Nickel and Dime: The Interview —
Trigger warning: Discussion of calorie counting, weight loss and weight loss surgery.
I should be surprised, but I’m not. After yesterday’s introduction to today’s interview on the ubiquitous 5-10% rule, the subreddit /r/FatLogic has broken out its tiny violins and begun pushing back against the peer-reviewed research and expert testimony I presented because BOOTSTRAPS!
Granted, I shouldn’t be surprised since this forum simultaneously accused the hyperbolic Weight of the Nation documentary of fat logic:
That’s right, those lazy, no-account, fat-glorifying bastards at HBO are just a mouthpiece for the Health at Every Size® (HAES) Industrial Complex. I mean, just look at who’s funding this unsubstantiated, unsourced propaganda:
The goal of The Weight of the Nation is to raise public awareness of the complexity of the obesity epidemic. The films were developed in association with the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), and with the support of the Michael & Susan Dell Foundation and Kaiser Permanente.
DAMN YOU CDC, NIH AND KAISER PERMANENTE FOR YOUR WAR ON HEALTH!!!
Anyway, back in Reality, USA, I left off my conversation with Dr. George Blackburn of the Harvard Medical School’s Division of Nutrition saying that 5-10% weight loss is the end game.
At this point, Dr. Blackburn brought up the Look AHEAD trial and how they wanted subjects to lose more than 10%, but subjects lost just an average of 7% and kept off 4%. He also mentioned that Look AHEAD essentially followed “Box 14,” which comes from “Guidelines (2013) for the Management of Overweight and Obesity in Adults” developed by the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society (all deep in the pockets of Big HAES). Box 14 is the treatment algorithm for fat patients.
In short, Box 14 means that if your 400-pound cardiac patient loses 20-40 pounds after six months and his metabolic profile improves, then you should consider that a success. But that patient is still 360-380 pounds, and society (and, more importantly, /r/FatLogic) would not consider that a success.
But Look AHEAD was cancelled because they weren’t getting the results they hoped for from Box 14. Metabobolic indicators improved some, but overall cardiac events did not. I asked Dr. Blackburn why the study was cut short.
Because when we started the trial, our best thoughts were that we could get on average a 10% weight loss, and we could accomplish that in 30%, but not 50%. So you live by the sword and die by the sword. Since we only got 30% instead of 50%, then that was never going to be evidence based on a perspective randomized trial… And we’re finding that 5% does some, but if you want to decrease your heart attack rate and your stroke rate, then you need to make the intense effort to lose 10% of your body weight, for which one out of three did. [emphasis mine]
At the time, I did not think to ask him about the relatively low cardiac risk of subjects, as I mentioned yesterday in the quote from Dr. Evans of the NIH. Perhaps in a followup. Instead, I asked what a person should do if they don’t reach 10%. Look AHEAD subjects were prescribed a 1,200 to 1,800 calorie diet depending on weight. What advice would he give to the subjects who plateaued at 5%?
Dr. Blackburn pointed out how Box 14 emphasizes health coaches as a critical tool in losing 10% of your weight. Look AHEAD subjects received free coaching and Dr. Blackburn said that the 30% of subjects who successfully lost 10% attended 16 intervention meetings over six months. He also said that those subjects adhered to the healthy eating recommendations, got 10,000 steps per day, and slept for seven hours per night. In essence, if subjects don’t lose 10%, then they are presumed to be noncompliant to a certain degree.
I wasn’t able to articulate my question at the time, but after-the-fact, I pondered this answer for a while. Because the thing is, these subjects had about as much support as a person could expect to receive. They had free coaching and top-notch medical assistance. Why weren’t half the subjects able to achieve a goal as modest as 10% of their starting weight. Personally, I believe part of the answer lies with the caloric prescription.
In this Word file I found from the Look AHEAD training sessions, I found that Look AHEAD used a simple equation to determine how many calories the subjects were allowed to eat:
For the sake of illustration, let’s assume that I’m a subject in this study. I’m 5’7″, 265 pounds. I input this into the calorie-counting Human Weight Simulator developed by the NIH, which is a really cool tool for determining your metabolism and how caloric changes theoretically affect your weight using the dynamic weight loss model developed by Dr. Kevin Hall, which I discussed in this post. Presumably the subjects were sedentary, and for someone my size, that would mean a TDEE of 2,900 calories per day. But add in intense walking and it jumps to 3,500 calories. Follow Look AHEAD protocol, and what began as a 900 calorie deficit has become a 1,700 calorie deficit.
I only found this transcript after the fact, but in a PBS episode of Frontiers:
Moderate dishes like these that you can eat essentially forever are a key part of the Blackburn strategy, because if you try to lose weight too fast, hunger signals become very hard to resist. We don’t fully understand the mechanism, but our bodies naturally try to maintain a particular weight. Depriving your body of no more than about 500 calories a day is the only way to avoid triggering those signals, says Blackburn. Otherwise you’ll just become a yo-yo dieter.
