eat a healthy diet.  Except she didn’t say anything about either of those things.  She didn’t ask about my level of activity or my diet (although it had been recorded during an earlier visit), nor did she give me any counseling on what a healthy diet should look like.

What if someone in my position were to take the nurse’s advice and begin dieting to reduce their weight or prevent weight gain (despite being weight stable and already healthy)?  As our colleague Dr Arya Sharma has argued, trying to lose weight is actually a pretty good way to gain weight over the long term.

as I have said before, all weight loss attempts should be medically indicated and anyone attempting to lose weight needs to be warned that they may in fact be increasing their long term risk of becoming (even more) overweight or obese.

I don’t want to be too harsh on the nurse because she clearly meant well.  But a clinical strategy that focuses exclusively on body weight, with no information or counselling related to healthy behaviours, and completely ignoring all context, is almost certainly going to fail (and possibly make things worse than they were at the beginning).

As always, I’m curious to hear what others think.  Has anyone had a similar experience? Have a different perspective on the nurse’s advice?  I’d love to hear about it in the comments section.  And don’t forget to check out Dr Freedhoff’s thoughts on the issue over at Weighty Matters.

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Travis

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27 Responses to Time to watch my weight?

  1. Bill says:

    Very good post. I had a doctor tell me I should keep my calories under 2000 total without asking about my exercise habits. I typically burn around 500 or so estimated calories, so that would be pretty low for an active guy. I clarified and she pushed it up. I did end up changing my diet and all of my biomarkers got better, but it was because I changed the types of food rather than reduced the calories.

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  2. marie says:

    This reminds me of a visit to my doctor for my annual check up. I eat very healthy ( I am an RD), I am very active and my BMI had always been stable and on the low end (~20). I love cardio activities, but wanted to gain more muscle through weight training which I had struggled with in the past, so I worked really hard with a great trainer over the course of the year to decrease my percent body fat and gain more muscle through weight training. The results meant that I was much fitter, my percent body fat decreased and my cardio performance increased…BUT, I had gained 5 pounds of lean muscle mass. Upon taking my weight, the nurse was very concerned when she told me that I gained 5 pounds since the previous year and that my BMI was rising. When I explained that the weight gain was a result of gaining muscle though training and that I had actually decreased my percent body fat and increased my fitness (including cardio performance), she stuck to her guns and suggested that I keep an eye on my weight gain. I was very concerned by her messaging and lack of understanding on the limitation of body weight and BMI (including one that still in the low end of the scale!). I agree, more training is needed..

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  3. steve says:

    I had an unusual experience during my last physical. I’m in my 50s and have good vital signs, am a vegetarian and get a lot of regular exercise. My BMI is 20.5, but I realize that isn’t terribly important.

    The nurse, who runs and cycles, gave me encouragement – no negative comments. My doctor gave me a speech about how important BMI was and how he was happy I was within the normal limits. He never asked me about my exercise or dietary habits. It was almost as if it was a one item checklist for being healthy.

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  4. Y says:

    I think athletes should have a different bmi chart than the one we use now. Body composition would be a more accurate gauge.

    Doctors… I’m in my late 20s and i remember about 7 years ago having a horrific year, being put on anti depressants, having surgery and other factors rendered me very inactive. At a checkup my dr weighed me and I was slightly over weight. He pointed that out and said ‘you know what to do’ and moved on. No advice, no consideration is might be the medication, nothing.

    My bmi returned to a normal range as I healed from surgery and stopped anti depressants but I will never forget that horrible shameful feeling of being ‘fat’ after my doctors appointment.

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  5. ksol says:

    @Y — drives me nuts when I hear stuff like this. A lot of psych drugs are notorious for adding weight, BUT some mental illnesses carry a much higher risk of mortality than a few extra pounds. Medicine is about balancing risks and harms. That’s why we give chemo to cancer patients — it’s not that we think chemo is good for you, it’s that it’s better than the alternative. We would not withhold or discourage chemo because you “might” get a chronic illness like diabetes from it 10-15-20 years down the road.

    @steve — sadly, they probably would have been just as happy with you if you were at BMI 20.5 and you sat on the couch night after night scarfing down twinkies and watching “American Idol” (some people can remain thin despite terrible habits.) You’ve got it right — it’s the 1-item checklist, and not a terribly accurate one at that.

