Is losing weight and keeping it off harder than kicking heroin?
“Losing weight” has supplanted “quitting smoking” as the most common New Year’s Resolution. The efficacy of dieting for weight loss has long been called into question, leading to the widespread comment that “weight loss is harder than kicking heroin addiction.” Is this true?
Probably the first time the futility of weight loss came in 1959 a report that followed 100 people who were placed in a New York diet program. From that study 95% of the patients regained their weight. Dr. Albert Stunkard and Mavis McLaren-Hume concluded, ”Most obese persons will not stay in treatment, most will not lose weight, and of those who do lose weight, most will regain it.” (1). This study is from a time when people were rarely obese, and weight loss was in its infancy.
When you contrast this to heroin addiction – recent papers show that of criminals who had drug addiction, 69% returned to prison with ongoing addictions (this was both to narcotics like heroin and methamphetamine). Non-criminal recidivism with heroin addiction shows that while the drug addiction is difficult, those who remain free of drug use are greater than 40%.
Why do diets fail? Is there a diet that will lead to long-lasting weight loss without such a high rate of recidivism?
Lifestyle vs. Diets
Part of the issue comes from needing to separate dieting from changes in lifestyle.
If someone changes their day-to-day eating habits, the hypothesis is that they will probably change their weight.
If someone engages in a short-term (less than two year) program for weight loss, but then resorts back to the foods they ate previously the overwhelming odds are that they will regain the weight they lost. This doesn’t matter if the person was on a low-fat diet, Paleo, Vegan, raw, or if they had weight loss surgery. When someone returns to the food that they ate that brought them to their heaviest or obesity, they will probably regain their weight.
In 1959 the weight loss clinic simply provided their patients with a diet and sent them on their way. This is similar to someone today purchasing a book, getting a diet plan, or buying a DVD set and attempting to lose weight in the short term without changing what and how they consume calories.
When weight loss strategies were examined forty years later, the world of weight loss changed. The poor results from the 1950’s were felt to be incomplete. Weight loss professionals now boast of programs that include behavioral and psychological counseling, drug therapy, nutritional/dietician counseling, in addition we have learned about the gut microbiome, as well as a change in our understanding of evolutionary biology, and more support systems. Even when interventions had changed (going decades later), it was noted that most patients lost weight in the first six months of the diet and then steadily regained weight to the original level (2). The authors noted that fresh new ideas were needed including better pharmacologic methods and support. Since that report was published new pharmacological tools have been added to weight loss, and some drugs have been taken off the market.
When “a comprehensive program of lifestyle modification” was examined there was a loss of 10% of weight in the first 4-6 months. This included programs such as the Diabetes Prevention Program. These programs had patient-therapist contact (including telephone, email), high levels of physical activity, and portion control. But even with this very comprehensive follow up, it still showed that one third of the weight was regained the first year after treatment ended (3). While this is far better than the recidivism of a simple diet, it is well below what expectations should be.
In order to determine a level of success, a proposed definition of success is 10% of weight loss and maintaining that loss for one year. At this definition there is a 20% rate of success with dietary and lifestyle interventions (5). But even with this short-term definition, as time goes on the percent of individuals maintaining that decreases except for a small group of individuals.
What About Rate of Weight Loss? If you lose weight too fast is that bad? Do you regain?
Is rapid weight loss better than slow and gradual. To answer this question a dietary intervention study was done in Australia where 204 obese individuals were enrolled into one of two programs. One was a 12-week rapid weight loss and the other a 36-week “gradual” weight loss. Those individuals who met success (their standard was slightly higher at 12.5% of their weight or more) were then placed on a maintenance program for three years. In this program 50% of the gradual weight loss group and 81% of the rapid weight loss group had met the 12.5% of weight loss and started the three year maintenance program. When the three year program was complete 93.5% of the individuals had regained their weight. (6). The study essentially showed it made no difference if the weight loss was rapid or slow. But it also showed that recidivism was high.
What About Psychological or Behavioral Therapy?
The inability to have prolonged success with behavioral or psychological therapy was first published in 1977. There have been no new types of intervention that have been found to provide much help. Some have suggested that “Intuitive Eating” might provide a better approach to weight loss than calorie restriction. Intuitive eating relies on internal signals of satiety, hunger, and appetite instead of calorie restriction. However, calorie restriction still proved better for weight loss. (10)
What About The Gut Microbiome?
Almost every newspaper has been discussing the possibility that the bacteria in the gut might make a person fat, or thin, or be responsible for cancer, heart disease, and a slew of other issues. Feed the bacteria in the guts something new and the bacteria that eat those foods will thrive – easy to understand that. This was proven in an elaborate stool sample study with food questions. A person who eats a high fat diet will have bacteria that thrive in the leftovers, the same with those individuals who have diets rich in meats, or vegetables, or even alcohol. Whether the gut microbiome pushes someone to obesity or if the diet pushes the microbiome to bacteria that prefer that as a diet is a chicken-egg philosophy.
