If you’ve been directed to this post, it’s probably because we’re discussing if there’s any practical, sustainable, healthy way for a typical fat person to choose to no longer be fat. As part of this discussion, I’ve asked you to refer me to peer-reviewed studies demonstrating that a typical fat person can become sustainably non-fat through deliberate effort (whether you call that a “diet” or a “lifestyle change”). Since so many people believe this to be indisputable fact, I don’t think it’s out of line of me to ask for good-quality evidence.
Let me explain what I’m not looking for. These are things that are not evidence that becoming and remaining non-fat is reasonably possible for a typical fat person.
NO ANECDOTES PLEASE
I’m not looking for anecdotes. I’m looking for peer-reviewed studies.
Obviously, thousands of fat people have become non-fat, perhaps including yourself. And that’s fine. I sincerely wish that all of those ex-fat-people find sustained happiness and health.
However, since millions of people diet and fail to become non-fat, that there are many such anecdotes of weight-loss doesn’t actually tell us anything about what would happen for a typical fat person. Your own personal experience (or that of people you know, or people you know of) may not be generally applicable.
SIGNIFICANT AMOUNTS OF WEIGHT LOST
To count as evidence, a study would need to demonstrate that a majority of fat subjects were able to become so-called “normal” weight1 – that is, they’re no longer fat – through intentional weight-loss.
Most studies about weight loss have extremely forgiving standards of “success.” A study demonstrating that most fat subjects were able to lose 6 pounds or thereabouts isn’t what I’m looking for. Fat people are still fat even if we lost two to ten pounds. A study demonstrating that fat people can lose a few pounds doesn’t establish anything at all about if a typical fat person can become non-fat.2
See, for example, this study, which declares “research has shown that 20% of overweight individuals are successful at long-term weight loss when defined as losing at least 10% of initial body weight and maintaining the loss for at least 1 y. ” Well, I weigh 330 pounds. If I lost 10% of my weight, that would make me 297 pounds – which is to say, I’d still be fat. (Also, a 20% success rate is not very impressive.)
WEIGHT LOSS WHICH LASTED AT LEAST FIVE YEARS
Another problem with that study I just quoted? “For at least 1 year” isn’t a very impressive claim, if we’re looking for evidence of sustained weight loss. I’m asking you for studies showing weight loss that’s maintained for at least five years, and a ten-year follow-up would be better.
This is important, because almost any weight-loss plan works for a few months or a year – which is the length of follow-up many, if not most, weight loss trials use. For the purpose of asking if sustainable weight loss is possible, it’s not meaningful unless the study can show the loss is sustained over the long term.
MOST PARTICIPANTS DIDN’T DROP OUT
I’ve seen a lot of studies claiming to show a successful weight-loss program – but when I look at the details, 75% of the study’s subjects dropped out before the study was complete. This is a problem because the people who drop out of a weight loss program are not a random selection – they are more likely to be the people who found the program wasn’t doing anything for them.
NOT A STUDY OF ONLY SUCCESSFUL DIETERS
Suppose I did a study of professional basketball players. My study shows that a typical NBA player exercises a lot and practices at basketball a lot. Therefore, I say, a typical person can become an NBA player by exercising a lot and practicing basketball a lot. That would be self-evidently ridiculous. The people who can successfully become NBA players are outliers; we can’t assume that a typical person who follows Lebron James’3 exercise and practice routine would experience James’ success.
Yet very often, when I ask for evidence that a typical fat person can stop being fat, people cite studies using data from The National Weight Control Registry. The NWCR “is a research study that includes people (18 years or older) who have lost at least 13.6 kg (30 lbs) of weight and kept it off for at least one year… On average, registry members have lost about 70 pounds and kept it off for five and a half years when joining the registry.”
In other words, to be part of the NWCR’s data, you have to already be an outlier. Just as NBA players are outliers, the NWCR participants are outliers. A study of self-selected outliers can’t tell us anything about whether a typical fat person is able to stop being fat.
PLEASE DON’T TELL ME ABOUT THERMODYNAMICS
That’s not a study, and not what I asked for.
Look at it this way – suppose I had asked you for an example of a spaceship that can successfully take living human beings to Venus and back. You might have many reasons, rooted in an understanding of physics, to believe that such a spaceship is definitely possible. But that’s not the same as demonstrating that such a ship has actually been built and successfully operated.
I’m not asking you for what’s possible in principle. I’m asking for documentation that there is a weight-loss approach that has been tried in the real world, and has been shown to successfully cause most fat people to stop being fat people, in a sustainable fashion.
Thanks for reading! Now that you’ve read all this – and thanks, sincerely, for your patience – I look forward to seeing your evidence.
- Weight Science: Evaluating the Evidence for a Paradigm Shift | Nutrition Journal | Full Text
- Medicare’s Search for Effective Obesity Treatments: Diets Are Not the Answer [eScholarship]
- Miller, W. C. How effective are traditional dietary and exercise interventions for weight loss? Med. Sci. Sports Exerc. 31, 1129-1134
- The science is in: exercise won’t help you lose much weight – Vox
- Diets do not work: The thin evidence that losing weight makes you healthier.
