Nutritional Pearls: It's Not About Weight Loss
Sam is a 36-year-old man struggling to lose weight. He has tried numerous diets in the past, but no matter how much weight he loses, he always gains it all back rather quickly. At a recent check-up, he asks you if you have any suggestions on how he can better lose weight and keep it off in the long-term.
How would you advise your patient?
(Answer and discussion on next page)
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Answer: Diets don't work: lifestyle change works, and works for the long term.
There's a long-standing divide in research's approach to the issue of obesity: on the one hand, there are those who focus solely on body weight and ways to reduce that body weight to a clinically normal level, and then there are those who contend that what you eat is at least as important as how much you eat. Adding to the confusion is the problem of weight maintenance: once people lose weight, the vast majority of them gain it back, and often more than they lost. My focus is not on weight loss—it's on improving what you eat.
A team of researchers affiliated with the Veteran's Affairs Health Service designed a study to help those who lost weight maintain their weight loss. At first they invited clinically obese but otherwise healthy men and women between the ages of 18 and 75 to participate in a 16-week weight loss program that focused on cutting calories and reducing the amount of fat in their diet. At the end of the program, those participants who had lost at least 4 kilograms (about 9 pounds) were invited to participate in a weight maintenance program (the study).
Half of those who accepted the invitation were assigned to a "usual care" program (the control group). After the weight loss program ended they were not contacted again until 14 weeks after the end of the weight loss program, at which time they revisited the research lab and were weighed. They were weighed again about every 4 months until the end of the study, at 56 weeks after the end of the weight loss program.
The other half of those who accepted the invitation were assigned to a "maintenance" program. In addition to the same re-weighings as the control group, 2 weeks after the end of the weight loss program these participants attended the first of 3 monthly group discussion sessions with a dietitian to work on weight maintenance skills. Further contact with the dietitians was by phone, for the first 6 months on a monthly basis, then 2 additional calls at months 8 and 10, with no further contact (other than the same weigh-ins as the control group) until the end of the study.
The authors make much of the fact that those receiving the phone calls maintained more of the weight they lost, with the control group regaining about 40% of the weight they lost and the maintenance group regaining about 15%, but the real difference between the 2 groups, on average, is only about 1.7 kilograms (about 4 pounds). That might be statistically significant, but this is a case where "statistically significant" equals "practically meaningless:" weight loss should not be a goal in and of itself (yes, I really said that).
Certainly your patients will lose weight if their focus is exclusively on cutting calories and fat for a limited period (they'll likely be eating fewer calories of junk). After the diet is over they won't be much healthier even if they weigh less. Rather than teaching the participants to simply reduce the number of overall calories they consumed as well as cutting fat, these participants would have been better served to have been taught how to choose higher quality calories so that they could pursue a dietary lifestyle that they could live with for the long term—rather than a "diet" they would inevitably stop following. They would be metabolically healthier even if they never lost a pound.
What’s the “Take-Home”?
Diets don't work: lifestyle change works, and works for the long term. Rather than focusing on weight loss as the primary goal, meet your patients where they live and help them to improve the quality of the calories they eat without giving up the foods they love. If necessary, refer them to a dietitian who can help them make small, realistic changes in their customary diet such as those in a Mediterranean-style diet: it can be adapted to any type of cuisine, from Asian to African, Southern United States to Napa Valley.
Voils CI, Olsen MK, Gierisch JM, et al. Maintenance of weight loss after initiation of nutrition training: a randomized trial. Ann Int Med. 2017;166(7):463-471.