Nickel and Dime: Prelude —
Trigger warning: Discussion of weight loss and weight loss surgery.
In my mind, there are two tiers of weight loss fraud.
Blatant weight loss fraud is easy to spot (e.g., diet pills, shakes, supplements, “superfoods”) and most of society eagerly points to it when talking about why diets don’t work. But I usually spend my creative energy on this blog trying to battle a different kind of weight loss dishonesty: the soft fraud of quixotic intent.
My favorite peer-reviewed paper on this phenomenon has the best title of all academic papers I’ve ever read: “Great expectations: ‘I’m losing 25% of my weight no matter what you say.'” To put that in perspective, this paper on unrealistic weight loss surgery expectations says that the average weight loss after 10 years of gastric bypass is 25% of initial weight; for gastric banding, it’s 14-18%.
In “Great expectations,” Wadden et. al. talk about how, despite the fact that weight loss researchers widely accept a loss of 5-10% of starting weight as “clinically significant weight loss,” society still encourages people to shoot for as much weight loss as humanly possible as the best goal. The worst example of this is The Biggest Loser, which First Lady Michelle Obama enthusiastically endorsed twice.
Even the Centers for Disease Control and Prevention (CDC), the foremost public health authority in the United States, pushes a confusing message on its weight loss page:
To lose weight, you must use up more calories than you take in. Since one pound equals 3,500 calories, you need to reduce your caloric intake by 500—1000 calories per day to lose about 1 to 2 pounds per week.
This is soft fraud in action. Without more information, someone reading this page would infer that by cutting 500-1,000 calories from their diet they can lose 50-100 pounds in a year. That’s a fairly simple prescription for an extremely complicated process. And yet, later on that page, they refer to the 5-10% figure:
The good news is that no matter what your weight loss goal is, even a modest weight loss, such as 5 to 10 percent of your total body weight, is likely to produce health benefits, such as improvements in blood pressure, blood cholesterol, and blood sugars… While this weight may still be in the “overweight” or “obese” range, this modest weight loss can decrease your risk factors for chronic diseases related to obesity.
Whoever wrote this info page seems to be attempting to dissuade readers from being disappointed by modest weight loss, but in the next paragraph they ruin that perspective completely by adding, “So even if the overall goal seems large, see it as a journey rather than just a final destination.” Again, the soft fraud creeps in, urging readers to look past the 5-10% toward that bigger, better goal of 25% or more.
In fact, when the CDC mentions the 3,500 calories per pound rule, it cites a public health booklet titled “Aim for Healthy Weight” (PDF) which gives the ol’ 5-10% bait and switch more explicitly:
Did you know that the amount of weight loss needed to improve health may be much less than you want to lose to look thinner? If your provider suggests an initial weight loss goal that seems too heavy for you, please understand that your health can be greatly improved by a loss of 5 percent to 10 percent of your starting weight. That doesn’t mean you have to stop there, but it does mean that an initial goal of 5 percent to 10 percent of your starting weight is both realistic and valuable.
But when the CDC mentions the 5-10% figure, it cites a peer-reviewed academic paper by Dr. George Blackburn, Professor of Surgery and Nutrition, Associate Director of the Division of Nutrition for the Harvard Medical School. Blackburn’s CV is unimpeachable:
He has trained over 100 fellows in applied and clinical nutrition and has published widely on various aspects of nutrition, medicine, and metabolism, with over 400 publications to date. He is on the editorial board of and reviewer for several journals including, the Journal of the American Medical Association, New England Journal of Medicine, Annals of Internal Medicine, American Journal of Clinical Nutrition, and Obesity... As an active participant in the field of nutritional medicine, Dr. Blackburn is a Past President of the Obesity Society (formerly NAASO) and the American Board of Nutrition. He also served on the Scientific Advisory Committee of the C. Everett Koop Foundation Shape Up America Campaign. He remains on the Board of Advisors for the American Society of Parenteral and Enteral Nutrition (ASPEN) of which he served as president; he was also President of the American Society for Clinical Nutrition and a member of numerous other medical societies. He was the Chairman of the Massachusetts Medical Society Committee on Nutrition, from 1992-1999. He is a also a fellow of the American College of Surgery.
