Guess What? A Single In Office Visit Encouraging People To Weight Themselves More Often And Exercise Doesn't Prevent Weight Regain

From the Journal of Duh! (ok, actually it was PLOS Medicine) comes Behavioural intervention for weight loss maintenance versus standard weight advice in adults with obesity: A randomised controlled trial in the UK (NULevel Trial). The study involved 288 people who had lost ≥ 5% of their weight in the preceding 12 months who were randomized into two groups. One where they received periodic newsletters, and the other where they had a single face-to-face visit where they discussed goal setting and self-monitoring (including being told to weigh themselves daily) followed by every other day automated text messages. The hope was that the single visit and text messages would help prevent weight regain in the group that received them. So did that minimal intervention help?

No, both groups regained the same amount of weight over the study's duration.

What was most surprising about this study wasn't that minimal interventions don't help prevent weight regain, but rather that someone thought they might. Because if minimal interventions prevented weight regain, do you really think weight regain would be so commonplace?

So in case you were looking for proof that single office visits and text messages aren't in and of themselves sufficient to prevent weight regain, there you have it I suppose.

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.

Are large amounts of exercise essential for weight loss maintenance?

Let me start things off by telling you that I do believe exercise to be extremely helpful in long term weight management. I'll also tell you that I'm a huge fan of the National Weight Control Registry. For those of you who aren't familiar with the Registry, Registrants are folks who are supremely good at maintaining their weight-losses. In fact, the average Registrant has lost 67lbs and kept it off for 5.5 years!

There's a great deal of variety in the Registry. Different types of dietary approaches and different strategies as a whole, but there are some commonalities, and exercise is one.

Studies on Registrants have their self-reported exercise as being quite high - an average of 58.6 minutes a day!

What we didn't have was an objective measurement of same, and sadly, despite a new study with Registrants and accelerometry, I'd argue we still don't, though it seems it wasn't the researchers fault.

26 Registrants were recruited to wear accelerometers for a full week and were matched with a never obese group, and an overweight, not Registrant control group.

The results were pretty interesting. Measured exercise actually turned out to be significantly less than self reported at 41.5 minutes a day (rather than nearly an hour), but was still of greater duration in Registrants than overweight non-Registrant controls and marginally more than never obese weight-matched controls.

But are the results useful? Do they really answer the question as to the importance of exercise in successful weight maintenance?

I'm not so sure. The problem I've got with the study's methodology is that Registrants were recruited with a description of the study's aim. Meaning that prior to enrolling they knew they were enrolling themselves in a study that involved objectively measuring their activity levels.

To me that's a big deal. It's a big deal because I would imagine that human nature would dictate that the folks who respond to just such a study are the ones who are the most proud of their activity levels (or the least embarrassed depending on how you want to look at it).

I suspect too that this was a limitation the authors were aware of as beside the disclosure in the methodology section is the parenthetic explanation, "(as required by our institutional review board)".

Another frustration from the study was the fact that individual data points weren't provided. Given the small number of subjects, I would have loved to see the distribution of minutes of exercise - especially given that in their discussion they mention that 2/3 of subjects engaged in >150 minutes weekly, and 1/3 of subjects >300. Did exercise reflect a normal distribution? Was it bimodal? Were there dramatic outliers?

Bottom line for me, I'd have loved to see this study performed with a random sample of Registrants, not a sample who may have self-selected for being more active. That's not to say the findings wouldn't necessarily be the same, but given this study's methodology, I wouldn't be hanging my hat on these results.

[Also fascinating (though not surprising) was the result that objectively measured exercise was significantly less than self-reported. Furthermore, if my assertion that folks who were better exercisers were more likely to have agreed to enroll, that result casts major doubt on the National Weight Control's finding of massive amounts of exercise being integral to maintenance.]

Catenacci VA, Grunwald GK, Ingebrigtsen JP, Jakicic JM, McDermott MD, Phelan S, Wing RR, Hill JO, & Wyatt HR (2011). Physical activity patterns using accelerometry in the national weight control registry. Obesity (Silver Spring, Md.), 19 (6), 1163-70 PMID: 21030947

The forgotten value of not gaining

Most people, when they undertake weight related lifestyle changes, measure success by the scale.

How many pounds did I lose this week? This month? This year?

