He Said, She Said: Weight Management

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Weight concerns are one of the main opportunities for improvement that bring people to our practice. Our approach may ring true for you or elicit skepticism.  Either way, we invite you to share your reactions and questions on our Facebook page.  Also feel free to contact us directly if you prefer to voice your questions in private.

He Said

“Weight Management.”  According to my business cards, that’s what I do.  Because weight is such a loaded term that quickly brings to mind so many thoughts, feelings, and expectations, coming up with concise language that accurately reflects my approach is a challenge that I am still trying to settle.

Indeed I do help with weight management, but not in the direct fashion that some people might expect.  We know from working with patients, collaborating with our colleagues, and reading the research that weight-centered approaches to losing weight almost always fail.  That’s the irony: The more we emphasize and focus on weight, the harder it tends to be to keep weight off.

This fact is hardly a secret.  In October, I wrote about a conference I attended where presenters showed that over 20 diets resulted in the same pattern of weight change: sharp initial weight loss followed by gradual and steady weight regain.  A few years back, I had a telephone interview with a commercial weight-loss program that was interested in hiring me.  A study they had posted on their own website showed that approximately 85% (I forget the exact number.) of their clients regained their lost weight after one year, so I asked the interviewer what strategies they had developed since that study to help prevent this rebound.  She said they realized that clients are unable to successfully transition off of the commercial meal replacements and must stay on them for life.  This is very similar to the diet drugs on the market, which also must be taken for life or else the weight will come back, as well as commercial weight-loss programs where leaders tell clients they should be prepared to be lifetime members if they want to keep the weight off.  Sounds like a great business strategy.  As you can imagine, I did not get the job, which was fine by me.  Philosophically, we were not a good fit.

It may come as a surprise to learn that the healthcare community is still uncertain to what degree weight in and of itself matters in terms of health.  The folks who officially declared obesity a disease state this past summer can cite research supporting their view.  The “Health at Every Size® supporters, who argue that health and body weight are independent, have supportive research as well.  Personally, I have been talking about the concept of “Health at Every Size” for a decade, long before it even had that label.  As a guy whose BMI labeled me as overweight despite a very low body fat percentage, excellent labs, and solid athletic capabilities, I could see firsthand that weight was not necessarily a good indicator of health.  Lest you think that the unimportance of body weight is a fringe theory or an excuse that overweight individuals use to stay that way, my energy metabolism professor, a lean and athletic guy himself, taught us the same concept back when I was studying nutrition at a large state university.

Clearly, there is still much that we need to understand about how important weight is when it comes to our health, but how much does this question even matter?  On one hand, determining the importance of weight is of course important from a public health standpoint.  In order to best help people be healthy, we need to understand the factors at play as well as their roles.

Speaking pragmatically, however, the importance of weight is largely irrelevant.  We know from epidemiological data that overweight and obesity have become more prevalent, not more scarce, over the years.  Closer to home, even if you have not tried to lose weight and keep it off through various permutations of food restriction and/or overexercise without long-term success, you at least know several people who have.  When Joanne and I listen to our new patients share their histories, tales of weight lost and regained are par for the course.  Society as a whole has been acting under the assumption for decades that weight matters, yet this assumption has not helped us to get any thinner.  In fact, quite the opposite is true.

If we remember that weight-centered approaches almost always fail, the only alternative is lifestyle change.  Even more radical approaches, such as bariatric surgery and lifetime medications, have to be coupled with lifestyle change in order to be effective.  There is just no getting away from it.  Whether weight matters or not, or whether somebody wants to undergo a radical approach or not, the bottom line is that lifestyle change is still necessary in order to improve health.

What constitutes healthy lifestyle change is based more upon one’s baseline than it is on some idealistic vision of what one should be doing in theory.  The efforts and constructs of lifestyle change are usually limited by other factors (e.g. time, finances, personal preferences, etc.) rather than by guidelines, so in a sense guidelines do not even matter all that much when it comes to helping people in real life.  The idea is just to start wherever you are and move towards better health one small step at a time. 

More specifically, instead of gravitating towards a particular mode of exercise because it burns the most calories per unit of time, find ways of being physically active that are fun and agree with your body.  You will be happier and more likely to make the activities long-term habits.  Instead of counting grams and calories, restricting your intake, and cutting out whatever food group is being scapegoated this week, learn to eat mindfully and listen to your body’s hunger/fullness cues.

As a result of these changes, weight loss does oftentimes occur, and when it does, it tends to stay off, but it may or may not be the magnitude that you, your friends, your parents, your partner, a BMI chart, society as a whole, etc. would like.  Therefore, part of establishing a healthy lifestyle means learning to love and accept yourself the way that you are and severing any link you may have between weight and self-worth.

It is really about putting forth your best effort to be healthy while still maintaining balance in your life.  This is what I help people to do; that is what I mean by “Weight Management.”

She Said

Well, we are closing in on the end of 2013. Inevitably, after the ball has dropped and the New Year’s celebration has ended, many people start to think about their New Year’s resolutions.  What’s at the top of the list for most people?  Weight loss.  Every January we become inundated with new patients looking to us for help with their weight goals. Most of them have tried every diet and eating program in the book (losing and regaining many pounds in the process), but they are certain that this time things will be different. This time I will find the perfect diet, most people think to themselves.  This time I will have more willpower, and I will lose the weight for good!

