Questions and quibbles about impossible weight loss

Balance scale
Henry N. Hooper and Company (ca. 1831–68)

The impossibility of long term weight loss success was in the news again last week and it made its way into this blog despite our view that body weight and fitness aren’t connected in the way many people think. Certainly I’ve been fat and fit and thin and woefully out of shape. In my life they’ve been different things, thinness and fitness.

Read last week’s posts for my analysis of why doctors mislead patients about the reality of weight loss, and in particular, about the reality of maintaining it, and my thoughts about what weight loss unicorns, those rare people who do keep the weight off, have in common. Tracy also blogged about her ongoing experiences with Precision Nutrition’s Lean Eating for Women program and how the “news” that long term weight is close to impossible made her feel.

My weight loss story:

I thought I was a fat kid. Looking back, I think I was a pretty normal sized kid who thought she was fat. I joined Weight Watchers in grade six, read about that here, and began a period of getting skinny and looking good all the while living on coffee and cigarettes. I was in horrible shape but I was a teenager and I looked great. It was the 70s. What can I say?

Enter feminism and university, the 80s, punk aesthetic, and an avowed rejection of mainstream beauty standards. I got a sort of gentle mohawk and dyed my hair pink and purple. I wore a lot of black. I also gained weight. By the start of grad school I weighed 235 lbs. When I stepped on the scale and saw that number, I was shocked. I was having a hard time finding clothes that fit. No wonder, I thought. I was a solid size 16 but clothes that size were in regular stores. The next stop would have been plus size fashion and it felt like enough was enough. I took up weight lifting, added some cardio, quit smoking, pretty much quit eating, and in the course of an academic year lost 80 lbs. I was twenty four.

I haven’t kept clothes from either high school or skinny me grad school with two exceptions. Can you guess? Probably you can. I kept my prom dress and my wedding dress, neither which even fit my kids as Halloween costumes. They looked impossibly tiny. Finally, a couple of years ago, I send both to a thrift store/charity shop. Enjoy some other/not me skinny person!

By the time I was 34, I had a PhD, three children, an academic job, tenure and had regained all weight I’d lost in grad school. It was the late 90s.

Coming up to 40, I became department chair, took up running, hired a personal trainer and made it back to 165 lbs. Lower than that never tempted me. I was a size 10. Though technically still overweight, I could feel my ribs and my hip bones and I felt skinny. Certainly I had skinny face!

Now with the fittest by 50 challenge coming to a close, I’m thinking again about weight. I’m not back to my highest weight but I wasn’t able maintain 165 either. I’m about halfway in between these days.

As a very active but larger person (or fat, whatever) with a pretty good health and fitness profile I wonder lots about weight, size, destiny and biology and here are some questions that I’d like to ask an obesity researcher if we had a long flight together to chat. (I’m thinking about that because I’m writing this on a flight between Toronto and Los Angeles.)

My weight loss questions:

1. What’s better in terms of losing weight and keeping it off, slow weight loss or fast weight loss? The common sense view is that it’s better do it slowly, that too restrictive a diet sends your body into starvation mode. But commonsense isn’t always right and though I like the common sense view, recent research casts some doubt on it.

But see 4 days, 11 pounds in the New York Times.

Losing weight is simple: Ingest fewer calories than your body burns. But how best to do that is unclear. Most experts advise small reductions in calories or increases in exercise to remove weight slowly and sensibly, but many people quit that type of program in the face of glacial progress. A new study, published in March in The Scandinavian Journal of Medicine & Science in Sports, suggests that minimal calories and maximal exercise can significantly reduce body fat in just four days — and the loss lasts for months. The catch, of course, is that those four days are pretty grueling.

In a study, on men, of course, a group of test subjects worked out a lot (8 hours a day) and ate next to nothing (just 360 calories a day) but 4 days. Of course, they lost a lot of weight but what got the researchers attention was that it stayed away.

More surprising, the men did not immediately put the weight back on after the study ended. “We thought they would overeat and regain the weight lost,” Dr. Calbet says. Instead, when the volunteers returned a month later, most had lost another two pounds of fat. And a year after the experiment, they were still down five pounds, mostly in lost body fat.

See also Seven Dangerous Myths about Weight Loss.

