"OBESITY" - 2019: Here We Go Again?

Here we are again at the New Year - 2019. This would be easy to tell even if you didn’t know the date because weight loss promises are flying off the internet and the TV like confetti at The New York City New Year’s parade. Here are just a few I have seen in the past week while working on this piece:

• Lose 7 pounds in the first week - money back guarantee!
• Lose up to 18 pounds in the first month - money back guarantee!
• Proud Mom Shares Her Incredible 106 LBS Weight Loss Transformation.
• Just eat the food and lose the weight!
• The 21-Day Weight Loss Breakthrough Diet!
• The Five-Day Weight Loss Miracle!
• Extra protein to rev up your metabolism!
• Pro-biotics to burn belly fat!

And my favorite - just yesterday morning:

• My wife and I are on a pace to lose a pound a day - it’s a lifestyle change model versus a fad diet model!

Seriously???

The pressure to lose weight will be intensifying over the next few months. More and more people will be pressured into joining programs, for many the same programs they have participated in over and over again. Our cultural obsession with thinness is so deeply rooted that even health professionals who should know better are again falling back into the same old traps.

Let’s be clear. We know what the outcomes will be for the overwhelming majority of participants of weight loss initiatives in 2019! Not a surprise! They will be the same results that occurred in 2018, and for decades before that!

• People lose weight during the program.
• Most people regain their lost weight.
• 1/3 to 2/3 end up weighing more than when they started the program.
• The resulting weight cycling may be hazardous to their health.

Before going any further, a word about why “obesity” is in quotation marks. For someone to be labeled “obese” they must have a Body Mass Index (BMI) of 30 or above. As many, though not all people are aware, the BMI was not created to be used as a health metric, and it is not a valid measure or proxy for health. The Top 10 Reasons Why the BMI Is Bogus written by NPR mathematician Dr. Keith Devlin is a great resource for those who need to be brought up to speed on this.

By default, this makes any discussion of weight and health issues based on the BMI invalid. That’s right - not valid! And contrary to what some have suggested, you cannot make it “more valid” by adding this or that additional measurement to it, any more than you make the Ptolemaic depiction of the solar system “more valid” by suggesting that the earth travels only half way around the sun. Invalid is invalid. And even though it may be the "best we have," that doesn’t make it any more valid or any more ethical to use.

SAME OLD SAME OLD

Unfortunately, in the face of this reality, the dismal results of the past 4 decades and the growing evidence of iatrogenesis from weight loss programs, contests and competitions, many health professionals continue to endorse them. Here are some of the reasons why, that I continue to hear.

1) Weight loss is different than weight maintenance. If people want to lose weight, we should help them (because we know how to do that safely and effectively) and eventually, we will figure out what to do about maintenance.

Weight loss is different than weight maintenance. From a physics standpoint, which has little practical relevance when dealing with human beings as discussed in great detail here and a bit more simply here (see picture), one involves a caloric deficit and one a caloric equivalence. The problem is that, for all the complex reasons discussed in these pieces, no one has figured out how to help people not regain the weight they have lost. This is precisely why the results are so dismal.

It would be great if we could figure out the second piece - but so far - we have not. Subjecting people to weight loss programs without informing them of that fact is simply unethical and would certainly not be tolerated with any other medical intervention. From a practical standpoint, it would be like buying a lawn mower from someone who knew that it would only work until the first tank of gas was used up.

The solution here is straightforward. People have the right to participate in a weight loss program if they so desire. As with any medical treatment however, they also have the right to know up front what the most likely outcomes and potential negative consequences are going to be, from the research, not from the marketing department.

After 4 decades and hundreds and hundreds of studies, we are well equipped to provide them with that information. The Employee Health and Wellness Program Code of Conduct can serve as a model. Before agreeing to participate in any weight loss initiative, potential participants should be given the following relevant information:

“Research shows that the vast majority of people who participate in weight loss programs will eventually gain their weight back after the program ends. Many will also gain back more than they lose. The weight cycling that occurs with repeated participation in weight loss programs may have negative effects on their health.”

Straightforward and unambiguous. Anything less is simply unethical no matter how you feel about fat people or what you believe about the relationship between fatness and health.

2) We need to pay less attention to health (nutrition) professionals and go with “changemakers” like Oprah, Michael Pollan and Morgan Spurlock.

This is a version of a sentiment I see often on social media and elsewhere, usually made by people who are doing work for which they have minimal if any training or experience. It is quite often leveled at nutrition professionals. I have written about this issue in more detail previously. The sentiment echoes the dangerous anti-science, anti-truth atmosphere all too prevalent in our country today and makes little sense when seen through the lens of the bigger context of people’s lives.