Of course many of those same people, when they started making changes, were regularly gaining weight. Not necessarily massive amounts, but perhaps somewhere between 1-10lbs annually, which over time, adds up.

Now lifestyle change is difficult, and many people don't feel like they've succeeded.

The thing is, I wonder how success is being defined. If the only definable success is a dramatic loss, sure, a great many folks are going to get disappointed, quit their changes, and once again start their slow marches up.

On the other hand, if folks recognized the value of simply not gaining, maybe, just maybe, we'd see our ever increasing obesity rates, begin to level off. And who knows? Perhaps, over time, as a person gets more and more comfortable with their changes, then slowly, but surely, they'll start losing too.

I guess what I'm trying to say is - don't underestimate the value of simply not gaining.

[And remember, for extra tidbits, or if you'd prefer to follow this blog there, you can also follow Weighty Matters on Facebook]

Why Oprah Regained her Weight

Simple.

All the money in the world (and I believe Oprah literally has all the money in the world) won't change the fact that at the end of the day the way you live is a choice and not a purchase.

In Oprah's case, she admits to stopping her exercise sessions, her meditations and going back to eating higher calorie foods.

Please don't misunderstand me, I'm not knocking Oprah. Frankly I can't imagine what her life must actually be like. The hours she works, her stress levels, her responsibilities - not to mention the incredible amount of meals out that her job likely requires of her.

Oprah had succeeded in losing weight before because she succeeded in changing her lifestyle. That said, unless you enjoy the way you're living while you're losing, ultimately you're going to gain it back.

Life's complicated and lifestyle for weight management is a treatment, not a cure. Stop treatment - regain weight. So really, you'd better pick a treatment you actually enjoy.

Is Exercise Necessary for Weight Maintenance?

Yes, but the much more important question really is why?

Today a new paper in the Archives of Internal Medicine again suggests that exercise is crucial for long term weight maintenance, but I think misses the boat on why.

The paper, written by one of the giants in exercise and its role in obesity treatment and prevention Dr. John Jakicic and colleagues, follows 201 women for 24 months randomizing them into one of 4 different exercise arms (having to do with intensity and duration) and giving all of them Calorie reduced diets.

They then subdivided the results into groups representing percentages of maintained weight loss at 24 months and analyzed scads of data.

Their results and conclusions?

The folks who maintained a weight loss of greater than 10% of their starting weights exercised more minutes per week than those who did not. The authors concluded that the magic number of weekly exercise minutes for weight maintenance therefore were 275 (an average then of 40 minutes daily or an hour 5 days a week).

The thing is, I don't think that's the whole story.

Looking more carefully at the data we can see that on a weekly basis the folks who exercised the most burned only 1,145 more Calories than the folks who exercised the least (illustrating that exercise really doesn't burn boatloads of Calories given that to burn those additional Calories those folks on average exercised 3.5 hours more a week). That's only an average of 163 Calories more burned daily - not much to write home about.

No, for me the story is elsewhere in the data.

Looking at those who exercised the most, on a daily basis they were consuming 444 Calories less than those exercising the least. Extrapolating that and those folks were eating 3,108 fewer Calories a week! That's almost a full pound of Calories less a week! They also had much better scores on an eating behaviour inventory meant to assess weight control eating behaviours.

Translation?

The folks who exercised the most, ate the least and controlled their eating the best and in fact the magnitude of their dietary interventions at 24 months were 3 fold higher in Caloric impact than their exercise interventions.

My conclusion?

Exercise works and is integral to most for weight maintenance, but not via its direct Calorie burning capacity (which is small), but rather through its remarkable ability to cultivate healthy attitudes about weight management and in so doing, support dietary restraint and thoughtfulness for the long run.

Therefore to truly harness the power of exercise, we need to explore how exercise leads these folks to consume less Calories and stick to weight control eating behaviours. If we can figure that out, perhaps we can create interventions that do not in fact necessitate seemingly other-worldly amounts of daily exercise.

Surprise! Protein's more filling!

Ok, maybe it's not a surprise, but today at least, it's sure going to be news (and perhaps I'll be the first to break the embargo at 12:01AM - thanks Blogger for allowing scheduled posts!).

