Tag Archives: weight loss

Doctors’ Views on Weight and Weight Loss

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Last week was the Cardiometabolic Health Congress, an annual event for which experts from around the world convene in Boston to discuss the latest developments and treatments for cardiometabolic conditions, such as diabetes, high blood pressure, and high cholesterol.

This was my third year attending the conference, and while I found the first two experiences to be largely interesting and pleasant, this time I had moments of anger and disgust so heightened that I occasionally considered getting up and leaving. If I want to fancy myself as having an open mind though I actually have to live it, not just pay the concept lip service and then bolt as soon as a presenter says something with which I disagree. I stayed, listened, and considered what the speakers had to say.

Following this paragraph is my list of key moments from the conference. By default, I was going to group them by disease state, but given the circumstances perhaps it is more appropriate to categorize them by the emotional state they created.

 

INTERESTING

• Gut Microbes A presentation on gut microbes revealed the immense impact they seem to have on body weight. Linda Bacon addresses this topic in Health at Every Size, and I found it interesting to learn more from a professor who made research in this realm the focus of his PhD work. In experiments he did on mice, he found that animals colonized with the microbes of an obese donor developed twice as much body fat as those colonized with microbes from lean donors, even though the recipients consumed the same diets and had the same initial weights and body fat percentages. Gut microbes seem to be so closely related to weight that he said he can predict one’s body mass index based solely on his or her gut microbes with 90% accuracy. He stressed that this is a developing field and nobody knows for sure yet how to take these research findings and clinically apply them.

• Eating Pattern A presenter stressed that overall dietary pattern is what matters for cardiometabolic health and that no individual foods should be considered “good” or “bad,” a point with which Joanne and I completely agree. All-or-nothing approaches may be popular, but balance and moderation are typically the keys to long-term success.

• “Diet can be so rarely effective in maintaining weight loss.” During his presentation, a bariatric surgeon acknowledged, “There is weight regain in every intervention,” even after surgery, and that body fat seems to have a set point just like red blood cells and the liver, both of which will regenerate to their original masses after partial removal. For that reason, he explained, “Diet can be so rarely effective in maintaining weight loss.” We already know this latter point, but it was interesting to hear a doctor say it. He seems to be moving the focus of his surgery away from just weight loss and instead focusing on the metabolic benefits that can occur after bariatric surgery even in the absence of weight change.

• Effects of Sleep Deprivation on Hunger A doctor who specializes in sleep presented research indicating that the risk of developing cardiovascular disease inversely correlates with sleep duration. In other words, the more sleep one gets, the less likely one is to develop cardiovascular disease. He also presented epidemiological data showing that the less sleep people get, the more likely they are to have a higher body mass index. He debunked the theory that people who get less sleep eat more simply because they are awake for a longer duration. Rather, people eat more when deprived of sleep because leptin and ghrelin levels change and increase appetite. His research found that people consume 35 calories/hour more when sleep deprived compared to when they are adequately rested.

 

STARTLING

• Aspiration Therapy A novel bariatric surgery of sorts, known as aspiration therapy, was presented. The procedure involves implantation of a tube through the abdomen and into the stomach, sort of like a PEG tube that is used for nutritional support. In this case, however, the tube is not used to feed the person, but rather to empty the person’s stomach soon after he or she has eaten.

It’s interesting, if I diverted food back outside my body soon after eating in order to keep it from being properly digested and absorbed, I would probably be diagnosed with the serious and sometimes-fatal eating disorder known as bulimia nervosa, but I guess if the behavior is performed via an implanted device and endorsed by a doctor in the name of weight loss then everything is cool, right?

 

DISAPPOINTING

• FDA Oversight On the conference’s second day, the woman sitting at the table next to me struck up a conversation at lunch time. Turns out that she works for the U.S. Food and Drug Administration (FDA) and part of her job is to keep an eye on the messages that drug companies are using to endorse their products. She explained that when she went into the exhibition hall to speak with vendors, she kept secret that she works for the FDA because if she revealed it then the drug company representatives would “shut up” and warn the other reps to keep quiet because the FDA is there. If the drug companies are telling the truth and not doing anything improper, then why do they care that the FDA is present? Reminds me of how I reflexively hit the brake with my lead foot when I spot a police car on the highway.

• “I just push them all to surgery. I don’t know if that’s a good thing.” During a break, I approached one of the doctors who had presented on hypertension and asked her a question about the effect of sodium lost through sweat. The conversation segued to sports nutrition and then ultimately to weight. She brought up the supposed benefits of losing weight for cardiometabolic health, to which I responded by sharing how dismal the odds are of keeping off intentionally-lost weight. While I expected resistance, instead I got agreement. “It’s biology,” she said, “The body is really good at gaining weight, but not very good at losing it.” While I was pleasantly surprised to hear her acknowledgement, this anecdote ends up in my Disappointing category because of what she said next, “I just push them all [my patients] to [bariatric] surgery. I don’t know if that’s a good thing.”

 

FRUSTRATING

•  Success? Two doctors presented on lifestyle interventions for weight loss. Every single graph they presented for each intervention showed sharp initial weight loss followed by slow and steady regain. With the exception of one four-year study, all of the others lasted two years at most. As the study timelines came to a close, the graphs showed that subjects were still regaining weight, yet the presenters called the interventions successful because the subjects weighed less as the studies ended than at baseline. But the subjects’ weight trajectory was still upward; aren’t they at least a little bit curious about what happened to their weight after the studies ended?

