Why do doctors weigh patients and offer weight loss advice? Other than “eat less and move more” which is kind of like the weight loss equivalent of “buy low and sell high,” what recommendations do they make and why?

I’ve wondered about this before. See Well-intentioned lies and doctors and concluded that,

Doctors shouldn’t prescribe weight loss to overweight/obese patients, especially not without mentioning the long term likely effect. Would we recommend any other treatment with these odds of success? Medical professionals should spend more time emphasizing weight maintenance. Second, especially if you’re a normal weight or overweight person, the last thing you should try to do is lose weight. That looks like a clear fast train to getting fatter.

Here’s the more interesting question, if doctors know this, why don’t they act on it? Here is my guess at an answer. Doctors hate problems they can’t solve. I saw that when they were dealing with a family member with incurable illness. They want to hold out hope.

So that’s part of it. Doctors are also human and reason as everyone does. The simple mathematical model of “eat less, move more” seems obviously true. Weight loss looks like just simple math plus will power. How could it go wrong?

Finally, doctors also know that healthy eating does matter and so too does exercise. Indeed a recent study in the British Journal of Sports Medicine concluded that  for women and heart health exercise matters more than any other factor including obesity. (See Study: Exercise Trumps Body Weight When It Comes To Women and Heart Health.) Doctors fear that without the promise of weight loss, no one would be motivated to eat well and stay physically active. As the article about the impossibility of weight loss says, “Health experts are also afraid people will abandon all efforts to exercise and eat a nutritious diet — behaviour that is important for health and longevity — even if it doesn’t result in much weight loss.” But I worry that this reasoning gets it exactly wrong. People aren’t idiots. Tell them to exercise and eat well in order to lose weight. What happens if they don’t lose weight? They’ll quit exercising and quit eating well. That’s because you told them to do it to lose weight. And clearly it wasn’t working so why stick with it?

I’ve written about this recently. See If inactivity matters more than weight, why the focus on the scale?

And then there’s a great letter in the British Medical Journal here, Why there’s no point telling me to lose weight?

I am one of over 97% of people for whom dieting does not lead to sustained weight loss.1 2 3

I’ve experienced health benefits from increased exercise, and from switching to a wholemeal vegetarian diet. My blood pressure’s normal, as are my fasting glucose and my lung function—as far as I can tell, my health is great. But my body mass index (BMI) has been above 30 my entire adult life.

When I worry that I might be unwell, I often try to avoid visiting a general practitioner. Almost every consultation I’ve ever had—about glandular fever, contraception, a sprained ankle—has included a conversation about my weight; and that’s inevitably the conversation that destroys any rapport or trust that might have existed between me and my doctor.

Fighting “the obesity epidemic” is supposed to be about making me—as a “severely obese” person—more healthy; but the impact of obesity rhetoric on my life has been quite the opposite

Go read the whole letter. It’s great.

And now there’s this, from doctors themselves:

Expecting all obese people to lose weight solely by “eating less and moving more” misunderstands the nature of the condition and will never solve the obesity epidemic, leading doctors have said.

In a staunch rebuttal to commentators who argue obese people have brought the problem on themselves and should rely only on diet and exercise, experts from leading American universities said that, even after actively losing weight, biological mechanisms kick in that make it extremely difficult for previously obese people to stay a healthy weight.

Writing in The Lancet, they say recommendations just to cut back on high calorie foods might be “no more effective for the typical patient seeking weight reduction that would be a recommendation to avoid sharp objects for someone bleeding profusely”.

Thing 1. The Dangers of the Appearance-Driven Diet

Researchers from the Netherlands published a study in the January 2015 issue of the Journal of Experimental Social Psychology that suggested that focusing on appearance could affect a person’s sensitivity to their internal satiety cues.

“We found that focusing on how you look may hinder how you listen to your body’s hunger fullness cues and how you adjust your food intake,” said Evelien van de Veer, the paper’s lead author.

Makes sense to me. We’re in favour of athletic rather than aesthetic goals, about what our bodies can do, rather than what they look like.