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  6. Deb says:

    I have aplastic anemia. At my annual physical, I weighed 184 lbs at 5’8″ tall. Sure, I’m a bit overweight but my energy and activities are kind of limited. In spite of that, I try to do horseback riding 3x a week but I am not nearly as active as I’d like to be. The nurse said I should lose weight. Sure, I’ll just add extra stress to my body. The way I look at it, my weight is the least of my worries.

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  7. Mark Haub says:

    Well done! Your experience is why did what I did for my students ;-)

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    • Travis Saunders, MSc, CEP says:

      Thanks Mark. Although I’m still a little disappointed that I didn’t at least try to say something constructive during the appointment itself, rather than just keeping my thoughts to myself.

      What’s your take on how people have interpreted your twinkie diet experience? It seems that there are many of us who got the idea right away, but I’m wondering how many people actually thought you were promoting a new fad diet. Did your students get the message?

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  8. Nora says:

    Sort of a sensitive topic for me right now, as I was told rather severely to lose weight based on my BMI last summer by a doctor who had not asked for (and had not apparently read the information that was in my chart) a weight/activity/diet history of any kind, though she did look at my glucose, blood pressure, triglycerides, etc. ( all of which are in extremely low/zero risk categories). I do have some arthritis and other occasional athletic injury sequelae/overuse issues. All of which were as big a problem (or bigger) when I was slender.

    Anyway, I asked her how many calories and how much activity she thought would be appropriate at my age, and she said maybe 1800 calories and 1/2 hour of moderate activity, like walking, a day. She said this without asking me what I ate or how much I exercised, but that is substantially more than I eat and way, way less than I exercise.

    She scheduled a follow-up visit in six months (which turned out not to be covered by my insurance — and cost me nearly $300 US — because it is coded “obesity counseling” or some such), and I took the opportunity to keep a food diary, which she hadn’t asked for but skimmed through briefly before referring me to a dietitian (who was similarly unhelpful but only $150, by the way).

    I am overly sensitive, sure, but I felt like the doc and the dietitian both dismissed my food log as delusional fiction. As a former professional cook and someone with a 30+ year history of dieting and eating disorders, I am very scrupulous and accurate about recording food intake. And I am not embarrassed if I mess up; I don’t feel like I need to lie. If I eat 5 cookies, I record that, and you can bet that I have weighed them and calculated the nutritional content to the last delicious fat gram :) I have a digital scale in my kitchen. I am good at math, and I am a total sucker for data collection. It’s difficult for me to use some of the food log apps, as I cook nearly everything from scratch, but not impossible. I consume roughly 1200-1500 calories a day, on average.

    If I don’t get to the gym, I typically get 5-10 miles a day (at least 1 mile of which is usually a slow jog with the dogs) of walking, plus “recreational” stair climbing several times a day. When I get fidgety during the day, I do 5-10 sets of 10 ab crunches on the exercise ball that I use for my office chair. When I can organize transportation to do so, I go out dancing as much as I can. I run in a couple of 5K races every year or so. I am not exactly sedentary, in other words. I like to move. Before I started falling down in traffic too often, I commuted on my bike, but now I live about half a mile away from my office and walk to work. I don’t drive, so I in fact I walk nearly everywhere. I have narcolepsy, so I rarely sit down at all unless I intend to sleep. Watching too much television is not an issue, as I don’t have one, and never have. I read (and knit, and play guitar) standing up and moving.

    I fear going back in for my annual physical, I fear bringing this most recent plantar fasciitis flare-up to my doctor’s attention, and I absolutely am in a tailspin of horror at my fat body and its doomed and hideous reality (I was more or less at peace with it a year ago). It’s all I can do to continue to socialize with my friends, if there is food involved. I’m embarrassed to be seen eating in public.

    And incidentally, my sister is a mailman — she carries 40-50-lb bags of mail around for seven hours a day or more, and she is a metabolically fit, similarly muscular gal who weighs about what I weigh (although she eats somewhat more than I do because she is hungry after all that).

