Evidence Based Weight Loss

[traumaRUs, MSN, APRN]

Congrats on your continued success....

[TheCommuter, BSN, RN]

Here is a tantalizing blurb from a sympathetic physician who specializes in obesity medicine. He argues that no obese person is ever truly cured of obesity.

We can also cure many forms of cancer, where surgery or a bout of chemotherapy removes the tumour forever. Those conditions we can cure” – obesity we cannot!

For all practical purposes, obesity behaves exactly like every other chronic disease – yes, we can modify the course or even ameliorate the condition with the help of behavioural, medical or surgical treatments to the point that it may no longer pose a health threat, but it is at best in remission” – when the treatment stops, the weight comes back – sometimes with a vengeance.

And yes, behavioural treatments are treatments, because the behaviours we are talking about that lead to ‘remission' are far more intense than the behaviours that non-obese people have to adopt to not gain weight in the first place.

This is how I explained this to someone, who recently told me that about five years ago he had lost a substantial amount of weight (over 50 pounds) simply by watching what he eats and maintaining a regular exercise program. He argued that he had conquered” his obesity and would now consider himself cured”. I explained to him, that I would at best consider him in remission”, because his biology is still that of someone living with obesity.

And this is how I would prove my point.

Imagine he and I tried to put on 50 pounds in the next 6 weeks – I would face a real upward battle and may not be able to put on that weight at all – he, in contrast, would have absolutely no problem putting the weight back on. In fact, if he were to simply live the way I do, eating the amount of food I do, those 50 lbs would be back before he knows it.

His body is just waiting to put the weight back on whereas my biology will actually make it difficult for me simply put that weight on. This is because his set-point”, even 5 years after losing the weight, is still 50 lbs higher than my set-point”, which is around my current weight (the heaviest I have ever been).

Whereas, he is currently working hard against his set-point, by doing what he is doing (watching what he eats, following a strict exercise routine), I would be working against my set-point by having to force myself to eat substantially more than my body needs or wants.

That is the difference! By virtue of having had 50 lb heavier, his biology has been permanently altered in that it now defends a weight that is substantially higher than mine. His post-weight loss biology is very different from mine, although we are currently at about the same weight. This is what I mean by saying he is in remission”, thanks to his ongoing behavioural therapy.

Today, we understand much of this biology. We understand what happens when people try to lose weight and how hard the body fights to resist weight loss and to put the weight back on. This is why, for all practical purposes, obesity behaves just like every other chronic disease and requires ongoing treatment to control – no one is ever cured” of their obesity.

Arguments For Calling Obesity A Disease #3: Once Established It Becomes A Lifelong Problem | Dr. Sharma's Obesity Notes

[andrea3434]

The craving cigarettes actually makes a lot of sense. You are using all of your will power to eat healthy and stay away from junk, so it's lacking in other areas (not smoking). I think it's awesome you are keeping a journal. I think addressing the root cause of WHY we are overeating is imperative when attempting to lose a substantial amount of weight.

I wouldn't be so hard on yourself about diet soda. I know it isn't healthy and can cause cravings for sugar, but at the end of the day, it's calories in vs. calories out and one diet soda a day is certainly not going to kill you.

Great job on the 46 lbs and I hope you see continued success in the future!

[calivianya, BSN, RN]

The thing about losing weight is you don't gain and lose fat cells (in general). The fat cells that you have gain and lose mass, until they get so large they can't hold any more fat, at which point you do make new ones. Anyway, a skinny person who has always been skinny has fewer fat cells than a skinny person who used to be fat.

Why does that matter?

Leptin is your "stop eating" hormone. It is released from your adipocytes, especially when they are at capacity. Large, full fat cells tell you - stop feeding me! I don't need any more! In contrast, small, shrunken fat cells from weight loss don't produce much (if any) leptin, which is just going to encourage you to eat.

Like the physician in the above post said, some skinny person with large, full fat cells is going to be producing leptin, and isn't going to be signalling herself to eat more and store more energy as fat. A skinny person with tiny, shrunken fat cells that feel like they are starving is NOT going to be producing leptin, and is going to have way more of an uphill battle keeping weight off, even at the same weight as the skinny person who has always been skinny.

Leptin is a times are good sort of hormone, like insulin. It says that it's okay to burn energy because you have enough. Let's turn your BMR up a notch so you can get rid of your excess energy. Without it, your body thinks it's starving, and will make every effort to lower your basal metabolic rate so that as much energy as possible goes to filling your tiny, shrunken fat cells back up. The human body is very efficient at saving every calorie possible - it really doesn't like starving.

This is just one small aspect of the very complicated pathway that is weight gain/weight loss, but overall, it doesn't matter which you choose - diet and exercise, or some sort of gastric surgery - either way your tiny fat cells once you've lost the weight aren't going to be producing much leptin. And it's not as simple as lipo to remove your fat cells, either - your body knows it's currently at 40% body fat, and if you wake up one morning at 30%, your body is going to be alarmed and produce more new fat cells over time. There is no good answer for weight loss.