Thing 2. Things you might not know about fat loss

Most of our readers engage in a distinctive combination of cardiovascular conditioning and resistance training; as such, it places an incredible strain on both your central nervous and musculoskeletal systems. While acute bouts of stress are necessary to trigger positive adaptations, chronic metabolic stress kills progress as it relates to body composition. As an athlete, you are infinitely better off keeping your Calories higher so you have the materials and energy necessary to recover from your training, especially when you first start off. Don’t fall into the trap of eating chicken and broccoli every day because conventional wisdom says it’s “healthy”.

I’m interested in this because I’ve been thinking lots about difficult it is to lose weight and the assumption that you can just achieve that goal by moving more and eating less.

Thing 3. Social embeddedness in an online weight management programme is linked to greater weight loss

The obesity epidemic is heightening chronic disease risk globally. Online weight management (OWM) communities could potentially promote weight loss among large numbers of people at low cost. Because little is known about the impact of these online communities, we examined the relationship between individual and social network variables, and weight loss in a large, international OWM programme.

Take note Precision Nutrition folks. Online friendships help!

Thing 4.  A memory trick to lose weight

Dieters often feel that they are waging war with their stomachs, but psychologists like Robinson believe that appetite is formed as much in the mind as our guts. So much so that if you try to remember the last food you’ve eaten, thinks Robinson, you can get thinner without the hunger pangs.

“Lots of research has now shown that subtle psychological factors can impact how much you eat – but people still aren’t aware of the influence,” he says. “And that’s important, given the worldwide obesity problem.” If this is true, how could it work?

I’m curious about the limits of intuitive eating about whether there are different ways of responding to hunger cues.
Lots to read out there and lots to think about!

I’m asked that question a lot these days. It’s that time of year, I guess.

I’m also spending time with a bunch of performance oriented athletes with race related reasons to want to weigh less.

I’m never sure what to answer.

The easy answer is this: Yes, yes I do.

On the one hand, I’ve been reassured by an endocrinologist that I have no health related reasons to lose weight. For whatever reason–healthy eating, lots of activity, or just plain genetic good luck–I’m in great shape healthwise by the usual standard measures.

One the other hand, we live in a world with pretty strong anti-overweight bias. While my self-esteem is pretty secure (see here and here), I do worry sometimes about the external effects. I’m pretty sure it hurts my teaching evaluations. Research also shows that being overweight has a financial impact.

And finally, there’s hills. And it’s harder to run fast when you’re larger. And pull ups. I’d love to be able to do an unassisted pull up.

So yes, I want to lose weight.

But wanting something doesn’t make it so.

I’d also like a million dollars, world peace, an end to global warming, and a second job in a warmer climate for the winter months. Oh, and nice boots that fit over my thighs.

And unicorns, and rainbows, and puppies…you get the idea.

If you’ve been reading the blog awhile you’ve heard lots about my weight loss journey:

• Fat, fit, and why I want to be leaner anyway
• Weight lost and gained
• Questions and quibbles about impossible weight loss
• Fit, Fat, and What’s Wrong with BMI
• I hate you Weight Watchers

So there’s things I’d love to have, better eyesight!, and things I can actually control to some extent, like my training and my nutrition.

I can control what I do. I can’t control the results.

It’s January and the group I cycle with is holding a “healthy weight loss challenge.” They’re ruling out extreme dieting. The goal is to get to racing weight by the time of our March training camp. Will I take part? Maybe.

But for me becoming thin, forget racing weight, isn’t likely on the agenda. I’ve never been thin. Even at my lightest (I wore a size 10) I was overweight by the standard measures.

Luckily, I’m a strong believer in the Healthy at Every Size  approach to life.

Health at Every Size is based on the simple premise that the best way to improve health is to honor your body. It supports people in adopting health habits for the sake of health and well-being (rather than weight control). Health at Every Size encourages:

• Accepting and respecting the natural diversity of body sizes and shapes.

• Eating in a flexible manner that values pleasure and honors internal cues of hunger, satiety, and appetite.

• Finding the joy in moving one’s body and becoming more physically vital.