I truly understand why so many people want to lose weight.  Every day we are bombarded by messages about our weight. Whether it is from doctors, the media, family, friends or partners, the message seems to be that it is desirable to be thin and it is bad to be fat.  Those who try to lose weight through dieting are to be admired, while those who are fed up with diets are viewed as weak-willed and lazy.  Fat is not only disliked but also feared.  According to a 2006 study by the Rudd Center for Food Policy and Obesity at Yale University, nearly 50% of the 4,000 people surveyed said they would rather give up a year of their life than be fat.  The same study found that 15-30% of the respondents would rather become unable to conceive, be depressed or become alcoholic than be obese. 5% would rather lose a limb. 4% would rather be blind.

Given most people’s dislike and, in some cases, fear of fat, it makes sense that weight loss is on the forefront of many of our patients’ minds.  But as much as I understand our patients’ feelings, focusing all of our energy on losing weight and fighting obesity by dieting restrictively and exercising excessively hasn’t helped anyone reach and maintain their goals.  I mean, if these methods really worked, would we still have a billion dollar weight-loss industry?  Of course not.

It is time to take the focus off of weight and put it on health.  As I’ve blogged about many times before, health and weight are not synonymous.  Numerous studies have shown that when talking about health, it is lifestyle behaviors that make the difference, not just weight loss.  When patients come into my office with the sole goal of losing weight, I try to help them shift their view to one that is health-focused rather than weight-focused.  By implementing healthy lifestyle changes such as eating intuitively, being more physically active, and dealing with stress appropriately, one’s weight will often settle into a “healthy weight range.”  This weight range might not be what the media or the BMI chart says is desirable, but it is one that is sustainable and will result in the best health outcomes.

To a large extent, our individual genes determine where our weight will settle.  There really is not much we can do about that.  But what we can do is work on becoming the healthiest person we can be, regardless of what we weigh.  By honoring our body’s hunger and fullness cues, being active in a way that is enjoyable to our body, and accepting and appreciating our body where it is now (not 20 pounds less than now), we will truly reach our health goals.  Now that’s a resolution worth keeping.

 

Extreme Disappointment

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In general, I don’t watch reality weight-loss shows. I used to. Biggest Loser was one of my favorites. I was always in awe of how many pounds the contestants would lose each season, many of them shrinking to half of their starting size. But, ever since I became a dietitian, I view these shows in a much different light. Shows like My Big Fat Revenge, Biggest Loser, and Extreme Weight Loss promote dangerous messages about weight management – namely, that fat people are inherently unhealthy and that the only way to be healthy is to lose copious amounts of weight quickly by drastically restricting one’s calories and exercising like a maniac.

Despite my dislike of these shows, I do (rarely) catch an odd episode from time to time. Many of my clients watch these shows and take what the “experts” say as gospel, so it helps if I am in the know about the latest and greatest gimmicks these shows use, so I can help re-educate my clients.  

Last night, I stumbled across an episode of Extreme Weight Loss that truly disturbed me. In this episode, a 23-year-old woman named Alyssa was the individual who was chosen to undergo a year of restrictive eating and over-exercising courtesy of trainer Chris Powell.  The episode started predictably enough: initial weigh-in tears, a loss of 100+ pounds over the first 3 months (Phase 1), and the inevitable struggles to lose weight during Phase 2 (months 3-6).  

This is where things take a serious turn. After Phase 1, Alyssa found that the weight just wasn’t coming off like it had been before. No matter how much she tried to follow the meal and exercise plan, her weight was at a plateau. So, in order to reach her goal of losing another 60 pounds during Phase 2, she decided to drastically reduce her calories even more, at times eating close to nothing. This resulted in rebound binges and subsequent purging. Alyssa developed an eating disorder (ED).

At this point, the show’s producers should have stopped the program for Alyssa, insisted she get treatment for her ED, and take all of the focus off of her losing weight. Instead, Alyssa had a heartfelt talk with Chris and his wife Heidi (who herself struggled with an ED for eight years), and despite the fact that clearly Alyssa needed help dealing with her ED, they continued to encourage her to lose weight and restrict her calories. She was instructed to eat 1500 calories per day while exercising for at least three hours per day to achieve “healthy” weight loss.

At the very end of the program (and after she had completed the program, losing a total of 200 pounds), Chris offered Alyssa a two-month stay at Shades of Hope, an ED treatment center. While at first she rejected the offer, Alyssa ended up going to the program two weeks later, as it was clear that her eating issues were continuing. Why wasn’t this offer made immediately after Alyssa admitted her ED to Chris? Why did they wait until the end of the year to offer her help?

When someone is struggling with an ED, there should be no talk of trying to lose weight, whether it is in a “healthy way” or not. In a sense, the show itself taught Alyssa how to eat in a disordered (re: restrictive) way, priming her for developing an ED. By letting her continue on in her weight loss program, the show did Alyssa a real disservice and gave the message that EDs are no big deal and are just a “phase” that can be dealt with easily. Unfortunately, EDs are not only extremely damaging (and potentially fatal), but they also often turn out to be a life-long struggle, not something to be glossed over.

These shows are not only doing damage to the contestants, but also doing an enormous amount of damage to their viewers. I am hopeful that one day these shows will run out of steam and stop reinforcing the idea that losing weight and the number on the scale are the end all, be all. Maybe someday shows will promote healthy behavior change, without focusing on the numbers. But, I guess that wouldn’t make for scintillating TV.