Yet, here we are.
According to the Human Weight Simulator, if I wanted to lose just 10% of my body weight after six months (which was the goal of Look AHEAD), I could achieve that with a 2,200 calorie diet and no exercise. If I have the same weight loss goal, but add in the 175 minutes of brisk walking per week, then my intake would actually rise to 2,400 calories.
But here’s the weird thing: when I input Look AHEAD’s protocol, the estimated final weight is 180 pounds, which is a 32% weight loss loss. So either the subjects were not adhering to an 1,800-calorie diet and 175 minutes of exercise per week as Dr. Blackburn said, or else they’ve broken the laws of thermodynamics. The other possibility is that even the third of subjects who actually lost 10% weren’t following the prescribed lifestyles because, as Dr. Blackburn told Alan Alda, depriving your body of more than 500 calories is a recipe for disaster.
Whatever the case, the question we should be asking ourselves is why are such modest outcomes so difficult to achieve? I would modestly propose that if 70% of Look AHEAD subjects were actually noncompliant, then part of the problem could be the chasm what is prescribed and what is necessary to achieve a 10% weight loss according to the Human Weight Simulator developed by the NIH, the undisputed authorities on metabolism and weight loss (unless, of course, you’re from reddit).
So, I posed this question to Dr. Blackburn: why is a goal of 25% or more weight loss so difficult to attain or maintain?
“When this all started back in the 1950s, the database was the insurance actuarial tables,” Dr. Blackburn explained. These insurance tables, the basis of the modern BMI categories, found that the most profitable customers were those who lost excess weight down to 120% of their ideal body weight.
Obviously we found nobody could do that except by surgical interventions, which there are huge side effects. But people thought that and believed that and wanted that — they didn’t care what the high risk was. They wanted to get within 120% of ideal body weight. That’s just too much harm, too much expense and it’s just not ethical. Then the surgeons got a safe operation and said, “Wow, look we can get a 20% weight loss and those medical people can only get a 5% weight loss. Go our way.” But that’s only for 200,000 individuals, who are severely obese, class 3 obesity. That’s not a solution for the readers of your blog or for public policy. There is no public policy that says get a 20% weight loss. The public policy is to get 5-10% weight loss. [emphasis mine]
I pointed out how pop culture typically pushes a weight loss narrative that you should lose 30 pounds or 50 pounds or 100 pounds.
That’s a problem. That is exploitation. The pop culture is exploiting the victim because they have no trials to say you can do that. Anything they’re selling, whether it’s lifestyle intervention or products, are not producing those results, except rarely. And that’s fraud. [emphasis mine]
I chuckled and said, “I like you, Dr. Blackburn.”
I then decided to switch gears and asked Dr. Blackburn about this study (fuck yeah, open access!) he wrote on lifestyle interventions for class 3 obesity (BMI 40 and above). “You recommended physical resistance training for improving cardiovascular risk factors in the absence of weight loss. Is strength training a critical key in improving insulin sensitivity and halting metabolic syndrome?”
You can probably get there without it, but the shortest distance from A to Z is strength training. So I think people need to work that into it, they need the walking. But actually, they could do strength training easier than they could do walking. It’s a very positive return, I can tell you. If you want to look good and feel good and have the strength to walk up stairs and participate in your activity of daily living, then you’ll do strength training. [emphasis mine]
I like how he says you can look good and feel good with strength training, despite the fact that he found those improvements regardless of whether you lose weight. And even if you lose the theoretical 10% of rigid compliance, that’s STILL not going to give the fattest fatties the “bikini body” that pop culture wants us eternally chasing. Afterword, I shared with Dr. Blackburn my own experience with adding strength training to my cardio, and how my metabolic indicators all improved significantly.
Changing the subject, I brought up Shaunta’s Eating the Food experiment, and her attempt to prevent the restriction/disinhibition cycle by ending her attempts at maintaining an 1,800-calorie diet and allowing herself to eat a caloric range between her BMR and TDEE, or more than her baseline metabolic needs but less than the amount of calories she spends each day. I noted that in doing so, Shaunta experienced a weight loss of one pound per week. “Is this a sensible approach?” I asked. “Do you believe this is something people could use as a guideline to improve their health?”
Try it, if they like it, absolutely. Whatever will take it off and keep it off, do it. And you can see how important the hunger control is so you don’t rebound and get binge eating. So you don’t want to follow a healthy diet which you end up hungry because you won’t be able to do it. That’s why we’re so restricted. that’s why all our efforts are in preventing the weight gain because losing more than 5-10% of weight just upsets hunger hormones in the brain and makes it very difficult to be compliant. [emphasis mine]
“So hunger is not a virtue,” I said.