- Odds of a severely obese woman becoming “normal” weight: 1 in 677. For men, 1 in 1290. | Alas, a Blog
- Why the “war on fat” is a scam to peddle drugs – Salon.com
- The Case Against Weight-Loss Dieting | Alas, a Blog
- Do 95% of Dieters Really Fail? | Dances With Fat
- Seriously, Weight Loss Doesn’t Work | Dances With Fat
- Why Don’t You Like My Studies? | Dances With Fat
- Why Do Dieters Gain Their Weight Back? | Dances With Fat
- National Weight Control Registry – Skydiving Without a Chute | Dances With Fat
- The Fat Trap – The New York Times
- All diets work the same: poorly | Shapely Prose
- Calories In/Calories Out? Science Says No | Dances With Fat
- Why You Can’t Lose Weight on a Diet – The New York Times
- Diets Don't Work, So Why Do We Still Pretend They Do?
Top image: painting by Fernando Botero.
- “Normal” weight, in most studies, refers to people with BMIs of between 18.5 and 24.9. I have issues with BMI, but for the narrow purposes of this post, I’ll accept that standard. [↩]
- If you want to argue that losing those few pounds is nonetheless worthwhile, that’s fine; but that still doesn’t demonstrate that it’s possible for most fat people to stop being fat. [↩]
- I know the name of a basketball player! [↩]
What is meant by “typical” in this context?
People are not born fat. They become fat for a reason. If they do not remove the reason, they will go back to adding weight, as soon as they stop dieting. There is no such as sustainably non-fat. No healthy person will remain non-fat if he eats and exercises the way the average 350 pound person does.
Thus, there will be no such study. You are asking the impossible. When I was kickboxing semi-professionally, I could drop one pound per week while continuing my training. Anything more, and I was losing my temper from being too hungry, or skipping on training from feeling without energy. I was still hungrier than I liked, just not hungrier than I could stand.
At one pound per week, it would take years of being hungry to get to a normal weight from 350 pounds. Forget it. Eat healthy, stay as healthy as possible, and just give up on the things your weight prevents you from doing.
By the way, if you are looking for a study that shows that the typical (male) person can remain non-fat for two years, you could look into any conscript military records. I know that in the eighties, the typical Bulgarian People Army conscript left the army non-fat. As a matter of fact, in seven years in the military, I remember one conscript who remained obese and one fat sergeant major. The conscript had mental problems (and ended up in the kitchen), and the sergeant had medical problems, and his commanding officer had to constantly tell people so. I must have easily come in contact with thousands of people…
Pesho, I’m having a lot of trouble parsing your comment (the first half seems to be agreeing with Amp that fat people won’t, in general, maintain weight loss, although with a more negative tone than I think is warranted; the second half then seems to disagree by saying you know people who did it–I’m assuming that some of the conscripts you knew were fat before being conscripted, and if not I’m not sure what the relevance is). However, I can respond pretty easily to your first sentence:
When I was born, I was at the 50th percentile for height but the 90th percentile for weight. So yes, people are born fat.
And one other thing:
Many people add the weight back on even when they maintain some or all of the new habits they formed. There is not a one-to-one relationship between lifestyle habits and weight, across populations or even for the same person over time.
Lots of studies and lots of people kept weight off:
It is very clear that some people keep weight off for several years, other people gain it back. You can argue over the percentages of people in each camp I guess. If there is nothing better to do.
Edited to add: Pesho, I was thinking about the military as well as an example. Fat kids come into boot camp and get fit and lose weight. Many are able to keep it off in the military (depending on which countries we are talking about).
I assume that you are female and American. The average newborn weight is 3.4kg. To be in the 90th percentile, you would have to be 3.75kg, or about 10% over average weight. 10% over normal weight does not make you fat, any more than I am fat for being more than 10% over the average weight for my height. When I was kickboxing, I was narrowly, but constantly into the obese BMI range for 156cm.
This is in addition to the fact that infants under three months are not considered to have a weight related problem until the 98th percentile (which for newborn girls is over 4.5kg). This is a lot more than 10% over average, because newborns’ weight has normal distribution. They can have disorders associated with subcutaneous fat (scary ones, though they do not make them any heavier) but obesity in infants is a result of either medical problems or feeding habits. As a matter of fact, there is no correlation between being fat as a 6 month baby and being fat as an adult, while there is very strong correlation between being an obese child and being an obese adult.
The relevance is that no one can add weight when his food is severely restricted (no seconds or bigger portions in the БНА, and no outside food for the first three months) and he is subject to regimen of physical exercise. The one obese conscript was losing weight, but going crazy – trying to trade services for food, switching between listless or combative an instant, breaking into the kitchen, screaming his head off, injuring himself, and eventually got his way – he was placed permanently in the kitchen, because no one wanted to deal with him. (Or, if you look at it another way, to use his culinary skills to prepare tastier food at the cost of his pilfering. Personally, I thought the food became better without the quantity decreasing, and I always hated kitchen duty anyway.)