    Both of our grandmothers were sturdy, strong, and heavy. They both died a little shy of their 100th birthdays, of nothing in particular: no diabetes, heart disease, etc. etc.

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    • Travis Saunders, MSc, CEP says:

      Thanks for the comment, Nora. I’m very sorry to hear about your experience. Fortunately not all health professionals are like the ones you have encountered – Yoni’s post from today is a good example of that:

      http://www.weightymatters.ca/2012/01/are-weight-ignorant-allied-health.html

      We also have a guest post coming up from a dietitian on this topic as well. Hopefully you are able to find health care professionals who make you feel comfortable, as opposed to your recent experiences. You may want to check out the Health at Every Size directory, which lists health care professionals who subscribe to that philosophy in various locations.

      http://www.haescommunity.org/search_registry.php

      Thanks for sharing your experience, and I hope that you’re able to find a more supportive health care provider in the near future.

      Travis

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    • Andrew Hunt says:

      Nora – Has your doctor checked you for hypothyroidism? The symptoms you mention are almost exactly the same symptoms my wife was experiencing a few years ago, and she ended up being diagnosed with hypothyroidism (TSH was over 5.0, tested positive for antibodies as well).

      Obviously, I am not a doctor, but I did end up reading a LOT about hypothyroidism after my wife was diagnosed…

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  9. June says:

    The last couple of months I’ve had some especially horrible experiences with doctors. For the past 1.5 years I’ve worked hard at losing weight (almost 75lbs) and now am just over 10lbs away from a “normal” BMI. However, I went to three separate doctors and all three gave me a lectures on how overweight I was (one actually printed off a BMI chart and explained it to me like I was a little kid… this is AFTER I had told him how much weight I already lost).

    Another doctor who I was seeing for knee and wrist pain told me that I was no longer allowed to do high impact exercises. When I asked what kind of exercises I was still allowed to do because I wanted to continue to lose weight he pointed at his mouth. When I asked him what that meant he answered “Stop eating!”. The last doctor told me that I was “really big” (I was 16lbs overweight at the time).

    I’ve found the whole experience extremely frustrating. It’s like they don’t even listen when I’ve told them how much weight I’ve lost. Almost as if it doesn’t matter even though I’ve very active and eat a whole foods diet, as long as I’m still even slightly into the “overweight” category.

    What I would love to see is doctors and nurses trained in measuring body fat %, not BMI. Also it would be extremely useful if they had actual knowledge about weight loss and nutrition and not just the eating-disorder promoting advice of “stop eating”. Additionally, I would LOVE to see doctors who could give exercise advice to those of us who have physical limitations. How can they tell you that you can’t do certain activities but not let you know what you CAN do?

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    • Travis says:

      Thanks for sharing your experience, June, I’m really sorry to see that it’s not an entirely uncommon one.

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  10. Mitzi says:

    They err at both ends. If you are overweight, they tell you to stop eating. If you are underweight or slim (I hover around a BMI of 20 at age 40), they assume you are anorexic and malnourished, never-mind the Ph.D. in biochemistry and cell biology. I’m 5’10″, so I look quite bony at 137 pounds (female). A doctor went to a BMI chart on her wall, saying “You are really … healthy” in a rather disappointed tone after she saw the number. Physicians are trained to memorize, diagnose from numbers on paper, prescribe, and shove you out the door these days. Anything requiring thought is something most are not paid enough to do. One who thinks is to be treasured.
    Mom is obese, and I am thin, but we joke about our treatment from doctors. They want to put her on lots of drugs because at her weight and age she MUST have hypertension, diabetes, and heart disease. She does not. Just crippling arthritis, which they want to treat with narcotics. She just says no. I’m fighting to avoid the arthritis, but they will not help me with prevention- no treatment for our joint condition is available until the damage is irreversible! Disappointing.

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  11. Zora says:

    My last visit to the doctor was almost as frustrating as June’s. I was still overweight, but I had lost 22 pounds in the last year. She gave me the “you need to lose weight” lecture. Sheesh, lady, what do you think I’m doing?

