Saturday, May 18, 2019

Saturday Stories: Dietary Guidelines, "Vaccine Injury", and "Chronic Lyme"

Kevin Bass, in his blog Nutritional Revolution, with the data driven case on how you can't blame people following dietary guidelines for a country's obesity rates.

James Hamblin, in The Atlantic, on the truth behind vaccine injury compensation.

Abby Hartman, in It's Training Cats and Dogs, with her first person account on walking to, and then away from, treatment for "chronic lyme disease".

Pic By Alan R Walker - Own work, CC BY-SA 3.0, Link

Tuesday, May 14, 2019

Calling People Successfully Maintaining Long Term Weight Loss "Unicorns" Is Dehumanizing, Unhelpful, And Misleading (And No, 95% Of Weight Loss Efforts Don't Fail)

A few weeks ago I tweeted about a patient of mine who is maintaining a 19% weight loss for 2 years, and who attributes her success to keeping a food diary and tracking calories, as well as to including protein with every meal and snack.

The point of my tweet was a simple pushback to those who want to claim that calories don't count or that counting can't help (like The Economist for instance whose recent article entitled Death of the calorie was the main reason I bothered to tweet), and those who claim that the only way to lose weight is their way (these days that's usually either #keto or #lchf).

A great many folks weighed in with their success stories, and some pointed to the National Weight Control Registry (where their over 10,000 registrants have kept off an average of 70lbs for 5.5 years). Others though weren't having it.

Instead they asserted that 95% of diets fail, that the weight loss industry was predatory (much of it is, no argument there), and called people who have succeeded "unicorns".

Unicorns. Not people. Mythical creatures.

And the implication of course is clear. Sustained weight loss is impossible. Those who succeed aren't human, or to succeed they employ superhuman efforts, sometimes even described as disordered eating and/or that those who succeed must be miserable. Consequently, trying is futile and those offering help (like me, as to be clear I am the medical director of a behavioural weight management centre) are unethical and are motivated by greed (despite the obvious irony that those championing explicitly non-weight loss programs are targeting the very same population of people and regularly charge a great deal of money for their services).

But boy, there sure are a heck of a lot of unicorns roaming around for something that supposedly fails 95% of the time. Putting aside the anecdotal facts that we all know people who have maintained weight losses, as well as my own office based experiences, this 2010 systematic review found that one year later 30% of participants had a weight loss ≥10%, 25% between 5% and 9.9%, and 40% ≤4.9%. In the LOOK AHEAD study, 8 years later, 50.3% of the intensive lifestyle intervention group and 35.7% of the usual care group were maintaining losses of ≥5%, while 26.9% of the intensive group and 17.2% of the usual care group were maintaining losses of ≥10%. Here's the DIRECT trial where mean weight loss at 2 years was 7.5% with 24% of participants maintaining losses greater than 22lbs. And in the recent year long DIETFITS study the average weight loss of all participants was 5%, with over 25% of participants losing more than 10% of their weights.

The Examine.com waterfall plots of the DIETFITS data

(And for an interesting thought experiment, have a peek at this thread from Kevin Bass that argues that even if the 95% failure number were true, those outcomes would be worlds better than the vast majority of medical treatments currently being offered for other chronic diseases)

So where does this 95% number come from? I could imagine it to be true if the goalpost for successful weight loss was total weight loss and reaching a so-called "healthy" or "normal" BMI. But that would be as useful a goalpost as qualifying for the Boston Marathon would be for running whereby the vast majority of marathoners won't ever run fast enough to qualify to run Boston. Does that mean non-qualifiers should be discouraged from running and told that running is impossible? It's also important to contextualize failures. If the methods being undertaken to lose weight are misery inducing overly restrictive diets, it's not people who are failing to sustain them, it's that their diets are failing to help them (which, with full disclosure, is the premise of my book The Diet Fix).

As far as what needs championing, it's certainly not failure. Given the medical benefits of weight loss, as well as the real impact weight often has on quality of life (especially at its extremes), what we need to collectively champion are the embrace of a plurality of treatments (including ethical behavioural and surgical weight management programs and greater access to them), along with more effective medications. What can simultaneously be championed is the removal of blame from the discussion of weight, fighting weight bias and stigma, recognizing that a person need not have a so-called "healthy" or "normal" BMI, that scales don't measure the presence or absence of health nor measure lifestyles, respecting people rights to have zero interest in losing weight or changing their lifestyles, that there is value to changing behaviours around food and fitness regardless of whether weight is lost as a consequence, and acknowledging that intentionally changing lifestyle in the name of health reflects a tremendous degree of privilege that many people simply don't possess.

Given the evidence maybe we can stop with the unhelpful, dehumanizing, and misleading unicorn talk, and while we're at it, stop telling everyone that failure is a foregone conclusion.

Saturday, May 11, 2019

Monday, May 06, 2019

What's The Point of Tracking Your Calories With a Food Logging App?

First up, the quantity and quality of calories matter both to health and to weight. You can't gain without a surplus. You can't lose without a deficit. And the quality of the calories you're consuming will affect health and satiety which in turn will affect the quantity of them that you consume. Moreover, the bioavailable calories you consume will differ by food, and also likely differs by individual (which is why some gain and lose with more ease than others).

Next up, we're crappy food historians. We may forget portions, choices, or both, not all the time, but certainly some of the time. We can't possibly know what's in meals we haven't cooked ourselves. And even if we are cooking ourselves, most aren't going to be weighing and measuring everything and eyes are terrible at both.

And a recent study confirms some of the above whereby researchers looking at users of myfitnesspal found the average user was missing nearly a meal's worth of calories a day (445). Yet studies on food diary use pretty much invariably report they markedly benefit weight loss efforts.

Personally, though I think having some rough inaccurate sense of caloric intake is valuable (if you were in a foreign country and didn't know the exchange rate, price tags would still be somewhat helpful), more valuable is the use of the food diary to remind yourself that you're trying to eat thoughtfully and likely differently.

Human nature being what it is, without a system designed to consciously remind you to change your usual default behaviours, you're likely to drift back to those behaviours, healthy or not, and a food diary, even if inaccurate, if kept in real-time, will remind you many times a day that you're trying to change.

So long as you're not using your food diary as a tool of judgment, as it's not meant to be there to make you feel badly about your choices, chances are it'll be of benefit, and likely it'll be of benefit regardless of what it is you're tracking (calories, macros, carbs, whatever) and even if inaccurate, because it's primary job is to serve you as your constant change reminder service, not as your judge and jury.

Saturday, May 04, 2019

Saturday Stories: Holocaust Memorial Day, Poway, And Synagogue Metal Detectors

Lori Gilbert-Kaye, may her memory be a blessing, murdered for being Jewish
A few days ago it was Holocaust Memorial Day, the day we commemorate the murder of 1 out of every 3 living Jews on earth prior to World War II. A week ago saw another murder for the crime of being Jewish, this time in California. Before that it was Pittsburgh. Though there's not much I can do about any of this, at least I can call your attention to these three pieces that try to weave it all together

Daniella Greenbaum Davis, in The Spectator, on antisemitism's new normal.

Rabbi Yisroel Goldstein, in The New York Times, on how being almost killed by a terrorist last week has affected his resolve.

Carly Pidlis, in Tablet Magazine, on how Jews can no longer simply consider themselves safe in America.