Previously in this series: Intro, Part I, and Part II.
Oprah 2005/2009
To test whether turning [fat people] into thin people actually improves their health, or is instead the equivalent of giving bald men hair implants, it would be necessary to take a statistically significant group of fat people, make them thin, and then keep them thin for long enough to see whether or not their overall health then mirrored that of people who were physiologically inclined to be thin. No one has ever successfully conducted such a study, for a very simple reason: No one knows how to turn fat people into thin people.
—Paul Campos, The Obesity Myth (2004)
Diets do cause weight loss…in the short term
People who think calorie restriction dieting “works” haven’t necessarily been duped by the diet industry or seduced by the prevailing nutritional “common sense” that weight loss and gain are a simple matter of calories in vs. calories out. Many of them believe it because their personal experience seems to confirm it, often repeatedly. Of course, “repeatedly” is part of the problem. Weight cycling—losing and re-gaining 5% or more of one’s total body weight—isn’t what dieters or public health policy makers are shooting for. Even people dieting with a specific occasion in mind, like a wedding or a high school reunion, would generally prefer to achieve permanent weight-loss.
But almost a century of research has shown that dieting—which usually involves calorie restriction—is not the way to do that. Studies repeatedly find that while eating less causes weight-loss in the short term, a majority of participants in weight-loss interventions focused on diet gain most of the weight back within 1 year and the vast majority (90-95%) gain all of it back within 3-5 years. Approximately 30% gain back more than they initially lost, and there’s some evidence that people who’ve lost and regained weight have more health problems than people who weigh the same, but have never lost and regained a significant amount of weight.
This is not controversial. Virtually every study of weight-loss dieting that has followed participants for longer than 6 months has found that the majority of dieters regain all the weight they lose initially, if not more. In other words, Oprah’s high-profile weight fluctuations are not the unfortunate exception to most dieters’ experience, they are the rule. A gallery of pictures of Oprah through the years illustrates the most frequent and reliable outcome of dieting:
1985 1988 1992 1996
2001 2005 2008 2010
I am not concerned (in this entry) with why calorie restriction diets fail—there are competing theories and perhaps I’ll try to tackle them some other time. However, when it comes to evaluating public health policies aimed at the general population, like posting calorie counts on menus, it doesn’t really matter why the kind of behavior it’s designed to encourage fails, especially when it fails so spectacularly. Whether the problem is that 90-95% of people don’t have the willpower to stick to calorie-restricted diets or that most peoples’ metabolic rates eventually adjust or both or something else entirely, continuing to prescribe calorie restriction to individuals seeking to lose weight is futile at best. Given the health problems associated with weight cycling and psychological distress caused by diet “failure,” it’s probably also dangerous and cruel. More on that another day, too.
The goal of this entry is to provide a condensed-but-comprehensive overview of the evidence that convinced me that weight-loss dieting—and particularly calorie-restriction dieting or eating less—does not “work” for most people. By “work” I mean lead to significant weight loss—at least 10% of starting body weight—that lasts for more than 3 years (in keeping with the clinical definition of “weight loss success” proposed by the 1998 National Heart, Lung, and Blood Institute [NHLBI] Obesity Education Initiative Expert Panel proposed). I honestly tried to keep this as short as possible and bolded the “highlights” if you want to skim. However, if brevity is what you’re looking for, see this 2007 Slate article.
A Meta-Review of the Literature
Of course, I’m not the first person to try to figure out what kind of picture decades of weight-loss research was painting. I found 14 reviews of weight-loss research in peer-reviewed journals (Mann et al 2007, Jeffrey et al 2000, Perri & Fuller 1995, Garner & Wooley 1991, Jeffrey 1987, Bennett 1986, Brownell & Wadden 1986, Brownell 1982, Foreyt et al 1981, Wilson & Brownell 1980, Stunkard & Penick 1979, Wooley et al 1979, Foreyt 1977, Stunkard & Mahoney 1976). And they all say basically the same thing: calorie-restriction diets don’t work long-term. Here’s how three of the most recent ones came to that conclusion, and one meta-analysis that claims to challenge the consensus, although it turns out that all they’ve really done is redefine “success.”
Diets Don’t Work—Mann et al 2007 (free full text): This review of 31 weight-loss studies by a team of UCLA researchers was aimed at developing recommendations for Medicare regarding obesity prevention and treatment. They were only able to find 7 studies of weight-loss dieting that randomly assigned participants to diet or control groups and followed them for at least two years (the “gold standard” required to make causal claims about the effects of dieting). And the “gold standard” studies did not support the claim that dieting promotes significant or long-term weight loss:
Across these studies, there is not strong evidence for the efficacy of diets in leading to long-term weight loss. In two of the studies, there was not a significant difference between the amount of weight loss maintained by participants assigned to the diet conditions and those assigned to the control conditions. In the three studies that did find significant differences, the differences were quite small. The amount of weight loss maintained in the diet conditions of these studies averaged 1.1 kg (2.4 lb), ranging from a 4.7-kg (10.4-lb) loss to a 1.6-kg (3.5-lb) gain. (223)
They also examined 14 studies with long-term follow-ups that didn’t involve control groups. The average initial weight loss in those studies was 14 kg (30.8 lb), but in the long-term follow-ups, participants typically gained back all but 3 kg (6.6 lb). Of the eight studies that tracked how many participants weighed more at the follow-up than before they went on the diet, the average was 41% with a range of 29%-64%, and in every case was higher than the percentage of participants who maintained weight loss. In other words, participants were more likely to regain more weight than they initially lost than they were to maintain their initial weight loss. Although Mann et al note several problems with these studies, like low participation rates in the long-term follow-ups, heavy reliance on self-reporting as the primary or only measure of weight, and failure to control for the likelihood that some of participants were already dieting again at the follow-up, those factors should have biased the results in the direction of showing greater weight-loss and better long-term maintenance, not less.
Finally, they looked at 10 long-term studies that didn’t assign participants to “diet” or “non diet” conditions randomly. In general, these were observational studies that assessed dieting behavior and weight at a baseline time and then followed up with participants to measure changes in behavior and weight over time. Of those studies, only 1 found that that dieting at the baseline led to weight loss over time, 2 showed no relationship between dieting at the baseline and weight gain, and 7 showed that dieting at the baseline led to weight gain.
Their recommendation to Medicare:
In the studies reviewed here, dieters were not able to maintain their weight losses in the long term, and there was not consistent evidence that the diets resulted in significant improvements in their health. In the few cases in which health benefits were shown, it could not be demonstrated that they resulted from dieting, rather than exercise, medication use, or other lifestyle changes. It appears that dieters who manage to sustain a weight loss are the rare exception, rather than the rule. Dieters who gain back more weight than they lost may very well be the norm, rather than an unlucky minority. If Medicare is to fund an obesity treatment, it must lead to sustained improvements in weight and health for the majority of individuals. It seems clear to us that dieting does not. (230)
Long-term Maintenance of Weight Loss: Current Status—Jeffrey et al 2000 (free abstract or full text with umich login): A review of 20 years of long-term weight loss studies that describes the weight loss and regain among patients who participate in behavioral treatments for obesity as “remarkably consistent” (7) which is visually represented by lots of graphs of different studies on the long-term results of weight loss studies that all pretty much look the same:
Basically no matter what researchers do, most dieters achieve their maximum weight loss at 6 months and then gradually regain all or almost all of the initial weight lost within 3-5 years, if not faster. They conclude:
The experience of people trying to control their weight is a continuing source of fascination and frustration for behavioral researchers. Overweight people readily initiate weight control efforts and, with professional assistance, are quite
able to persist, and lose weight, for several months. They also experience positive outcomes in medical, psychological, and social domains (NHLBI Obesity Education Initiative Expert Panel, 1998). Nevertheless, they almost always fail to maintain the behavior changes that brought them these positive results. Moreover, as we hope we have shown, efforts to date to change this weight loss-regain scenario have not been very successful.