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  12. Andreas Johansson says:

    No healthcare professional has, that I can recall, commented my weight or BMI (no big surprise as I’m low end of the ‘healthy’ range), but on two separate occasions I’ve been told I’m getting an adequate amount of exercise by doctors who, near as I know, had no way of knowing how much exercise I was getting. Maybe they really could tell just from looking at me, but it’s hard to suppress the suspicion they merely presumed I must be because I’m thin.

    (As for if I really was, I don’t know. I wasn’t, and amn’t, getting very much exercise, but I’m not a complete couch potato either.)

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  13. Nora says:

    Thanks, Travis. I will keep looking — for a new internist, not a dietitian or whatever. The worst part of it was that I wasn’t there seeking treatment for obesity or help losing weight. I was there for a yearly physical. I am a longtime HAES advocate myself, and I am usually the first one to stand up for it. A few years back I saw a nutritionist /dietitian who specializes in people who have a history of eating disorders, and she helped me change my very low-calorie, extremely low-fat vegetarian diet to add a lot more protein (and a bit more fat and some more calories) – there was very little change in my weight, but I had a lot more energy and my strength training was the better for it.

    In the meantime, I found a new foot doctor; I’ve got a 5K in March I gotta run!

    And @Andrew – yes, my thyroid has been checked, and is regularly re-checked. Not a problem, but good call.

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  14. freeman dennis says:

    your experience and the comments confirm my experience that most readers of obesity panacea and links are much better informed on these topics than primary care docs and even cardiologists. these topics evidently not taught in med school and the doc has access, if interested, to the same studies,etc on the site. of course the real prob is unsuspecting “cicilians” who think these people know what they are talking about. thanks for the good info!

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  15. WRG says:

    I don’t know whether to laugh or cry after reading this post. And these people are called health “professionals”? When it comes to the complex relationship between weight and health, they are no better informed than the average stupid fool.

    Unfortunately, while what you experience, Travis, can be more or less laughed off, for many people, it’s part of the daily hate-fest that they must contend with. As long as BMI is the (often only) accepted marker for health, we will remain a long way from effecting true positive changes to our health in society as a whole. And fat people–no matter what their health status–will continue to be treated with contempt and considered to be slothful, slovenly gluttons.

    It’s a wonderful world!

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    • Travis Saunders, MSc, CEP says:

      It probably won’t surprise you that I was writing this post with your past comments in mind. I hope it didn’t come across as making light of the situation, my goal was to show how ridiculous and counter-productive (and as you and other commenters have pointed out, oftentimes painful) an approach that focuses exclusively on BMI can be. Of possible interest, we’ve got a follow-up guest post from a HAES dietitian which I’ll be posting tomorrow.

      Travis

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      • WRG says:

        Not to worry, Travis. I didn’t detect one iota of flippancy in your post. And I’m honored that you thought of me.

        I can’t wait to read your interview with the HAES dietician!

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  16. I agree completely with what I think is the key line in this post:

    Weight is an outcome, not a behavior.

    This applies by way of analogy to the world of work (my own field), where “training” often focuses on changing behavior, rather than on the variety of causes that produce a given result. You can’t train your way out of a problem caused by, say, insufficient time to do a job properly.

    The best spin I can put on the nurse’s advice is that “watching your weight” is about monitoring. (Okay, given your description, that might not be what she meant, but that’s the message I’ll read into it.)

    I’ve lost 40 pounds that I’ve managed to keep off for a year. I have weighed myself nearly ever day for two years–not obsessively (if I’m away from home, it doesn’t bother me that I don’t have a scale), but as a way of collecting data points. I have a good sense of what typical fluctuation looks like (up to a pound and a half). In other words, if my weight goes up by a pound from Sunday to Monday, I don’t freak out. If it goes up a pound a day for five days in a row, then I’m getting feedback that some part of the system isn’t working.

    (Usually, that’s the intake part of the system.)

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    • steve says:

      As someone who is in the maintenance phase I second Dave’s comments. I weigh myself every other day and still journal what I eat along with my exercise. If there is a trend that is out of the normal measurement noise I deal with it promptly. This is about the only method I’ve heard of that works for long term maintenance for someone who has lost weight and is fighting signals from an old set point.

      It is always the intake phase with me.