The gut microbiome can quickly change, but that does not lead to long-term weight loss. The microbiome simply responds to what you eat.
What About What We Are Meant to Eat?
This is a fallacy of argument known as biotruth. What humans were “evolved” to eat, or “did” eat does not mean that this is what humans should be eating. Cavemen did not evolve to drive automobiles, ride in airplanes, read books, or be injected with antibiotics to cure diseases. Diets based on “biotruth” are fitting into the fallacy – in spite of what the teeth appear like, what the gut looks like, or what bugs we have cultivated in our colons. Our notion of what biology or evolution meant is, at best, ignorant.
There have been short-term studies (two weeks) with the “paleolithic” diet that improved cardiovascular risk factors, but short-term diets did not translate to long-term success (12). When the paleolithic diet was compared with the Nordic Nutrition Recommendations there was no difference at two years in terms of health measurements. The Nordic Nutrition Recommendation (NNR) is a diet with lifestyle changes and is based on the best medical evidence and re-assessed yearly. NNR typically includes plenty of vegetables, fruit and berries, pulses, regular intake of fish, vegetable oils, wholegrain, low-fat alternatives of dairy and meat, and limited intake of red and processed meat, sugar, salt and alcohol. (13)
Confirmation bias rules with those who are fans of certain diets, and nothing the beer and sausage diet showed that weight loss can occur with some simple principles of adhering to caloric restriction, even in the presence of beer (which has grain and thus the scourge of the religion of Paleo) and sausages (processed meat). This last October instead of a beer and sausage diet, Evo Terra went on a beer and small portion diet, with equal success.
What About Drug Therapy?
The Food and Drug Administration (FDA) approves drug therapy for two years of therapy but not for beyond those two years. The safety and efficacy of drugs for weight loss (such as Orlistat that reduces fat absorption) has been studied for two years, but not more. A number of drugs have been removed from the market such as Sibutramine that had a high rate of heart attacks and strokes. Sibutramine (Meridia) has tainted non-regulated over-the-counter medications especially those brought in from overseas. New drugs continue to be approved by the FDA such as Contrave: the FDA relents when it had previously denied it.
Overall, drug therapy has been disappointing, with somewhere from 30-60% of patients unable to achieve a 5% weight loss reduction at 12 weeks. Drug therapy is not a long-term solution to weight loss. One final note – no obesity medication has been shown to reduce cardiovascular morbidity or mortality. (14)
What About Weight Loss Surgery?
Weight Loss Surgery has been more effective than any diet, medication, or lifestyle change for those who suffer from obesity. Analysis of multiple studies show that thee is greater weight loss, higher remission rates of type 2 diabetes and metabolic syndrome. Weight loss surgery changes the internal anatomy, biofeedback, and in some cases the absorption of macronutrients. (15)
But weight loss patients who resort to their previous lifestyle also have a rate of recidivism. While lifestyle changes will bring about some weight loss, and weight loss surgery will bring about a great deal more- when patients regain weight the search often yields to patients returning to their “old habits.” Recidivism post surgery is not just a return to previous lifestyle (psychiatric, physical inactivity, endocrinopathies/metabolic, dietary non-compliance) there were also technical issues with some of the weight loss operations (stretching of the stomach-small bowel anastomosis for RNY, stretching of the stomach for gastric sleeve, or stretching of the upper pouch for the Lap-Band). (16)
What about Heroin vs. Weight Loss?
In a six month follow up 22% of the subjects who were treated for opioid use had returned to use. While that is still a high number, and may be underestimated because the follow up- clearly weight loss is even more difficult with the non-surgical techniques that are available. (17)
What about Biggest Loser, or all the people we read about who lose weight?
When someone makes news for weight loss, it is news. That means it is less than common. Placing someone in a different environment, where they can focus on their diet and begin a program of working out is artificial. There have been a number of stories of individuals who leave such programs and return to their weight.
What about Exercise?
Speaking of “Biggest Loser” what about exercise? While many gyms tout membership to assist in New Year’s resolutions, the data for weight loss with working out is not that great. In fact, a recent study from Arizona State University put 81 women into a program, and found that at the end of several months a number of them were more fit but had more fat. There was a subgroup who, after a month on the exercise program lost weight and continued to lose weight. The interpretation was that some were consuming more calories – with the suggestion that a month after an exercise program to check weight and if not losing then reconsider the calories in diet (18)
So What Do We Do?
We know what doesn’t work – a temporary fix. Changing lifestyle is problematic, because some feel they change lifestyle after being on diets- and yet they have assumptions about food that are not true. For example – they might feel the potato should be avoided when in fact, it is a perfectly good food that offers long-term satiety and low calories (about 135 per medium potato).
When we looked at our weight loss patients who had lost weight and kept it off we noticed several important factors:
(1) They cooked.