Confronting the Failure of Behavioral and Dietary Treatments for Obesity—Garner and Wooley 1991 (free abstract or full text with umich login): Like Mann et al, Garner and Wooley were seeking to translate the available evidence about weight-loss dieting into recommendations for treatment—in this case, best practices for mental health practitioners seeking to counsel and treat overweight and obese patients. They note that short-term behavioral studies consistently show that modifications in eating and exercise behaviors lead to weight-loss, but that as the duration of studies increases, “over and over again the initial encouraging findings are eroded with time” (734).
The authors are particularly perturbed that poor results are often presented by study authors as positive. For example, an 1981 study comparing standard behavioral therapy with a weight-loss drug, or the therapy and drug combined found that all of the treatment groups lost a significant amount of weight in the first 6 months, and then all of the treatment groups showed significant re-gain by the end of the 18 month follow-up.
Instead of concluding that all of the treatments had failed to produce lasting weight loss, the authors conclude that these results provide hope for behavioral therapy, because that group showed the slowest rate of weight re-gain:
This most recent study provides grounds for optimism as to the future of behavioral treatment of obesity . over the long run, behavior therapy clearly outperformed the most potent alternative treatment with which it has yet been compared. (734 in Garner and Wooley, 135 in the original)
This pattern is nearly as consistent as the finding that weight is gradually regained and many individuals eventually weigh more than they did at the start of the treatment. After four years, nearly all participants in nearly all studies gain back nearly all the weight they initially lost: Adams, Grady, Lund, Mukaida, & Wolk, 1983; Dubbert & Wilson,1984; Kirschenbaum, Stalonas, Zastowny, & Tomarken, 1985; Murphy, Bruce, & Williamson, 1985; Rosenthal, Allen, & Winter, 1980, Bjorvell & Rossner, 1985; Graham, Taylor, Hovell, & Siegel, 1983; Jordan, Canavan, & Steer, 1985; Kramer, Jeffery, Forster, & Snell, 1989; Murphy et al. 1985; Stalonas, Perri, & Kerzner, 1984; Stunkard & Penick, 1979. And yet, the authors of those studies insist that the diet interventions are “effective,” sometimes claiming that if the subjects had not dieted they would weigh even more. They almost never admit that the treatments completely failed to do what they set out to do, which is produce a clinically significant weight loss that can be maintained long-term. When they do admit that the results are “disappointing,” they frequently call for more “aggressive” treatments like very low calorie diets (VLCD or <800 kcal/day) or supervised fasting (which is no longer approved because of the risk of mortality).
Garner and Wooley also evaluate studies that used VLCD, some of which involved Optifast, the protein shake that Oprah used to achieve her 67 lb weight loss in 1988. Just like with other calorie-restriction diets, people on VLCD generally lose weight initially, although drop-out rates are much higher than in other weight loss studies (50% or more). Participants who stick to the diet typically maintain the weight loss for about a year, but regain most if not all of the weight they lost within three years and many gain more than they initially lost (Swanson and Dinello, 1970, Sohar and Sneh, 1973, Stunkard and Penick, 1979, Johnson and Drenick 1977, Drenick SC Johnson, 1980, Wadden et al., 1983, Wadden, Stunkard, & Liebschutz 1988, Hovel et al., 1988). Based on all of those studies, they conclude:
Although the rate and magnitude of weight loss have been the basis for recommending the VLCD, its most remarkable feature is the speed of weight regain following treatment. (740)
Garner and Wooley found only two studies of weight-loss dieting that reported better long-term results, and both had extremely low rates of participation in the follow-up and relied on self-reported weights. For example, Grinker et al (1985) reported that 55% of the participants in a residential treatment program had maintained a 5-kg weight loss based on the responses of only 38% of the original participants. They suggest that it seems far more likely that the low participation in the follow-up biased the results than that those studies are right and all the other ones or wrong and conclude:
It is only the rate of weight regain, not the fact of weight regain, that appears open to debate. While this may be discouraging to the individual intent on weight loss, it should also provide some solace to the many individuals who have failed at dieting and have attributed the failure to a personal lack of will power. (740)
It is difficult to find any scientific justification for the continued use of dietary treatments of obesity. Regardless of the specific techniques used, most participants regain the weight lost. (767)
They make the following recommendation to mental health practitioners:
We suggest that at the least, if weight loss is offered, it should be done with full disclosure of the lack of long-term efficacy and of the possible health risks [which, as they explain, include physical and psychological risks correlated with weight fluctuation]. It is further recommended that alternative nondieting approaches aimed at improving the physical and psychological well-being of the obese individual be given priority over dietary treatments as a subject of research and that such treatments be offered on an experimental basis. (767)
Long-term weight-loss maintenance: a meta-analysis of US studies—Anderson et al 2001 (free full text): As the title suggests, this is a meta-analysis rather than a review article, meaning rather than summarizing and evaluating what other studies found, they lumped together the data from 29 different studies. 13 of the studies involved “very low energy diets” (VELDs), 14 involved “hypoenergetic balanced diets” (HBDs) and 2 involved both—in other words, they were all calorie-restriction diets, and about half of them required participants to eat less than 800 kcal/day. The authors claim that no long-term randomized, controlled studies were available, and it’s unclear why they didn’t think studies like Jeffrey and Wing 1995 (discussed below) should count.
They don’t provide details for any of the studies individually, but do disclose that the number of participants ranged from 6 to 504, the length of treatment ranged from 8 to 30 weeks, average initial weight loss ranged from 3.5 to 37.9 kg for women and 6.2 to 44.2 kg for men, and follow-up participation rates ranged from 50% to 100% with a median of 82%. In other words, these were very different studies. Here are the results of their aggregation of the data:
The average weight loss at 5 years for both VELDs and HBDs was 3.0 kg, or ~3.2% of the participants’ starting weight and 23.4% of their initial weight loss. Anderson et al conclude:
These average values are higher than those reported in earlier studies and indicate that most individuals who participate in structured weight-loss programs in the United States of the type reported in the literature do not regain all of the weight lost at 5 y. of follow-up.
Sure, not all of the weight, only 76.6% of it. It still seems to me like a perversion of the idea of “success” to claim that these results show that calorie-restriction diets are “effective.” The average initial weight loss was 14 kg. If you lost almost 31 lbs and then regained 25 lbs, would you consider your diet a long-term success? Mann et al wouldn’t. In the 14 long-term studies without control groups that Mann et al evaluated, they also note an average maintenance of ~3 kg. They just don’t think that’s very impressive:
It is hard to call these obesity treatments effective when participants maintain such a small weight loss. Clearly, these participants remain obese. (Mann et al 223)
Interpretation/equivocation aside, there’s still some discrepancies between their analysis and the consensus in the other reviews which I wish I could explain. It’s not like this was a study of a new treatment—they relied exclusively on existing studies, at least some of which were also included in the reviews of the literature discussed above. However, some of the studies they included must have reported (possibly significantly) better results to bring up the average. Since they didn’t evaluate the studies individually, it’s impossible to tell from their write-up whether those studies involved some sort of strategy that made calorie restriction dieting “work” (and somehow didn’t attract widespread attention) or whether the results in those studies were biased by low participation rates in follow-ups, self-reporting, or some other factor(s).
A Closer Look at the Studies Themselves
I have not read every single study referenced in the review articles, although I have at least glanced at many of them. The ones I chose to explore in further depth here either 1) meet the “gold standard” of randomized assignment to diet/non-diet conditions and at least 2 years of follow-up or 2) are too recent to be included in the review articles.