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  17. I am in WRG’s camp. I have nothing but respect for front-line medical caregivers (GP’s and nurses, etc.) as people, because every single one I’ve met is a warm, friendly, caring person. But in my experience, standard corporate medical practice is dehumanizing and totally statistically-oriented. Even when I’ve seen the same GP for three or four years, the exact same thing always happens when the doctor walks into the exam room. I let him lead the conversation, and he (0r she) always leads with, “Hi,” (glancing at clip-board), “you need to diet and exercise. You should also consider cutting out animal fats and salt. Do you smoke?”
    My reply is always polite, and truthful, and generally runs like this: “Last time I was here two months ago, and several times before that, I explained that I am mostly vegetarian, so I don’t eat much animal fat, and I have cut out salt since college 20 years ago. And that my office has a fitness program, so I’ve been going to the gym religiously twice a week for a year. Also that I don’t smoke and never have.”
    In my experience, if you’re generally healthy and don’t have big problems that demand your doctor’s attention regularly, it takes at least five years of seeing the same doctor before they start to recognize you as a person and understand your overall health tendencies. Until that happens, you’re just another stack of numbers on a clip-board to them, and in our corporate system they are expected to shovel a hundred such clip-boards in and out of their office every single day, 300+ days per year. Ergo, they do the only logical thing, which is to play the odds: hand out generic medical platitudes, because 92.5 of those 100 clip-boards are within two sigmas of the mean, and therefore will benefit to some degree (however small) from the generic medical platitudes. Our corporate system leaves doctors no time to think or understand; it’s all just playing the statistics.
    Every time I get a blood test, and the doctor doesn’t know me as a regular, I get a gasp and raised eyebrows. “O my God, your Bilirubin is up at 2.2 mg/L. Do you have any history or symptoms of hepatitis or jaundice?” Hepatitis is indicated around 20 mg/L. I once had to submit a blood test for a job overseas, and it took four blood tests (not covered by insurance) before I found a doctor who was willing to stick his neck out and diagnose me with Gilbert Syndrome, a totally harmless condition where your Bilirubin is slightly high, with no other symptoms in and of itself. As many as 10% of the population has this harmless syndrome, and I had to pay $1200 of my own money and my job application was delayed by 4 months, in order to find this out?? Doctors have no professional, monetary, or legalistic/liability reason to tell you that you are normal and have nothing to worry about. If your statistics are just one fraction of a pip out of what some distant medical association decided was “normal”, then they have every reason to make you think you’re in danger and need to take action.
    Sorry to vent, but that’s my experience. Frustration with the standard “diet-and-exercise” tap-dance is one reason I have been reading your blog off and on for a couple years, although I’ve never commented before.

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  18. Pingback: Iatrogenesis or Good Intentions? Why do Health Care Practitioners Continue to Ignore the Health At Every Size Philosophy? | Obesity Panacea

  19. ruthdemitroff says:

    I’m a skeptic. My first thought when talking to any professional is whether or not their advice is evidence based. My husband, on the other hand, takes professional advice straight to heart and is extremely compliant. He was told that he was heading towards obesity , was totally taken by surprise, felt shame and was determined to never be described as almost obese again. He continued walking. gardening and doing a hundred sit-ups and push-ups every morning, reduced his intake, took his vitamins and baby aspirin but his weight remained in the 165 to 170 range. He died at 60 from a Type A aortic dissection. I’m awaiting the results from an extensive autopsy. Got a phone call from his doctor’s office 2 days after his death saying that he needed to come in because he was deficient in some vitamin. Said, “He’s dead – don’t think it matters.” Live wrapped in whatever shaped body is a marvel – forget the shame – you are totally awesome!

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  20. Michelle says:

    Though I am a little late in “weigh-ing” in here…pardon the pun, I totally agree with most sentiments above. You know what really galls me as a former obese person? Its the way that people want to make you feel about yourself.

    What about cultures of the Caribbean, Pacific and countless other places where woman are encouraged to be a little “plump” in order to get partners and might I add that a lot of these places, the average age of longevity is among some of the highest in the world.

    But you know what, I lost my weight and feel good about it, for myself and for my family but ease up on the obese people, a lot of it is the processed tripe that is available to us. By the way I think exercise should be a natural thing and not so structure as it is….

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