Monday, January 09, 2012

Are You Doomed to Regain? Thoughts on Tara Parker Pope's Fat Trap.

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.

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22 comments:

  1. Thanks for your excellent rebuttal of the NYT article. I'm in complete agreement. Successful "losers" must find a strategy they can live with and even enjoy for the rest of their life.

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  2. You're talking about relatively small amounts of weight loss here. Most people aim to get thin, not to lose 18% of their weight. A 250 pound person that used to weigh 304 is still 250 pounds and is perceived as fat, lazy, ugly, etc. Until that type of bias ends, nobody is going to be happy with an 18% weight loss - not unless they started out 18% heavier than the ideal.

    The BMI categories also create confusion about what a "healthy weight" is. If someone loses 10-20% of their weight and is still considered "obese," then most doctors will not even bother to ask them about their weight history before lecturing and urging more weight loss. it doesn't matter how good the rest of their numbers are.

    I was 30 pounds below my maximum weight for close to ten years (around 185 pounds after peaking at 215). I NEVER had a doctor ask me what my maximum weight was. Instead, they lectured me, made incorrect assumptions about my eating habits and activity level, and didn't believe me when I tried to set them straight. This was in spite of the fact that I was healthy. My BMI - slightly over 30 - was my only risk factor.

    You are never going to get people interested in maintaining weight losses that don't make them thin until doctors learn to acknowledge that some fat people are already doing as much as is reasonable for their health and do not need to lose more weight and until society stops judging people by their size.

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    1. Anonymous2:03 am

      applaudes.....I totally agree with you.

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  3. I've been one of the successful, long-term losers, however it wasn't a steady progression downward. at 5'7" my peak weight was 235lbs in '96. After some step-down weight loss in the first 4 years (losses followed by long plateaus), I yo-yo'd between 175-160 for the next 10 years. Finally in 2011 I was able to lose again (and maintain) down to 155. I'm still 8 pounds from my goal.

    In all that time, I never regained back to my original weight. I attribute this to having made a lifestyle change where I embraced (heck, LOVE) exercise and no longer "use" food to avoid feeling emotions.

    As you say, I am mindful of what I eat, I do indulge from time to time, but I monitor my weight regularly so that things never get out of control again.

    I'm currently reading Tim Caulfield's new book and just finished the section on food/exercise yesterday (nice quotes from you in there!), so this topic is very timely since I often wonder why I have succeeded where so many others have failed.

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  4. I read Tara's article in not so much a negative light. I found that knowing that it is harder to maintain a healthy weight if you were formerly overweight or obese as encouragement to keep going.

    I find maintaining my weight loss much harder than losing weight itself. Losing weight you have a goal and determination and with weight management only a fear to backslide. Knowing that it is hard for everyone to maintain only empowers me to improve my eating regimen and exercise. Like maybe I will keep on doing the strength training I've added in to my only cardio workout regimen. Or if I eat bad one day to remember to not slide into bad habits because maintaining is about keeping up healthy habits.

    My sister and I cook weekly portioned meals we call Mealpods which so help us keep on track!

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  5. Tessie9:34 am

    Thank you for this. I have lost 100 lbs of the 130 I aim to lose, and greatly fear maintenance as everything I read is so discouraging in terms of longterm success. I have, however, lost the weight in a sustainable way - homecooking delicious meals in reasonable portions, avoiding hunger, walking daily, and occasionally indulging during celebrations or holidays. I feel this is something I could do for forever, and clearly, if I keep this up, I can be successful at maintenance.

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  6. Bobbini9:36 am

    Agreeing with dee.calarco! The folks profiled in the Times piece had lost more like 40% of their body weight. I think that's a different league than 10%, and probably requires a different level of attention to food.

    I also read Dr. Arya Sharma's blog, and a few studies he's reported on lately show good health outcomes for individuals with weight loss in the 3-10% of body weight range.

    But as long as the public health and clinical messages that fat people get are "get your BMI below 25", the value of livable changes to food and exercise will be invisible.

    If the point is to live the healthiest life you can enjoy, why look at weight at all? Why not look at individual health measures instead?

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  7. Awesome critique. I've lost about 25% of body weight, kept it off for a few years now, and while I don't weigh, measure, count anything, I am still conscientious about what/how much I eat, and I get my exercise. It takes constant retraining/re-evaluating, and occasionally I get caught up in a bit of resentment about my perception that everyone else eats however much they want, but I'm learning that that's not really true either. It's comfortable, and I like being healthy and in reasonable shape. Occasionally someone asks, and I tell them there's no sense starting anything that you can't keep up the rest of your life, and they look at me as if I'm smoking crack. However, I think for me to actually get to slim, rather than slightly chubby, would require uncomfortable changes that I couldn't maintain, which is probably why it's not happening.

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  8. I think the difference between 'vigilance' and 'thoughtfulness' is whether or not the person turns their weight loss/health improvement journey into a passion.

    My non-scientific observations are that many people in successful recovery from obesity, if they don't have a complete career change and become a personal trainer (I did that for a while), they do become advocates (sometimes evangelists) for healthy lifestyles, participate in communities of like-minded individuals, or otherwise embrace the environments that are conducive to continued success.

    I think one of the real keys is to find that modality that changes a person's perceived effort from 'vigilance required' to 'thoughtfulness'.

    I think Dr. Sharma was really onto something with his COACH Ambassador program. At the grassroots level, communities like www.livestrong.com and www.fitocracy.com have real potential to help people discover their courage and their passion.