Apparently not, for one of the doctors continued, “As long as you keep the diet and exercise going, you will maintain the weight loss.” But we know that is not true! People often regain weight even as they maintain the behaviors that lost it. Even the doctor I mentioned earlier, the one who pushes everybody to bariatric surgery, acknowledges this.

• Medical Recommendation or Disordered Behavior? The presenters advocated people weighing themselves daily, knowing exactly how many calories they are consuming, and burning at least 2,500 calories per week through exercise. They also suggested that people get together in weight-loss groups for the “healthy competition” of inspiring each other to lose more weight. You know, if lean people did these same things we might describe their behaviors as disordered.

The above point reminded me of an excellent piece that Ragen Chastain wrote about how behaviors that are considered dangerous for thinner people are routinely recommended for heavier people. Trying to keep that open mind I mentioned earlier, I thought to myself that plenty of medical interventions exist that would be cause for concern if someone without a warranting condition began to utilize them. For example, if I prick myself with a needle until I bleed people will probably be concerned about my emotional well being, but a diabetic who does the same thing in the name of checking his blood sugar is taking good care of himself.

The crux of the issue, therefore, is whether or not obesity in and of itself is really a disease. Despite all of the evidence to the contrary, much of the medical community still sees it as one so they advocate treatment for it. We could debate obesity’s place as a disease state all day long, but even if it is one, the problem is the “paradigm blindness” that I mentioned in an earlier blog entry: The presumed solution, dieting, actually exacerbates the condition so they keep adding more of the supposed solution to the ever-worsening issue not realizing they are caught in a feedback loop.

• Can’t See the Forest Through the Trees A doctor presented some research that looked at the influence of lifestyle behaviors (eating patterns, physical activity, stress management) on cholesterol and blood pressure. Researchers controlled for weight by screening out subjects whose body weight increased or decreased by more than 3% over the course of the study. They made this decision based on the presumption that excess weight itself is harmful and would confound the data. What the research showed, however, is that the lifestyle interventions themselves improved blood pressure and cholesterol even when no significant weight change took place. I would have thought the researchers would use these results as a basis for reconsidering the generally-held assumption that being overweight/obese is harmful, but interestingly they did not.

 

HORRIFYING

• Yay, Surgery for Everybody! The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for obesity. “Clinicians should offer or refer patients with a body mass index of 30 kg/m2 or higher to intensive, multicomponent interventions.” The presenter who shared this continued that USPSTF’s recommendation is a grade-B level. He was excited because he said that the Affordable Care Act mandates that all grade-A and grade-B recommendations be covered, meaning that the USPSTF’s recommendation opens the door for individuals to receive pharmacotherapy and bariatric surgery based solely on their weight. The presenter continued that he looked forward to a day when everybody with a body mass index over 30 kg/m2 could get bariatric surgery.

And there it is. Ever since obesity was officially declared a disease, I have heard people talk about how this controversial decision was about finances. Although I did not know enough about the decision-making process to have a solid opinion, I always leaned away from conspiracy theories and figured that those involved in the decision had not fully considered the overall body of research. Given this statement though, I must acknowledge that it sure does seem likely money played at least a part, if not a large part, in the decision. While other moments from the conference made me more angry, as you will soon read, no other instant made my stomach drop like this one.

 

INFURIATING

• Is Weight Cycling Funny or What!? One of the presenters who discussed lifestyle interventions for weight loss concluded his presentation with what I guess was supposed to be a joke, “Better to have lost and regained than to never have lost at all.” That offensive and ignorant comment garnered huge laughs from the audience. Weight cycling (“yo-yo dieting”) is associated with everything from diabetes to depression. Hilarious! Association is not causation, but he should have at least acknowledged the potential dangers of weight cycling and shown some respect for the people who have gone through it. Instead, he literally used it as a punch line.

• It’s All About the Money During a break between sessions, I visited the exhibition hall and wandered over to a table where sales reps were pitching a medically-supervised weight-loss program that physicians can license for use in their clinics as a way to make more money. One of the reps told me that the patient’s first visit is with a “salesman” (Yes, that is actually the term he used.) who asks the patient how much weight he or she would like to lose and then tells the patient how many visits and injections he or she will have to receive to achieve it. Injections? Those would be phentermine injections, which the Mayo Clinic cautions, “Phentermine may be a way to kick-start your weight loss. But once you stop taking it, you’re likely to regain the weight you lost . . . . Although phentermine is one of the most commonly prescribed weight-loss medications, it has some potentially serious drawbacks,” and then continues on to list its side effects.

Presumably the program also includes dietary counseling, so I asked the rep who is responsible for helping patients with their eating. “Dietitians are too expensive,” he said, not knowing that I am one myself. He said they recommend using “lower level” workers, like “nutritionalists.” I have never even heard of a nutritionalist and have no idea what one is. So far, everything the rep had told me was about sales and finances, so I asked him about outcomes. He had no data to offer me about how patients fare on the program and said he would email me some, but he never did. The rep could not even anecdotally offer any information regarding results. My impression was that little consideration was given to health and patient welfare in this program that seemed to be all about making money.

• Question Dodging This year, the conference organizers diverted from the normal format of having attendees verbally offer their questions through stationed microphones and instead invited us to submit our questions via text. The last event of the conference was a panel discussion on obesity, so I texted in the following question, “Research compiled by Linda Bacon in her book Health at Every Size and Ellen Glovsky in her book Wellness Not Weight show (1) long-term research that looks at least five years out shows that only 5% of people who intentionally try to lose weight keep it off and 60% of them end up heavier than at baseline (2) research that controls for behaviors indicate that these are better predictors of health than is weight. Given this, ethically how can we be prescribing weight loss to our patients?”