Going back to relevance – as long as pressure is maintained, there will be no gaining the weight. But the pressure maintained in a conscript army, at least in Bulgaria, was significantly higher than the pressure in our minimum security prisons (In both, you were practically a slave to the State, and you got paid a lot less as a conscript, despite not having your upkeep deducted from your wages. Convicts were paid citizen wages, conscripts were paid enough for two haircuts and 12 chocolate wafers per month)
And to make it absolutely clear. I completely agree with Ampersand that there are probably NO studies showing obese people losing weight and keeping it off en masse. Losing weight is a matter of thermodynamics, and can be forced upon a body, not necessarily in a healthy way. Remove the constraints, and the weight will be regained. Those individuals who keep it off have kept the constraints on, by choice or by external pressure. For most people, remaining uncomfortable for the years and years that will take for their metabolism to adjust to the new normal is not an option. In my kickboxing club, we took it for granted that it took two years to become comfortable in a weight class that you forced upon yourself. I never lasted outside my normal class for that long, and if my trainer had tried to force me to do so, I would have left the club. (I went higher once and lower three times, because a pro wanted to switch classes, and us semis were supposed to accommodate them. I always hated it, both going up and down. Going up is much, much harder, unless you enjoy getting your ass kicked.)
I take your point about baby weights; however, that there is no correlation between weight at 6 mos and weight as an adult does not mean there is no overlap (I stayed at ~50% and~ 90% all the way into adulthood, incidentally, with a brief excursion upward in both when I hit puberty earlier than the typical girl), so there are indeed people who have never been “normal” weight. Leaving aside all considerations of the metabolism- and fat-relevant genes present at birth.
As Amp asked for citations, not anecdotes, I realize I should probably provide for my statements above:
Basal metabolic rate varies with age. It also changes after weight loss in a way that encourages regaining the weight. Additionally, given the same excess calories above what they needed, 12 sets of twins displayed more than a factor of 3 difference in how much they actually gained. The Biggest Loser study also demonstrates that you can indeed gain weight on quite restricted diets, despite your claims, if you precede it with enough weight loss first.
Sorry, that last line sounded more combative than I meant it to be.
To start with, I am a physician, and I have to counsel patients about this issue all the time. Like most physicians, I received astonishingly little education on this topic during medical school and residency, but I do feel that my background has helped me evaluate the sources I eventually came to rely on. How I have come to counsel patients on this issue has evolved as my understanding of the issue has evolved.
There are few current peer reviewed studies, because no one will fund them. Or the studies have an undeniable bias because of how they are funded. Nonetheless, there is a lot of data on healthy eating patterns, and good evidence of long term sustainable weight loss on particular dietary regimens, such as the Rice Diet of Dr Kempner (which was pretty drastic and needed medical supervision).
But the success of any medical regimen is usually dependent on compliance with the regimen. Most patients do not live in a metabolic ward (a closed living environment where diets are often studied); they are free living individuals. As such they are prone to societal and psychological pressure, sabotage from friends and family, the difficulty of obtaining the proper nutritious food, and perhaps most difficult, the saturation of the market with foods designed to be addictive (Kessler’s The End of Overeating covers this issue in great detail).
The advice I used to give patients is “Eat less, exercise more”, which was, frankly, counterproductive as it likely led to feelings of guilt and yo-yo dieting with eventual weight gain. I regret it.
My current advice (which no doubt remains imperfect) is:
Don’t diet! Focus instead on healthy food choices. For example, if you are the type to snack, then plan ahead to have healthy snacks available. Don’t focus on “not snacking”, which just sets one up for failing. When you are hungry, eat! But eat healthy unprocessed foods. The current evidence for healthiest eating plan is here: http://nutritionfacts.org/2014/09/09/the-healthiest-diet-for-weight-control/
and here: http://nutritionfacts.org/video/thousands-of-vegans-studied/
Realize that although exercise can promote health (positive mood, blood pressure control, blood sugar control), it does not help most people lose weight.
I could go on, but that is the quick summary.
Finally, I agree that:
The current drugs are useless–tiny weight loss for not-tiny cost.
Diets that focus on calorie counting or portion control are not effective for most people and overall lead to more weight gain.
Surgeries have high complication rates and are prone to long term failure (read the work of Garth Davis, MD, a bariatric surgeon, who now advocates an approach similar to the one I came to adopt, after seeing long term weight gain in patients with initially successful surgeries, his book Proteinaholic is great but he can also be found on Facebook and the web).
Nothing is to be gained by fat shaming or ridicule.
Good luck to any and all trying to achieve a healthier life and looking to feel better.
PS: I am not Dr Greger, but I do hold him in the highest regard, and recommend his website NutritionFacts.org to anyone looking for an accurate and understandable guide to the current state of evidence.