It's going to be on radio, print and television - the results of the first prong of the DiOGenes study. DiOGenes is a multi-pronged study spearheaded over in Europe and today's spear has to do with trying to answer the question, "What's the best diet to help maintain weight loss?".

This study was an enormous undertaking as it looked at whole families, in 8 different European countries for between 6 and 12 months and randomized their dietary intakes to compare weight gain with diets high or normal in protein and high or low in glycaemic index carbohydrates.

In total, the study aimed

"to recruit a total of around 850 obese/overweight parents (BMI>28) from the 8 participating centres, corresponding to 450 families with an estimated 450-1050 children, where at least one child in each family is overweight."

Mandatory too was an 8 week run-in weight loss phase where adult family members were required to lose 8% of their body weight before their family was admitted into the study.

The results weren't particularly surprising. Dietary protein helped maintain weight loss while GI index did not.

I think the most important part of the whole paper was a quote in the introduction that does a great job explaining why the world's getting so big so fast,

"Given our genetic background, it is essentially infeasible for humans to self-regulate food intake under current environmental circumstances."

What this basically states is that in 2008, the default is weight gain, and I can't agree more. People haven't changed in the past 100 years, but our environment sure has and the reason we're gaining weight so quickly now is that since weight gain is the default, that means by definition maintenance of a healthy body weight in our current environment has actually become a skill. And just like other skills (martial arts for instance), just because your minds' eye might know what it looks like to do a jumping, spinning hook kick, it doesn't mean you can simply jump up and do one.

To extrapolate a martial arts analogy to healthy weight think of it this way: Just because your minds' eye might know what a healthy lifestyle looks like, to expect yourself, without instruction, to be able to simply jump up and happily live with one is often too much to ask (people do it unhappily all the time - that's called dieting).

Not surprisingly this study was funded by Big Food and here's one time where I think it's a great partnership. Here's an opportunity for Big Food to help by using their study to help pave the way to the creation of new food products that may be useful in preventing weight gain/regain.

Hurray for Big Food!

(there's something I don't say very often)

[BTW, I'll likely have a 5-10 second sound bite on CTV's National News tonight in Avis Favaro's story on this study should any of my Canadian readers want to watch]

Subway's Jared Celebrates 10 Years of Weight Maintenance!

Congratulations go out to Subway's Jared for doing what the vast majority of those that lose weight don't do - keep it off.

According to an article in the Washington Post, Jared's Subway eureka moment came back when he weighed 425lbs and his college roommate at Indiana University made a tape recording of the sounds he made while sleeping (severe sleep apnea can sound quite dramatic and frightening). He reports trying a few other efforts before finally settling in on his now famous Subway diet which arose with him reading a nutrition facts panel while standing in line for a sub. The rest of course, is marketing history.

Jared's Subway diet amounted to roughly 1,500 Calories a day, low for the majority of men, combined with lots of walking.

Subway took notice after Jared was featured on multiple local media outlets and he has remained a spokesman for them every since.

He no longer formally counts Calories but certainly practices Calorie awareness and knows what portions work best in his own personal foodscape.

Jared's not alone in his weight maintenance success. The National Weight Control Registry (NWCR) now numbers well into the thousands and to be a registrant you've had to have lost over 30lbs and kept it off for over 1 year. The last time I saw Dr. Rena Wing (one of the registry's founders) speak, the average registrant had lost 66lbs and kept it off for 5.5 years.

So how do the registrants do it? The NWCR has a great facts page and here are some highlights,

Duration of successful weight loss has ranged from 1 year to 66 years!

Some have lost the weight rapidly, while others have lost weight very slowly--over as many as 14 years.

45% of registry participants lost the weight on their own and the other 55% lost weight with the help of some type of program.

98% of Registry participants report that they modified their food intake in some way to lose weight.

94% increased their physical activity, with the most frequently reported form of activity being walking.

78% eat breakfast every day.

62% watch less than 10 hours of TV per week.

90% exercise, on average, about 1 hour per day.

One thing's absolutely certain and during a working day you'll hear me say it at least 5 times a day,

"The more weight you'd like to permanently lose, the more of your lifestyle you'll need to permanently change"

which of course then leads me to the,

"Therefore if you don't like the life you're living while you're losing, you're much more likely to gain it back"

Jared has kept his weight off because he likes his new lifestyle.

Do you like yours?

Congratulations again Jared.