Put Health First, Not Weight Loss- part 2: Scientific Evidence and Tips

There are several claims I did not offer detailed proof for in my previous post on this topic. I’ll give those details here. First let me point out that my best resource for finding this proof was Dr. Linda Bacon’s book Health At Every Size: The Surprising Truth About Your Weight, another highly recommended book. Dr. Bacon suffered so badly from weight loss obsession as a teenager and in college that she decided to devote her studies to it, getting a master’s in psychotherapy (specializing in eating disorders and body image) a master’s in exercise science (specializing in  metabolism) and a PhD in physiology (emphasizing nutrition and weight regulation). So here’s proof from someone who knows what she’s talking about. I could just say, go read her book, but I did my homework and chased down the references myself.

Before I get to that I want to point out there is a bit of a paradox here. By putting health first, you start doing behaviors that are good for your health without focusing on the scale. But, these are the same behaviors that are probably the only long-term way to successfully lose weight- more physical activity including NEAT, and eating better so your body’s internal wisdom of knowing when you have had enough to eat kicks in. These are the kind of behaviors that can lower your set point over time. With a lower set point your body can gradually adjust to a new lower weight without fighting you. But you to put health first, you have to be ok with your current weight, and the fact that you may not lose weight. Then you do the things that will lead to good health, and as a byproduct, your weight may adjust down long term. By eating better I mean eating more nutritious food, till full. This food tends to be less calorically dense so you naturally take in fewer calories than when you are eating overly processed food. But you need to avoid intentional calorie deprivation because that can trigger the set point mechanism to fight any weight loss.

There is a strong case to be made that the health consequences of the “obesity epidemic” have been overblown, as noted in both Body of Truth and Health At Every Size. But it is also a fact that the weight of the average American adult has crept up more than 20 lbs in the last few decades. There is controversy over what caused that, but there are two undeniable factors: the average person is getting less physical activity, and the average person is getting a higher percentage of their calories from overly processed commercial foods. These both contribute to driving our set points up, so the average body weight has adjusted upward. It just so happens that getting more physical activity and eating less overly process food and more minimally processed food are the correct measures for good health. It seems logical to me that by taking these two measures, thereby addressing the issues that drove set point up in the first place, we might gradually lower it back down, permitting some long term weight loss. Dr. Bacon admits to that possibility in her book, but does not want to promise it, because in a couple of years some people may be healthier, feeling better about themselves, enjoying eating healthy foods without cravings, but still not lose weight. Obviously they are much better off, and shouldn’t get discouraged because their weight didn’t change. Now lets get back to the evidence supporting focusing on health, not weight. Assuming you’re convinced about that, I’ll then discuss how to actually do it.

Here are the topics I think proof is required in:

• Weightloss programs, including well-designed ones with a long term emphasis (as opposed to quick fix diets, have a low success rate. Short term weight loss up to a year is fairly common but long term maintenance is low. Further, “weight cycling” or losing weight following by regaining it (“yoyoing”) is damaging to health.
• The relation between being overweight/obese and mortality is weaker than normally thought
• The relation between being overweight/obese and important chronic conditions like hypertension, heart disease, and type 2 diabetes is weaker than thought, and lifestyle interventions that improve activity level and promote healthier eating habits improve health whether or not weight loss occurs.

So let’s get to each of these.

Poor Success of Weight Loss programs:

Whenever I’ve read in the past about the poor success rate of sustained weight loss, I always thought, yes but that’s because they are dieting, making a short term change to lose weight, but not successfully transitioning to a long term way of eating. And I’ve seen it happen with loved ones and friends. They might do low-carb for a few months and lose weight. If you look at the low-carb section in the post on various alternative ways of eating, they are then supposed to gradually reintroduce good carbs, and stop if there’s any weight gain. But no one I know does that. They have so many pent-up cravings that they make a beeline back to cookies and pastries and gain all the weight back. Or they do a program like Jenny Craig where they are supplied all their food, and lose weight, but gain it back after because they never learned how to choose healthy food for themselves long term. I never thought these people were failing because they were lazy or undisciplined. I just thought they were using an incorrect short term approach. And it’s possible that some of them would have done better if they’d taken a longer term approach.

But what was eye opening for me in researching this, is that even long-term, medically supervised programs where the participants are advised on healthy eating behaviors and exercise have poor success rates. There is a lot of evidence for this: [1-7]. The discouraging statistic you’ll often hear is that only 5% of people who try to lose weight keep it off long term. A recent review estimates that even this is optimistic [8].

