A few days ago I posted on the LifeShape Facebook page a link to an article from the New York Times that summarized the many reasons it is difficult to sustain significant weight loss. The article very nicely describes some of the scientific data that regulates weight maintenance and caloric balance but also examines some of the studies that try to learn from the relatively small percentage of people who have been able to sustain significant non surgical weight loss.
At this point I would like to point out that the same issues also pertain to patients who achieve surgical weight loss. Surgical weight loss helps patients lose weight by decreasing hunger. With some surgeries this decrease hunger can fade after the first few years. For patients (and surgical programs) who do not embrase a more holistic approach to long term success including diet exercise and behavioral modification, they are at higher risk of weight regain as well.
Some of my key “take home points” are as follows:
- After someone loses a significant amount of weight the body tries to modulate activity, metabolism, and hunger to promote not the present weight but the previous weight.
- The degree to which this occurs is in large part genetically determined. (That is NOT the same thing as saying your weight is genetically determined)
- To counterbalance this phenomenon a long term state of hyper-vigilance is required to titrate both food intake and selection verses activity.
- This altered metabolic state of last for a very long time, definitely longer than two years, and likely forever.
- Given the above it seems clear that we should redouble our efforts in preventing people from getting into this situation. The time to do something about your weight is…… NOW. Don’t wait to add 10 or 20 more pounds. Optimally dont ever let your BMI climb above 27 (technically overweight but not associated with as severe medical sequela)
One of my favorite Medical Weight loss experts Dr. Yoni Freedhoff in his excellent blog took issue with the pesemistic tone of the article. His blog post is reproduced below. My main take home points from his post are:
- That even if patients can’t maintain all of the weight lost. Maintenance of medically important amounts of weight (greater than 10% of body weight) still has significant health benefits that are worth the struggle. Put another way, patients should be encouraged to hold the line and not get discouraged to putting it all back.
- If patients look at what needs to be a new life long commitment to exercise as years of unrelenting labor in the gulag, it is no wonder this will be unsustainable. Instead if their new activity plan is fun and becomes their passion, it becomes just what they do….automatic.
If you haven’t read Tara Parker Pope’s Fat Trap in the New York Times, her premise is pretty straightforward – permanent weight loss is virtually impossible, and for those who succeed it requires near superhuman willpower.
Why?
According to Tara, the body adapts to weight loss in multiple ways that make weight gain easier, and it’s basically a full time job to keep it off from a vigilance perspective.
I think Tara’s article’s great and highlights two tremendously important points. Firstly, that there’s way more to all of this than simply pushing away from the table, as the body keeps tucking people right back in. Secondly, that society’s approach and attitude towards weight management is just plain broken – and I suppose it’s here where Tara and I effectively diverge.
Tara talks of extremely restrictive diets as if they’re what are required to lose. I couldn’t disagree more (I’ll come back to this). Then she discusses the ongoing and incredible vigilance of successful losers, quoting Yale’s Kelly Brownell as stating,
“Years later they are paying attention to every calorie, spending an hour a day on exercise. They never don’t think about their weight.”
That does indeed sound rather severe, and she definitely writes about it with the spin of negativity.
What do I think? I think negative depends on approach and attitude. For instance where Tara might use the word vigilance, I’d use the word thoughtfulness and that being aware of every calorie doesn’t mean you’re not eating indulgent ones.
Tara picture though is definitely the incredibly strict life that typifies society’s eye view of “dieting”. But even if severity’s what’s required, why can’t people just stay hard core? Superficially you might think people would in fact be able to remain hard core, because people really, really, really want to keep the weight off and I imagine this confuses many folks, including Tara.
How badly do people want this? In a now classic study, Rand and MacGregor revealed that formerly obese, bariatric surgical patients would rather be of normal weight and deaf, dyslexic, diabetic, legally blind, have very bad acne, have heart disease or one leg amputated, than return to being severely obese. If you felt that way about something, for whatever the reason, don’t you think you’d do whatever it took to keep that weight off, even if it were a hardship?
So why do people gain it back if it’s so important to them? If they’d rather be blind or have a leg amputated, why can’t they just keep up with their weight management efforts? Is it because as Tara describes their bodies work against them? Certainly in part, but I think the bigger reason is because they’ve likely chosen inane methods of loss and maintenance – like those described by Tara. To lose their weight they’ve gone on highly restrictive diets, they’re denying themselves the ability to use food for comfort or celebration, they’re regularly white-knuckling through hunger and cravings, they’ve set ridiculous Boston Marathon style goals for their losses, and they’ll often possess highly traumatic all-or-nothing attitudes towards their efforts. In short? They’ve chosen suffering as their weight management modality.
Suffering as their plan? Go figure it ain’t working. Incredible desire or not, people aren’t built for long term, relentless, suffering.
I guess what I’m getting at is that there is zero debate about the fact that weight management, whether it’s losing or just not gaining, does require effort. What I’m positing here is that if your effort is personally perceived as a misery, given human nature, eventually you’ll fail, not because you’re weak willed, but rather because you’re human, coupled with the fact that the world we live in is now a Willy Wonkian treasure trove of calories and dietary pleasure. This calorically non-intuitive wonderland is also why without ongoing thoughtfulness in terms of choices, lost weight comes back even for those who do it smart.
My weight management philosophy has always been rather straightforward – whatever you choose to do to lose your weight, you need to keep doing to keep it off, and therefore choosing a weight loss modality you don’t enjoy is just a recipe for regain.
So is there one right way to do this? I don’t think so. As far as weight loss and maintenance go there are many different strokes for many different folks, but there is one essential commonality for those who succeed where others fail – if you’re going to keep it off you’ve got to like how you’ve lost it enough to keep doing it.
Now back to Tara’s premise that almost no one keeps it off.
That graph up above?
It’s from a recently published study of something called the Look AHEAD trial where Tom Wadden and colleagues studied those factors associated with long term weight loss success. The factors? Paying attention to intake, exercising, and applying the education they received from their expert research team. And would you take a look at that graph! By year 4, of the folks who’d lost more than 10% of their weight in the first year, some did indeed gain it back, but 42.2% kept off nearly 18% of their presenting weight for the full 4 years! In fact they kept off virtually all of their year one losses. Moreover, looking at all comers of the trial and not just the folks who lost a pile in year one, nearly 25% of all participants maintained a 4 year loss greater than 10% of their initial weight.
That’s sure a far cry from no one. In fact if those results came from a pill some pharma company would be making billions of dollars.
So it is indeed doable, but ultimately weight loss and maintenance require lifelong effort, therefore if you don’t like the effort required, you’re not going to keep it up and your weight’s going to return.
Somehow I wouldn’t have thought an article that reinforces the fact that if you don’t like the life you’re living, you’re not going to keep living that way would grace the pages of the New York Times.