And according to Blackburn’s research, which the CDC cited, that 5-10% figure should be the goal: (PDF)
Although most dieters strive to achieve “ideal” body weight — whether defined by life insurance height-for-weight mortality tables or by a more stringent social ideal — clinical and laboratory evidence clearly supports the value of a modest weight loss goal to attain health and emotional benefit.
Despite citing Blackburn’s paper from 1995 on an opinion that has only become more widely-accepted since then, the CDC continues to promote the idea that 5-10% is just an important milestone on your way to your ideal weight. Blackburn et. al. goes on to explain the counter-intuitive benefits of having more modest goals:
Goldstein has published a comprehensive review of the medical effects of a 10% or less weight loss on NIDDM, hypertension, hyperlipidemia, hyper-cholesterolemia, and cardiovascular disease. He concluded that “modest weight loss improved glycemic control, reduced blood pressure, and reduced cholesterol levels.” Kanders and Blackburn have also discussed the effect of weight loss on primary risk factor reduction, noting that “a 10% to 20% reduction in initial body weight, with maintenance of at least half of this weight loss over 2 to 5 years, has been shown to be sufficient to maintain health benefits”
This is the kind of research that fascinates me and has become my primary educational goal on this blog: to change what people believe is possible, let alone beneficial, in terms of losing weight. It’s not that I think people need to lose weight. I don’t. I promote Health at Every Size® (HAES), the idea that health is best served by eating a healthy diet, moving your body in a way you love and loving your body no matter what results you get in terms of weight or waist size.
But in my five years of research, what I’ve learned is that in most research, someone going from sedentary and non-restrictive eating to pursuing an intensive lifestyle change (typically in the pursuit of weight loss) will typically lose about 5-10% of starting and that these same researchers say that they should consider this a success. And yet in pop culture, we’re sold something completely different. For example, I recently wrote this bizarrely-framed critique of Huffington Post and its Weight Loss page which promotes an average weight loss of 140 pounds.
If I can spread the message that >10% weight loss is a largely a pipe dream, then I will consider my blogging to be a success. Beyond that, my stretch goal is to persuade people that if they want to be healthy, then they should pursue a healthy lifestyle for the sake of its metabolic benefits, regardless of the amount of weight lost. If I can play some role in the dissemination of that simple, absolute truth, then I can die a happy man.
In pursuit of that goal, I noticed Blackburn’s name on that CDC weight loss page, and then again when I stumbled upon that paper on WLS expectations. I also learned that Blackburn was Co-Principal Investigator for the Look AHEAD trial, which grabbed headlines when it ended earlier than planned — 11 years rather than 13.5 years. Basically, they wanted to see if weight loss could reduce the risk of cardiovascular disease (CVD) in diabetics. In short, it didn’t despite an intensive intervention.
According to The New York Times, people in this group were put on a diet of 1200 to 1500 calories a day. Those who weighed more than 250 pounds were allowed 1500 to 1800 calories a day, a pretty tight restriction. The exercise program was at least 175 minutes a week of moderate exercise… At year four, subjects had gained back roughly half of their relatively modest weight loss. For a 200 pound person, an 8% loss (average for the group) is 16 pounds, and half of that was regained.
In a letter responding to the disappointing paper, one critic blamed the weight loss results:
The reason for negative outcomes in this study was the lack of significant weight loss (which unfortunately was not hypothesized) achieved with the intensive lifestyle intervention. The conclusions should have clearly reflected this fact.