Long-term Effects of Interventions for Weight Loss—Jeffrey and Wing 1995 (free abstract or full text with umich login): This is one of the seven studies included in the first part of the Mann review. 202 participants between the ages of 25 and 45 who were between 14-32 kg above the MetLife standards for the “ideal weight” for their height were randomly assigned to one of five experimental groups:
- a control group which received no intervention
- a standard behavioral therapy group (SBT) that received instruction on diet (including advice on how to follow a 1000-1500 calorie/day diet), exercise (including the recommendation to walk or bike 5 days/wk with an initial goal of burning 250 kcal/wk and gradually increasing that to 1000 kcal/wk), and behavior modification (including keeping food and exercise diaries. This advice was given in weekly counseling sessions for the first 20 weeks and monthly sessions thereafter for a period of 18 months.
- a SBT + food group, which received the same counseling along with premeasured and prepackaged breakfasts and dinners for 5 days/week for 18 months
- a SBT + $ incentive group, which received the same counseling along with up to $25/week for achieving and maintaining weight loss
- a SBT + food + $ incentive group, which got the counseling, meals, and money
In addition to the 18 months of the study, the participants were contacted at 30 months (a full year after the study ended) for an additional follow-up, which was completed by 177 (88%) of the original participants. Here are the results:
All the treatment groups lost weight during the intervention, achieving their maximum results at 6 months. However, by 12 months—even though they were all still receiving the treatment, they were beginning to regain weight. By 30 months, there was no significant difference between any of the treatment groups and the control group. The authors wheedle a bit, claiming the difference “approaches levels of statistical significance” (.08), but are honest enough to admit in the end:
The overall results of this evaluation reemphasize the important point that maintaining weight loss in obese patients is a difficult and persistent problem.
Preventing Weight Gain in Adults: The Pound of Prevention Study—Jeffrey & French 1999 (free full text): This more of a “failure of low-cost educational interventions designed to encourage weight loss” than a failure of weight loss dieting per se, but it’s still relevant because 1) the experimental group “got the message” communicated in the educational intervention but gained the same amount of weight over 3 years as the control group and 2) calorie labeling is essentially a large-scale, low-cost educational intervention. The idea that education will make people thinner relies on the assumption that people would not be (as) obese if they only knew they were gaining weight, that they should eat more fruits and vegetables, that they should reduce their consumption of high-fat foods, and/or that they should get more exercise.
But most people do know all those things. In this study, 228 men and 594 women employed by the University of Minnesota and 404 low-income women, all between the ages of 20-45, were recruited to participate in a 3-year study. Half of the participants were assigned randomly to a control group and the other half were assigned to the “intervention” group, which received a 2-4 pg monthly newsletter called Pound of Prevention. The newsletter emphasized five themes:
1) weighing yourself regularly (at least once a week)
2) eating at least 2 servings of fruit per day
3) eating at least 3 servings of vegetables per day
4) reducing the consumption of high-fat foods
5) increasing exercise, especially walking
In other words, “common sense” nutritional advice, although not explicitly calorie reduction. The newsletter included recipes, suggested particular areas/routes in the local areas for walking, and included a return-addressed, stamped postcard asking participants to report their current weight and also answer whether they had walked for 20 minutes or more, eaten 2 servings of fruit, eaten 3 servings of vegetables, or weighed themselves in the last 24 hours. Intervention participants were also invited to take part in a variety of activities during the three years, including 4-session weight control classes, aerobic dance classes, free 1-month memberships to community exercise facilities, walking groups, and a walking competition. Additionally, half of the “intervention” group was assigned randomly to an “incentive” group who were eligible for a monthly $100 lottery drawing for members who returned the postcards.
All participants were evaluated in annual physicals where they were weighed, their height was measured, their dietary intake evaluated using a standard 60-item Food Frequency Questionnaire, and they were asked about behaviors like exercising, eating fruits and vegetables, decreasing fat intake, using “unhealthy diet practices” like laxatives and diet pills or liquid diet supplements, weighing themselves, and smoking. At some point in the study, a questionnaire was administered to test “message recognition.”
Participation in the “intervention” group was high—68% of postcards were returned, 80% of the participants reported having read most or all of the newsletters at their annual visits, and 25% participated in one or more of the extra activities. The “message recognition” test was somewhat successful—the intervention group was significantly more likely to identify the 5 targeted treatment messages as being among the best ways to prevent weight gain; however, even 66% of the control group endorsed the treatment messages. The intervention groups were slightly-but-significantly more likely to weigh themselves and more likely to continue practicing “health weight loss practices” as measured by a 23-item questionnaire. However, changes in BMI, energy intake, percent of calories from fat, and rates of physical activity were not significantly different between the control and intervention groups. All participants gained an average of 3.5 lbs over the course of the 3 years.
In short, the intervention was a failure. The authors conclude:
It is easier to teach people what to do than to persuade them to actually do it…. The overall impact on weight itself…was very weak, indicating that stronger educational strategies are needed or, alternatively education alone is insufficient to deal effectively with this important problem.
Weight Maintenance, Behaviors and Barriers—Befort et al 2007 (free abstract or full text with umich login): Based on the abstract, this study sounds like a success, but under closer examination, not so much. The data was collected at a university weight loss clinic where participants were recruited to follow low-calorie or very low-calorie (500 kcal/day) weight-loss diets followed by a maintenance program. The “weight-loss” phase lasted for 3 months during which participants consumed prepackaged meals and/or shakes. The maintenance programs ranged from 6 to 21 months and consisted of weekly or bi-weekly meetings at the clinic during which participants were counseled to follow a structured diet plan with a daily calorie goal and exercise 150-300 minutes per week. In 3 out of 4 trials, the participants were also encouraged to continue consuming the shakes/prepackaged meals.
Out of 461 participants who started treatment, 44 dropped out during the 3-month weight loss phase and 211 dropped out during the maintenance phase. They sent follow-up surveys to everyone who completed the 3-month weight loss phase (n=417), and got 179 back (46.6.%). The more recently participants had been part of one of the studies, the more likely they were to respond to the follow-up survey. Responders had only been out of treatment for an average of 14 months.
Their claim that a “majority” of the participants maintained their initial weight loss is based on them lumping together respondents who had only been out of treatment for 6 months with people who had been out of treatment for 24 months or more, despite the fact that—just like in every other study of calorie-restriction weight loss—the results showed that most participants gradually regain weight. As they admit:
Compared to participants who were out from treatment for 24 months or longer, those who were out for less than 6 months (P<0.05) or for 6–12 months (P<0.01) had significantly greater weight loss maintenance, both in terms of kg and percent of baseline weight.
What they don’t say is that the percentage of respondents who report maintaining their initial weight loss drops off precipitously after 24 months.
Of the 31 respondents who’d been out of treatment for 24+ months, only 25.8% had maintained a weight loss of 10% of their body weight or more and 48.4% had maintained a weight loss of 5% or more. That means out of the original pool of 417 who completed the 3-month diet, only 8 had proven capable of maintaining weight loss equal to 10% of their body weight for more than 2 years and only 15 had proven capable of maintaining a weight loss equal to 5% of their body weight. Other participants might be able to maintain their initial weight loss—that data isn’t available, but the trajectory certainly doesn’t look good. And that’s based on the half of the participants who participated in the follow-up—as Garner and Wooley note, the higher the rate of participation and the longer the follow up, the less weight loss on average is maintained.
What About the National Weight Loss Control Registry?
Several of the studies and at least one person who commented on one of the earlier posts in this series mentioned the National Weight Loss Control Registry (NWCR) as evidence that people can indeed lose weight and keep it off. I’ve never disputed that. Even in the studies that show the least hope for long-term maintenance, there are exceptions to the general trend. But that’s what they are: exceptions.
