Critiquing Peter Attia

This post reproduces an email that, after much nervous deliberation, I sent to Peter Attia in August 2023. I’d enjoyed other episodes of his Drive podcast in the past, and when a colleague shared an eating disorder-related episode of his podcast with me in late 2022, I expected something good.

After listening once, I was angry enough that I thought I should do something with the anger. I listened twice more to the full 2+ hours, with zero pleasure, over the next few months, in order to make good enough notes and then fact-check a draft email to him thoroughly enough to be confident in sending it. I then asked several people I trust for advice—about whether to write to him, or to his guest Holly Baxter, and how to improve what I’d written. I simply couldn’t face listening a fourth time when one of them suggested that it’d be good to include timestamps when referencing specific moments in the interview!

I don’t know quite why I got so nervous. I have no idea whether he or any of his team ever read my message. I only ever got an auto-reply informing me that “Unfortunately, due to the high volume of inquiries that Peter and his team receive, we are not able to read or respond to all questions or inquires [sic]”.

I think four months is enough time to give him to reply. So in case it can be of use to anyone else, I’m sharing my message here. Since I sent it, I’ve been thinking about the episode as an example of how to bypass listeners’ mental immune systems (an idea recently popularized by Andy Norman)—here, for instance, through the combination of Attia’s medical credentials and an appeal to common and deep-rooted body insecurities.

I won’t link to the original episode, because I think it’s a shoddy piece of work that doesn’t deserve more listeners, but you can find it quickly enough if you insist!

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Hello Peter,

I hope this finds you well. I’m a recovery coach working with people with eating disorders (EDs) as well as a researcher at the University of Oxford. I also lift weights, and had a brief spell as a competitive powerlifter. I’m writing in response to your podcast interview with Holly Baxter, in case my perspective on it can be of use to you in guiding future decisions about your podcast.

I’ve listened to this episode carefully three times, and from my perspective, it’s a poor fit for a podcast whose remit encompasses cognitive and emotional as well as physical health. Indeed, my sense is that it directly encourages self-objectification and disordered eating.

In this email, if I may, I’ll offer a summary of the main points in the episode that lead me to this conclusion, followed by some references to relevant research.

***

Starting with the details of your conversation with Holly, I’ll divide them roughly into themes.

Holly has an ED:

• Holly describes herself as not fully recovered from her ED. Based on her experience of partial ED recovery and your own experience of alcohol dependency, you agreed with each other 1) that EDs align with the substance-abuse model of addiction and 2) that therefore full recovery from an ED is impossible. Many people who have fully recovered from an ED (myself included) would take issue with these conclusions, and would observe that the second view is voiced only by individuals who haven’t fully recovered yet.

Holly’s business practices originate in her ED experiences:

• Holly recounts her experience of an ED and describes herself as having only recently started to work on her mental health, after years of working with nutrition/training clients whilst suffering from an ED herself, with varying degrees of anosognosia and suicidality. That is, her current business model grew out of methods developed under the influence of an ED.

Holly’s business practices encourage attitudes and behaviours that she understands as contributors to her own ED:

• Holly states that the desire for control of her nutrition was the starting point for her ED, and her business model depends on teaching others how to exert control over their nutrition, including via calorie restriction.
• Holly states that “trying to control your body, which is trying to control you”, was the hardest thing about being seriously ill. But her business model revolves around helping clients to try to control their bodies’ (shape, size, composition).
• Holly states that restriction of foods reliably makes one crave them, and that practising self-compassion and self-forgiveness and allowing herself to eat ice cream and gain weight was integral to the recovery progress she has made so far. Yet her business model centres on advising clients to engage in dietary restriction, for example to develop expertise in what a 4oz piece of chicken looks like, because there’s “so much value in dedicating a set amount of time to weighing food”. She criticizes individuals who are unwilling to put the work in to make calorie-counting cognitively automatic: “I really struggle with people who don’t want to invest that time, because it’s a lifelong skill”. As she says, it might take 6 months to get the hang of it, but she’s been doing it over 12 years now, so she can estimate or eyeball anything. “You get really good”, she says, in the same conversation that began with her acknowledging that her ED recovery is incomplete. I hope it will take her less than 12 years to unlearn this skill, but for many individuals in recovery from an ED, the calorie-counting habit and all its associated pathology is hard to eradicate—and their health and happiness depend on their doing so.
• Holly begins her work with clients by asking them to show her somebody whose physique they like on social media. Yet she concludes your conversation by saying that “the best step I ever took” was to get rid of aesthetics-focused social media.
• Holly claims not to understand why with female body ideals we “seem to find ourselves back at these extremes”, while making a living from promoting extreme self-objectification in others.
• Holly describes the damaging limitations that methods like hers impose on individuals’ lives, and both the joys and the difficulties of lifting these restrictions: how gradual (still energy-restricted) reintroduction of slightly more nourishing ways of eating feels itself like a diet; how without the immediate goal of measurable bodily objectification, continuing restriction is really hard; how allowing themselves a couple of glasses of wine or dessert with friends makes a meaningful difference to these women’s lives. 