Although I do think that the resources I shared represent the current best evidence for a healthiest diet for the majority of people:
I would agree there is not “One True Way”.
That approach will not work for everyone that tries it.
Nor do I mean to imply that it is easy. It takes a long time to learn new recipes, new norms for celebration meals, and new ways to relate to food.
Anecdotes can’t show a pattern. But they can refute claims of a universal fact. So, in the interests of casting doubt on Pesho’s claim (“No healthy person will remain non-fat if he eats and exercises the way the average 350 pound person does”), here’s an anecdote of mine.
My first girlfriend was 5 inches shorter than me and over 100 pounds heavier. She wasn’t 350 pounds, but she was fat and I was skinny. And we ate the same things and shared the same, ahem, exercise program (3 flights of stairs plus young love.)
Patrick, when you give your patients this advice, do you give it to those who are overweight and preface it with “this is the best way to lose weight” or do you give it to all your patients and preface it with “this is the best way to eat a heatier diet”. Because I think the secend approach would have the benefits of a) not setting fat people up for disappointment when they don’t lose weight (which can lead to them giving up, even though despite not losing weight,they are overall more heathy) and b) reaching all those people who are not overweight but nevertheless would benefit from a healthier diet.
tl, dr: health at every size is a thing that I whish doctors knew about
Would a study showing that bariatric surgery is effective over five years count? It’s a pretty drastic solution but I’ve been told that it is indeed effective. (And it apparently reduces all-cause mortality, too; obese people who get it live longer than those that don’t.)
Lauren-I try to have the conversation with most patients who are there for a physical/annual exam. I let them know that this is something I struggled with as well, and that I adopted this way of eating (8 years ago now), and it has worked for me (weight down 30 pounds, never hungry on this plan, blood pressure normal, cholesterol down 50 points, no meds). I never make the focus about weight but about health. I put the websites or names in the after visit summary, so they can read on their own and make changes when they want.
So you didn’t even bother reading the abstract, did you? A loss of 3 kg does not resolve obesity.
Could the fact that so many people drop out of weight loss studies be put down to other factors, such as lack of willpower?
It’s a lot easier to avoid fatness than it is to stop being fat. Most people successfully avoid being fat. In many countries, almost everyone successfully avoids being fat.
So a typical fat person is someone who lacked the mental/physical ability to avoid getting fat in the first place. And since they already failed the easier test of avoiding fatness, they will usually fail the hard test of getting thin. This makes your requirement sort of dumb. If you didn’t have the ability to avoid the first problem you won’t have the ability to solve the second problem.
The solution is to stop people from becoming fat in the first place. That is much easier to do. Then eventually there will be fewer fat people. And we know that is possible because most people don’t get fat.
but this post is sort of funny in how limited it is. i could define an equal question. “Show me peer reviews demonstrating that a typical fully motivated fat person is unable to sustain weight loss, even when they have the mental strength to fully maintain their diet and health regimen as required by their doctor.” The result of that question would be meaningless. the framing makes the answer one-sided. so is yours.
I think you read too quickly: there was 3 times as much variation *across* the pairs than *within* the pairs. That is – each twin reacted similarly to their own twin, but there was more variation over the entire group (all sets of twins).
This just indicates that there are genetic variations in fat metabolism – which we already know.
There are similar variations in muscle-building response to exercise.
Not sure what this is supposed to “prove”….
By saying studies like the NWCR participants don’t count, you’ve entered special pleading that makes your request contradictory from the start. You’ve said people who succeed do so because they’re special, so they don’t count to show a typical person can do it.
There is nothing physiologically special about the NWCR that makes them capable of sustaining weight loss – nearly anyone matching their diet and exercise would, in fact, having similar weight loss results and maintenance. It isn’t at all like the difference in height an NBA all star has. To extend the analogy, it isn’t like saying NBA players don’t count, it is like saying weekend athletes don’t count, that research on them can’t show that a typical person can improve their ability at basketball.
No, I was saying something really simple: the weight gained in the sample of 24 people varied from 4.3 kg to 13.3 kg. I specified “12 sets of twins” instead of “24 people” because, if you think metabolism is strongly linked to genetics, then that was more like 12 tests, not 24.
Wow. That went off the rails promptly. My sympathies, Amp.
I can’t raise the other moderators directly just now, so I am putting on my Moderator Hat. Other moderators may modify as they see fit, but for now:
Pesho, yes, people in the military can be made to lose weight. So can people in concentration camps. These populations are probably not what Amp meant when he specified, in the post,
It seemed reasonably clear to me that Amp was asking about how a typical fat person could lose weight
That it, on their own initiative. Military conscripts, clearly, are not in charge of their activity level nor their caloric intake.
I would comment further, but this is not actually the thread for that. Maybe Amp will make a thread for that. This is a thread for people to direct Amp to
Harlequin, please restrict replies to the topic. If you want to range away from topic, please take it to an open thread.
Ashley, your question is off-topic. If you must bring up the topic of willpower, do it on an open thread.
realist, your comment is off-topic, and insulting. Take it to an open thread, and find a way not to insult your host.
