There is a terrific commentary in this week’s Journal of the American Medical Association (JAMA) that calls for an end to the diet debate. The idea is that while the research community, public, and various members of the weight-loss industrial complex argue about all sorts of diet schemes, the long-term results are uniformly bad. The only things that make a difference are adherence and long-term behavioral. In pretty direct language for a scientific paper, they note:
The only consistent finding among the trials is that adherence—the degree to which participants continued in the program or met program goals for diet and physical activity—was most strongly associated with weight loss and improvement in disease-related outcomes. The long history of trials showing very modest differences suggests that additional trials comparing diets varying in macronutrient (protein, fat, carb) content most likely will not produce findings that would significantly advance the science of obesity. Progress in obesity management will require greater understanding of the biological, behavioral, and environmental factors associated with adherence to lifestyle changes including both diet and physical activity.
Real Biggest Losers
The comments above echo what has been found from self-reports from thousands of long term “biggest losers” as part of the National Weight Control Registry. People who lose weight, sometimes a lot of weight, and keep it off do a few very simple things, but they do them almost religiously. The key facts about sustained weight loss include:
….continuing to maintain a low calorie, low fat diet and doing high levels of activity...and
78% eat breakfast every day.
75% weigh themselves at least once a week.
62% watch less than 10 hours of TV per week.
90% exercise, on average, about 1 hour per day.”
Low Fat, Low Carb, Paleo
The conclusions above are going to get a lot of push back from the weight-loss-industrial complex. Over the years, all sorts of fad diets that report miracle results have been promoted. But almost any of these diets will work—if people stick to them, which isn't easy, and also modify their daily behavior by increasing their activity level.
Low carb diets also typically cause some impressive short-term weight loss as the body stores of glycogen (sugar) are depleted. Glycogen is stored in the body with a lot of water so, this is not about fat loss but is about water loss. A hallmark study from the 1990s showed a 4.3 kg (9 lb) weight loss after a few days of a low carb diet that was almost entirely due to changes in body water. A lot of the appeal of low-carb diets is this early and impressive weight loss. Don’t be fooled into thinking it is fat loss.
What To Do About It?
Currently about 60 to 70 percent of Americans are overweight or obese, and the rest of the world is catching up. Just like the diet data, you can slice and dice the details of the obesity data, but here are few observations and solutions to think about:
- Most of us don’t exercise enough to ignore what we eat. As I pointed out a couple of posts ago, the key is to both exercise and build low level physical activity into your routine.
- Should we have incentive-based health-insurance-premium schemes? In other words, should we charge people for their unhealthy behaviors? A majority of people support this concept for smoking but fewer support it for obesity. As a society, we need to consider whether and how to hold people accountable for things they can control. Already, the push back against this idea is fierce.
- Do we need fat taxes, soda taxes or other restrictions? So-called sin taxes and other policies have had a dramatic effect on smoking. Should they be tried for the food we put in our mouths?
- How else can we add activity into our daily lives? Biking and walking friendly communities might be a good place to start. How about more PE in the schools?
- Support research that stresses adherence and focuses on long-term behavior modification. The idea that there is some sort of magic-bullet diet out there that will make it easy for people to lose weight and keep it off is nuts. Evidence is accumulating that mindfulness training about eating can help reduce food cravings.
I want to end this post with a quote from the commentary that stimulated it because it summarizes a lot about diet and weight loss, in specific, and health care policy, in general. Sometimes arguing about details is a sophisticated way to avoid the bigger issues and promote other agendas. To steal a phrase from Elvis, do we need a little less conversation and a little more action?
In a shrinking funding environment for both health care and research, it is puzzling that the diet debate continues when lifestyle interventions with well-established long-term efficacy are available but have not received the necessary support to be widely implemented. The ongoing diet debates expose the public to mixed messages emanating from various trials that have yielded little but have heavily reinforced a fad diet industry that derives billions of dollars from a nation that is not getting healthier.
Because behavioral adherence is much more important than diet composition, the best approach is to counsel patients to choose a dietary plan they find easiest to adhere to in the long term. Patients should develop an appropriate physical activity program and learn behavioral modification to promote long-term adherence.
Although research specifically focused on improving adherence is ongoing, the number of studies being conducted is small compared with head-to-head macronutrient-focused diet comparison studies. Advancing obesity treatment requires emphasis on the biological, behavioral, and environmental factors influencing adherence to lifestyle changes and developing reimbursement strategies to support lifestyle interventions.
The key to getting or staying lean is to watch what you eat, exercise, and build other forms of physical activity into your day. Adhering to a comprehensive approach built into your routine, not trying a fad diet, is what leads to real weight loss. The same principles apply to almost any physical thing we do. With the never-ending debates over the subtleties of training programs and diets, it's easy to ignore the simple fact that fit people do something active basically every day. And you should too.