The moderator never presented my question to the panel. I could give him the benefit of the doubt that perhaps a technical glitch kept my question from entering the cue, but I received a reply confirming that they received my text. I could give him the benefit of the doubt that perhaps they ran out of time, but in fact the question-and-answer period ended earlier than scheduled.

Perhaps the moderator did not want to address my question because one of the conference’s industry sponsors is launching an anti-obesity drug that is pending final FDA approval? There I go with conspiracy theories of my own. Perhaps the moderator had a legitimate reason for not fielding my question, but it was hard to escape the feeling that he was dodging it.

 

MADE ME WANT TO THROW SOMETHING

• A Seed Is Planted Fortunately, somebody with a little more clout than myself raised a similar concern. A member of the panel, a bariatric surgeon, interjected the proceedings with a question of his own. “Sometimes we do surgery too much,” he began, and cited obese patients who are metabolically healthy, yet have bariatric surgery anyway. He continued that over the course of the conference, research had been presented indicating that lifestyle interventions that address eating, physical activity, and sleep can improve cardiometabolic health even when no weight loss occurs, that even bariatric surgery can have positive metabolic effects independent of weight loss, and people who are overweight tend to fare better than leaner counterparts when battling certain diseases. Given that, he asked, “Are we overemphasizing weight?”

I heard a couple of chuckles, but otherwise the room went silent. Crickets. Nobody on the panel wanted to touch the question. Sensing the uncomfortable silence, the moderator said we would come back to the question and moved on to other topics. The surgeon reiterated his question, this time rephrasing it so as to suggest that the presumed link between weight and health might be inaccurate. Fellow panel members trickled out answers: The exercise specialist said that excess weight can make movement difficult, the surgeon himself said that surgery can be more challenging in the context of obesity and specifically mentioned transplant operations, and another doctor offered, “Some individuals are genetically predisposed to have more adipose tissue . . .” before trailing off. Another surgeon on the panel, who seemed angered by the question, emphatically called attention to the association between obesity and cardiometabolic disease.

At that, the moderator cut off the discussion and moved on to other questions. There it was, one of the most important questions of the entire conference, a question of which I had tried to raise a different permutation myself without success, offered by an open-minded panel member, yet the moderator quickly dismissed it before it received the full attention that it deserved. I found myself literally shaking my head at the missed opportunity.

The upside though is that at least the question was raised. Even if it did not receive a proper discussion in response this time around, the seed was planted, and in that action exists the potential for growth.

Preaching Beyond the Choir

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“A lot of people have anti-racist groups. They get together and meet and have a diverse group and all they do and sit around and talk about how bad discrimination is. Then someone says ‘there’s a Klan group across town. Why don’t we invite them to come and talk to us?’ and the other person says ‘Oh no! We don’t want that guy here!’ Well, you’re doing the exact same thing they are. What’s the purpose of meeting with each other when we already agree? Find someone who disagrees and invite them to your table.”

– Daryl Davis

Joanne and I certainly have company among many practitioners across the globe who have abandoned weight-centered models of care for health-centered approaches. We congregate virtually in communities like Health at Every Size® and the Association for Size Diversity and Health. While these resources are important for building support and sharing best practices, we run the risk of only preaching to the choir if we confine our communications to people who are already on the same page as us.

Many practitioners and activists, like Ragen Chastain, Aaron Flores, Ellen Glovsky, Kerry Beake, and Linda Bacon, just to name a small handful, have been putting themselves out there, subjecting themselves to everything from ridicule to blatant hate, as they share research and perspectives that run counter to widely-held beliefs about weight and health.

As for me, while I do not consider myself part of any sort of crusade and prefer to influence change on a one-on-one basis with the patients who come to meet with me, I increasingly feel an obligation to step up to the plate when opportunities to share my perspective arise. Silence is easier, but I fear that it comes across as support for the status quo, so in essence my passivity makes me part of the problem. I need to change that.

A sales rep emailed me in August trying to get me to use his company’s product at our practice. He made some statements about weight that sounded ridiculous, but I ignored his email. In September, he emailed me a second time, and once again I did not write back. When he emailed me for a third time last week, my conscience compelled me to engage him in conversation and confront him about his statements. An email exchange ensued. Following are some excerpts.

Sales rep: “Take a moment to consider all that you can do with [product name] as your tool. You are given a list of the top 5 foods in 7 different categories that will allow an individual to reach their goals the faster than any other foods. This means losing 6 lbs a week and not 2 lbs. Or gaining 5 lbs a muscle the first month of training, instead of a mediocre 3 lbs. If your clients were able to see this amount of increased results and you were able to make more money in the process, don’t you think you would be interested?”

The underlined passage, which I underlined for emphasis, set off my BS alarm.

Me: “Thank you for your email; however, our businesses seem to be on different pages so I do not envision us working together. If you have any research to support the claims that [company name] is making I would be interested in taking a look at it.”

Sales rep: “I would be happy to provide you with literature on the claims our diet plans make if you would like. We have scraped from thousands of published articles.  Is there any specific topic that would be of interest to you?”

Honestly, at this point I was fairly certain that no such research existed, as I probably would have heard about it by now if it did, but I wanted to keep an open mind, and I also felt like this guy was George Costanza lying about a house in the Hamptons and I wanted to see how far he would go.

Me: “Thanks for your email. In your previous email, you talked about weight loss/gain results with [product name] versus without it. I’d love to take a look at that research.”