All: the post is a request for a resource. If you don’t have that resource, please consider contributing to the rest of the Internet. That is all.
I appreciate Grace stepping in. :-)
BUT, since this is my thread, I’m going to allow things to digress. So please continue discussing.
That said, the usual “Alas” moderation policy still applies.
Question for the new folks here: Where did you find this post? It looks like someone popular linked us. :-)
Okay, I definitely don’t have time to reply to everyone, but I’ll do what I have time for and come back to it later. Apologies to everyone I don’t respond to.
I’d accept a majority of fat subjects in a study becoming nonfat.
Out of curiosity, do you have a citation for an actual, empirical study of how the average 350 pound person eats and exercises?
The rest of your comment is literally nothing but anecdotes, which I don’t think are very impressive. In addition, as Grace said, if a typical person needs to be in the military or in some similar situation in order to maintain weight loss, then I think it’s fair to conclude that the weight loss cannot be sustained as part of a typical life.
In the US, the army is pretty strict about its weight requirements for joining up; if you’re significantly fat, they won’t let you join in the first place. If you know of an English-langauge study of weight loss in the Bulgarian army, of course I’d be happy to take a look at it.
Viso, as S.T. said, the subjects of that study didn’t lose enough weight for fat people to cease being fat.
Also, boot camp anecdotes are meaningless. Show me the study with the five-year follow-up, please.
I just read your second comment, Pesho. We’re more in agreement than I had earlier assumed. :-)
Pactrick, thanks for your comments, and for the interesting discussion of what you tell your patients. I appreciate it that you’re not telling your patients to focus on weight loss.
Regarding the rice diet, an interview with Dr. Don Rosati, who took over the program after Dr Kempner, indicated that the weight loss patients were eating 800-1000 calories a day:
If that’s correct, then I’m sure they did lose weight – but that doesn’t sound healthy, and definitely not sustainable.
I don’t doubt that a vegan diet (as your links recommended) is healthy. However, for purposes of this post, I should note that I couldn’t find any studies of vegan diets and weight loss with a five-year followup. The studies I did find indicated some weight loss, but not remotely enough for a fat person to stop being fat.
Lauren, I totally agree!
(And while I’m being agreeable, thanks for your comments, Harlequin!)
Doug S., as Patrick says, some studies have found that many patients regain weight after having bariatric surgery – especially those few studies with longer followups. (For example.)
But that aside, I don’t think it counts for purposes of this particular post. My purpose here is to point out the enormous lack of evidence for the proposition that a typical fat person could choose not to fat through diet and exercise. Bariatric surgery is sort of a separate topic.
Ashley, why does that matter?
If a treatment is too stringent or difficult for most people to successfully follow it with their ordinary human amount of willpower, that suggests that the treatment would be unsuccessful for most patients.
You anecdote is as relevant to casting doubt on what I said as the word ‘skinny’ is relevant for a 250 man.
Note that I am not even questioning the accuracy of ‘over 100 pounds heavier’ (50kg being the weight of an extra large bag of cement) ‘eat the same things’ (because I’ve seen people trying to lose weight think nothing of eating a 600Kc Danish cinnamon snail) and ‘young love’ as exercise.
On the other hand, I know exactly how much potential energy is added to lifting 250 pounds three flights or stairs, and how it compares to a single piece of Tic Tac. (Tic Tacs are worth 2 calories in US advertising, not in Système international d’unités)
With all respect to Ampersand, Kinematics, Thermodynamics, etc… are relevant to everything.
And on rereading, I saw that I have put kcal down as Kc. I remember the time when I sneered at bastardized notations of the sort, now I am doing it myself.
Vive le joule, anyway!
Seneca, it’s hardly special pleading to say that findings from non-probability sampling cannot be generalized to a larger population. In this case, the sample was voluntary (aka self-selected), which makes the findings even less generalization. See, for example, what these webpages say about voluntary and/or non-probability samples: “sampling disasters,” “degree of generalizability is questionable,” “this can either lead to the sample not being representative of the population being studied, or exaggerating some particular finding from the study,” “The sample will not therefore be truly representative of the target population,” and “Inability to generalize research findings.”
Can you find a single statistics textbook, anywhere, which will say that a self-selective, non-probability sample (like the NWCR’s) doesn’t have severe limitations with regard to generalizing the findings?
[Reposted from Tumblr, with permission.]
I understand his frustration with trolls and other obnoxious people who just want to hate on fat people. These purple are dumb, and even if most very fat people could lose a significant amount of weight from (not unhealthy) diet and exercise and keep it off in the long term (a question I’m largely agnostic on), they still shouldn’t be judged as people or hated on.
That said, I cannot help but feel this post is a quintessential example of an isolated demand of rigor. Very very few studies in the entirety of the social and medical sciences will fit the criteria he laid out because studies like this are very very hard to do. If this is evidence he requires to be convinced that dieting and exercise for long term weight loss works, then he’ll probably never be convinced because it seems highly unlikely such a study will ever exist, even if diet and weight loss in the long term do work.
