JAMA‘s editorial this week on the failure of the multibillion dollar diet industry to make a dent in the growing rate of obesity pointed out that dieting and going to a gym are only the first steps along the difficult path toward a permanent weight loss. Diets, especially fad diets, are, in the long run, ineffective. A permanent change in lifestyle must occur for a permanent change in weight.
This is hardly new information; indeed it falls under the category of conventional wisdom. But this conventional wisdom finally received some scientific support as a result of several studies, spanning years, on the effectiveness of behavioral interventions on decreasing health risks. In an example given in the editorial, volunteers who received years of behavioral intervention to improve their food choices had a significantly lower rate of diabetes for many years following the end of the study, than those not receiving this support.
So why don’t we do the obvious and put our labor, money, time, and marketing into programs that help individuals permanently improve their food choices, increase their physical activity and identify and change, where they can, the situations that are causing them to gain weight? Moreover, why don’t we admit that it is hard to do this regardless of how weight has been lost? Why don’t we have as many interventions to prevent weight gain as we do to initiate weight loss? Few weight-loss programs provide this; Weight Watchers is an exception.
Rather, the dieter is assured that whatever diet he or she is now on will be the last ever needed! Of course this is rarely the case. Even patients who have undergone surgery to reduce food intake fail to reach their weight-loss goal, and many fail even in keeping off any of the weight they lost initially.
I have a friend who did everything right to lose weight. He went on a slow, sensible weight-loss diet, exercised daily, markedly decreased his alcohol intake and welcomed all the good wishes and congratulations that came his way as he lost over one hundred pounds. And then the weight started to come back. Slowly, after six or so months, he regained most of his weight. We, his friends, shook our heads, murmured among ourselves, “What can we do?’ said nothing. One person, a close friend who is also a physician, thought about saying, “Do you need help?” Some one else had discussed taking him aside, when only 10 or 15 pounds had been gained, to say, “I know there must be a good reason why you are starting to gain weight. Do you want to talk about why this is happening?”
But we did nothing. We did not want to step over the boundary of privacy.
Maybe he did look for help but from where would it come? He needed someone or some organization that would help him work through the reasons why he abandoned his year-long healthy lifestyle to go back to his former weight-gaining one. Who would provide this help? According to the JAMA editorial, primary care physicians, physician assistants and nurse practitioners for Medicare and Medicaid Services (CMS) will reimburse lifestyle interventions but only if this care is provided for in their approved Centers.
This is tantamount to saying that instruction on using a treadmill or a weight machine can come only from an orthopedic surgeon. What primary care physician, nurse practitioner or physician assistant has the time or training to offer the intensive and personally insightful support our friend required? And psychiatrists are just as unlikely to do this; indeed, they do not even provide information to their patients on how to prevent the almost inevitable weight gain that accompanies the use of psychotropic drugs. And so much to everyone’s dismay, our firend became obese. Again.
What is needed is an approach to permanent weight loss that:
1. Defines the inability to maintain a normal weight as a medical/behavioral issue. Even though obesity is now considered a disease, the process of becoming obese has not yet achieved that status. People unable to lose significant amounts of weight or unable to keep it off (like my friend) would be able to seek help from therapists who would be reimbursed for their services;
2. Trains weight-loss counselors, trainers, dieticians and therapists to approach weight loss and weight maintenance as a complex, complicated problem that requires more than a diet plan and exercise program. They must be made aware of the many reasons for overeating, ranging from severe premenstrual syndrome bingeing morphing into a lifelong pattern, Seasonal Affective Disorder, medications with weight-gaining side effects, and situational stress. Then it becomes necessary to recognize that overeating, like alcoholism, may be a life-long problem;
3. Establishes drop-in overeating groups similar to AA where people can gather to support each other. Ideally these would be near food courts or strip mall clusters of fast-food restaurants. Someone wrestling with the urge to order batter-dipped sweet and sour chicken with fried rice or several slices of a four-cheese pizza might decide instead to attend an overeating support meeting. Unlike Overeaters Anonymous, no diet program would be offered, and “membership” should not be restricted only to people with an obvious need to lose weight. Indeed, since weight regain is such a major problem, people using such a group might well be thin, but emotionally inclined to believe that they are on their way to becoming fat again;
4. Removes the double standard some corporations have toward the health of their employees. Wellness programs, Weight Watcher meetings and onsite gyms are useless if the employee’s work day is so arduous that there is no time to eat, exercise, relax, and get enough sleep;
5. Gives friends and family permission to help someone like my aforementioned friend in a non-judgmental way. If we had a relative or friend tying to abstain from smoking or drinking, wouldn’t we make an effort to remove temptation, for example, not suggest going to a bar or a wine tasting evening? We should be similarly sensitive to the needs of the newly thin or struggling obese. Just as you don’t bring wine to a dinner party whose host is a recovering alcoholic, you might suggest a taking walk, a visit to a museum, or attending concert rather than a restaurant, or make sure that if you do go out to eat, the restaurant offers food choices compatible with a healthy eating style; and
6. Throws out all the old fad diets and makes the new fad, which is the holistic support of overeaters attempting to lose and keep off their weight.
Permanent weight loss is achievable only if realistic assessments every step of the way are provided and supported as part of the process. And a true friend always speaks up to help another see that they are not alone and cherished to the be and remain the very they can be, every step of the way.