Sales rep: “Well as you know, weight loss and weight gain is majorly dependent on the amount of Calories consumer and burned over a given amount of time. What we have done is scraped many articles that claim increased weight loss or weight gain when matching a SNP to a certain macronutient profile of a food. We have also analyzed research that observed increased energy levels and increased activity levels in people who ate a majority of the food we recommend. If you’re referring to clinical trials where [product name] users and blinds are closely observed over a period time, we have not conducted a controlled study. One reason being the difficulty that diet research usually has with compliance. The second reason is we believe we can access enough data from the people using [product name] and we will be able to quantify all our results. I personally have lost over 30 lbs in the last 2 months since I started to flow a [product name] approved diet plan.”

Did you catch that? Despite the specific claims that he previously made about the weight-change results that his company’s product supposedly creates and despite his offer to provide me with the research to back up said claims, when pressed he admitted to having no such research.

Me: “Thanks, I appreciate the explanation. It is important for us to remember though that losing weight is relatively easy. Virtually any kind of restriction will create it. Data presented at last year’s Cardiometabolic Health Congress, for example, compared the results of over 20 different diets and showed that all of them resulted in the same weight loss pattern. The problem though is that all of them also resulted in the same weight regain pattern as well. Most studies that look at weight loss only look at the short term, but those that look at least five years out show that approximately 95% of people regain the lost weight and most of them end up heavier than they were at baseline. Sure, some of that is due to people not maintaining the behaviors that created the weight loss, but what I find very interesting is that many of the people who do maintain the behaviors experience weight regain as well. My clinical experience mirrors what the research indicates, as I have certainly had individuals who are so frustrated because they are working so hard to keep off lost weight, and yet it slowly creeps back on. For all of those reasons, we take the focus off of weight and instead focus on behaviors, which research shows are better predictors of health outcomes than weight anyway. Although the public is generally still hyperfocused on weight, we are seeing a slow shift in the medical community away from a weight-centered model of care to a health-centered model of care as more and more practitioners are becoming aware of the research.”

Sales rep:

That’s right, he did not write back, at least not yet. For the sake of fairness and completion, I will update this entry if and when he responds, although I am not holding my breath waiting for a reply. Most likely, he crossed me off his list when he realized he would not get any business from me and he has moved on to other sales leads without giving my latest email a second thought.

On the other hand, perhaps – even for a brief moment – I got him to rethink his stance and consider another point of view. Either way, at least I did not exacerbate the problem by staying silent.

He Said, She Said: Halloween Candy

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He Said

Halloween is when I first learned the meaning of the word “nauseous.” After returning home from trick or treating, I sat at the kitchen table eating candy until I no longer felt well. “Do you feel nauseous?” my mom asked. A loose definition formed in my childhood mind: Nauseous (adjective): Feeling completely gross from eating too much Halloween candy.

My brother, in contrast, always paced himself. While I blew through my own candy in a few days tops, he made his candy last for weeks, if not months. Eventually I realized that eating small amounts of candy at a time not only spared me from feeling nauseous, but the candy lasted longer. Preservation became fun, and at some point I started freezing candy. As springtime flowers bloomed, I would be eating last fall’s frozen Snickers.

Upon returning home from trick or treating, my brother and I dumped out our candy sacks, sorted our bounties into piles by kinds of candies, and traded with each other so we each had our favorites. In order to make our trades with each other, we each needed a foundational hierarchy of our candy likes and dislikes so we each knew which pieces we wished to keep and obtain more of and which ones we hoped to trade. In other words, we had to mindfully eat our candy in order to assess enjoyment.

Halloween and its associated candy provide opportunities for children to build their relationships with food. The healthiest relationships are built on a foundation of internal-cue recognitions and responses: having the ability to not only ask ourselves questions like “Am I hungry?” “How hungry am I?” and “What is it that I really want?” but more importantly, to be in touch with our bodies enough to be able to appropriately answer.

Building these skills involves trial and error. As I did on that Halloween so long ago, sometimes kids overeat and regret it. Sometimes they burn through their stash too quickly, not even truly enjoying a large portion of it, and wish they had conserved some for later. It is through these and similar lessons that we build the intuitive-eating skills that can serve us so well throughout our lives.

The alternative is to regulate children’s candy experience for them by forcing or coercing them to donate, trade, or throw out all or some of their candy, or by rationing the candy for them. Using external cues to regulate our eating may seem to work in the short term, but in the long run the approach almost always fails us. One particular patient comes to mind, a teenage girl who ignores her body’s hunger signals and eats according to the commands of an app. She tells me that she does not trust herself to listen to her body and that obeying the app is already “ingrained” in her. I think of the countless adults who sit across the table from me, fold their arms, lean back, and say, “Just tell me what to eat,” because for most of their lives they have been taught that they cannot trust themselves.

Well-intentioned parents want to help, but the assistance is often misplaced. Help your children to build their relationships with food by giving them the freedom to manage their Halloween candy themselves. Consider prompting your children to ask themselves how hungry they are and what do they really want before the eating begins, but not in a leading or coercive way. Give them the space to answer honestly and to follow up their candy experiences with more candid questions: “How full am I?” “How am I feeling now?” “How did I enjoy it?” and “What, if anything, would I do differently next time I have candy?” Give them the freedom to make mistakes and learn through experience, for it is partly through these lessons that we build healthy relationships with food.

 

She Said

The other day, Jonah told me about a local news story he had seen about a bunch of people who are now going to put signs on their front doors proclaiming that they are a “candy-free” house and that, as such, they will not be handing out any candy on Halloween this year. Instead, these individuals will be handing out small toys to the youngsters who come trick-or-treating to their door. Of course, the intention of these individuals is to not promote the “obesity epidemic” by handing out sugary treats to little ones.