I can sympathize with the fact that most social and medical science is terrible and shoddy, but if you’re going to have such a high standard then you also have to hold the hypothesis that diet and exercising doesn’t work to the same standard, and be agnostic if such studies for that hypothesis don’t exist. Maybe there are rigorous studies in this ideal mold that do show that, but I kinda doubt it from my layperson’s familiarity of social and medical science.
[Reposted from Tumblr, with permission.]
I don’t understand what you’re driving at, Sacrum. I work in medical research, and none of these are criteria that I wouldn’t expect to see applied to clinical studies in general. In the field of transplantation, which I know most about, people are obsessed with long-term outcomes, and justifiably so, because something that only works for a year isn’t usually good enough in the context of a lifetime condition. And having most of the participants drop out is a major red flag in any clinical research. As for ‘significant amounts of weight lost’, well, this is probably the most stringent demand here, but clinicians – and this should hardly be surprising, if you think about it – are always asking whether results are clinically significant, as in do they really represent a non-negligible change. This is exactly the kind of thing researchers get grilled about in my field when they present their research. I agree with you that there are some bad studies out there, but there are also some pretty damn good studies, which have resulted in marked increases in outcome for many conditions. And if you think that scientists and doctors aren’t concerned with the difference between those two categories, that’s… very much not my experience, is all I can say.
I think it’s sensible and necessary to look very critically at ‘science’, rather than accepting reported findings without examination, but if you just sweep it all away as being ‘terrible and shoddy’ then you actually lose the ability to distinguish good evidence from bad.
I agree that which 1) have > four-year followups, 2) don’t have most of their sample drop out, and 3) are not a self-selected sample of people who have already had success with the treatment as a condition of joining the study are high-quality, but they’re hardly nonexistent. There are literally thousands of studies which meet those criteria. (Some random examples: 1 2 3 4 5 6)
(And I’m hardly asking for the most rigorous study design possible – I’m not demanding long-term randomized control studies.)
Here’s the thing: I’m not responding to people who say “I’m agnostic” or “well, we really don’t know.” I’m responding to the many, many people who say that any fat person can choose to not be fat, and who believe this is a well-established scientific fact. In that context, I think that asking for rigor is reasonable.
“Maybe there are rigorous studies in this ideal mold that do show that…”
It’s difficult to prove a negative, so no, there are no observational studies showing that “diet and exercising doesn’t work”; all any one observational study can prove is that the particular method(s) under examination didn’t work.
But yes, of course there are studies with > four year followups, without most subjects dropping out, and which don’t pre-screen subjects for already having success with weight loss; and which have shown that the large majority of subjects either did not maintain weight loss, lost only small amounts of weight (that is, not enough to turn a fat person into a non-fat person), and in many cases gained weight.
If you look at table one of this review article, you’ll see there are five observational studies of diet-based weight loss which meet the criteria I’ve asked for here (and a bunch more that don’t). In none, however, did the subjects lose enough weight at the five-year mark for a fat person to no longer be fat.
That review article is interesting; it’s examining whether or not any diet-based weight loss treatment has been effective enough to meet the standards required for Medicare to cover a treatment, and determine that none have been. Since many treatments have met Medicare’s standards for coverage, it seems reasonable to think that they are not asking for an impossible level of rigor.
From their conclusion:
They hold out more hope for exercise, but research hasn’t borne that out, either.
Here’s another review article. “Although long-term follow-up data are meager, the data that do exist suggest almost complete relapse after 3-5 yr.”
We can also look at population-level studies (from countries in which the goverment-run health care keeps such data), such as this one, showing that long-term weight loss is incredibly rare. That’s obviously not the same thing as a observational study of a particular weight-loss treatment, but it doesn’t lack rigor.
Most people I know, even those who refuse to believe that some people are naturally fat, admit that there are people who are naturaly thin. “lucky”, “good genes” etc are often the comments.
Why can we then not also accept that there are those who are naturally fat?
Leaving aside that I have serious issues with the value we place on being thin and the way being fat is regarded as negative: “bad luck”, “bad genes” should be just as plausible as explanations.*
Why is one group lucky, but the other is lazy, failed a test, doesn’t have willpower?
*(I can’t find the article, but I remember reading about a study that posited weight being related to different kinds of bacteria in the stomaches of different people, as one possible explanation not at all related to any kind of lifestyle differences)
(Reprinted from Tumblr, with permission.)
Bucket of Shells:
[CW: fatphobic language]
The point is, it turns out to be very difficult for fat people to lose a meaningful amount of weight. It is very, very difficult for them to lose the kind of weight that would transition them from being viewed as “gross lazy fatties with no dignity” to being viewed as “basically normal folks.”
In other words, as Mr Deutsch points out, a 10% weight loss ain’t gonna change the shit sandwich the world makes folks like him eat.
