I want to lose weight. Will you help me?
You are not alone. Approximately 51% of American adults want to lose weight. Given how terribly our society treats people living in larger bodies, who can blame them? Examples of weight stigma are prevalent and run the gamut: clothing and airline seats designed for smaller bodies, cyber bullying, verbal insults, physical attacks, social exclusion, trouble finding work, and subpar healthcare. Even our own government has declared war on fat people. Of course people want to escape this mistreatment.
Given all those valid reasons for wanting to lose weight, you will help me to lose it, right?
Sometimes people do lose weight as a side effect of our work together. If weight loss does occur and that is an outcome for which they are hoping, great, but it is neither the goal nor the focus of our nutrition counseling.
The truth is that while numerous methods of inducing short-term weight loss exist, nobody has demonstrated an ability to produce long-term weight loss in more than a small fraction of the people who attempt to achieve it.
Some research has found “almost complete relapse” after three to five years, other data are more specific and suggest 90% to 95% of dieters regain all or most of the weight within five years, while other research has found that between one third and two thirds of people end up heavier than they were at baseline. The Australian National Medical Health and Research Council issued a level A evidence statement – the highest possible level of certainty – indicating that weight regain is the norm, not the exception. Research in adolescents has found that dieters were three times more likely than non-dieters to become “overweight,” regardless of baseline weight.
For these reasons, dietitians often say, “The best way to gain weight is to lose weight.”
How can that be? I know plenty of people who have lost weight and kept it off.
Approximately 45,000,000 Americans set out annually to lose weight. Even if only 5-10% of the people who hope to achieve long-term weight loss attain their goal, the result is still a few million people showing off their new bodies and discussing their diets at the gym, office, grocery store, and dinner table. These “success stories,” while the exception rather than the rule, are prevalent, visible, and vocal enough for most of us to know at least a handful of them.
Meanwhile, the 90-95% of people who regain the weight will stay relatively silent as they blame themselves for what is really their diet’s failure. For these reasons, the perception we have of weight loss pursuits is that they are much more likely to be successful than they really are.
The people who lose weight and keep it off are like lottery winners. Their testimonials sure are enticing, and you may even feel inspired to ask them for and emulate their secrets, but going down the same road is unlikely to produce similar results for you. If your friend wins Powerball, you certainly have the right to buy a ticket in hopes of striking it rich too, but the fact remains that the most likely result is that you will lose your money.
Even if the odds of success are slim, there is no harm in trying to lose weight, right?
Unfortunately, striving for weight loss is not necessarily a benign pursuit in which the worst-case scenario means that you simply returns to where you started. Research has shown that weight cycling – repeatedly losing and regaining weight – is associated with numerous health problems, including a higher overall death rate and an increased risk of dying from heart disease, regardless of one’s baseline weight.
Okay, but my doctor told me I need to lose weight.
“Obesity” is associated with a number of health woes, and, clinically, your doctor probably finds more problems in heavier patients than in thinner ones. Consequently, your doctor recommends weight loss as a supposed path to better health. On the surface, such well-intentioned advice sounds reasonable, but it is problematic for a multitude of reasons.
Correlation does not equal causation. In other words, just because two factors tend to occur together does not mean that one necessarily causes the other. The diseases blamed on “obesity” could be due to other factors that tend to co-occur with increased body weight.
- Cardiovascular disease, which is often blamed on “obesity,” is also associated with stress. In fact, research has suggested that many of the health woes blamed on “obesity” might actually be due to the stress of weight stigma.
- Heavier people are also most likely to embark on weight loss endeavors, which are likely to result in weight cycling, which in and of itself is associated with worsened morbidity and mortality.
- Some doctors spend less time with “obese” patients, fail to order diagnostic testing, and have less patience and get more annoyed the heavier a patient is, meaning that heavier people are subjected to worse medical care than thinner people receive.
- Wary of being fat shamed, heavier individuals are less likely to seek regular medical care, so their diseases may be more severe by the time they are detected, as opposed to illnesses that are nipped in the bud and therefore have a better prognosis.
In other words, the causal factor might not be your weight, but rather one or a multitude of other factors associated with your weight.
Your doctor may have heard of the National Weight Control Registry, a database of “over 10,000 individuals who have lost significant amounts of weight and kept it off for long periods of time.” Some doctors believe that if their patients adopt the behaviors exhibited by people in the Registry, their patients are likely to achieve similar weight loss.
Unfortunately, presenting these behaviors as the key to long-term weight loss makes little sense when so many other people perform the same actions without achieving similar outcomes. The lottery crowns new millionaires every single day, and a quick study of the winners reveals that a behavior common to all of them is that they bought tickets, but that does not mean your financial advisor is giving you sound, ethical, evidence-based advice if he suggests you take your life savings and invest in Powerball.
