Tuesday, April 22, 2008

The politics of weight control

In doing research for my last post, I happened to come across an article written by Joanne Ikeda and her colleagues (1), critiquing the National Weight Control Registry program. Ikeda is a member of the board of directors of the Association for Size Diversity and Health, which promotes the Health at Every Size program. Their paper recycles the claim (twice) that 95% of persons who lose weight regain it (without providing any references), and basically makes the argument that since weight loss efforts are generally futile, HAES should be promoted instead of weight loss.

This is an argument that has been picked up by many in the Fat Acceptance movement, and I can understand their motivation. After all, if you say that significant permanent weight loss is impossible, then obese people are not "culpable" for their obesity, because it is utterly beyond their control. And if you say that it is possible, then you can rightfully accuse obese people of sloth and gluttony, right?

Obviously, I'm utilizing some hyperbole here, so you can probably tell that I personally don't agree with these viewpoints. I think the evidence strongly suggests that some people can lose weight permanently and others can't. It may even be the case that some people are able to lose weight at certain times in their lives and not at others. And it's impossible to make a judgement about any one individual's ability to lose weight.

So, I don't agree with the FA movement when they say that nobody should try to lose weight. And I don't agree with fat bashers who say that all obese people should try to lose weight. Having a "normal" BMI takes a different amount of effort for everyone, and people should be left to make their own decisions about how much energy to invest in regulating their body weight without being judged or criticized by others (except, obviously, in extreme cases involving eating disorders).

And I hope people will feel free to share their own views on the matter in the comments...

1. Ikeda J, Amy NK, Ernsberger P, Gaesser A, Berg FM, Clark CA, Parham ES, Peters P. The National Weight Control Registry: A Critique. Journal of nutrition education and behavior 37: 203-205, 2005.


Jodith said...

The reason I support HAES is that it takes the judgementalism out of obesity. Doctors encourage you to exercise and eat more healthily, but they rely on only weight as a measurement of goal attainment. A fat person can tell their doctor truthfully how much they eat and how much they exercise, hand over their painstakingly kept diaries, and have the doctor totally discount their efforts because they haven't lost any weight.

One day, I just decided that I wasn't going to worry about weight any more (long before HAES hit the scene). I tossed my scale in the garbarge and the only time I weigh is at the doctors office. If I've lost or gained weight, I don't really care. I'm healthier than I've ever been in my life, I'm more active and more involved in life in general. If the doctor doesn't like my weight, he can damn well keep his opinions to himself. We can discuss lifestyle changes, but we will not discuss weight.

G.G. said...

I wanted to thank you for the last couple of posts, since I had asked for your opinion on the subject. What you're describing kind of sounds like a common sense approach to the whole thing, which is refreshing. It's difficult for me to get on board with the true believers in either camp. It makes sense to me that people can acheive permanent changes in their bodies with hard work and determination, and it makes sense that in every situation there may be important factors beyond an individual's direct control. I think, when it comes to the realities of weight control, there's got to be some sort of balance between biological determinism and the blind assignment of personal responsibility. Of course, I'm no scientist.

Karen said...

The idea behind HAES is that you should create a healthful lifestyle. That weight loss in and of itself is a cosmetic procedure, and that the major determinant of health is a healthy decisions such as proper nutrition and regular enjoyable exercise. If such lifestyle leads to weight loss, fine, if it does you still have a healthy lifestyle.

Most people with Fat Acceptance reject the need for cosmetic weight adjustment, not the usefulness of produce and exercise in maintaining your body.

Dr. LaWade said...

Karen, as I have described in previous posts here, the HAES program has failed to show consistent evidence of improvement of physical health among its participants (though it does appear to improve self esteem). There is ample evidence, however, that weight loss improves physical health in obese people. So I don't agree that weight loss is merely cosmetic.

Committing to long term weight loss, however, takes a tremendous amount of effort, with inconsistent benefits from person to person, so I completely understand and appreciate that everyone has to decide for themselves how much time and effort they want to channel into weight control.

What I object to is people (one of the HAES founders among them) criticizing the very idea that anyone should try to lose weight because it is not feasible (based on bogus statistics).

Jane Doe #4 said...

"There is ample evidence, however, that weight loss improves physical health in obese people."

Is there? Or is there ample evidence of a correlation between weight loss and improvement of other health markers? Are there any studies you're aware of that (a) demonstrate that the improved risk factors/outcomes associated with weight loss are not present or present to a lesser degree in individuals who receive the same intervention (dietary changes, exercise, drugs, whatever) but don't lose weight, AND (b) somehow exclude the possibility that the improvement is actually caused by some other factor (genetic, metabolic, etc.) that also determined why some people lost weight with the intervention and some didn't? That is, it seems possible to me that there is some underlying physiological difference between people who lose weight with Intervention X and people who don't, and that that physiological difference, rather than the weight loss itself, could account for the difference in outcomes. I have yet to find a study that provides evidence one way or the other on this.