I mean, I lived that life and it’s awful. Furthermore, regardless of our aspirations for social change, fat people gotta live their lives now.
Similarly, as a trans women, I agree that we over-emphasize certain narrow beauty standards. Nevertheless, I work very hard to fit those standards. The reason is, my life ain’t merely a political statement, and I want to be happy.
Anyway, this conversation is in desperate need of a truth-bomb. It seems like, a significant fuckton of people believe that weight loss is easy, and that fat people are just lazy or unmotivated or whatever — cuz it is easier to justify being a mean-spirited shit to someone if you believe they deserve it. It is easier to believe they deserve it if you believe they have a choice.
Which, we can all see the holes in this. But all the same, people are going to believe all manner of dumb things. Laying out the truth about weight loss seems an obvious good thing.
This is not an isolated demand for rigor. There are plenty of studies showing that weight loss is much harder than believed by the general public. If people insist on believing otherwise, we get to ask them why they believe this.
(Reprinted from Tumblr, with permission.)
Thank you for the detailed response, I really appreciate it.
I’ll have to look at those links at some point.
Admittedly I have been reading various sources lately that have made me be pretty down on medical and social sciences, so I was probably unfairly biased against them when responding.
Amen to that. The sooner the US, Libera and Myanmar go metric, the better.
I’ve been looking for such a study for about 9 years now. Kempner’s is the only one that comes close. What his data communicated to me most strongly (in addition to his work with type 2 diabetes) is that carbohydrate is not what is fattening — at least not when eaten alone.
For a non-fatphobic, non-psycho babble discussion of why people get fat I highly recommend Dr. Doug Lisle’s presentation “How to Lose Weight Without Losing Your Mind” which has several incarnations on YouTube.
But no, not even he or the folks in his camp (McDougall, Ornish, Bernard, Esselstyn) have a clinical trial on obesity.
One of the things I tried to address in my longer, rambling post is the multifactoral nature of obesity in the US. We did not collectively lose our willpower. The genetics of the US did not change significantly. A calorie is still a calorie.
What changed? Advertising. Hyperprocessing of foods. Saturation with environmental toxins. Animal foods that were grown with chemicals and hormones to make them rapidly gain weight. Which we then ingest, the meat and the chemicals and the hormones. Overprescribing of antibiotics (one of the tricks used to make animals rapidly gain weight). Rich food as everyday celebration and reward. Food scientifically tested for addictiveness. The list goes on.
So how do most people succeed? They create their own micro-environment, a mini-metabolic ward. It is difficult to design studies at the personal level that combat sociological problems. People make these changes in response to health scares–such as a heart attack or diabetes diagnosis. Overweight patients with no acute health issues and surrounded by family and friends that mirror and or support them have little desire to disrupt their stable social system for minimal apparent gain.
So the experiment is: people who move from the skinny areas of the world to the US gain weight, people who move from here to skinny regions lose weight.
It is easy to design a healthy 1800 calorie diet with the same volume and satiety index as a 2200 calorie diet currently consumed by an overweight patient on a 2200 calorie diet. The trick is sticking to it in the food jungle but nutrition desert we are surrounded with.
There is a medical parable about upstream medicine, which I feel is fairly well applicable. We keep looking for downstream solutions to upstream public health issues. http://www.primarycareprogress.org/blogs/16/317
As far as I know, such a study does not exist. Not for lack of trying either; long-term diet trials are hard. Unless you can actually feed the patients yourself, the “study” diet is generally statistically indistinguishable from control within six months or so, no matter what you’ve told them to eat. And of course, it doesn’t help that long-term diets are hard. Even bariatric surgery has a five-year failure rate pushing 40%.
I’m keeping my fingers crossed for NuSI, which was founded to do these kinds of studies properly. Among other things, they’re running Atkins vs Ornish (high vs ultra low fat) head-to-head, tracking what people actually eat by making them photograph it with their phones.
There is some…compiled anecdata?…from the National Weight Control Registry regarding successful weight loss maintenance. Frankly, it’s a little depressing; it appears that many of the people who do maintain on low calorie diets have to develop a low-grade eating disorder to manage it.
For what it’s worth, I’m in the Registry myself…keto saved my life. It wasn’t even intentional (I have a neurological problem, the ketones help), but somehow I went from life-long fatty to a weight I left behind in third grade.
Nope – at least, the “12 tests” part doesn’t seem relevant.
If all you are looking at is the range of response to the same diet, then the fact that these were twins doesn’t really matter. (And probably lots of other studies with even larger samples show even greater variety in response to a controlled diet.)
Each pair of twins DID demonstrate similar behavior, certainly indicating that there is a genetic factor. Not sure if you intended to disprove this, or believe it yourself…
I’m very confused now about what you think I’m arguing. :) I was attempting to demonstrate that people have widely varying responses to excess calories due to biological factors; that makes it hard to start with weight and deduce what diet (and diet history) is, as lots of people seem to like to try. The 12 vs 24 thing was a very minor point that has to do with the fact that I was reporting a min-max range as a measure of variation, which depends on how many samples you have, rather than something more sensible like a standard deviation–I can talk more in an open thread if you really care.