According to the NWCR website, they have over 5,000 members, all of whom have lost at least 30 lbs and kept it off for at least 1 year; however, most of them have done far better—registry members have lost an average of 66 lbs and kept it off for an average of 5.5 years. As the research above suggests, that’s not remotely “representative” of people who attempt to lose weight. On the contrary, the entire raison d'être of the registry is to figure out what’s different about the 5-10% of dieters who lose significant amounts of weight and keep it off. The goal is to identify strategies that might help other dieters, but as the researchers who run the registry admitted in a 2005 article (free abstract):
Because this is not a random sample of those who attempt weight loss, the results have limited generalizability to the entire population of overweight and obese individuals.
Indeed, the kinds of things the registry members do are generally the same things the participants in most weight loss studies are counseled to do (or, in clinical settings, forced to do): most of them follow a low calorie, low fat diet, eat breakfast every day, weigh themselves at least once a week, watch less than 10 hrs of TV per week, and engage in very high levels of activity—420 minutes per week on average. The NWCR has yet to figure out what makes those things work for them and/or makes them capable of sustaining those behaviors when for most people, they don’t/can’t.
Collecting 5,000 success stories does not prove that dieting “works” for most people let alone that it’s the norm. Somewhere between 45 million and 90 million Americans diet to lose weight every year, most of them by attempting to reduce their caloric intake. According to a survey conducted in April 2010 by a private consumer research firm on behalf of Nutrisystem, 30% of Americans have dieted repeatedly—an average of 20 times. Unsurprisingly, weight loss attempts are more common among overweight and obese people. If calorie-restriction dieting “worked,” America would be a nation of thin people.
Conclusion: Putting the burden of proof back where it belongs
Traditionally, researchers assume that a treatment is not effective until they have evidence that proves otherwise. The reverse is true in regard to weight-loss dieting: most people assume dieting is effective for long-term weight loss and challenge anyone who believes otherwise to prove that it doesn’t—not that that’s difficult, given the consistent failure of most weight-loss interventions to produce lasting results. I have not been able to find one long-term, randomized, controlled study that shows that dieting works (i.e. a statistically significant group of people following a calorie-reduction diet losing a clinically significant amount of weight and keeping it off for more than 3 years). Instead, what all the research to date shows is that the most reliable outcome of calorie-restriction dieting is short-term weight loss followed by weight regain.
I suspect the stubborn persistence in prescribing calorie-restriction dieting as a weight loss strategy in spite of the available evidence probably has a lot to do with dominant and deeply-engrained attitudes about fatness, meritocracy, virtue, and effort. People exhibit remarkable cognitive dissonance when it comes to the research on weight loss—they hold up exceptions as the rule and claim that the 90-95% of people for whom calorie restriction dieting does not produce weight loss must simply not be trying hard enough.
Imagine this scenario playing out with any other condition—imagine that instead of weight, we were talking about some kind of rash that was widely considered unattractive and thought to be correlated with a variety of other health problems. There’s a treatment that showed promise in short-term trials. In virtually every study, most of the people who get the treatment experience significant improvement in their symptoms, with peak results around six months. However, in longer-term studies, there’s a reversal. Just as consistently, the vast majority of sufferers—at least 75% and usually closer to 90 or 95%—experience a gradual return of their symptoms. For approximately 30-40% of participants, their symptoms actually get worse than before they started the treatment. Only 5-10% show lasting improvement. Of course you would want to do more research to figure out why the treatment works for that 5-10%, but in the meantime, would you keep prescribing it to everyone with the same skin condition?
Even if the problem is that only 5-10% of them fail to use the treatment as instructed—say, it’s a topical cream that only works if you apply it every hour on the hour and people get fatigued, especially by trying to wake up at night to put it on. If 90% of the affected population can’t use the treatment effectively, the results are the same as if the treatment never worked in the first place. Well, except for that part where 30-40% of them end up worse off than before they started the treatment…
So even if the calorie counts on menus were accurate, and people could accurately and reliably estimate how many calories they burn, and they did choose lower-calorie options at least some of the time, and they didn’t compensate by eating more on other occasions…in other words, even if the calorie counts worked the way they were intended to, the best you could hope for would be short-term weight loss. There’s no reason to believe the policy—even under ideal conditions—would have a lasting effect on most Americans’ weight or health.
I thought of you today when I
I thought of you today when I was at Paneras. They post the calories contents of their foods. This was helpful for me because I don't eat there that much and didn't want to over-consume. I ended up with a plain bagel (290 calories) and about 1 oz. of cream cheese. In this case, it totally helped me!
I do question studies that put so much emphasis on walking. On some days, I wear a (sorry, I always forget the name...the watch thingie that measures your calories burned) whatever you call it and walking doesn't do much for me. I realize it's better than sitting on my ass on my couch (which is my natural state) but an hour walk burns less than 150 calories. If I go and drink a beer, I've just negated my hour walk. I guess my issue is that, like the study that says "increase exercise esp. walking" is misleading. Walking your dog is not a workout; it will burn some calories, but not many. I am sure people think, "Well hell, I walked to the Quik-E-Mart and back and I've earned this Stucchi's!" Um, no.
Next time we hang out, remind me to tell you about the time I made the kids tell me what they ate in a typical day and how we looked up the caloric contents...KFC is really f'in bad for ya!
activity isn't about the calories burned
you're totally right that walking doesn't burn a lot of calories and probably won't cause significant weight loss unless you're walking a LOT. even engaging in much more strenuous activity doesn't usually lead to weight loss, even in the short term. HOWEVER, even though it doesn't lead to significant weight loss, physical activity does improve people's health in just about every way we can measure--reduces hypertension and inflammation, lowers triglycerides and fasting glucose levels, improves bone density and immune system response, etc.
that's what the experimental research has shown. but it applies to epidemiological research too--people who are obese but active (not just overweight, OBESE--overweight people live longer than "normal" weight people even without taking activity into account) live longer, healthier lives than people who are "normal" weight but sedentary.
in other words, exercise won't make you thin, but it will make you healthier, which is more than we can say about cutting calories.
for more on the relationship between activity and health, see _The Obesity Myth_ by Paul Campos or basically any of the 300+ articles written by Stephen Blair. here's an interview with him in the NYTimes: http://health.nytimes.com/ref/health/healthguide/esn-exercise-qa.html
Dieting vs. Lifestyle
Good article--very in depth. However, I think your conclusion might be missing the point: diets don't work because they are temporary changes in behavior, and they predictably result in only temporary achievement of the desired outcome (if even that).
But posting the caloric value of food (as insufficient as it might be, anything more complex than a simple number might escape the limited attention span of America at large) is more than that. It ensures that people who are not dieting see what they are putting into their bodies--it's more likely to spark a lifestyle change than a diet, and a healthier lifestyle DOES result in keeping weight off (and, more importantly, a higher level of fitness if exercise is involved). After all, a dieter is going to look at calories while dieting. But if calories are posted where everyone can see them, it gets them thinking even when they're not dieting.
Granted, it's unlikely that many people will have an epiphany in the Taco Bell drive-thru and swear off processed foods forever, but it can't hurt. There are people out there who genuinely believe fast food is healthier than it actually is. How many people think chicken-based items are less calorie and fat laden than burgers, or that fries are somewhat healthy because they're vegetables? It would be better if everyone would educate themselves as to what is healthy and what isn't, but that's not realistic. Baby steps.
