The bottom line is that our bottoms are getting larger. The solution, according to nearly everyone, is to eat less and move more. I’m all for moving more, but I don’t think eating less does what we think it does. Here’s a study from 2007: “obese subjects participating in LCD (Low Calorie Diet) programs have a weight loss less than half of that predicted.” (study here)
We would all assume that those obese subjects were simply cheating on their diets. Our logic about diet is circular. Since obesity is caused by eating too much, eating less is the solution. But if eating less doesn’t work, then rather than look at this assumption we assume the person must be at fault. In other words, you’re either fat because you lack willpower or because you lie. No wonder obesity continues to be an area where mockery and discrimination continue to be tolerated.
The only people who can change this image are the doctors making the diagnoses. They need to be recognizing that the treatment doesn’t work. Instead we perpetuate the stereotype: “(a)ny clinician who works with patients struggling to lose weight or to maintain weight loss has observed a common paradox: that, on the basis of how much our overweight or obese patients may tell us they are eating and exercising, we believe they should be losing weight, but they aren’t. In fact, in this process of expending more energy than they consume, sometimes our patients actually gain weight. Unfortunately, clinicians may conclude—mainly out of frustration—that these patients are not being completely truthful (either with us or themselves) or that all they need is more willpower.” (article here)
As the population ages, few doctors or patients realize that the studies done on weight loss are overwhelmingly done on younger patients. We have very few long term studies on caloric restriction long term on older patients. (review here) If a person happens to be African American, we have almost no information: “African American men were an exclusive sample in only four studies” (out of 1,403). (review here)
The short term studies on weight loss are positive. Almost any diet can work short term: “At 12 months, Weight Watchers participants achieved at least 2.6% greater weight loss than those assigned to control/education. Jenny Craig resulted in at least 4.9% greaterweight loss at 12 months than control/education and counseling. Nutrisystem resulted in at least 3.8% greater weight loss at 3 months than control/education and counseling. Very-low-calorie programs (Health Management Resources, Medifast, and OPTIFAST) resulted in at least 4.0% greater short-term weight loss than counseling, but some attenuation of effect occurred beyond 6 months when reported. Atkins resulted in 0.1% to 2.9% greater weight loss at 12 months than counseling. Results for SlimFast were mixed. We found limited evidence to evaluate adherence or harms for all programs and weight outcomes for other commercial programs.” (review here) This review gives more information than an older review that mentions other commercial programs: “We found studies of eDiets.com, Health Management Resources, Take Off Pounds Sensibly, OPTIFAST, and Weight Watchers. Of 3 randomized, controlled trials of Weight Watchers, the largest reported a loss of 3.2% of initialweight at 2 years. One randomized trial and several case series of medically supervised very-low-calorie diet programs found that patients who completed treatment lost approximately 15% to 25% of initial weight. These programs were associated with high costs, high attrition rates, and a high probability of regaining 50% or more of lost weight in 1 to 2 years. Commercial interventions available over the Internet and organized self-help programs produced minimal weight loss.” (older review here)
Anyone doing the math will realize that after a year of trying a diet, the average person did not lose a dramatic amount of weight. But does the weight loss continue? Unfortunately not. “At 12 months, the 10 RCTs comparing popular diets to usual care revealed that only WW was consistently more efficacious at reducing weight (range of mean changes: -3.5 to -6.0 kg versus -0.8 to -5.4 kg; P<0.05 for 3/4 RCTs). However, the 2 head-to-head RCTs suggest that Atkins (range: -2.1 to -4.7 kg), WW (-3.0 kg), Zone (-1.6 to -3.2 kg), and control (-2.2 kg) all achieved modest long–term weight loss. Twenty-four-month data suggest that weight lost with Atkins or WW is partially regained over time.” (review here)
Adding drugs to the weight loss mix seems to support a small amount of short term weight loss. But that came with “higher frequencies of adverse gastrointestinal events.” (review here)
The reality is that: “Behavioural weight management interventions consistently produce 8-10% reductions in body weight, yet most participants regain weight after treatment ends…” This particular study found that extending the treatment program kept the weight off longer. (Study here)
As a result of frustration, many people are getting gastric surgery, which is seen as a solution for obesity. Few seem to realize that overall surgery will not solve, but only improve (drop the BMI by about 5) obesity. It is also not a solution. A significant proportion of those receiving surgery had to have reoperations or suffered complications. (review here) A recent review of the surgery found that less than 1% of surgical studies followed up on the long term benefits or effects of the surgery. (review here)
Liposuction, the celebrity weight solution, has amazingly little data to support it. The long term effects are that it tends to grow back: “evidence from experimental and clinical studies, which support fat redistribution and compensatory fat growth, as a result of feedback mechanisms, triggered by fat removal” (study here). The reason is that: “Adipose tissue (fat) is considered as an endocrine organ, which is developed in specific depots…” Cutting out part of an organ doesn’t make that organ go away. It causes it to regenerate.
But there may be light at the end of the tunnel. More researchers are beginning to recognize the complexity involved with weight loss. One aspect is that we, like other mammals, may experience seasonal weight fluctuations. Perhaps, just perhaps, Mainers should NOT attempt a diet frenzy with six feet of snow on the ground. Forget New Year! Think about dieting when mud season shows up. (study here, and here)
The true treatment of obesity involves dealing with the complexity, and it cannot be done within the context of a fifteen minute office visit.
“other factors contribute to a patient’s overall health and, therefore, to his or her actual ability to lose weight in a sustainable and healthy way. These factors include:
Psychological stress levels
Quality and amount of sleep
Toxic chemical exposure (for example, alcohol, tobacco, processed foods, caffeine, and pharmaceutical drugs)” (complete abstract here)
So the first step to achieving lifelong weight loss is getting a health care partner who will take the time to go through your history, fears, past failures, and concerns in depth. It’s time to put the care back into healthcare.