So… I’m supposed to believe that Dr. Lisle has cracked the code of what causes weight gain, when he has no clinical trials to prove his hypothesis?
Mmm, no thanks.
In that spirit :)
I understand the “politics of body image” angle that leads to the challenge in the original post… the notion of impossible goals, related/resultant shaming etc.
This is what I would say to you if we were dear friends:
Please don’t ignore the body of evidence that indicates even moderate fat loss has significant health benefits.
The challenge in the original post posits an extreme transformation over a 5 year period. But there is considerable evidence that a 20-30 pound loss – however long it takes to achieve – has health benefits.
My intuition is that it would probably be more easily maintained.
At the very least it would halt the creeping weight gain that complicates many conditions of aging.
I am thinking of an approach similar to the mindset and behaviors common in my family, knowing that we are predisposed to diabetes.
What would you do about your weight (if anything) if all the cultural static were not there, and it were strictly a self-care issue? (I realize that part of the problem is that internalized social biases keep one from self-care let alone self-acceptance… I realize that’s part of the consciousness-raising being undertaken here…)
But if you could get to that place – I think there is ample evidence that modest fat reduction has benefits.
Again – this is offered from a self-care/health rather than an image/identity perspective…
Ben David – as the footnote in the OP says, “If you want to argue that losing those few pounds is nonetheless worthwhile, that’s fine; but that still doesn’t demonstrate that it’s possible for most fat people to stop being fat.”
The research on small weight loss is unclear; the problem is, if someone changes their diet and exercises more and loses 7 pounds, and their numbers (blood pressure, etc) improve, then is the improvement due to losing 7 pounds, or is it due to the changed diet and exercise?
I think it makes sense, for people who want to improve their health (and not everyone does have that as a goal, and that’s okay), to just go ahead and eat better and exercise more. The benefits of that seem to come regardless of if weight is lost or not, for most.
And, Amp, that’s been borne out by at least one comparative study on HAES vs. weight loss efforts – the HAES group didn’t lose weight, but their “health numbers” improved, while the weight loss group had extremely modest success with changing their weight but no real improvement in health outcomes.
I think I have something to add that isn’t present above. Some people become overweight because of illness, or because of medication they are given to treat illness. For example, I am taking two prescriptions that are known to cause weight gain, and I have sleep apnea which is associated with weight gain. It might be that I could return to my previous weight if I stopped taking meds, but they are treating life-threatening conditions. My apnea is adequately treated but the weight didn’t go away.
I’ve also had three major surgeries in the last four years, each of which required two months of almost complete bedrest for recovery. I had to eat enough to recover from surgery, and put on some weight.
So not everyone can avoid gaining weight. I don’t believe in dieting to lose weight, so I haven’t done that; but I lift weights and take walks and have a moderately active job, and I am healthier being obese (and taking prescription meds) than I was when I was of average weight.
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While I applaud calls for rigor in general, I do wish to object to this comment of Ampersand’s:
Just as it’s important that the ascertained population not be self-selected for success, it’s equally important that they not be self-selected for failure. Thus a key element in the design of the study you want to see is to gather a large population of typical adult fat people who have never tried to lose wait deliberately.
The “thousands of studies” you mention are mostly either (a) about kids, (b) about a condition with sudden onset, or (c) about an intervention which is not obvious and readily available to the subject. Telling an adult fat person to eat less and exercise isn’t the same kind of thing, because they’ve had plenty of time to try it, and probably already have.
Unlike, say, appendicitis, people generally don’t wake up one morning, suddenly fat, and report to the nearest hospital to be admitted into a study group.
So the impossibility of the study you want is consistent with the following hypothesis:
1. Some people can lose weight deliberately (group A) and some can’t (group B).
2. Most people get fat gradually, and when they realize they’re fatter than they’d like, they usually attempt to deliberately lose weight.
3. If they’re part of group A, they generally lose the weight and keep it off.
4. Therefore, any “typical fat person” you meet is almost always a member of group B.
This hypothesis also explains the plethora of anecdotes about people in group A.
Right now there isn’t, no. The issue is of having the right method/ technique to achieve the eminently achievable. Human metabolic function is just too responsive not to be adjustable to reverse or advance weight pretty much as desired. We can see signs of this, so there’s no doubt.
What’s required is means to adjust the function of that physiology first, with weight change following as a side-effect of that. Homeostasis can then regulate that adjustment.
Right now, cal res assaults our energy supply, whilst metabolic function retains the same settings of our starting point. It’s just pointless cruelty really. People want us to keep doing it though. There’s something about fat people being corralled into starving ourselves that is an overwhelming compulsion of the collective consciousness.
Until we really stop humouring this, i.e. asking for evidence that cannot possibly exist, this cycle will continue. In that sense its up to fat people to walk away from this. Speaking positively, we should concentrate on trying to hack/solve the puzzle that is human metabolic function.
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