You choose a conversational structure that espouses ED-compatible (and highly gender-normative) attitudes and behaviours:

• Fairly early on in your conversation, Holly gives an example of how she helps her clients achieve perspective on their body appearance preoccupations, by asking them “would you have been invited to that wedding if you’d been 10 kg heavier?” The typical response is “yes, of course”. She points out that this is the obvious response because this individual has something admirable about them that people like (e.g. a sense of humour) that has nothing to do with bodyweight or bodyfat percentage. You nonetheless proceed to structure the episode via the conceit of a woman who wants to “look the best she can” for her wedding or for a “girls’ trip coming up”—a woman who at the end of the process is meant to look better in her wedding dress than she would have a year earlier.
• Holly describes how praise for her “superior physique” fuelled her ED, from which, again, she has stated that she has not fully recovered. In your conversation with her, you repeatedly praise her physique, and you structure the conversation around an in-depth investigation of her methods for achieving aesthetic change in her own body and assisting others in achieving it in theirs.

You fail to highlight the health risks of the way of life that informs her business model:

• At one point you challenge Holly briefly on the health dangers of engaging in an activity that resulted, for most of her career, in amenorrhea. When she responds with “It depends; lots of people in the bodybuilding space don’t even want kids, so fertility is not an issue” you instantly back off and neglect to point out that having a functioning hormonal cycle is crucial to health in numerous ways that have nothing to do with a desire to procreate. 

Holly admits that her methods do not work:

• The devastating punchline to this long conversation is that Holly’s methods don’t even work. After all the calorie-counting, all the photo exchanges, all the damaging lessons in how to ignore your body’s appetites and eat according to a preset regime mapped out by someone else, “the change is not as visible as you’d think”. The first attempt at fat loss often doesn’t get you there, and multiple “recovery diets” are often needed. This is ideal for a business model aiming to keep clients paying in hope of elusive future rewards. It is also an excellent way to get individuals trapped in an endless cycle of dissatisfaction, unrealistic targets, and the self-destructive habits fed by both.

In sum, in this episode you showcase a business run by a woman with an active ED who communicates numerous ways in which her business encourages the pathological attitudes and habits that continue to impair her own health. And you offer no meaningful critique of any of it.

***

To offer a research context for these observations, I would refer you to a range of research literature indicating strong associations between EDs or subclinical disordered eating and 1) bodybuilding, 2) calorie counting and related practices, and 3) self-objectification. Here are some examples with illustrative quotes.

Bodybuilding:

Goldfield, G. S., Blouin, A. G., & Woodside, D. B. (2006). Body image, binge eating, and bulimia nervosa in male bodybuilders. The Canadian Journal of Psychiatry, 51(3), 160-168.

“High rates of weight and shape preoccupation, extreme body modification practices, binge eating, and bulimia nervosa (BN) were reported among MBB [male bodybuilders], especially among those who competed. CMBB [competitive male bodybuilders] reported higher rates of binge eating, BN [bulimia nervosa], and AAS [anabolic androgenic steroid] use compared with RMBB [recreational male bodybuilders], but exhibited less eating-related and general psychopathology compared with MBN [men with bulimia nervosa]. Few psychological differences were found between CMBB and RMBB. 

Devrim, A., Bilgic, P., & Hongu, N. (2018). Is there any relationship between body image perception, eating disorders, and muscle dysmorphic disorders in male bodybuilders? American Journal of Men’s Health, 12(5), 1746-1758.

“eating disorder psychopathology is positively related to body dissatisfaction and body dysmorphic disorders in male bodybuilders”

Lapinskienė, I., Mikulevičienė, G., Laubner, G., & Badaras, R. (2018). Consequences of an extreme diet in the professional sport: Refeeding syndrome to a bodybuilder. Clinical Nutrition ESPEN, 23, 253-255.

“Refeeding syndrome, as a life-threatening condition, is well known among severely malnourished or deeply metabolically stressed patients. This case presents an atypical manifestation of the syndrome to a young bodybuilder, whose extreme diet, including 5 months of insufficient nourishment before the sport competition and 6 days of carbohydrates overload afterwards, has led him to a bilateral lower – limb paralysis and drastic homeostatic disturbances. […] This case reflects to high prevalence of eating disorders or non-adequate nutrition among weight-sensitive sport athletes.” 

Chaba, L., D’Arripe-Longueville, F., Scoffier-Mériaux, S., & Lentillon-Kaestner, V. (2019). Investigation of eating and deviant behaviors in bodybuilders according to their competitive engagement. Deviant Behavior, 40(6), 655-671.

“dietary strategies and deviations (e.g., disordered eating, doping use, addictive training) develop with competitive commitment”

Efthymiou, D., Kokokiris, L., Mesiari, C., & Vassilopoulou, E. (2021). Perceived ideal body weight exacerbates bulimia and dieting in bodybuilding athletes. Toxicology Reports, 8, 1777-1782.