Rena Wing, the study’s chairwoman, led the response with a biting reminder of the facts:
Dhooria et al. and Martínez-González et al. raise concerns about our intervention. We know of no study examining long-term lifestyle interventions that achieved better weight loss and maintenance than ours. Dhooria et al. cite the results of the Diet, Obesity, and Genes study, which examined weight loss at week 26 in a subgroup of patients who had successful weight loss initially; in contrast, our trial examined weight loss over 9 to 10 years in all participants who were randomly assigned to participate in the intensive lifestyle intervention. [emphasis mine]
Now, to be sure, there are many valid criticisms of why Look AHEAD failed to achieve the results that are essentially dogma. For example, according to David Spero of Diabetes Self-Management, the results may actually be good news:
It could be that study participants were a selected group whose hearts were in pretty good shape. Participants had to pass a prestudy treadmill test, and their blood pressure had to be at least moderately controlled (below 160/100). They were also motivated — they had to log their food intake for a couple of weeks just to get in the trial. So maybe they weren’t at that much risk in the first place.
Dr. Mary Evans of the National Institutes of Health said the positive news is that “both groups had a low number of cardiovascular events compared to previous studies of people with diabetes.”
Finally, I wanted to interview Dr. Blackburn because he’s a colleague of Dr. Walter Willett, a man notorious for feuding with Dr. Katherine Flegal, a prominent epidemiologist for the National Institutes of Health. For an excellent overview of their ongoing information war, check out this excellent article in Elle.
Dr. Blackburn has his finger on the pulse of the American obesity research community, which makes him an ideal subject. To that end, I decided to see if I could score an interview with the man who wrote the book on modest weight loss (read a summary here), Dr. George Blackburn. Lo and behold, he agreed to let me ask him questions for a half hour two weeks ago, which turned into one of my favorite interviews of all time (including Dr. Flegal, Dr. Arya Sharma and Dr. Steven Blair).
First and foremost, I wanted to ask Dr. Blackburn for some clarity on this whole 5-10% figure. The assumption I hear from critics is that modest weight loss is okay, but you need to lose more weight to see the real results. I asked Dr. Blackburn, “Is that the end game or is it just a guide for realistic expectations? Do you think people should be aiming higher for 10%?”
A huge effort by the NIH [National Institutes of Health], and the best investigators who can serve on a panel, had developed an obesity guideline for prevention and treatment of obesity. They have accumulated all this data in an evidence-based fashion, and that policy says, for all practical purposes, with intense lifestyle intervention, a 5-10% weight loss is the end game. We’re not all equal in this area. If we’re blogging for scientific evidence, if we’re blogging for something that won’t allow people to be exploited by people who depart in their guidelines [of] 5-10% weight loss, whether you call it modest or not. I can tell you that trying to get it, don’t think it’s modest because it’s hard to do. But that will produce so much health that it’s the best return on investment that the individual can do, that the employer can motivate the person to do, that the family can work with the individual to do. So I’m hoping that that gets to be a solid take home of your blog. [emphasis mine]
And so, within the first 30 seconds of this interview, I’m chuckling to myself because I sense a kindred, iconoclastic spirit in Dr. George Blackburn. Now, I’m personally skeptical of any employer program that is coercive in nature (as opposed to a positive incentive programs) or that are weight-centric (as opposed to lifestyle-centric), but as far as public health messages go, this is huge step in the right direction.
“It’s something that I’ve been promoting for quite a while, that you don’t have to lose 25% of your weight to see the improvement,” I told him. “It’s more of a focus on the lifestyle and the weight loss is kind of a bonus.”
“Well, I think we’re even getting that way,” Dr. Blackburn said. “We’re much more interested in people having a healthy lifestyle — meaning healthy foods, healthy exercise, healthy sleep, healthy stress management. And then, as a consequence of that, you will lose 5-10% of your body weight.”
“Is that what you found is the average?” I asked. “Like, most people who adopt healthy lifestyles, they just kind of float to that 5-10% number or is that the most sustainable? How did you reach 5-10%?”
“I reached it in the 1990s by epidemiologic analysis and our randomized controlled trials, when we were prepared to let them lose all the weight they want and that’s the weight that they lost,” Dr. Blackburn said. “Now, the good news was, counter to any publication before that, that was enough to seriously improve the cardiovascular risk factors for cardiovascular disease. And since then, all subsequent studies have come up with the same answer.”
This is just a taste of my conversation with Dr. Blackburn, as the full interview is pretty involved. So stay tuned tomorrow, when I present the rest of my interview with Dr. George Blackburn, Forefather of 5-10%.