One type of study I can imagine that might help answer that question is a study of people who have had significant amounts of adipose tissue surgically removed (e.g. by liposuction). If reducing the amount of adipose tissue in one's body by brute force, as it were, led to similar health improvements as those attributed to weight loss through diet/activity changes, that would be pretty striking evidence that it's the weight, not the behavior or one of the physiological links between the behavior and the weight, that makes the difference. I'm not aware of any such study, but maybe it's out there, and/or maybe there are other lines of evidence out there that I'm not aware of.

To come back to the broader point, the more I look into it, the more I think the science/medicine of weight control is a lot less certain than a lot of people (physicians and scientists included) would like to believe. HAES then starts to look to me like just a more cautious, let's-not-jump-to-conclusions response to this uncertainty than the mainstream weight control paradigm. As a somewhat cautious person by nature, HAES appeals to me on those grounds.

Also, your own literature review a couple of posts ago found "success rates" for weight loss ranging from 2% to 20%. Even if the 5% statistic is bogus, 20% isn't really a runaway success rate either. I can see how reasonable people might vary in how much burden they're willing to take on for a 20% chance of reducing future health risks. HAES does neatly sidesteps this issue, and therefore might make a lot of sense as a public health/health promotion strategy. In an individual patient-doctor relationship there may be other equally good or better strategies for dealing with it (e.g. individual setting of goals congruent with the patient's values, which may include weight loss for some patients and not for others).

Dr. LaWade said...

Jane, the literature is too vast for me to delve into in the comments here, but there are many studies, including surgical studies involving the removal and addition of fat, that show that weight loss (actually fat loss) improves health parameters independent of diet and physical activity. These include insulin sensitivity, immune function, and various endocrine parameters. Someday soon I'm going to get to that post...

Jane Doe #4 said...

I'll be interested to see that post whenever you write it. And sorry for writing you a novel in the comments! It's a line of questioning I've been developing for a while but never before had the opportunity to ask someone who might actually know.

Girth-Watching Matt said...

Define "normal" - I dare ya'.

we say "this person ain't normal" or "that person is not normal" but the truth is there is no such thing as normal.

There are just people in every size and shape you might imagine.

Anonymous said...

Weight loss happens but it's really rare to see people keep significant amounts of weight off long-term (more than a few years). If you look retrospectively and compare it with smoking, long-term "success" rates are about an order of magnitude worse for weight loss than for smoking cessation, even when you define smoking success by stringent standards (e.g. going from a pack a day for ten years to quitting for ten years) and weight loss success by modest standards (keeping off just 5 or 10% of greatest weight ever for the same amount of time) and even if you include people who have bariatric surgery, illness or just don't adjust for unintentional weight loss.

And as you define success - achieving "normal weight" - for obese people anyway - you're talking probably two (and for the very fat three) orders of magnitude more rare than long-term smoking cessation.

As for health effects. Yes there's some data that links a decrease in weight (particarly small amounts) to at least short-term changes in various risk factors (though not much that I'm aware to actual morbidity), but most of these studies are not randomized, and difficult to demonstrate what the long-term impact on health or longevity will be.

Studies that look at the bottom line - overall mortality rates for people who "successfully" lose weight typically show higher mortality rates for people who lose significant weight - even when you do your best to adjust for unintentional weight loss, discounting mortality within the first *eight* years, smokers, etc. The lowest mortality rates are almost invariably for people who maintain stable weight.

This is not some incomprehensible counterintuitive result - people who lose weight lose lean mass, plus they face an array of physiologic changes pushing them towards a positive energy balance (e.g. a starvation response) which appear to be long-lasting, and there's no reason to assume couldn't negatively impact their health. Plus the positive effects you mentioned are mainly linked to metabolic syndrome, but there's the whole issue of the obesity paradox(es) where higher weight appears to have beneficial effects in certain populations and for certain conditions. And reducing your BP for however long, or your triglycerides, or improving insulin resistance may or may not be offset by these other effects.

On top of all of which weight cycling - weight loss and regain - which is by far the most common result of weight loss attempts - has been linked to its own deleterious effects metabolic risk factors that you're claiming weight loss is good for. Not in all studies, but certainly in more than a few.