Also, I do take issue with your assertion that exercise doesn't result in weight loss. It most certainly does. Quite simply, if you expend more energy without consuming more (or without consuming enough to cover the amount expended), you will lose weight. This is the first law of thermodynamics--either people who just can't seem to lose weight are not burning as many calories as they think they are, or they're eating more than they think they are (snacking throughout the day is a big culprit--especially in an office setting where it's easy to blank out most of the day). In any case, it's disingenuous to say obesity is okay. Depending on your physical build and where your body stores its fat, it may or may not be healthy to carry extra weight according to government standards, but most people who are obese are obese because they do not get physical exercise and they do not eat right--the "fat but fit" demographic is a small minority, and more often than not, they lose the "fat" status over time and become simply "fit." It is important not to demonize people who weigh more than they should just like it's important not to demonize smokers or drug addicts, but it's also important not to shrug off their behavior as if it's harmless, because it's not.
missing the point
I can provide just as many studies to show that exercise alone does not make people lose weight. It does seem to help people maintain weight loss a little longer than dieting alone, but most people who begin exercise regimes without dieting lose at most 3-5 lbs. Part of the explanation is probably that people eat more to compensate for the exercise; however, the idea that human bodies faithfully obey the laws of thermodynamics is sadly outdated.
The problem with the idea that what people really need is a "lifestyle change" instead of a "diet" is that those "changes" are not sustainable for most people. Doctors tell people they need to make a change, and they do...for a little while. It's not just an issue of short-term initiatives, it's a problem of what humans are capable of. Anything that people experience as deprivation or a tax on their will-power is necessarily temporary.
I'd like to see the evidence that obesity is not "okay." I've been pretty well convinced by Paul Campos’ The Obesity Myth, J. Eric Oliver’s Fat Politics, Glen Gaesser’s Big Fat Lies, or Michael Gard and Jan Wright’s The Obesity Epidemic: Science, Morality, and Ideology (see http://soursaltybittersweet.com/content/why-posting-calorie-counts-will-... for links to free text where available) that most of the "evidence" showing that obesity is not okay, or that it's increasing at a dangerous rate, is at best exaggerated, if not totally invented.
It would be more accurate to
It would be more accurate to say that people who exercise tend to not lose weight for a variety of reasons (thinking they've burned more calories than they actually have, "rewarding" themselves with a donut afterwards, etc.). Most of this can be fixed through education. I hate to use personal anecdotes as a part of an argument, but I think many people have gone through this. Years ago when I first started to get in shape, I'd go out on a short hike a few times a week. Then, thinking I'd done well and burned so many calories, I'd reward myself with a couple beers or a donut or something else that actually contained more calories than I'd burned. I didn't realize the error of my ways until later, when I discovered a calorie expenditure calculator online and was able to ballpark how much a 30 minute hike burned. However, I did not violate the law of thermodynamics. It's true that not all calories are equal in terms of nutrition for the human body, but in terms of energy, a calorie is a standardized unit of measurement. If you push yourself to run a mile, you will burn the same number of calories regardless of where they came from.
As for a lifestyle change being self-deprivation or a matter of willpower, that shows some pretty big cultural issues we face. The point is that everyone should go out and find something active they enjoy (or make themselves enjoy it). They should learn to cook and make themselves enjoy it if they already don't. Substitute healthier ingredients (i.e. whole-wheat or spelt flour for white flour), get out from in front of the TV. If you feel like you're being deprived, you're doing it wrong. But in today's world deprivation shouldn't be an issue unless you're poor, and that's a whole different social problem altogether. The fact is that in all of these studies you've posted there are a small percentage of people who did manage to keep the weight off. This suggests that they're either doing something extra or the majority who gain the weight back are not doing something, and it would be worth it to investigate what that might be.
And finally, here's a good rebuttal to Paul Campos: http://stuartbuck.blogspot.com/2008/07/paul-campos-obesity-myth.html
While I agree the emphasis on obesity in our society is bigger than it needs to be (especially in regards to overall fitness), that doesn't mean it's not a problem. Due to the nature of science and all the variables involves, it's very hard to provide conclusive links between obesity and many medical problems. But here's the rub: even if correlation is not causation in the cases of diabetes, heart disease, hypertension, joint damage, allergies, chronic inflammation, and overall increased risk of morbidity, it's telling that these things occur far less across the board in individuals who are not classed as obese. Social stigmas aside, you have to ignore essentially all of the medical literature on the topic to say that obesity is not a health risk and that it's okay to be fat, and while it's unlikely the literature is all correct, it's even more unlikely it's all incorrect.
I do understand that you're making an argument here, but with all due respect, most issues are not simple dichotomies where you can just brush aside exceptions as if they don't matter. I agree that overall fitness is more important than weight, but weight can't be ignored. Sumo wrestlers tend to be very fit and have lots of muscle mass, but their life expectancy is some ten years less than other Japanese folks, and they tend to be disproportionately plagued by health problems later in life (and most sumo wrestlers aren't ridiculously oversized as portrayed in popular culture).
Anyway, I apologize for the length of this. Brevity isn't my strong suit. I do want to say that I enjoy your blog, however, and that it's nice to see such thorough work on socially relevant topics that most Americans are somewhat mistaken about (i.e. corn syrup, saturated fat).
Wow, this is a toughie. I
Wow, this is a toughie. I see heavy kids at my school every single day. The problem is a combination of lack of exercise and crappy diet. Increasing exercise OR changing diet probably wouldn't help that much...but doing BOTH probably would. I think the nail was hit on its head when someone said that those who exercise end up consuming more calories. I know a kid who was really proud that he and his dad wnet swimming for an hour, but failed to see the problem with then consuming 1/2 of a Meat Lovers pizza from the Hut. Sure, that 150 or so calories that he burned is great, but barely makes a dent in the 1500 or so calories he then consumed.
I fell into that trap for about a year and wondered why I wasn't losing weight. Once I reduced calories and upped the exercise quotient, I began to lose.
That Bites!
I just lost 50 lbs. Yes a calorie restricted diet and I still have 60 lbs. more to go. Basically after reading your article, I shouldn't bother because I will just gain it all back... and then some. I will be even more unhealthy than I am right now. THANKS for the depressing news! Yes, I am thinking in the back of my mind.. maybe I will be the exception to the rule.
I have two daughters and they have completely different body types. One was born long and lean and the other was born short with rolls of fat. Now they are 7 and still very thin and 5 and still chunky. I feed them the same diet and they have a similar activity level but the younger one will be like her mom and probably always struggle with her weight. I think we are sometime made to be heavy.
I skimmed the book Good Calories, Bad Calories and it was really good read, if you are into health and weight which you obviously are, I recommend it. It is very scientific and shows how carbs are really bad for you. I think those that can restrict their sugar and starch consumption can be very successful in keeping the weight off. At least this is what I an hoping to do with all of my research and personal experience so far. I know it will be my life long battle and I will have to weigh myself everyday as I do now. In our culture it is all processed and refined white crap that is not good for our bodies.
hope
I think a lot of people do find the research demoralizing--at least at first--but I think it can also be liberating, especially in light of the fact that health outcomes have a much stronger relationship to physical activity levels than weight. A growing body of research is showing that people who are obese and active live longer and suffer fewer so-called "lifestyle diseases" than people who are "normal" according to their BMI but sedentary.
People who exercise with the primary goal of losing weight naturally get frustrated and often stop exercising when their repeated efforts to "get healthy" fail. However, if we take the goal of weight loss off the table and encourage people to exercise because it makes a big difference in their health whether or not they lose much--if any--weight, it often becomes a more sustainable behavior.
And I think there's a lot of comfort in the idea that it's not your fault--that it's not about willpower or self-control, which is how it's generally portrayed. As you've seen in your daughters: people have different body types and often those differences are stubborn. I think knowing that it's probably futile often helps people take the first steps towards acceptance and can help people build a healthier relationship to food, because making foods "forbidden" or "bad" also makes them tempting and makes many people more likely to abuse them.