[Empire Chick, BSN, RN]

Thank you very much everyone for feedback. I am still compiling my paper and I can't seem to find solid research that shows consistent loss of weight with surgery vs conventional means and a outlook in 5,10,15 years. There seems to be no study that has followed patients past the point of an average of 24 months. I have hard data for at least 12 but we all know a year is nothing. You can backslide in a year. You can backslide in 5 . I am really interested to know which is more effective and what changed the effectiveness. Was it education? Support? Stress management in a healthy way not succumbing to food or other detrimental habits. Are there studies out there that followed a population, male and female over at least 5 years post surgery or normal weight loss? I think this is so important to explore because I don't want to be at a healthy weight for one year. I want the tools to be at a healthy weight for the rest of my life. I want to give those tools to others too.

[TheCommuter, BSN, RN]

Over the long term, surgery is more effective than other forms of weight control.

I have linked to a website maintained by a nephrologist who references multiple studies about longitudinal weight control using the calories in/calories out method:

The Calorie Debacle - T2D 19 - Intensive Dietary Management

[amoLucia]

Calivianya - do you have experience in bariatrics ? Your explanation of leptin and adipocytes/lipocytes is the most succinct & excellent explanation of the topic as any I've ever read. It's what I believe TheCommuter's doctor's article is alluding to.

It's the reason I've learned that when those cells are 'empty' post-weight loss, they send out biological signals that cause the body to want to 'fill the tank up' because the body is 'running on empty 'signals. It makes sense in that our prehistoric body human is biologically engineered to be as plump as possible to ward off starvation. A chubby caveman was more likely to survive than a skinny one. Kind of like when bears seek to put on weight before they winter-hibernate. Their fat cells seek to replenish.

To OP - I believe that the studies you seek must really be out there as weight lose surgery has been around since at least the 1960's. I knew of women undergoing 'stomach stapeling'(as it was called back then) for massive weight loss. That surgery was in its infancy and its morbidity & mortality was at issue as I remember.

As a disclaimer, I will disclose that I lost 'another body' some long time ago. That realization hit me one afternoon while I watched a "175 running back from UCLA" make some fancy play during a TV football game. I thought - "dang! I lost more than one of him". "Where did he go"? That's a whole other explanation about where all the 'lost' weight disappears to.

A medically-supervised, very restricted diet with strong group support did it for me. I lost the first 100 lbs in about 5 months; the second 100 lbs in about a year after. And a little more. Just by dieting. Oh, the stories I could tell! But I will also disclose that the weight slowly came back. And I have my problems now.

I hope understanding wgt loss recidivism is now a little better understood.

OP - you sparked me to do some new searching on my own. Perhaps I can initiate some self motivation. I wish you all the greatest success in your personal & professional endeavors.

[Libby1987]

I'd like to know how much strength training and increasing muscle mass affected the success of either modality.

[TheCommuter, BSN, RN]

If Behavioural Interventions to Induce And Sustain Weight Loss So Often Fail, Why Bother? | Dr. Sharma's Obesity Notes

Here's another blurb from the obesity specialist Dr. Sharma...

Behavioural interventions (generally aimed at reducing caloric intake and/or increasing expenditure) are notoriously unsuccessful as a strategy for sustainable weight loss in the vast majority of people (at any weight).

For the few, who do succeed (and the word succeed” is used here rather loosely), it takes nothing short of constant (daily) diligence and ongoing determination to make it work – any reduction in effort is immediately punished” by weight regain – even after years of successful weight-loss maintenance.

Yet, the scientific literature abounds with study after study after study with one behavioural strategy (diets are behaviours!) after the next to try and achieve the almost impossible – sustainable weight loss.

The simple reason why behavioural measures fail is because they are up against a powerful array of neuroendocrine defences that our bodies can harness to effectively sabotage our efforts.

Any time we try to wander off into negative energy balance, our bodies instantly respond with opposing increases in appetite and reduction in energy expenditure to defend and restore energy stores. That is simply the reality of human (=animal) physiology.

[mmc51264, BSN, MSN, RN]

I had gastric sleeve surgery Feb 2015. I chose that over any of the bypass surgeries for personal reasons, which now I am grateful for having spoken to a liver transplant NP.

The surgery is a TOOL to weight loss. I eat zero bread, pasta, etc. I cannot have soda-diet or otherwise (no carbonated drinks allowed ever). Alcohol is frowned upon and I don't miss it.

The "deal" with my surgery is protein, protein, protein and replacement vitamins (calcium, iron, multi and iron mostly).

I have lost 65 pounds, with 15 left to goal, which I most likely will not make. However, I am 52 years old (this was part of my mid-life crisis). I was diagnosed with DM2 and hated having to say that. I have not gone into DM remission, but I am doing really well with a little medication and exercise. Exercise is the second key. Last March I ran a 1/2 marathon. I had never run a mile before. The surgery has changed my mindset dramatically. I think that is the benefit of surgery. There is a lot of prep and a lot of follow up. It took about 6 months of consults and appointments before surgery and I go every 3 months to see dietician and surgeon. It is not something taken lightly.

I feel better that I ever have and do not regret it one bit. I am saving now to try and afford a tummy tuck. Having 2 c-sections and losing the weight has left me with an ugly pannus that is going NO WHERE.

I am never going to be 110 pounds. If I can get to my goal of 160-165, I will be in the normal range for my height and age. Right now I am just overweight. I do not have any other health issues except some OA but this was the right decision for me. I have a friend that did WW and lost 55 pounds and keeps it off using that system. I think everyone is an individual and what works for one may not work for another. Motivation is key.

I cannot believe there are not more longitudinal studies done on WLS as it has been done for years now. Is there a bariatric practice near you that might help you?