The first thing that came to my mind about Halloween candy and kids was, “What would Ellyn Satter say?” Ellyn is a registered dietitian and eating specialist focusing primarily on children. She has written a number of pivotal books about how to feed children and how to prevent and/or help rectify problematic eating early on to promote a healthy relationship with food in years to come.

As luck would have it, Ellyn wrote an article in 2008 about the topic of Halloween candy and kids. In her opinion, she believes that Halloween candy should be treated the same way other sweets are treated and that the child needs to learn how to manage his sweets and how to “keep sweets in proportion to the other food he eats.” She cites a 2003 research study that found that girls that were “treat-deprived” (i.e., were restricted by their mothers in particular around treats and sweets) were more likely to overeat forbidden foods even if they weren’t hungry. Conversely, the study found that girls that were allowed treats on a regular basis ate them moderately and sometimes not at all.

Given the above study, Ellyn’s advice is to use Halloween candy as a “learning opportunity,” in which the child should work toward being able to manage his or her candy stash with minimal interference by the parent. What does that look like? Well, she would suggest that upon returning from trick-or-treating, the parent should let the child “lay out his booty” of Halloween candy, sort it out, and “eat as much of it as he wants.” After letting the child do this on the evening of Halloween and the next day, the child should put away the rest of the candy, and it will then be “relegated to meal- and snack-time: a couple of small pieces at meals for dessert and as much as he wants for snack time.” She goes on to say that “if [the child] can follow the rules, he gets to keep control of the stash. Otherwise [the parent does], on the assumption that as soon as the child can manage it, he gets to keep it.” Finally, she recommends offering milk with the candy to make sure the child is getting some good nutrition.

Now, when I first read the above, I found my inner skeptic coming up front and center. How could one possibly trust that his or her child could regulate his or her sweets intake? Isn’t that the parent’s job? Otherwise, wouldn’t we have a bunch of little kids gorging themselves on any sweets they could get their hands on? What’s next? Letting kids start drinking at a young age to help them learn to do so moderately as adults? It all sounded a bit too much to me.

But the more I thought about it, the more it made sense. By taking the taboo off sweets and treats, kids will be less likely to overdo it when they are faced with them. I have a colleague who regularly has a rotation of sweet treats and salty snacks in her house and does not limit her kids around this. What ends up happening, she says, is that her kids don’t see these foods as “off-limits” and therefore not so tempting. They know that if they want these foods, they can have them, but since they are always available, the forbiddenness is no longer an issue, and they eat them in moderation or sometimes not at all.

So what’s the take-home message from the above? Restricting sweets and treats can lead kids (and adults) to view these foods as “forbidden” and then when faced with them, they will find themselves overdoing it on these foods even if they aren’t hungry or in the mood for them. By incorporating these types of foods into one’s meals and snacks on a regular basis, they become less charged, and the individual will view them simply as part of their diet, not as forbidden fruit.

What is weight loss really about?

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We know that the long-term success rate of weight-loss attempts is poor, yet patients often act like their reasons for wanting to lose weight are so justifiable that the odds should change just for them, as if I hold some magic solution that I keep secret and only break out when somebody gives me a really good reason to do so.

Attaining the ability to fly like a bird would sure make my life easier. No more getting stuck in traffic, spewing environmentally-harmful emissions, or spending money on gas, and perhaps I could save money on a gym membership since my physical activity would be built naturally into my daily commute. All good and valid reasons, but still the chances of me acquiring a superpower are probably not very high.

Whenever a patient tells me he or she wishes to lose weight I always ask why, but not so he or she can build a compelling case that somehow changes the dismal odds, but rather so we can find alternative paths to achieving the underlying goals.

If someone says, “I need to lose weight because I have hypertension (or high cholesterol, or high blood sugar, etc.)” I suggest we explore more effective ways of directly addressing those markers. One particular person comes to mind, a woman who had been dealing with high blood pressure and elevated cholesterol for most of her adult life, who had gone from diet to diet trying to finally achieve the long-term weight loss she had desired since her teen years. Ultimately, when she gave up that weight-centered model of care, and instead focused on improving her relationship with food and finding modes of physical activity that were enjoyable rather than punishing, both her cholesterol and blood pressure improved even as her weight actually increased.

One of my long-term patients talks about how he feels bad about himself and his appearance. He is afraid to take off his shirt at the beach for fear that he will disgust other people and himself. In my experiences, patients who link their weight to how they feel about themselves only sometimes feel better when the weight drops. Oftentimes, someone reaches his or her goal weight and then expresses a desire to lose more because the negative feelings did not dissipate with the weight lost to date.

The weight is really not the issue, but rather just the vehicle through which emotional complexities are playing out. Even for those who do feel better about themselves when the weight drops, we know that almost all weight loss is only temporary so what happens when the weight comes back? Although this particular patient does not feel ready to go yet, I have been gently encouraging him to see a therapist to work on his body image and self-esteem. For his sake, I hope that someday he learns that one need not have a certain body shape or size to feel good about oneself.

Earlier this year, a man came to me saying he wanted to lose weight in order to complete a marathon. I explained that if he chose to continue working with me, I would help him change his eating to run his best, and as a result of said eating changes he may or may not experience a change in his weight, but that I would not be directly helping him to lose weight. Skeptical, he made some condescending and rude remarks, left, and never returned. Weight and running performance are not synonymous. In fact, I ran my fastest marathon when I was at my heaviest. If someone wants to improve sports performance, then let us focus directly on that and put issues of weight aside.