“No, you have to have a diet that you’re not hungry,” Dr. Blackburn agreed. “If between meals you’re hungry or you go to bed hungry, it’s a lost cause.”
At this point, I decided to become a devil’s advocate on behalf of /r/FatLogic and the like. Dr. Blackburn also played a role in the Weight of the Nation, which prominently features the fattest of fat subjects talking about their struggles.
As the anti-fat logic goes, 5-10% might be okay for moderately fat people, but people who weight 400 or 500 pounds have to lose much much more. So, I asked Dr. Blackburn about fat people in Weight of the Nation. “If they follow your instructions, your prescription, and lose just 10% — so a 500-pound person drops to 450 — would you consider that a treatment success?”
“Absolutely,” Dr. Blackburn said. “And any doctor who measured the blood pressure, the triglycerides, the lipid profile, the blood sugars, the inflammatory markers, all would find those improved, just like you say. When you added resistance exercise, you further enhanced your health markers, and exactly the same thing would happen with a 50-pound weight loss in a 500-pound person.”
I would also point out my interview with Dr. Arya Sharma, the Alberta Health Services Chair in Obesity Research and Management at the University of Alberta, Edmonton, when he said he would consider a 500-pound person who had not gained any weight in the past year a treatment success. In other words, weight stability year-over-year is just as valuable an outcome as modest weight loss.
I then doubled back to a point Dr. Blackburn brought earlier. “You mentioned that public health messages have been focusing on this 5-10%,” I said. “So if we hear a public health advocate promoting the idea that people in the obese category should drop to the normal-weight category, would you say that is off message from what most public health advocates are promoting?”
I wouldn’t say anybody who was saying that was a public health anything. They’re not qualified. We pried, we have masters of public health, we have societies of public health, none of them would say differently than the kind of guidelines that we’ve been talking about. I would say they’re both public health things. One is speaking a falsehood, is giving misdirection that will be harmful for people who are desperate to get to a healthy weight, but with these ridiculous promises followed by sale of merchandize are racketeers. [emphasis mine]
I can hardly believe the answers he’s giving me. Flying high, I decide to get his thoughts on HAES, the approach that encourages people to exercise, increase the healthy foods in your diet, and not focus so much on the scale as an end goal in and of itself. I explained that the metrics of progress in HAES are metabolic indicators and other health markers, as opposed to strictly the scale. “Would you say this is a sensible approach or not?”
I would. We now have all this technology that allows you to wear wristbands that track your steps and dashboards where you can record your food intake. You can enter your laboratory values for what are your health markers, including your blood pressure, your heart rate, your blood sugars and things like that, so these devices that allow you with a computer with a smart phone and with a wristband to have moment by moment — one of them alerts you if you’re too sedentary. Those are very helpful. So you’re exactly right. Go to what motivates you and, of course, what you’ll find is that will also show you the lower weight. They go hand in hand. If you’re not motivated by the rate of weight loss, the absolute weight loss, surely be motivated by less risk for a heart attack or stroke or cancer by getting these improved markers. [emphasis mine]
To that end, I mentioned the HAES talking point that when people adopt healthy lifestyles in anticipating of a >25% weight loss, that if they “only” lose 10%, then they get discouraged and give up the healthy behaviors. “On that note, weight cycling, you wrote a paper about how it doesn’t have a negative impact on future weight loss or metabolic improvements,” I said. “But isn’t the real problem with weight cycling that after each cycle severe cyclers tend to push their weight higher and higher?”
A variety of things happen. The reason we don’t want people to take off weight they can’t keep off, the rebound can go beyond that because they’ve disrupted the circuits. And that falling off the wagon, they go back past their original set point to a higher one. But it still doesn’t mean if at first you don’t succeed, try, try again and you’ll be able to. In other words, if you didn’t do it the first time, then go to school. We find, for example, that people in their 40s and 50s, now they’ve got their children out of the way, they’ve got a steady lifestyle and they have some time to now comply with the intense lifestyle that I mentioned, Box 14. So don’t give up. If at first you don’t succeed, then do it again and be smarter this time. Don’t lose it too fast. Be creative about controlling your hunger and get the sleep, the stress management, the steps and the food, and you’ll get to a healthy set point. It may not be the one you were led to expect by the pop culture, but it will be a new weight that will give you happiness throughout your life. That interaction, that knowledge that my health indices and my weight are associated with long living, will replace any disappointment in not losing 20% of your body weight. [emphasis mine]
Set point theory is relatively controversial, but plays a huge role in Linda Bacon’s book on HAES. Despite my exhaustive research, I forgot that Dr. Blackburn actually wrote a book on set point during the interview and was kind of amazed that he brought it up. So, I asked him, “What are your thoughts on set point? Do people have a genetically-defined set point that can get skewed by weight cycling or things like that?”