“There’s no reason to think that slow, gradual weight loss is better over the long-term compared to losing lots of weight fast. A pooled analysis of randomized clinical trials that compared rapid weight loss and slow weight loss (or, to be more precise, extreme diets and less grueling ones) found that though the extreme diets resulted in the loss of 66% more weight (16% of body weight versus 10% for the regular diets), there was no difference at the end of a year.”

That’s reporting on research in “Myths, Presumptions, and Facts about Obesity,” by Krista Casazza et al, New Engl J Med 2013; 368:446-454, January 31, 2013.

2. The commonsense view also says it’s really bad to regain weight. So bad that you ought never have lost in first place. You’re setting yourself up for a lifetime of yoyo dieting and ruining your metabolism. But how true is that? How bad is regaining weight if it happens slowly, over time? Yes, it’s depressing and demoralizing but is it bad from a health point of view?

This question has bothered me so much that I’ve set out to find out answers. I’ve looked through Google scholar and started reading way outside my field of research expertise. No clear answers emerged. If you’re reading and you’re an obesity researcher and you know the answer, please email me.

My experience is that of regaining weight over the course of years, not months. Did my health benefit from those years at a lower weight? The weight crept back on for sure but kind of the rate of a pound a month, or less.

Suppose I only do the complete up down cycle three times my life, would i really ir have been better off at a consistent but high weight? That doesn’t seem obviously true to me.

Suppose too that my low weight keeps changing, getting higher, first 155, then 165, and maybe next time 175. And my high weight on the up cycle gets lower. First 235, then 225, now 200. Maybe eventually it’ll settle somewhere in the middle as the ball’s bounce diminishes.

I think that on my optimistic days!

3. What counts as success? Suppose I only ever regain half the weight I lost. Is that success or failure?

Yoni Freedhoff commented on the blog saying there were lots of unicorns in a study he’d written about.

“There sure were a boatload of unicorns 8 years after the Look AHEAD trial began – even among those with the most minimal of interventions:”

I trundled off to look at it and saw was measuring something different. Writing about the study on his blog Freedhoff says, “It’s quite heartening to see that after 8 years, for 35% of the DSE control group, 3 1-hour group talks a year were sufficient to help fuel a sustained weight loss of 5 percent or more of their presenting weight, and for 17% of them, enough to fuel and sustain a greater than 10 percent loss. ”

There are at least two different ways to measure long term weight loss success. We can focus on those who maintain a goal weight or on those who maintain a weight loss of just five or ten percent of their starting weight. By that more easygoing measure, I’m in, I’m a success story. Lots more people are in even if we don’t typically think of only losing 5-10 percent of your body weight, a weight loss success story.

Call the people who meet standard 1, getting to goal and staying there, the unicorns. They are rare. Far more common are people who meet standard 2, exotic but not unfamiliar. Call them the weight loss alpacas. I’m a weight loss alpaca! (I’ve got a soft spot for alpacas.)

Animals and mythical creatures aside, the point here is a serious one. Let’s think about success a bit differently. There are tremendous health benefits that come with some pretty small weight losses. Even bariatric surgeons are starting to think in terms of small differences in weight instead of unsustainable weight loss miracles.

Rethinking success is part of Freedhoff’s pitch too. He writes, “What I’m getting at is that I think what makes maintaining weight loss seem “almost impossible” are the goal posts society has generally set to measure success. No doubt, if the goal set is losing every last ounce of weight that some stupid chart says you’re supposed to lose then the descriptor “almost impossible” may well be fair. On the other hand, if the goal is to cultivate the healthiest life that you can honestly enjoy, subtotal losses, often with significant concomitant health improvements, are definitely within your reach. ”

4. Is all obesity alike? Catherine Womack and I have chatted about whether there are medically significant different kinds of obesity (her suggestion). You know that there’s conceptual cleaning up to be done, of the sorts philosophers love, when medical researchers start talking about “thin fat” people and metabolically healthy obese people. It seems clear that these weight categories aren’t doing the work we need them to do. “Thin fat person?” What the heck is that? Oh you mean a metabolically unhealthy thin person. Then why not say so and leave weight out of the picture?

There’s far too much running together of various health problems with various numbers on the scale, with seemingly little awareness about the ways in which the two might be linked (or not).

So, lots of questions. I’ll keep reading and thinking. But for now, back to fitness!



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