“Body image perception and satisfaction in bodybuilders and strength athletes can be impaired by their desire for a lower body weight, leading to disordered eating behaviors.”

“The degree of deviation between the perceived ideal body weight and the actual body weight was associated with increased risk of eating disorder.”

“As the recreational bodybuilding athletes appeared to be more vulnerable to disordered eating behaviors, appropriate educational intervention should be undertaken to provide holistic dietary, psychological and sport coaching, for both professional and non-professional athletes, to promote the original dual concept of healthy body and mind.”

Calorie counting:

Levinson, C. A., Fewell, L., & Brosof, L. C. (2017). My Fitness Pal calorie tracker usage in the eating disorders. Eating Behaviors, 27, 14-16.

“My Fitness Pal is widely used in an eating disorder population and is perceived as contributing to eating disorder symptoms.”

Simpson, C. C., & Mazzeo, S. E. (2017). Calorie counting and fitness tracking technology: Associations with eating disorder symptomatology. Eating Behaviors, 26, 89-92.

“Individuals who reported using calorie trackers manifested higher levels of eating concern and dietary restraint, controlling for BMI. Additionally, fitness tracking was uniquely associated with ED symptomatology after adjusting for gender and bingeing and purging behavior within the past month. Findings highlight associations between use of calorie and fitness trackers and eating disorder symptomatology. Although preliminary, overall results suggest that for some individuals, these devices might do more harm than good.”

Self-objectification:

Mehak, A., Friedman, A., & Cassin, S. E. (2018). Self-objectification, weight bias internalization, and binge eating in young women: Testing a mediational model. Body Image, 24, 111-115.

“Results indicated that women who self-objectified and internalized negative weight-related attitudes reported greater binge eating (rs=.43 and rs=.57, respectively) and these associations were mediated by the combined effects of body shame and appearance anxiety.”

Schaefer, L. M., Burke, N. L., Calogero, R. M., Menzel, J. E., Krawczyk, R., & Thompson, J. K. (2018). Self-objectification, body shame, and disordered eating: Testing a core mediational model of objectification theory among White, Black, and Hispanic women. Body Image, 24, 5-12.

“Existing experimental and correlational research largely supports the proposed associations between self-objectification and its behavioral manifestation self-surveillance, body shame, and disordered eating […]. In particular, there is considerable support for the core mediational model proposed by objectification theory, wherein body shame mediates the association between self-objectification and eating pathology.”

Daniels, E. A., Zurbriggen, E. L., & Ward, L. M. (2020). Becoming an object: A review of self-objectification in girls. Body Image, 33, 278-299.

“Self-objectification is associated with a number of negative effects on psychological well-being in adult women including body shame, heightened risk for disordered eating, reduced self-esteem, and reduced sexual satisfaction. Self-objectification also negatively impacts women’s cognitive performance […].” (references omitted)

Most of these data are only observational, and it remains to be established whether the correlations reflect a direct causal relationship in either direction (bodybuilding/calorie-counting/self-objectification leads to disordered eating, or vice versa) or all result from some other cause—or, more likely, complex feedback dynamics exist amongst these and other factors. Regardless, it seems reasonable to hypothesise that businesses encouraging healthy or vulnerable women into aesthetics-oriented body control and restrictive eating practices are unlikely to have positive effects on any dimension of health.

***

I was unsure whether to write to Holly or to you about this. I’m sure she thinks of herself as sincere in her passion for mental health and her desire to “do education now”. In the meantime, however, she has so little formal knowledge of EDs that she doesn’t even take time to familiarize herself with the diagnostic criteria for a high-profile podcast interview. I hope that one day she’ll drop the pretence that being fully recovered is impossible, get there herself, and transform her business practices into ones that do something other than turn human bodies into aesthetic objects.

But ultimately, you had the power here. She runs a business that contributes to strengthening precisely the sociocultural trends that contribute to her unresolved ED. And you gave her a wide-reaching platform from which to voice her perspectives unchallenged. So I’m writing to you. 

I’ve rarely encountered material presenting itself as professional and health-oriented that promotes pro-ED messaging as strongly as this interview does. You speak from a position of considerable perceived authority in the medical domain, and I imagine that you and Holly together may already have done considerable harm via this episode. I hope that in the future you’ll think carefully about how you configure the conversations you have with your podcast guests when they are promoting questionable practices for financial gain, especially when they are in ill health themselves. I would be glad if this message could offer any practical pointers as to how you might do so.

In the New York Times Morning briefing last weekend, an excerpt of your interview with David Marchese was featured, starting with the quote, “Many people, I think, are underemphasizing strength training.” I think it’s wonderful that you’re encouraging more individuals to consider taking up strength training. I also find it deeply depressing to imagine that a woman who wanted to follow your encouragement by seeking out more content of yours on the topic might land on this podcast episode and think that this is how she should proceed.

Thank you for taking the time to read this long message.

Emily 

And thanks to DALL-E for the image!