Our reasons for wanting to lose weight and the importance of said reasons do not dramatically impact our ability to achieve it, but by looking deeper at our motivations to lose weight, we can move beyond focusing on weight and more effectively target the underlying goals. For example, I may never attain the ability to fly, but you know what I could do that would satisfy all of my reasons for wanting to do so? Ride my bike.

“Weight that will stay off”

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TextThe above text exchange appeared in my Facebook feed, placed there by a personal trainer (whose name I blacked out from the image) who shared it to promote his business, a testimony to his prowess and the results he can bring to his clients who are seeking to lose weight.

Let’s talk about results. Losing weight is relatively easy and numerous paths to weight loss exist. Keeping off the lost weight, well, that is a completely different story. Research shows us that about 95% of people who try to lose weight will ultimately regain it (whether or not they maintain the behaviors that created the weight loss in the first place) and of that 95%, 60% of them will end up heavier than they were at baseline.

Said differently, if 100 people intentionally lose weight, five of them will keep it off, 38 of them will return to baseline, and 57 of them will end up heavier than when they started.

These facts may not be talked about very much in our weight-loss-obsessed society, but they are no secret. At the 2013 Cardiometabolic Health Congress, data were presented showing that this pattern of weight loss and subsequent regain was virtually identical regardless of the mode somebody used to lose it. That is why some people in the healthcare field say that the best way to gain weight is to go on a diet.

So when the trainer refers to his client’s 10 pounds of lost weight as “Weight that will stay off,” on what is he basing that claim? Based on the research, if he says something like that to 20 of his clients, 19 times he will be wrong. Not only is he misleading people with false promises and expectations, but he is putting them at high risk for weight cycling and the negative consequences with which it is associated.

Chances are better than not that the client in question will eventually regain the 10 pounds he or she lost plus more. What will the text exchange between the trainer and client look like then?

The sad thing is that I think the trainer in question is actually a good trainer in terms of the mechanics of his profession. He just needs to be more careful about the lessons he is teaching his clients. Had he responded to his client’s text with a sentiment along the lines of, “Losing weight feels important to you right now, but let’s remember that being physically active is doing wonders for your health and well-being regardless of what happens with your weight,” I would not be writing this blog.

Weight Loss Specialist

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“Luck is the last dying wish of those who want to believe that winning can happen by accident. Sweat is for those who know it’s a choice.”

Suggesting that achieving our goals is up to us if only we work hard enough sounds motivating on the surface, but really it makes no sense. So, what, the 99.2% of players in the U.S. Open main draws who walked away without a title did not realize all they had to do was work hard and choose to win? Outcomes that rely on factors beyond our control breaking our way are not automatically there for the taking if only we put our mind to it.

Where that quote originally comes from is not clear to me, but I know I first heard it from a personal trainer who cites it as one of his favorite quotes. According to said trainer’s Facebook page, he now employs a certified “Weight Loss Specialist.” Awesome.

Here is the problem: If a supposed specialist is giving you the information you supposedly need to lose weight, and achieving your goal is framed as a choice that is entirely in your control and can be attained through hard work, and you do not achieve your weight-loss goal, then who is to blame?

You.

If we mislead people into believing that weight loss is entirely up to them and they do not achieve (or more likely maintain) it, they typically turn their frustration and disappointment on themselves with berating thoughts like, “I have no willpower,” “I need to be more disciplined,” “I’m such a loser,” and “I just need to work harder next time.”

Behaviors that in and of themselves were beneficial to health independent of weight loss, such as being physically active or eating fruits and vegetables, are abandoned because they did not lead to weight loss. Restriction gets taken up a notch. They pursue an even more rigid diet and/or intense exercise regimen, not realizing that these behaviors themselves can make weight increase and/or lead to health issues. A colleague of mine calls it “paradigm blindness.” In other words, many people do not realize that their presumed solution to being “overweight” actually exacerbates the condition, so they keep adding more of the supposed solution to the ever-worsening issue.

I used to help (and I use that verb loosely, as I was actually part of the problem even as I thought I was part of the solution) people with weight loss earlier in my career too, but that was before I knew better.

Well-constructed research, my clinical experience, and the experiences of many of my fellow dietitians teach us that weight loss is typically not in one’s control. Sure, our behaviors do matter, but other factors, such as genetics, environment, medical conditions, and personal history, are either partially or completely out of our hands.

The paradox is that any true “Weight Loss Specialist” would know that nobody by that title actually exists. Healthcare practitioners are supposed to help people with, you know, health, which is why Joanne and I take the focus off of weight and instead focus on behaviors that can actually make a difference.

He Said, She Said: Protein

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He Said

Most Americans get more than enough protein. Dietitians think about protein needs in terms of grams of protein per kilogram of body weight (g/kg). For the average person, 0.8 to 1.0 g/kg is perfectly adequate. For a 160-pound individual, this translates to a range of 58 to 73 grams per day of protein. Someone who is extremely active or has elevated protein needs due to a medical condition, such as recovery from surgery, may need more in the range of 1.2 to 1.5 g/kg. Those of us who suffer the misfortune of life-threatening traumas, infections, and burns need upwards of 2.0 to 3.0 g/kg as our bodies fight to survive and rebuild themselves. Under these circumstances, my example of a 160-pound person would need 146 to 219 grams per day during recovery.

