by Barbara Berkeley, MD
Not to say I told you so, but this blog has been talking about the vital importance of studying and learning about successful weight maintenance since 2008. When I wrote Refuse to Regain that year, there was only one other book on the shelves that was focused on how to avoid regain after weight loss. Nothing much has changed. You still can't find any books on the subject.
Although maintenance is pretty much the whole ball of wax where weight loss is concerned, no one wants to write about it, talk about it, study it, or help people achieve it.
The field of medical obesity treatment has exploded in the last twenty years, but our professional journals and medical meetings still center mostly on weight loss and how to promote it. Our pharmaceutical companies continue to search for the magic weight loss drug. Our surgeons persist in inventing new techniques to create weight loss. Our populace continues to be in love with the idea of transformation through shrinking body size.
It's all so backward. As those of you who read this blog regularly already know, I believe that weight loss is meaningless without understanding the regain process. I also believe that our preoccupation with getting to a certain, small body size is misguided and ultimately harmful to those who are looking for permanent change.
With that said, the New York Times published a major story yesterday that has created a lot of buzz. Shocking! Incredible! How could it be??? The contestants on The Biggest Loser tend to gain their weight back!!!
This story prompted over 2000 comments (one of them mine, by the way) so obviously people are interested in weight regain. And why not? Regain is common, some might say ubiquitous. And if you read only this article, you might believe that it is inevitable and that you should give up on any efforts to get healthier.
That's my problem with this article and others the Times has printed. In 2011, the Times published a major piece called The Fat Trap. Again, the conclusion was that avoiding regain is pretty much impossible. No guidance or suggestions for how one might try to negotiate successful maintenance were offered.
The Biggest Loser article offers no helping hand to maintainers and takes an extremely pessimistic view of weight maintenance. About the nicest thing it says about maintenance is that weight gainers no longer have to feel guilty for regaining, because they now know it's all the fault of their biology.
But from where I sit, the Times article has a number of serious flaws. Perhaps these are flaws that might only be obvious to someone who reduces and maintains people for a living.
Here's a major one.
According to the Times, most of the 16 contestants have regained significantly...a "bitter personal disappointment", the article calls it. But it actually isn't true.
In fact, let's look at the actual outcomes of those profiled in the Times article six years after appearing on The Biggest Loser:
Danny Cahill: (portrayed in the article as a failure) Starting weight 430, current weight 295. Cahill is thus maintaining a weight loss of 130 pounds (or 31% original body weight).
Dina Mercado: Starting weight 248. Current weight 205.9. She's maintaining a weight loss of 42 pounds or 16% of original weight.
Sean Algaier: Starting weight 444. Current weight 450. Full regain.
Amanda Arlauskas: Starting weight 250. Current weight 176. She's keeping off 74 pounds or 30% of her original body weight!
Rudy Pauls: Starting weight 442. Had bariatric surgery because of regain.
Tracey Yukich: Starting weight 250. Current weight 178. She is maintaining a weight loss of 72 pounds or 28%!
Errin Egbert: Starting weight 263. Current weight 157 (lost more after the show was over when she weighed 176). She is keeping off 106 pounds or 40%!!!
Yes, there are some profiled here who put all their weight back on. On the other hand, others have done very nicely indeed.
Doctors and obesity specialists have long known that a weight loss of as little as 10% greatly improves health and risk factors. We also know that obesity programs are thrilled to get a 20% weight loss in most patients. You can see that a number of the people profiled in this article and characterized as failures are actually maintaining highly significant amounts of weight loss.
To give you a further reference point, the professional association of bariatric surgeons defines successful surgical weight loss as loss that is equal to or greater than 50 percent of excess body weight." (Note the underlined language Surgeons measure success by percentage of excess weight that is lost. This differs from the way that medical docs measure weight loss: which is by percent of total body weight lost).
If we look at Tracey Yukich above, we'll see that she is actually maintaining a 'surgically successful' degree of weight loss. How so? If her starting weight was 250 and we assume that her ideal weight was 140, she had 110 pounds of excess weight. 55 pounds of loss would have qualified her for the 50% loss of excess body weight that is considered a success, but in fact she is keeping off 72 pounds. In other words, had she undergone bariatric surgery, the degree of weight loss she is currently maintaining would have made everyone happy. Not exactly a failure.
Gaining some weight back after a large weight loss is very normal. Keeping off significant amounts of what was lost is difficult---but as we see here----it's not impossible and we shouldn't suggest that it is. The Times article mentions that most contestants don't have access to dietitians, trainers and weight loss specialists once they leave the show. Maintainers generally do better when they have support. But even without this suppor, many of the profiled contestants are actually doing very well at six years out.
A fundamental problem in the Times article (and for society in general) is an unrealistic and incorrect expectation for weight maintenance. Success does not mean keeping every pound off. People who lose weight and are able to keep off a medically significant amount are successes, NOT FAILURES!
A second significant problem with the article is the assumption that metabolic and hormonal measurements taken from this small group are applicable to others who have lost weight. The rapidity of weight loss and extreme nature of intervention on The Biggest Loser leads us to suspect that these subjects may, in fact, be very different from others. Perturbations in metabolism might well persist for a long time. We simply don't know. As a point of reference consider this: winner Danny Cahill lost what the Times calls "an astonishing 239 pounds in 7 months". Simply put: This isn't astonishing, it's insane. Our practice benchmark for safe weight loss is 50 pounds in six months and 100 pounds in a year. What occurs metabolically to someone who forces his body to lose at the pace that Cahill did is anyone's guess. In my opinion, it is beyond lucky that The Biggest Loser has never had a tragedy.
And here's a third issue. There may be ways around a slower metabolism---even if someone does develop one. In our patients, a significant decrease in carbohydrate consumption during weight maintenance makes the difference. Weight gain and hunger are modulated by a number of factors, but insulin---the hormone that pours forth in response to carbohydrate---is a major player. Keeping insulin at bay with a lower carb diet depresses hunger and fat storage. Our patients who adopt a more primal diet which is low in sugars and starches do well in maintenance. Combined with behavioral strategies to reverse small regains, a good amount of physical activity, ongoing support and an assiduous avoidance of addictive foods, we have a good recipe for successful maintenance without ever worrying about metabolic rate.