by Barbara Berkeley, MD
It's been a message I've been repeatedly posting since 2008. That was the year when, frustrated to the max with a lack of attention to regain, I found the energy to write a book about it. My intention was to create support material for my patients and for other weight loss practices. I discovered blogging around the same time and started putting my perspective out on the internet.
In the intervening seven years there has been scant improvement in professional attention to weight regain. There has been no interest in looking at the issue from the point of view of the mass media and almost as little from the medical establishment…including obesity organizations.
I continue to object to the fact that our now ubiquitous obesity conferences focus almost solely on methods for weight reduction. With the exception of the National Weight Control Registry there are few professionals who are focused on the prevention of regain. Yet the problem is so glaringly obvious: the vast majority of successful dieters reaccumulate their fat. How can we continue to endlessly concern ourselves with creating an intervention that has absolutely no staying power?
Is there any indication that things are changing in this regard? A recent article in the British journal Lancet suggests that some doctors are at least willing to begin to state what would seem to be obvious.
The brief review from four doctors who are respected for their experience in treating obesity begins this way:
"Many clinicians are not adequately aware of the reasons that individuals with obesity struggle to achieve and maintain weight loss, and this poor awareness precludes the provision of effective intervention. Irrespective of starting weight, caloric restriction triggers several biological adaptations designed to prevent starvation. These adaptations might be potent enough to undermine the long-term effectiveness of lifestyle modification in most individuals with obesity, particularly in an environment that promotes energy overconsumption. However, they are not the only biological pressures that must be overcome for successful treatment. Additional biological adaptations occur with the development of obesity and these function to preserve, or even increase, an individual's highest sustained lifetime bodyweight".
In other words, those who deal with overweight patients basically don't get it. The body's desire to reaccumulate weight has strong biological underpinnings. When we blithely suggest that people "simply" restrict calories to lose weight, we are setting another force in motion: the powerful regain machine.
In a recent blog (When Public People Regain Their Weight), I used the analogy of a sling-shot. Here's a an exerpt:
Weight loss is not a slide downhill. It is not a journey that lands you in a new and different land. It is not a happy progression to a healthy place. It's not necessarily a cause for celebration. This is what it is.
Weight loss is a gradual triggering of the body's desire to regain. The more you pull, the more the body wants to return. My personal hypothesis is that this occurs because our bodies are completely unaware of how much weight we accumulate. On the other hand, our bodies respond strongly to weight loss and perceive it as threatening. These two characteristics fit with our ancient genetics. Humans evolved over millions of years during which fatness was impossible, so likely did not develop programming to combat it….or even measure it. By the same token, loss of weight from starvation or illness would have been highly threatening, so programs to reverse the process would have been vital. It is this programming that is causing the problem we face in the modern environment.
The Lancet article makes some vital points, particularly important because they are so rarely stated or defended. The first is that bodily changes appear to occur with increasing obesity and that these changes (like increased fat cell mass, increased addictive response to foods and others not well defined) persist after weight loss. The bottom line: these changes cause long term problems.
Second, the authors remind us that it is easier to correct weight when we are simply overweight. At this point, the problem may not yet have gotten a biological hold. But obesity is very hard to permanently defeat and the body's impetus for regain is much increased. This is of vital importance, because it strongly suggests that we should be devoting our strongest efforts toward encouraging overweight people to defeat the problem before they become obese. Perhaps we should change the overweight designation to "Pre-Obesity" as we've done with elevated blood sugars (Pre-Diabetes).
Third, this paper focuses on the importance of MAINTENANCE. Hallelujah! The authors also strongly defend the use of medications and/or surgery if needed to support long term weight control. Here is their advice to practitioners:
Inform patients of the challenges to weight-loss maintenance. Patients who achieve significant weight loss via lifestyle change are likely to become more metabolically efficient and will have to ingest up to 300 fewer (or burn up to 300 more) calories per day than someone of the same weight who never had obesity, just to maintain that weight. Inform patients that powerful biological mechanisms encourage weight regain and use of biologically based treatments (eg, drugs) is not a reflection of weak will.
The bolding of the last sentence is mine. If we are to understand obesity as a biological entity that appears in a toxic food environment, we have only two choices: treat the problematic biology or eliminate the food environment. Sometimes, effective treatment will have to combine both entities. What is most important is that we, as physicians, eliminate any shame or blame involved with using available therapies. This is a continuing problem, because our patients are just as brainwashed as we are about what causes obesity. In the deep recesses of their hearts, most of them (at least the ones I've treated) believe that they SHOULD be able to defeat the problem if only they could muster the strength. The persistence of the problem is felt deeply as a personal failure. Time to give this idea up completely!!
So what does all of this mean for you, the person who is actively trying to lose weight or maintain a loss? Here's my take-away:
1. If you are overweight, but not yet significantly obese, now is the time to tackle the problem and try to keep it under control by significant dietary change. (My advice as you know: adopt a 90% primal diet)
2. If you have struggled with obesity, strive to understand it scientifically. Keep up with the literature and with those of us who write about it. Recognize that your body has undergone changes which are akin to a chronic condition and that these changes will encourage regain.
3. Don't feel guilty one bit if there is an adjunct treatment like a medication or surgery that helps tamp down the problem. However, recognize that current meds are not very effective. There will be more coming down the pike. In the meantime, your best bet is continued participation in a program that teaches you how to eat in maintenance, continues to monitor your weight, and adds other therapies if needed. I still firmly believe that those of you who have lost weight and can adopt a diet that is devoid of (or very low in) grains, starches and sugars will find that many of the mechanisms which encourage regain are aborted.
4. Maintenance is where it's at, pure and simple. Clinicians, including those who wrote the Lancet paper, will tell you that a weight loss of 5-10% is medically significant. Personally, that bar is too low for me. If you have lost weight and are maintaining a weight of around 15% less than what you originally weighed, you are a superstar. This is true even if you originally lost 20% or more of your heaviest weight. Perfect maintenance is tough and rare. But excellent maintenance is something to be very much celebrated.
5. If you are struggling in maintenance, recognize that this is part of the relapse phenomenon that goes along with this "disease". Find the right moment to rededicate yourself to your efforts. Seek support.