"And I think there's a lot of
"And I think there's a lot of comfort in the idea that it's not your fault--that it's not about willpower or self-control, which is how it's generally portrayed."
I find it interesting that you say that it's "not about willpower". My conclusion would have been that it isn't about willpower, but rather that the vast majority of people lack the necessary willpower. Do you have any particular reason for seeing it that way?
yes, several
reason #1: there's no evidence that the distinction between the 5-10% who can maintain weight-loss long-term and the 90-95% who can't is "willpower." this is testable, although i haven't found any research on it.
there are measures of the individual variation in self-control, which could be administered at the beginning of a weight-loss study to see if it's true that the outliers who maintain weight loss have abnormally high self-control.
my hypothesis is that people who test high on a measure of self-control might maintain weight loss longer than people who test low on a measure of self-control, but that they would ultimately re-gain the weight too, because i think there probably biological differences between the very few people who maintain weight-loss and the vast majority who don't and because i don't think the individual variation in self-control is so extreme that 5-10% of the population has enough to maintain chronically restrained eating and 90-95% do not.
reason #2: some people following even very low calorie diets (<800 kcal/day) begin to regain weight after a period of weight-loss even if they continue following the diet. many weight loss diets probably "fail" not because the people following them fail to continue them, but because underlying biological mechanisms resist the loss of fat (i.e. hormones that regulate fat storage, metabolic rate, and appetite).
reason #3: semantically, i think when people claim that weight-loss requires and results from "self-control," what they are implying is that most people can do it, not that long-term weight loss is something only 5-10% of the population has the requisite willpower to do.
#1. There are measures of the
#1. There are measures of the individual variation in self-control? What are they?
It seems odd to me that we would think that we could measure a person's self-control, since it seems to me that self-control in one area of their life does not translate into self-control in other areas. (So, for example, I would not particularly expect people in the National Weight Loss Registry to have more self-control in the areas of, say, gambling or sex, even if they did have more self control in the area of eating and exercise.)
#2. The standard advice that I've heard (the same ones recommending changes to eating in the first place) have often said that "starvation" dieting kicks you into some other metabolic stage, so that your body tries to conserve every bit that it can, making it difficult or impossible to lose weight, and making you highly lethargic to boot. (That's why they recommend cutting back moderately and only losing one or maybe two pounds per week for a more sustainable goal.) I would have thought that that was the explanation for people on VLCD gaining back the weight, rather than a general application to all diets.
Are you really saying that you think that some of us biologically have no hope of losing weight, that our bodies will do whatever it takes to hold onto the pounds and fat, no matter how much healthier we eat and how much we exercise?
#3. Hmm. That's actually a very good point. Sort of like people who will tell homeless people to "just get a job".
I don't know what your religious beliefs are, but I tend to view losing weight in spiritual terms, at least insofar as it involves willpower. That is, humans are weak by nature, and can only overcome that weakness with God's help (whether conscious of it or not). So I sort of see "not having the willpower to overcome the vices to which we are inclined" as the inherent, the default, state of the human race, and any story otherwise is ultimately a story about God's grace.
Have you ever read the book The War of Art by Steven Pressfield?
There are a number of
There are a number of questionnaires and tests used by research psychologists to measure self-control (some of which have been positively correlated with particular eating behaviors but none of which have been used in long-term weight loss studies, at least to my knowledge). Here's a paper on the validity of a 20-item self-report measure that addresses some of the issues involved in defining and measuring self control: http://www.uky.edu/~kdbrad2/Jonathan.pdf. The Conscientiousness scale from the five-factor personality model of personality is also often seen as a measure of self-control.
Yes, I am really saying that variation in body size is a natural form of human diversity and that some people cannot be thin, long-term, no matter how little they eat, how "healthfully" they eat, or how much they exercise.
Other people, like me, can stay relatively thin (I'm 5'4" and weigh about 110 lbs, so my BMI is on the low end of "normal": 18.9) without dieting or exercising a lot. I basically eat whatever I want and as much as I want. My job is sedentary and I engage in moderate levels of physical activity for 30-40 minutes 3-4 times/week.
I have not read The War of Art. But perhaps I'll put it on my list for sometime after I finish my dissertation. I'm sure I could use a little more "creative discipline." Thanks for the recommendation.
Maybe you and I are on two
Maybe you and I are on two different wavelengths. Of course some people biologically have larger builds than others, and most people can never obtain that supermodel-thin look that some people are born to. (And shouldn't be trying to). And I'm willing to buy that the official standards of what is "overweight" or "obese" could be off - maybe even seriously off. But even so, there are still a lot of fat people in the world (myself included), who are overweight by any reasonable definition of overweight. (I'm 5'6" - officially I could weigh up to 156 lbs before I cross into "overweight" status according to BMI. And it might be that a more realistic upper limit would be somewhere in the 160 to 180 range. Whereas, what I actually weigh is 230 lbs.) So I guess what I'm asking is whether you think that people who actually ARE overweight (as opposed to people who just think they are overweight because of bad guidelines and cultural obsession with thinness) cannot lose weight, even with healthy eating habits and exercise?
Interesting stuff about measuring self-control. Although, after finding a 13-item version of Tangey's self-control measure, it rather seems to me to be the equivalent of finding different ways to just *ask* people if they are self-controlled. But, clearly, if they're finding a positive correlation with things like anxiety and alcoholism, then it's getting somewhere.
So I should probably say something about why I brought up The War of Art, aside from its general fabulousness as a book. Although it is mostly directed at efforts that involve creative work, it also includes efforts to better yourself physically (or spiritually) too, such as eating healthy and exercising. The author does a very good job of showing up what he calls "Resistance"; all the internal forces that array themselves against us succeeding at anything. In the end, I think he does a great job of inspiring sympathy for ourselves and others when we fail (by showing us just how *hard* it really is to succeed at anything) while also giving us hope that we *can* succeed and motivating us to do so. It's a delicate balance to maintain. And the book played a major role in my eventual decision to start the No-S diet.
Yes, I believe that some
Yes, I believe that some people in the BMI ranges currently defined as "overweight" or "obese" cannot achieve and maintain a "normal" weight, long-term, no matter how they eat or how much they exercise. I'm not sure what standards you think are "reasonable" or how you would determine when someone is "actually" overweight, but it probably doesn't matter. I believe that some who eat "healthfully" and exercise regularly for their whole lives will still be fat by any definition of fatness. I think some bodies tend towards fatness, and that that is normal and healthy and those people may not be able to be thin or average no matter what they do.
Another thing the research on self-control suggests is that what we think of as "willpower" is a limited resource. There is individual variation, and people may be able to cultivate or strengthen their willpower. However, it is not infinite for anyone. Therefore, any behavior that requires someone to exercise willpower continuously and indefinitely is not sustainable. Everyone will run out of willpower eventually. Of course, ultimately it doesn't matter if the reason 90-95% of people in randomized weight-loss studies regain all the weight they lose is because their metabolisms adjust or because they run out of willpower--either way, they can't maintain the weight loss. If they could, they would.
That doesn't mean permanent lifestyle changes are impossible. It might be possible to re-frame some kinds of behaviors so that they don't use scarce willpower resources. For example, if people construct food as "poisonous/undesirable" to them rather than "bad/tempting/desirable," maybe they won't actually have to exercise willpower to avoid it. Many long-term vegetarians develop a disgust/fear response to meat. Essentially, they don't have to "spend" willpower to avoid eating meat because they simply don't see it as desirable. Meat might as well be plastic. Similarly, if people focus on how exercise makes them feel good rather than framing it as drudgery that they have to force themselves to do, exercising regularly might be more sustainable. But that also doesn't mean that anyone can make any lifestyle change or that those lifestyle changes can make all fat people thin (or "average" or whatever counts as not overweight).