So why is it then that we routinely see patients who are feeding themselves as much protein as a hospitalized third-degree burn victim? Among the multiple reasons, the most significant seems to be misinformation that spreads rapidly in our weight-centered society. Those of you who are my age or older have been around long enough to remember the low-fat fad that passed through a couple of decades ago. Just like fat phobia, today’s high-protein craze is based less on science and more on fear and a desperate feeling to grab hold of something, anything, that might be an answer to weight control. Accuracy of said answer is a distant concern.

An excessive protein intake comes at a cost. If we are consuming too much protein, only two possible scenarios exist: (1) We are consuming too few of other nutrients in order to make room for the protein, so we face the risks associated with inadequate intakes of other necessary nutrients. (2) We are still consuming adequate amounts of other nutrients, which means our overall caloric intake is excessive, and we have to deal with the ramifications of taking in more energy than our bodies need. Joanne offers additional concerns in her She Said section below.

When my patients work on building their intuitive-eating skills, oftentimes they discover that they feel better (i.e., greater energy, more regular bowel function, happier mood, etc.) when their protein intakes decrease to the recommended ranges in order to create appropriate room for healthy carbohydrates and fats.

 

She Said

In my work with those struggling with eating disorders, it seems as if protein can do no wrong. Nine times out of 10, my patients find protein to be much more benign than carbohydrate or fat. It is not unusual for a patient to report to me that all she has been eating is vegetables, some fruit, and egg whites/cottage cheese/boneless, skinless chicken breast/fish, while steering clear of bread, sweets, oils, and butter. When posed with the question about why she is avoiding the other macronutrients, the fallback answer is, “Well, protein is healthy for you, and carbs and fats will make me fat, so I don’t eat them.”

The logic behind this assumption is flawed for a few reasons. First, while it is possible to gain weight if one eats too much carbohydrate or fat, the same could be said for protein as well. Excess calories from any macronutrient will result in weight gain (to varying degrees). 500 extra calories of protein equal 500 extra calories of carbohydrate equal 500 extra calories of fat. It doesn’t matter a whole lot where those calories are coming from: If your body doesn’t need that extra fuel, it will store it.

Second, by eschewing carbohydrates and fats, one is losing out on a ton of nutrients. For example, fat-soluble vitamins A, D, E, and K are virtually impossible to absorb if they aren’t eaten in the presence of fat. This means that all of that vitamin A found in your carrots and all of that vitamin K found in your dark leafy greens will pass right through you if you don’t eat them with fat (like that found in salad dressing). Carbohydrates are also a gold mine of nutrients: Whole grains found in many breads, crackers and pastas provide fiber to keep us regular and can help manage our cholesterol levels. Carbohydrates are also the building blocks of serotonin, a neurotransmitter in the brain that is responsible for feelings of well-being and happiness. Protein can’t do any of the above by itself.

Finally, there is such a thing as too much protein. In general, it is recommended that healthy adults take in 0.8-1.0 grams of protein per kilogram of body weight. That translates to approximately 67 grams per day for an average man and 57 grams per day for an average woman. Most Americans get more than enough protein in their diets without cutting back on carbohydrates or fats. What does a typical day of protein intake look like? Well, let’s say you have two scrambled eggs for breakfast – there’s 12 grams of protein already. For lunch, you have a turkey and cheese sandwich – there’s another 32 grams of protein. Dinnertime is fish with veggies – another 25 grams of protein. That amounts to 69 grams of protein, which is more than enough. Many of my patients will confess to having double or sometimes even triple that amount, which is troubling. Excess intake of protein can take a serious toll on your kidneys, as they will work overtime to filter out the byproducts of protein breakdown. What could that mean? Kidney failure.

Protein is a valuable nutrient, to be sure. But overdoing it on any one macronutrient is not only potentially harmful to one’s body; one could be missing out on many other nutrients from other sources.

ASDAH, Please Reconsider the ®

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Our practice was using the Health at Every Size® (HAES®) model before I even knew it went by that name. My personal and academic backgrounds, the legitimate research I had read, and my clinical experience all pointed towards a health-centered, rather than a weight-centered, model of care.

Earlier this year, we learned about the Association for Size Diversity and Health (ASDAH) from Green Mountain at Fox Run, a program to which a colleague had pointed us. Because we happened to agree with everything we knew about the association, we became proud members. Then I discovered one point on which our opinions differ: the requirement that the ® symbol must follow mention of the HAES® approach.

I understand the advantage of having a title for our approach. By naming it, we can succinctly communicate in a universally-understood fashion how we go about our work, find like-minded individuals in online communities, and separate ourselves from others who take a different approach to health. Entitling different approaches has precedent, just as labels like cognitive-behavioral, interpersonal, humanistic, and psychodynamic denote different techniques that fall under the umbrella of psychotherapy. Notice, however, that none of these names have an ® attached.

Know who does use the ®? PointsPlus®, Nutrisystem®, Medifast®, FirstLine Therapy®, Atkins®, HMR®, and similar ilk. By including the ®, we take the HAES® approach out of the realm of legitimate, evidence-based models of healthcare and put it smack in the middle of gimmicky programs that sacrifice health for money. Call it guilt by association; in essence, the HAES® community loses credibility because of the company we are inadvertently choosing to keep.

Concern and confusion lies on both sides of the counseling room. From the patients’ perspective, the ® makes some of them feel like they are being sold a program, as if their practitioners are nothing more than local distributors for a product so standardized it bares no discernible differences if bought on one side of the world or the other. From my perspective as a practitioner, I have chosen to align myself with ASDAH because of our common approach to healthcare, but at the same time we are separate entities with neither one of us speaking for the other. In that sense, the ® feels like a threat to my professional independence.