My guess is that none of the people making these claims will have any trouble getting a score of 100 when asked to connect the appropriate letter answer with questions one through four in the following quiz:

1. To whom would you turn if you have an infection? _____
2. To whom would you turn if a loved one is suffering from depression? _____
3. To whom would you turn if you cat or dog was sick? _____
4. To whom would you turn if your car breaks down? _____

a. Psychologist and/or psychiatrist

b. Doctor or nurse practitioner

c. Mechanic

d. Veterinarian

And yet, these same people will argue that nutrition counsel can be given by someone with no training or experience (other than with their own eating behaviors, and perhaps having scoured the nutrition literature) as opposed to someone who has dedicated their life to working in the trenches with real, messy, complex, struggling human beings.

One health professional supported the contention by saying: “You don’t need to be a doctor to help people learn how to advocate for themselves and their health and their wellbeing.” Maybe not, but if you need surgery to save your loved one's life, I would wager that there would not be much question about “who you gonna call.” 

3) Body acceptance can be a good thing, but we don’t want to give people permission to live unhealthy lifestyles.

I hear this time and time again from people who are often commenting on the Health at Every Size (HAES) movement and its strong belief that being healthy at any size starts with acknowledging the right of people to inhabit and respect their bodies. The first response I want to give (which I don’t usually do) is – “who the hell do we think we are that we have the right to give people permission to do anything?” It is not surprising that most of the people making these kinds of accusations have read little if anything about HAES which is clear about the relationships between weight and health. And then of course there is what should be a very confusing reality to these folks. Their weight loss programs are more likely to do harm than improve health - and yet, somehow, they persist!

4) If people lose weight, it might help alleviate the stigma and discrimination that they experience because of their size.

Perhaps because it is so outrageous, this one is often couched in less than overt terms. But the bottom line notion is that weight loss can be beneficial, especially to kids but also to adults, because by getting smaller they will be able to minimize the stigma and discrimination they have experienced as a result of their size.

This is as disturbing as it is ridiculous. Imagine the suggestion that discrimination against people of color could be diminished with a large supply of white paint! Truly outrageous! The problem with discrimination lies with those doing the discriminating, not with those being discriminated against. The way to stamp out discrimination is to stamp out discrimination.

5) I know weight loss programs don’t work for almost everyone, but we must do something about “overweight” and “obesity” because they are such threats to our health.

This is perhaps the most common reason I hear. First, as we have already discussed, these labels are based on an invalid metric, so their meaning is suspect at best. Secondly, “overweight” individuals (in parenthesis for the same reason that "obesity" is) actually live statistically longer than “normal” weight people. Third, for “obese” individuals, we are not improving their health by subjecting them to weight loss programs that result in weight cycling and often weighing more than they did when they started. Yes, a few people may end up keeping their weight off, but what about the vast majority that do not?

The number that often gets bandied about in this regard is 5%. This means that out of every 100 people in any weight-loss initiative, only 5 will keep their weight off long term. While that number is depressing and difficult to quantify, there is significant evidence that it is an exaggeration - that the percentage of “obese” humans who are likely to get and keep their weight out of the obese range is much, much smaller.

So back to the need “to do something.” The bad news is, the research is clear that what we are “doing” is not resulting in sustained weight loss or improved health. The good news is that we now have approaches than can result in improved health, while minimizing the likelihood of iatrogenesis. More than 20 studies have now confirmed the positive impact of Health at Every Size Approaches, as a 2014 meta-analysis concluded:

“Studies that encourage individuals to eat intuitively help participants abandon unhealthy weight control behaviors, improve metabolic fitness, increase body satisfaction, and improve psychological distress. Results from our review favor the promotion of programs that emphasize a nonrestrictive pattern of eating, body acceptance, and health rather than weight loss.”

Take Home

As we move into the new year and review the research from the past 4 decades, we realize that until such time as the results of weight loss programs improve, we should stop subjecting people to them; or at the very least give them complete, transparent and informed consent beforehand. And especially for health professionals, we should become acquainted with and begin to promote HAES approaches that have been shown to improve the health of people of all sizes, while minimizing the negative consequences currently inherent in weight loss programs.

If you are interested in learning how to facilitate such a program at your workplace or in your community, feel free to check out our upcoming live, online Health for Every Body Facilitator Training - next session begins April 9.

Let’s make 2019 the year we put the BMI in the trash bin where it belongs, quit focusing on weight, and start focusing on wellbeing! As the Centers for Disease Control’s own journal put it recently:

“Rather than harming patients with stigmatizing measurements that limit our ability to have a productive relationship, let’s focus our precious clinical time on helping patients to engage in active lifestyles. The result may be better outcomes in patient health and patient trust and improved patient-provider relationships.”

Definitely A New Year’s Resolution worth making and sticking to!

Happy New Year! - Dr. Jon