One caveat regarding low-carb diets: The studies above all deal with calorie-restriction dieting, and there's some anecdotal support for the idea that low-carb diets might produce significant, long-term weight loss for some people. However, I haven't found any large-scale, randomized studies that convince me they really work for all or even most people who fit the current definitions of overweight and obese. Without large, randomized studies to confirm, it's possible that the anecdotal support is coming from the same kinds of people who can achieve permanent weight loss using calorie restriction--a small, unrepresentative minority for whom the diets "work." So far, in long-term studies where people have been assigned to follow low-carb diets like Atkins, their results have been similar to calorie-reduction diets: they lose weight initially, but regain most of the weight they lose within a year and often end up regaining more than they lost in the first place. Only about 25% of the people in the NWCR lost weight or maintain their weight loss by following a low-carb diet.
Fortunately, it doesn't seem like even obese people need to lose weight in order to be healthy. "Overweight" people already live longer on average than people in the BMI range defined as "normal." "Obese" people who are even moderately active live as long as active "normal" weight people and live longer and do better on almost all measures of health than sedentary "normal" weight people. However, people who weight cycle (lose and regain), which as the studies above show is by far the most common result of weight-loss dieting, have shorter lifespans and do worse on most measures of health (higher rates of cardiovascular disease and Type 2 diabetes) than people in the same BMI range who never dieted and lost weight in the first place.
That's why I am a supporter of the Health at Any Size philosophy and movement. I think the focus on body size is counterproductive and that tying lifestyle changes to weight loss goals makes people less likely to maintain behaviors that do actually improve their health, but don't tend to lead to long-term weight loss, like exercising. For most overweight and obese people, dieting for weight-loss leads to weight-cycling, which is demoralizing at best and may actually be harmful. I believe that more people would achieve better health (physical and mental) and have a more peaceful, more enjoyable, less anxious, and less guilt-ridden relationship to food and exercise if they accepted their body size and cultivated practices like mindful eating and pleasurable physical activities.
Food For Thought
There's a lot of food for thought in what you say.
For the record, I don't have any particular standard in mind for deciding who is overweight and who is not. Mostly I just know there's a woman my height who is (if I recall right) ~180 lbs, and while I wouldn't call her thin, I decidedly don't think she's overweight. Whereas, I do think I am. If I had to find a way to decide when someone is at a healthy weight, I'd say eat right and exercise and find out what weight you end up at. But I've always assumed that if *I* did that, I would be noticeably less weight than I am now, whereas it sort of sounds like you're saying I probably (or maybe?) wouldn't be, that I shouldn't expect that, which is a completely new thought for me.
"Therefore, any behavior that requires someone to exercise willpower continuously and indefinitely is not sustainable."
This one I have to mull over. I'm sort of torn between complete agreement and thinking - doesn't life in general require us to exercise willpower continuously and indefinitely? I mean, take your dissertation (which I use as an example because I have my own writing that I do). Don't you find that you have to keep exercising willpower to keep working on it? Maybe it doesn't fit the "continuous" part, since (presumably) there are times when you just love working on it, when it fires the inner creative spirit and makes your life that much more worth living. But won't there always be times, too, when you have to power through all the resistance and just force yourself to sit down and write something even though you wish you could be doing just about anything else at that moment? (Because you know that, in the end, it will be worth it.) Does that count as exercising willpower continuously and indefinitely? If not, what's the difference?
On a semi-related note, you wrote the following excerpt in an earlier part of this series:
"As Roberts told Time, she decided to do the study because when she was trying to follow the diet advice in her own book, substituting prepared or restaurant meals, “the pounds stopped dropping off. Just as suspiciously, she always felt full” (more on the idea the fullness means a diet must be failing when I get to the issue of why calorie-restriction doesn’t work for long-term weight loss)."
And I've been wondering about that "fullness means a diet must be failing" part. Could you explain that?
Also... what makes you think that mindful eating works? And by "works", I don't mean "makes you lose weight", I mean "could be scientifically shown (if a study were done) to help people eat healthier food or improve their health in some way". Do you think mindful eating doesn't require willpower, and therefore is more sustainable? Because, frankly, it seems to me just as difficult to start as a diet would be.
I find that thinking of my
I find that thinking of my dissertation as a challenge I have to do battle with is the least productive mode for me--even if I can power through for a while, weeks at a time even, I end up feeling tense and exhausted and emotionally needy and eventually incapable of going on. I have had far more success at doing consistent work without sacrificing my quality of life when I frame my dissertation as something that is worthwhile, that I enjoy working on, that is a choice rather than an obligation, etc. I literally give myself permission to walk away and quit, and generally find that I do actually want to continue and that I enjoy working on it. That works much better than treating myself like child prone to misbehaving who needs to be scolded and punished in order to behave. The latter seems to me like operating by willpower: forcing yourself to do something you don't want to do. It's not like it's black and white or all of one vs. all of the other. Cognitive framing is subtle, and I have to work on it and use "tricks" to help me approach my work that way rather than through "willpower." But I do think there's a difference and that if I had always framed my dissertation as a challenge to be fought, I probably would not be on track to finish next month.
I don't think most people, or possibly anyone, really has it in them to force themselves to do something they don't want to do every day, forever. And I think that's why you see the same pattern in 90-95% of weight-loss dieters: most people can do whatever it takes, no matter how hard, for a while...but then either they plateau or start regaining weight despite continuing to deprive themselves, which completely undermines their motivation to go on, or they run out of willpower and start "cheating" and that's why they start regaining weight. Again, I don't think it really matters which one: either way, they can't keep losing weight or maintain their weight loss long-term, and they usually end up regaining all the weight they lost if not more. After a while, most people can muster the willpower to try again. But in the long run, that cycle probably damages their health (physical and mental) and the end result is that they end up weighing as much or more than they started off weighing, and unhappy about that.
You're right: the idea that if you feel "full," your diet must be failing is related. Because what that suggests to me is that her diet, when it's "working," involves feeling hungry on a regular basis. I think many people are willing to tolerate feeling hungry now and then, for a while. But I don't think most people can tolerate feeling hungry every day, indefinitely. If they can, I kind of wonder if that isn't a sign of a disordered relationship to food.
Mindful eating is the opposite of that--it's not about doing something that's painful and hard or involves feeling hungry. And yes, there have been a few studies that suggest that people who are counseled about mindful eating techniques are better able to maintain their current weight and improve on measures of physical and mental health, like blood pressure, activity levels, self-esteem, depression, and body image, compared to people who get more traditional weight-loss diet counseling. Attrition is also far lower in the mindful eating/health at any size groups than in the weight-loss diet groups (8% compared to 40%) suggesting people also find it easier to do and stick to. Here's the abstract for a study involving 78 women with 2 years of follow-up: http://www.ncbi.nlm.nih.gov/pubmed/15942543.
Steven Blair is the main man on activity & health, and he has published dozens of studies over the years. Here's an interview with him from the New York Times: http://www.nytimes.com/ref/health/healthguide/esn-exercise-qa.html. There's also some evidence to suggest that lots of low-impact activity (walking, gardening, etc. for 3-5 hours a week) along with full-body strength training (~30 min./wk) and occasional bursts of vigorous activity like sprinting (10 min? doesn't take much) result in better health than consistent cardio (i.e. jogging on a treadmill 40 min every day), but the evidence for that is still a little mixed. Google "high intensity exercise" if you want to explore those debates more.
To be fair: I don't think there is enough research on mindful eating and "health at any size" counseling to make really definitive statements about its effects, either. But the results that do exist are promising and at least it doesn't seem to do any harm--which is more than I can say for calorie-restriction dieting.
Cognitive framing is subtle,
Cognitive framing is subtle, and I have to work on it and use "tricks" to help me approach my work that way rather than through "willpower."