So yes, I eat well, I track what I eat, and I try to make better choices. I follow the main precision nutrition habits. I’ll likely spend more time with my Lean Eating buddies on Facebook. (Our group from our 2013 class is still very active. Go Team Switch! We archived all the PN materials and we continue to reuse them.) If that results in weight loss, then fantastic. I’ll be thrilled. If it doesn’t, I’ll keep on moving. Because that’s what I love best. It’s a good thing. It would be sad thing to have my sights set on being a weight loss unicorn.

Why? Because when it comes to the long term, they’re both equally bad.

You might decide you want to lose weight anyway. I’ve got some hills I want to climb on my bike. Maybe you’ve got some health reasons that make losing weight even in the short time worthwhile. I wouldn’t recommend losing weight for a high school reunion or a wedding but I wouldn’t judge you for it either.

A recent blog post looked at a new study that showed slow, gradual weight loss and speedy, dramatic results style weight loss had the same effect long term. No matter how you lose it, small changes in habits or drastic measures, the weight returns for most of us. It’s not even the case that weight lost slowly comes back slowly and weight lost quickly comes back quickly.

Mainstream media instantly declared it a victory for Team Speedy.

How so?

Well, in recent years the tide has turned against quick weight loss. The claim was that quick weight loss just leads to quick weight regain. It was thought that slow gradual weight loss, with a lifetime change in habits, had better long term results.

And you can see how the reasoning goes. With long, slow weight loss you have time to consolidate the changes. What was once strange becomes the new normal. The slow losers seem to have taken the moral high ground. They can be anti diet and lose weight the right way.

I confess that I’ve been judgemental about friends who set out to lose weight quickly, whether it’s on the Tim Ferriss diet or the more usual extreme low calorie plans. I’ve also touted gradual habit change over quick fixes.

After all, it sounds so sensible. Give yourself time to make the new habits stick. It’s not a diet, it’s a lifestyle change, blah blah. But here’s something about that that’s never sat quite right with me.

Here’s the thing: I don’t think weight regain is about necessarily going back to your old ways and having old habits creep back. It hasn’t felt that way to me when I’ve regained weight. Indeed, I’ve tracked and counted and weighed and measured all the while gaining weight.

See Weight lost and gained where I talk about the idea of habits and weight loss maintenance.

While debate exists about how many people regain weight they’ve lost (let’s just say most, or lots), how much weight they regain (all of it or more) and how long it typically takes to regain weight (certainly within five years pretty much everyone will have gained it back), no one denies that keeping weight off is much, much harder than losing it in the first place.

When people talk about weight regain one thing they often say, which I think is mistaken, is that people regain weight because they give up the restrictions and go back to their old habits. As Ragen Chastain says, “The myth goes that almost everyone fails at weight loss because almost everyone quits their diet and goes back to their old habits/doesn’t have the willpower to keep dieting/doesn’t do it “right”” But that’s not what the evidence says. People have a hard time keeping the weight off because their bodies have changed.”

This recent study isn’t the first evidence against the claim that slow weight loss is better than fast.

I asked about our preference for slow weight loss in an earlier post, questions and quibbles about weight loss:

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.

What this means is, it’s up to you.

If you decide it’s worth it to lose weight for as long as you can keep it off, it’s up to you how you do that. Slow and gradual sounds more sensible but if you prefer the “pulling off a band aid” method then go for it.

I’ve had experience with both kinds of weight loss this past year. I did the Precision Nutrition online nutrition counseling program for a year and lost 15 lbs during our run to up to “fittest by fifty.” Then the year went badly wrong with two deaths in the family and I regained most of the weight I’d lost within a couple of months.

Lesson learned, weight lost slowly can be regained pretty quickly. Also, death changes everything.

But then the summer cycling season hit and my significant other decided time on the bike was excellent grief therapy. I rode 1300 kms in July and the weight dropped off quickly. Zoom! Speedy weight loss.

Normally I get off the bike starving so that never happens but I’ve also gotten better about eating a lot on the bike and so now that happens less often.

I’ve also given up my belief that slow and steady is necessarily better than making progress in hard, fast bursts. I should have known that. On the bike, I’m a better sprinter than I am endurance athlete. Maybe that’s the case with weight loss as well.