Even if a causal relationship exists between body weight and your medical condition, endeavoring to lose weight is still not the answer. In light of the research showing the prevalence of weight regain that often surpasses baseline weight, we can only assume that the condition you are trying to improve by losing weight would actually worsen in the most likely scenario that you end up heavier than you are now.
For these reasons, many healthcare providers – including us – believe it is unethical to recommend weight loss to patients as a path to better health.
Well, that sounds pretty dismal. What am I supposed to do then, just give up?
Even though you may never experience the weight loss for which you were hoping, you still have other options for taking care of yourself and pursuing better health.
As it turns out, weight and health are not as synonymous as common perception would have us believe. For example, researchers who have examined long-term data have concluded that weight loss failed to correlate with improvements in cholesterol, blood pressure, and blood sugar.
Behaviors, rather than body weight, seem to be better predictors for health. Research has shown that healthy lifestyle habits are associated with a significant decrease in mortality regardless of baseline body mass index. Similarly, other researchers have found cardiovascular fitness to be a predictor of cardiovascular disease and all-cause mortality, independent of body weight.
Given that, we take a weight-neutral approach that is aimed at directly improving whatever health concerns you may have. Our approach entails:
- Respecting that bodies naturally come in different sizes, shapes, and weights
- Pursuing better health directly, as opposed to using weight loss as a proxy, in a fashion that takes into account the various social, cultural, financial, and emotional factors that influence your relationship with food
- Working to bring an end to the stigma and biases that patients face in healthcare because of their weight, size, shape, sexual orientation, religion, gender, skin color, ethnicity, age, or physical ability
- Focusing on building, enhancing, and honoring internal eating cues that provide invaluable guidance regarding what, when, and how much to eat
- Encouraging enjoyable and comfortable physical activity
The general approach that we just outlined is called Health at Every Size (HAES)®. Unlike weight-focused approaches, the HAES approach is associated with improvements in blood pressure, blood lipids, diet quality, and eating and activity habits. HAES has also been shown to improve psychological or emotional issues, such as binge eating, depression, self-esteem, and body image. While diets have high rates of attrition, the HAES approach better enables people to maintain long-term behavior change.
Sometimes people do lose weight as a side effect of taking a HAES approach. If weight loss does occur and that is an outcome for which they are hoping, great, but losing weight is neither the primary goal nor the focus of our work.
Despite the trademark, HAES is not a program like one would find from a diet company. In fact, HAES is not a program at all. Rather, HAES is an approach to healthcare much in the way that the field of psychotherapy offers different approaches to talk therapy: cognitive behavioral, psychodynamic, dialectical behavioral, and family systems, just to name a few.
In order to prevent the diet industry from co-opting the term HAES and warping its message, the Association for Size Diversity and Health (ASDAH) trademarked HAES. However, Soolman Nutrition LLC is an entirely separate entity from ASDAH. We do not speak for ASDAH, they do not speak for us, and we do not pay them – or vice versa – in order to use a HAES approach with our patients.
But I know from personal experience that I lose weight when I eat better and exercise more, so of course I will lose weight if I change my behaviors.
Contrary to popular myth, our weight is largely out of our hands. The calories-in-versus-calories-out paradigm is a gross oversimplification of the complexities affecting weight regulation. While we might be able to manipulate our body size through behavior changes for a short while, biological mechanisms promoting weight regain almost always win out in the end. Given that, there is no telling whether or not you will experience long-term weight loss as a result of behavior change.
One of the dangers of making assumptions in this regard is that progress can stall, or even revert, if the weight loss you expect does not occur. We have seen patients make terrific progress with binge eating, blood sugar levels, and other health concerns, but if they expected – but did not experience – a corresponding drop in weight, then they felt caught between continuing down their current road or switching to a path of restriction in hopes of losing weight, even if the latter meant losing all the progress they had made regarding their health.
A weight-neutral approach sounds fine for other people, but as for me, I really need to lose weight!
We firmly support a patient’s right to choose for themselves the approach to healthcare that feels most appropriate for them at any given time. Similarly, we also believe in disclosure and informed consent so patients can make educated decisions.
After knowing the facts, you may still decide to pursue weight loss. If so, we certainly respect you and your decision. Unfortunately, given the dubious connection between weight and health and the lack of any known treatment plan that is likely to result in long-term weight loss, our professional ethics do not allow us to travel that road with you.
Even though we are not the most appropriate resource for you at this time, we sincerely thank you for having considered us, and we wish you the best of luck going forward. Should you experience a change of heart, please do not hesitate to reach out again.
Part of me still hopes to lose weight, and I am not 100% convinced regarding a weight-neutral approach, but I get what you are saying, and I am curious to learn more.
If you are interested in pursuing a weight-neutral approach to healthcare, or you simply want to learn more about it before you decide one way or another, we will be happy to meet with you to continue the conversation.