See, when you say "I have to work on it", I think of that as using willpower. Working on anything - whether it is dieting, mindful eating, exercise, or writing something - involves not taking the path of least resistance, which means exerting some degree of effort, of willpower. Although I will grant that there is a radical difference between trying to work on something which presents difficulties but which you see as ultimately worthwhile, as life-giving, versus something which you see as pure drudgery. And I agree that expecting people to keep choosing to do something which is pure drudgery, indefinitely, is unrealistic.
On the other hand, mindful eating sounds like a lot of drudgery to me. It's not physically hard, the way that dieting would be, but it is mental work: the work of forcing your thoughts and attention in a particular direction, of trying to discern what your intuition says, and so on. The lower attrition rate in the abstract certainly suggests that it is easier work than dieting... but I have a hard time seeing myself sticking with any attempt to do that for very long.
I am reassured that you weren't agreeing with the author who said feeling full is a sign that a diet is failing. I don't know why I had the impression that you WERE agreeing with her, but I definitely agree with you that relying on feeling hungry indefinitely is not a good plan.
So here's a question for you... what counts as a calorie restriction diet? Presumably all diets that involve actually counting calories directly and setting a limit on them. What about other attempts to limit how much food is eaten, without setting a direct limit on or counting calories? Like the Pyramid Diet, where you aim to eat some recommended number of servings of each category of food (grain, fruit, vegetable, meat, dairy...) each day? Or the No-S diet, where you can eat (almost) anything you want, as long as you can fit it on one plate and don't eat between meals? Or the points diet, where different foods are assigned points and you have a number of points that you aim to eat each day? Would all of these require just as much "willpower" as a calorie-counting diet? Do any of them seem like they would be more sustainable than the others, to you? (Or more sustainable than a calorie-counting diet)?
(If I'm bothering you at all with this discussion, let me know).
Oh, and kudos on being close to finishing your dissertation! That's awesome.
Interesting. I tend not to
Interesting. I tend not to think about the kind of work or effort that goes into re-routing my thought patterns as a matter of willpower, because it doesn't seem tiring or hard and I don't feel like my ability to do it is limited. It requires continual work because my default tendency is to moralize and then push myself to do the "good" thing (diet, exercise, work, whatever). But I've become increasingly convinced that that approach is unsustainable for me--not to mention unpleasant. I can do it for a while, but eventually I burn out.
Changing my cognitive frames isn't "work" in the sense of doing something hard that you'd rather not be doing, it's more like the practice of mindfulness associated with meditation and yoga. In yoga, if your attention wanders, that's okay, you don't have to beat yourself up about it. People's attention naturally wanders. But when you notice your attention wandering, you try to bring it back to what you want to be focused on--your breath, your goals, the pose you're in, etc.
How that manifests for me in terms of work is in trying to recognize my limits and realize that it's okay to take a break, that I'll do better work after taking a real break that I don't feel guilty about taking than if I beat myself up about how I "should" be working until I burn out. How it manifests for me in terms of food is really letting myself eat whatever I want whenever I want. And when I find myself moralizing or judging myself, I try to treat it just like when my attention wanders during yoga: I try to notice it and set it aside and return to the kinds of thought patterns and focus that are more self-accepting and productive.
I'm not saying it's always easy, but it does seem conceptually and practically different to me than the kind of work that requires "willpower."
I'm really enjoying our correspondence--it has encouraged me to think through things that I haven't necessarily been clear about in my own mind and reminded me about things I'm still kind of mulling over. But I do wonder if maybe I can get back to your question about what counts as calorie-restriction dieting in April...as fun as this is, it is probably diverting my attention a little from the dissertation. But I promise to get back to that question of what kind(s) of "diets," if any, are sustainable, and for whom, sometime after I send the dissertation off to my committee. That probably deserves its own blog post anyhow.
Oh, and I checked out your blog, which is lovely, and I'm flattered that you've taken an interest in the things I write about. Raw milk is on my agenda to think more about too. My tentative feelings about it are that I'm not sure the evidence about the health benefits outweighs the risks, especially for children, pregnant women, and people whose health is compromised in any way; however, I think people should probably be able to weigh the potential risks and benefits for themselves and make their own decisions about whether to buy and consume it, and that the legal restrictions on raw milk and especially raw milk cheeses are pretty absurd.
Overly long comment?
So you set up an interesting dichotomy between making something into a moral issue, and self-acceptance. If food was a moral issue - or if yoga or writing were - why would you then feel as if you had to beat yourself up if you got it wrong?
The thing is, I have a theology of forgiveness that tells me that if I mess up, I can repent and be forgiven. So, sometimes my thoughts look like what you say - I'll be writing something, my mind will wander, I'll notice it, accept that that happens, and get back to work. But other times, I'll realize that my mind hasn't just wandered, but that a little bit ago, I chose to let it *keep* wandering. If I know that God wanted me to be focusing on writing right then - and this is by no means always the case - then I will know that I did something wrong. But instead of wasting more time dwelling on it and beating myself up about it, I try to just tell God "Hey, I'm sorry I did that" and then move on. If I try to skip that step of "sorry", if I try to go straight to "let it go", it doesn't usually work; the feelings of angst linger on like a bad cold.
It's like this with all other areas of my life, whether eating or exercising or more serious matters. There's always that tricky part of discerning what is right or wrong, what I should be doing or whether it even matters at all. (And there's a lot of things that don't). But if I can remember, no matter how bad I mess up, that I will be ok - I will still be lovable and worthwhile as a person - then it's all a lot easier, even if I am still seeing things in terms of "good" and "bad". Does that make sense?
What might also be relevant here is the discernment process. Someone once told me (well, I read it in a book, that is) that God never speaks harshly; that he is always gentle, even when he is correcting your errors. So then I started to notice the difference between those times when my thoughts had a harsh, accusatory tone ('you're a piece of [bleep] if you don't do the dishes right now') and those times when I knew I should do something, but in a gentle way. All those thoughts that literally said I wasn't good enough if I didn't do the impossible, that berated me for having any limitations or weaknesses (like your example of taking a break while working)... I was suddenly free to throw all those ideas out as lies.
I do actually see those thoughts and feelings within me as lies told by Satan (Trivia fact: "Satan" means "Accuser", and he's known as the "father of lies".) But I don't think you need to believe in either God or the devil to observe the difference in your own experience between harsh accusatory thoughts and gentle promptings that make your life better, (even if sometimes you don't really want to hear them). Thinking of the harsh thoughts as ... coming from outside yourself ... coming to you, rather than coming from you, from who you are at your core - that made it a lot easier for me to let go of them.
If I've gotten too preachy, I apologize. It's difficult to express this without bringing God into it, since that's how I think of it, but I don't think that this is something you have to be religious to "get". And in a lot of ways, I think you already do "get" it. But I think you can apply your thinking a little farther: that you can be self-accepting and not beat yourself up even if you see something as a moral issue. And that what makes a particular effort into sheer drudgery, requiring unsustainable willpower, is when we believe the harsh things that we think. (Sometimes the harsh thing that we are believing is that we need to be doing it in the first place; sometimes the harsh thing we are believing is that we can't do it at all, or that it needs to be done more perfectly than we can do it, or so on.)
Moving on. :) Of course it is totally cool if you wait till you are done with your dissertation before comparing diets. And if you want to not respond to everything I've just written, because that would also distract you from your dissertation, that's fine, too. :) I look forward to your thoughts on various diets, whenever you have time to write it.
I'm glad you liked my blog. Feel free to stop by or comment any time. :) I spontaneously decided to try out your homemade yogurt recipe today, so there might be a blog post about that (late) tomorrow. And thanks for your thoughts on raw milk; I appreciate that!
Post new comment