I'm not saying that weight loss is necessarily bad - there's lots of room for debate - I'm just saying that the data that long-term weight loss is "good" for you (were it even common) is underwhelming and is at least equalled (and in my estimation surpassed) by the data that suggest it may not be so good for you - at least given the technologies and methods available to us. I'm happy to leave open the possibility that as technologies change, the data may change. But we're not there yet. We're in the real world. And in vivo, not in vitro.

Also, from a do no harm perspective, HAES doesn't have to show that it improves health (even were anything like the resources being put to researching its effects as have been put to finding good effects for weight loss). It's not an intervention, it's a conservative resistance to intervention given the absence of sufficient data showing that intervention (attempting weight loss)is both safe and efficacious.

Because if you're proposing an intervention for hundreds of millions of people - if you're not only proposing it, but going to people's schools and employers to bully them into it - if you are (as they are in Japan) fining companies whose employees fail to do it, or refusing surgeries (as they are in the UK) to people who don't do it, or suggesting that kids whose parents fail to do it be removed from their homes...your evidence had better be rock solid that your intervention is *both* safe and effective. And that evidence isn't there. Not by a longshot.

And I've barely touched on the cultural context. The way this war on obesity has been waged has been utterly reckless - seemingly willfully oblivious to its effect on stigma and the social welfare of the people it proposes to want to help. It's like what happened to gay men at the beginning of the AIDS epidemic squared. And worse - people who are fat are eminently visible and almost completely without legal protection.

How can the anti-obesity warriors possibly believe they'll improve our health? The "solutions" that are being suggested now are the same ones that fat people were trying throughout the decades during which weights started climbing. Already the overwhelming majority of the "obese" either have tried to lose weight or are actively trying. They don't need more "education." Certainly not the mythologies about weight loss that typically pass as education.

Let's not kid ourselves. We're not educating fat people to be thin, we're educating the culture to discriminate against them. And the most likely effect of all of this won't be health. It'll be the amplification and institutionalization of stigma, and the enrichment of industries which prey on their increasing desperation.

wriggles said...

This is an argument that has been picked up by many in the Fat Acceptance movement

It is not an argument, it is a statistic, if you think it's wrong, correct it, explaining why 'obesity' is not going down.

...if you say that significant permanent weight loss is impossible

95% is not impossible, it is highly improbable, this is consistent with the fact that WW started in your country in 1945, in this country in about 1968, no reduction in fatness has occured. When something fails to achieve it's aims, it is called a failure, you have to explain, why the almost total absence of success = success.

obese people are not "culpable" for their obesity,

It's not a question of culpability or blame, I don't care if you blame me for my 'obesity' or not, I'm just telling you whether we become fat, achieve fatness or have it thrust upon us, diets still fail the same way.
But if it makes you feel better to blame me, then go ahead, I still cannot order my biology to do what is required if it cannot do it that way.

IOW I am fully responsible and accountable for my actions, but I did not design my biology, therefore I have to take note of how it actually works, not how other people tell me that it works.
I think the evidence strongly suggests that some people can lose weight permanently and others can't.

The fact is anyone can and does lose weight, those of us who have experienced years of daily weigh ins know this, the issue is not people, or will, it's biology, the overwhelming majority of people will regain the weight they lose, at some point, a small number don't, that is due to statistical probability, we don't know why they succeed, anymore than why the body can shed weight with consumate ease, except when we choose to diet, go figure(it's
your job isn't it?)

....it's impossible to make a judgement about any one individual's ability to lose weight.

It's entirely possible over the wholesale experiment on the public for the latter half of the last century shows it clearly, the results are in already, open your eyes.

I don't agree with the FA movement when they say that nobody should try to lose weight.

The fat acceptance movement as a whole is not saying no one should lose weight, FAM says statistically and healthwise diets are bankrupt. If you can find a way that actually works and doesn't compromise health, I'm sure FA will be as varied in it's response as any group of randomn people. Dieting clearly isn't it, no matter how much anyone wants it to be. That's common sense.

Having a "normal" BMI takes a different amount of effort for everyone,

It isn't about effort, it's about dieting or lifestyle change or whatever euphemism you want to use for diets, being a total exercise in futility. Losing weight sets in motion rebound gain, the body is programmed to do it, it isn't conscious will at all.

I tried to lose weight, on a daily basis, since about the age of 11. I was perfectly happy for dieting to work, if it had I would not have complained. I persued it 'til I was 29. I never came close to succeeding at any point, even though it dominated my life and damaged my health, although I didn't fully understand this until I stopped.
I accept this, what I can't accept, is why it is so hard for people to believe, when usually abject lack of success equals failure.

You can call me greedy, you can tax me, heck lock me up and throw away the key, diets will still not work.