While over 85% of patients did not cook before (defined as cooking the majority of their meals) – those who were successful found success in the kitchen. Some had “cooked” before, several were even trained as a chefs but had gone into other work.
(2) Their tastes changed.
When drilling down on the 15% who had cooked before what they ate changed. The meals they had eaten prior to surgery were completely different five years after surgery. Few of them had soda or other sugary drinks more than once a week.
(3) None were following classic “diets.”
Not a single one of them were “protein first” or “vegetarian” or defined themselves by a diet. Most were enjoying a wider variety of foods than they had before. For many of them it was liberating, “I free so much of my brain up because I don’t think about dieting anymore.” Remarkably, the average number of salads per week was less than one.
(4) They exercised.
77% of them engaged in some activity – although for the majority of them this meant a long walk five to six times daily.
Long term weight loss is difficult – but from what we can determine, it does involve some delicious changes. Getting out of the restaurant and into the kitchen being one of them.
(1) The results of treatment for obesity: a review of the literature and report of a series. AMA Arch Intern Med. 1959 Jan: 103 (1) : 79-85.Stunkard A, McLaren-Hume M.
(2) Long-term maintenance of weight loss: Current status. Psychol. 2000; 19 (Suppl 1) 5-16. Jeffery RW, Drewnowski A, et al.
(3) Efficacy of lifestyle modification for long-term weight control. Obes Res. 2004 Dec;12 Suppl:151S-62S. Wadden TA, Butryn ML, Byrne KJ.
(4) Preventing weight regain after weight loss.Perri MG, Foreyt JP.In: Bray GA, Bouchard C, editors. Handbook of obesity: Clinical applications. 2. New York: Marcel Dekker, Inc; 2004. pp. 185–199.
(5) Successful weight loss maintenance. Annu Rev of Nutr. 2001;21:323–341. Wing RR, Hill JO.
(6) The effect of rate of weight loss on long-term weight management: a randomised controlled trial. Katrina P, Priva S, et al. The Lancet Diabetes & Endocrinology, Early Online Publication, 16 October 2014
(7) Long-term results of behavior therapy for obesity. Behav Ther.1977;8(5):898–905.Brightwell DR, Sloan CL.
(8) Weight loss and behavior change 1 year after behavioral treatment for obesity. J Consult Clin Psychol. 1978;46(2):368–369. Jeffery RW, Vender M, Wing RR.
(9) Behavior modification in the treatment of obesity. The problem of maintaining weight loss. Arch Gen Psychiatry. 1979;36(7):801–806. Stunkard AJ, Penick SB.
(11) Diet rapidly and reproducibly alters the human gut microbiome Nature. Jan 23, 2014; 505(7484): 559–563. David LA, Maurice CF, et al.
(12) Favourable effects of consuming a Palaeolithic-type diet on characteristics of the metabolic syndrome: a randomized controlled pilot-study Lipids Health Dis. 2014; 13(1): 160. Boers I, Muskiet FAJ, et al.
(13) Long-term effects of a Palaeolithic-type diet in obese postmenopausal women: a two-year randomized trial Eur J Clin Nutr. Mar 2014; 68(3): 350–357. Mellberg C, Sandberg S, et al.
(14) Long-term Drug Treatment for Obesity A Systematic and Clinical Review. JAMA, 2014; 311 (1) 74-86. Yanovski SZ, Yanovski JA
(15) Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials BMJ. 2013; 347: f5934. Glov VL, Briel M, et al.
(16) Weight recidivism post-bariatric surgery: a systematic review. Obes Surg. 2013 Nov;23(11):1922-33. Karmali S, Brar B, et al.
(17) A Randomized Trial of Oral Naltrexone for Treating Opioid-Dependent Offenders Am J Addict. 2010 Sep-Oct; 19(5): 422–432. Coviello DM, Cornish JW, et al.
(18) Predictors of fat mass changes in response to aerobic exercise training in women. J Strength Cond Res. 2014 Oct 28. Sawyer BJ, Bhammar DM, et al.
Dr. Terry Simpson
Dr. Terry Simpson received his undergraduate and graduate degrees from the University of Chicago where he spent several years in the Kovler Viral Oncology laboratories doing genetic engineering. He found he liked people more than petri dishes, and went to medical school. Dr. Simpson, a weight loss surgeon is an advocate of culinary medicine. The first surgeon to become certified in Culinary Medicine, he believes teaching people to improve their health through their food and in their kitchen. On the other side of the world, he has been a leading advocate of changing health care to make it more "relationship based," and his efforts awarded his team the Malcolm Baldrige award for healthcare in 2011 for the NUKA system of care in Alaska and in 2013 Dr Simpson won the National Indian Health Board Area Impact Award. A frequent contributor to media outlets discussing health related topics and advances in medicine, he is also a proud dad, husband, author, cook, and surgeon “in that order.” For media inquiries, please visit www.terrysimpson.com.