Because of the ® and the concerns and confusion that it brings, I stay away from using the term HAES® on our website. Instead, we have come up with our own synonymous language to convey the same concept. In doing so though, we lose the universal recognition of the HAES® name and its associated benefits. How nice it would be to able to write HAES and just leave it at that.

If my understanding is correct, the founding members of ASDAH took a great deal of professional risk by going against widely-held beliefs, building the association, and formalizing the HAES® approach. For everything they did, they have my gratitude and admiration. However, just because ASDAH can require the ® does not mean it should. There is a better approach, a solution that will convey the same meaning yet decrease patient confusion and increase practitioner credibility: Drop the ® requirement.

Physical Activity: So Much More Than Burning Calories

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“Just finished a seven-mile run – definitely earned the right to splurge at the party tonight!”

“I play tennis six times per week to keep my weight in check and to be able to eat what I want.”

“Just gorged at my friend’s Fourth of July cookout – looks like I will need to hit the gym extra hard to burn all those calories off!”

The above are just some of the comments I have either seen posted on Facebook or heard in conversation over the past few weeks. While these types of comments are quite common and universally agreed upon, I have a problem with them for a few reasons.

There is an abundance of evidence that exercise improves one’s health. It not only has been proven to improve blood pressure, blood lipid profiles, inflammation, and heart health in general, it has also been found to help the processing of glucose and insulin as well. But despite all of these positive findings, there is very little scientific evidence that exercise is an effective way to control weight and that exercise by itself does not have as much of an impact on our metabolism as most people think it does.

In one study, a group of volunteers from a hunting and gathering tribe in Tanzania were studied to see if there was a link between their activity levels and the number of calories they burned in a day. While it was true that the tribe members were much more active than the average American, walking about 7 miles per day on average, their metabolic rates were about the same as the average metabolic rate for Westerners. That means that despite the fact that the tribe members were doing significantly more physical activity than Westerners, they were burning the same number of calories as Westerners. Their increased activity did not mean they burned more calories.

Aside from the problematic idea about using exercise as a weight control mechanism, the bigger problem I have is the common belief that exercise’s only benefit is to burn calories. I know so many people who run regularly, not because they love to run, but rather because they are repenting for their dietary “sins.” Whatever happened to being physically active because we enjoy the way it makes us feel? Whatever happened to playing a friendly game of pick-up basketball for the sheer fun of it? Or jumping into the pool on a hot summer day to cool off and splash around? So many of us view exercise as a way to punish our bodies into submission rather than as a way to feel more alive and appreciate what our bodies can do.

How about we start using physical activity as a way to connect with our bodies and enjoy what they can do for us? How about engaging in exercise as a way to improve our health and help our bodies to function at their best? Or taking up a sport for the thrill of the game? The benefits of physical activity are so much more than simply burning off last night’s nachos. And no one needs to “earn” the right to eat what he or she wants. That is no way to live life.

The Real You Is Sexy

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Aerie, the lingerie branch of American Eagle, is going with a “The Real You Is Sexy” campaign for their spring line.  My understanding is that the ads are not retouched in any way and show the models just as they were when the photographers took their pictures.  Aerie deserves credit for this move, but this change alone does not fix the underlying problem.  The greater problem is with us, not the fashion industry.

Reality is more complex than I am about to make it seem, but the basic premise is that we compare ourselves to models, feel pressure to look like them, feel bad about ourselves for not looking like them, and adopt certain behaviors – healthy or not – in an effort to match them.  Other advertisement campaigns that do retouch photos can dramatically alter a model’s appearance making him or her seem flawless.  When such a picture is held up as the ideal, we are comparing ourselves to someone who does not even exist.  As such, who can possibly live up to that standard?  Aerie deserves credit for at least removing this as a factor from the equation.

The larger problem though is that we compare our bodies to others in the first place, and that is not going to go away even if the fashion industry completely does away with retouching.  For example, I work with a patient who watches women leaner than herself pass by in town and feels bad about herself as a result.  No retouching there; she is comparing herself to people she sees with her own eyes.

We do not know what somebody does to look a certain way.  I do not know any of the Aerie models and I have no idea what they do to maintain their looks, but chances are neither do you.  They might look the way they do because they are genetically predisposed to have that figure and on top of it take excellent care of themselves.  On the other hand, they could also look that way due to eating disorders, overexercise, or other unhealthy behaviors.  One of my patients, a former model who is working to overcome anorexia, tells me of the pressure in the industry to gain a certain look at any costs, healthy or not.  If a model gets his or her frame through an eating disorder, are we really to look up to that image as an ideal just because there is no retouching involved?  In that sense, we still should not be using models – retouched or not – for a point of comparison.   

To further the point, we should not be comparing our bodies to anybody else either.  I discussed with my patient, the one who compared herself to other women in town, that we have no idea what those women do to maintain their looks.  Some of them are probably perfectly healthy, while others might struggle with eating disorders or other unhealthy behaviors.  Some of them are deeply unhappy and live rigid lives in isolation so they can do exactly what they need to do in order to maintain their physiques.  Some of them would laugh if they knew other people look up to them because no matter how great somebody else says they look, they still hate their bodies themselves.  I know all of this because I just described patients of mine.  These problems are much more prevalent than one might think.

It is time to stop comparing our bodies to others.  Weight, waist-to-hip ratio, and other anthropometric measurements do not define us and should not determine our self-worth.  Love and accept yourself the way you are now, not X pounds from now, and focus on leading a healthy lifestyle built on a foundation of balance.