Sure, we all have set point once we finish puberty and we enter into the age 20, we are now adults and we have a set point that, in large part, is set by our genes as reflected in that children look like their parents, and the mesomorphs look like the mesomorph parents and the ectomorphs look like the ectomorphs and the endomorphs look like the same. We’ve all got a genetic base and a genetic set point to live by. They may call it a settling point because the Framingham Study looked at adults at aged 20 and then at 30 and 40 and 50, and over that 30 years, there was about a ¾ of a pound change in that set point per year from age 20 to 50. Over that 30 years, there was a 20 pound change in the set point. We all have set points. Reducing that by reducing your set point, your body weight, that activates all these hunger hormones to fight you doing that because evolution didn’t recognize any benefit from starvation or reduced weight. It’s the opposite. [emphasis mine]
Given his views, I decided to ask Dr. Blackburn something that I had felt intuitively based on the research I’ve read: “Is that 10% guideline the boundaries of your set point?”
“That’s right,” Dr. Blackburn said. “Twenty pounds in 30 years, and the average woman is 120 and she’s 5’6 or 5’7″, we’re talking about a 20 pound weight gain over 30 years. You do the math and see those are the boundaries of a healthy set point.”
And another question I had that I had a hunch on: “Is it easier to push set point up than down?”
Oh, absolutely. That’s what happens. During 1980 and 2010, we went from 10% of the population exceeding that end point to 30%, so there’s been an epidemic of increasing the set point. Now, keep in mind, if you do the math for that, the people who do these sort of things, that that’s a change of 200-250 calories a day to create this epidemic. So, said again, we’ve been talking about reducing 500 calories a day. In fact, reducing them between 200 and 300 would return the population’s set point to where it was before 1980. [emphasis mine]
Finally, I wanted to ask Dr. Blackburn for his take on Walter Willett’s crusade against Katherine Flegal, as mentioned in my previous post. I saved this question for last because I worried that it might put him on the defensive. “The Harvard School of Public Health and your colleague Walter Willett have been very publicly admonishing the work of Katherine Flegal of the CDC. Her work has shown that the lower end of obesity and overweight don’t have a hugely increased risk of mortality. Why are they so vocal in their opposition to that research?”
First of all, we all admire and respect Katherine Flegal and her publication list is staggering. And the work that she has put in to working that database. We just have to wait until the next cycle of Katherine’s data, but we think that you need to adjust for the smokers and watch out for the exclusion and inclusions as you look at that normal weight/overweight population. But it’s probably not going to stand up that being overweight is healthier than being normal weight.
When Willett has dismissed Flegal’s work, he frequently makes the claim that Flegal did not control for smoking or preexisting illness, which is not true. So, I said, “She did control for smoking.”
I think they had the panel. I would refer you to the commentary by Steve Heymsfield in JAMA on this subject because I think this is where Katherine published this paper. They invited commentary and it came from Steve Heymsfield and I think that’s the best answer. Epidemiology is not my forte because I’m surrounded by geniuses in that area. these are well-intentioned people and you have to admit that Katherine has never published data like that before and she hasn’t published a followup data. NHANES is done every two years, so there will be a new NHANES study and a new opportunity to look at the analysis and see how it turns out.
I did as Dr. Blackburn advised and read Heymsfield’s response, which reads:
Mortality was significantly lower among those who were overweight compared with normal weight individuals. The findings remained consistent even after adjusting for smoking status, preexisting disease, or weight and height reporting method (self or measured)… Orphana et al estimated the relationship between all-cause mortality and BMI in a nationally representative sample of 11,326 Caucasian adults and found a relative mortality risk of 0.76 (95% CI< 0.58-0.99) in overweight nonsmokers.
So I’m not entirely sure how Heymsfield corroborates the oft-cited claim that Flegal did not control adequately for confounders in per paper, but the claim persists. Perhaps someday I will be able to follow up on many of the after-the-fact questions that I wish I had raised. For instance, rather than talking about the general concept of “pop culture” influencing weight loss perceptions, I should have asked him what he thought of The Biggest Loser.
But all in all, I cannot complain. Dr. Blackburn was incredible forthcoming and direct in terms of what he has learned over decades of research in this field. I now feel that any future experts I talk to will be held to the exacting standards of Dr. Blackburn’s definition of a public health advocate. Nobody who advocates weight loss of greater than 10% is qualified to speak on public health and weight.
After speaking with Dr. Blackburn, I feel more confident than ever (something I did not previously imagine possible) that HAES is the best approach to long-term, sustainable and successful lifestyle interventions. And there’s nothing that reddit or any other low-information concern troll can say to convince me otherwise. We have a surfeit of peer-reviewed research on our side, while all they have are feels.