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  9. I'm 6'1 and went from 220 to my current 155 slowly with a combination of dieting and exercise. Both required some vigilance and effort, but the results have been worth it. There is clearly effort (I try to stay in a 155 to 160 pound band) required, but I keep daily track of eating and exercising. Not a bad trade-off for feeling *much* better than I ever have.

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  10. Anonymous4:59 pm

    There's a letter to the Editor in today's Edmonton Journal suggesting that we tax the obese. I guess the educational message is just not getting out there.

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  11. I absolutely agree with your approach, but not with your critique of Tara's article. My reading of the article was not that it's impossible, but that a large number of people do gain the weight back ... and she was trying to explain some of the factors that cause this problem. I think she did a good job of doing that, but did very little in presenting solutions (perhaps in a follow-up article she'll do that?). Your solutions are pretty much what I'd suggest as well.

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  12. Dr. Ellis comments (#501) on NY Times article

    I lost 125 lbs over 20 months and have been stable for 2 years. I am rigid, but my habits are now ingrained and "automatic." Keys have been:
    1. Not accepting as OK what is now "normal" in terms of American diet and activity level.
    2. I didn't lose weight so quickly as folks on 800 cal/d diets, who likely lost a lot of muscle.
    3. Conversely, weight training in addition to aerobic activity has been key in my weight loss and maintenance. Even when doing aerobic exercise, I do interval training so as to improve fitness.
    4. While not vegetarian, I eat 1-2 lbs of green vegetables a day. I prepare almost all of my own food (#1 above)
    5. Some thoughts on the weight regain issue on my bloghttp://www.howilost100lbs.com/do-hormones-doom-weight-loss

    John E. Ellis MD
    HowILost100lbs.com

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  13. I read the same article the part that caught my eye was how muscles in obese individuals are converted into slow twitch muscles, which apparently decreases the amount of calories they burn. My approach to long-term weight loss (which really should be called long term fat loss) has heavily revolved around putting on more muscle. This will better help me burn calories for years. It seems to me that lifting is vital to keeping weight off especially for those previously obese.

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  14. Anonymous10:17 am

    Very insightful article.

    Just another point I'd like to add from personal experience. The negative spin on what people need to do to keep weight off (pay attention to calories, saturated fats and exercise frequently) seems to be a bit misguided.

    I have found that the motivation for doing these apparent chores of thought and body do not exist from the get go. It is only after a few weeks of exercise and healthy eating that you realise how much better you feel and look. As soon as that is apparent it feels foolish to do anything contrary to the progress you've made.

    People too often look at people at the other end of the spectrum thinking that they will never get enough motivation to maintain the lifestyle of an athletic health conscious person. What they don't realise is that the motivation comes with time and that absolutely anyone can do it with the correct education in nutrition, as long they do not set ridiculous goals that prevent themselves from feeling satisfaction.

    Just a thought.

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    1. I agree with Anonymous' comment: It is only after a few weeks of exercise and healthy eating that you realise how much better you feel and look. As soon as that is apparent it feels foolish to do anything contrary to the progress you've made.

      I'm also sick of the media's growing emphasis on how "difficult" or even "impossible" it is to maintain weight loss. Yes, it does require a great deal of vigilance and dedication, but these negative articles overlook the tremendous benefits of losing weight in the first place.

      I've lost 40% of my weight, dropping from a BMI of around 40 to 23.5, and maintained steadily now for over eight years. The difference in how I feel and look - not to mention how I feel about myself - certainly makes the attention I need to pay to diet and exercise worthwhile.

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  15. BRoach11:25 am

    To echo what some others have said, thank you for your response to Pope's article. Much of what you said was my exact reaction when reading her piece.

    It's a pet peeve of mine. I don't stay thin by some biological miracle. I stay thin because I have a healthy diet that I am accutely aware of, and try to get regular exercise through recreation (I suck at "working out" - can never do it). I think about my diet every time I go to buy food, go out to eat, etc. As your article talks about, however, I don't see it as a "hardship" - it's simply what I need to do to stay healthy.

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  16. Anonymous12:36 pm

    I'm looking at a poster on my office wall.

    Losing weight is hard,
    maintaining weight is hard,
    staying fat is hard;
    CHOOSE YOUr HARD.

    Says it all for me, I choose to maintain and accept that is requires diligence and hard work. I'm Ok with that.

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  17. Michelle10:13 am

    A line in her column stuck with me "The research shows that the changes that occur after weight loss translate to a huge caloric disadvantage of about 250 to 400 calories." Essentially, the claim is that, after weight loss, metabolic changes mean that the individual needs to eat less than a never-fat person of the same weight to maintain that new, lwer weight.
    What does this mean and has this been your experience?

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  18. That's true.

    But what it doesn't mean is that the weight that's lost inevitably gets regained, just that less weight is lost.

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  19. Alexie6:26 am

    Thank you, thank you, thank you for writing this. I have lost 30% of my highest body weight and for the last 14 months have managed to maintain the loss. I'm glad that weight gain isn't inevitable. However, what's clear to me is that vigilance, not thoughtfulness, really is the right word. Keeping weight off becomes an ongoing project, that requires constant management in the face of food saboteurs, a calorie-rich environment, the siren call of the sofa etc. I do know that my body has altered and that weight comes back far more easily than it did in the past and is harder to shift when it does. I think those of us who do keep it off can do so because the process becomes interesting and finding ou about fat, health and exercise becomes a hobby.

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  20. Anonymous5:35 pm

    Woohoo determinism! Let's all gather together and console each other it can't possibly be done because of various mechanisms in the brain!

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