The clincher for me was an amazing study supervised by Dr. Bacon herself [9,10]. What made it more impressive was that she collaborated with other experts that are skeptical of the “health at every size” (or HAES) approach. Dr. Bacon oversaw the group that was taught to focus on health, not weight, while her collaborators designed the “control group”, which was supervised by a registered dietitian. There were roughly 40 women in each group, a sample size large enough for the results to be statistically significant. It was interesting to me was that the control group in this case was taught to do a weight loss intervention, based on what was thought to be best practice: they were given nutrition advice, told how to count calories and fat grams and how to shop, advised to monitor their eating with a food log, and weigh themselves weekly. And encouraged to lose the weight slowly (avoiding the “short term fix” mentality). The “HAES” group was given a draft copy of Health At Every Size and given advice on topics like accepting their current body shape and living a full life. In Dr. Bacon’s words, the goal was to “disconnect their feelings of self-worth from their weight”.

At the end of 1 year, the diet group had lost 13 lb (5.9 kg) on average, while the HAES group had lost nothing on average. But after 2 years, the diet group had gained almost all of it back (with a final weight loss of 1 lb on average), while the HAES group still had not lost or gained anything on average. Further, the diet group actually gained some fat while the health group stayed the same. This means the diet group had lost some muscle mass which will make weight maintenance more difficult in the future. The diet group’s health risk indicators, such as ldl (“bad”) cholesterol and blood pressure, were unchanged at the 2 year mark, while the HAES group showed significant improvement in these measures. What Dr. Bacon thinks is the most important is that the HAES group showed significant progress in “intuitive eating”, or unrestrained eating, trusting their body’s wisdom. The diet group was worse in this aspect, as expected, because they had been taught to closely monitor and control their eating.

Weak relationship between being overweight/obese and mortality

We already saw proof of this from Dr. Flegal’s two studies, mentioned in a previous post. Just to show they are not flukes, the same thing was demonstrated in these studies: [11-15].

Relationship between being overweight/obese and chronic diseases; improving chronic disease with healthy lifestyle change whether or not weight loss occurs.

There is an undeniably strong correlation between being severely overweight and two major chronic health conditions: hypertension (high blood pressure), and type II diabetes. But as we’ll see this is a case of correlation is not causation. I discussed that concept in my post where I reviewed how to interpret scientific evidence and gave an example. But Dr. Bacon gave a more relevant example: it turns out the premature baldness, or “male pattern baldness” is strongly correlated to heart disease. Does that mean that bald men with heart disease should cure it by getting a hair transplant? Of course not, it turns out higher levels of testosterone appears to promote both male pattern baldness and heart disease. The fix is lifestyle measures like physical activity and healthier eating.

A sedentary lifestyle is also correlated with both being overweight and the 3 chronic conditions mentioned above. And the importance of physical activity in improving or preventing these conditions is well documented. I already mentioned Dr. Steven Blair’s work in the previous post, and here are more references: [15-20]. They clearly show the health benefits of physical activity whether or not you become active. In Dr. James Levine’s book Get Up!: Why Your Chair is Killing You and What You Can Do About It, he also recounts fascinating evidence he collected about moving around during daily life (NEAT, or “non-exercise activity thermogenesis”): Back in the days before activity monitors like fitbits existed, he designed a special pair of pants for people to wear that were instrumented to measure movement, that he called “fidget pants”. These were prototypes for research purposes, and were actually made with the help of Apple Corporation. After getting a large enough sample to be significant to wear these, he had data on how much people move throughout the day vs how much they weighed. This showed clearly that people who are in the obese bmi category move significantly less on average than people in the “normal” bmi category during their activities of daily living. This does not mean they are lazy, it could be something like it becomes a bit more uncomfortable to get up and down from chairs so you unconsciously start moving less. So becoming physically active instead of sedentary is universally recommended regardless of weight, but so is bumping up your moving around throughout the day (NEAT).

Here’s additional fascinating evidence I was unaware of: weight cycling (losing and regaining weight) is a likely contributor to hypertension. Hypertension does not occur in overweight people in societies that don’t diet [20-26]. So here’s a case where focusing on weight loss, can lead to losing and regaining weight, making health worse!

It turns out that being overweight is not strongly correlated with heart disease: Overweight people are not any more likely to have coronary artery plaque buildup, their arteries are as clean (or not) as thinner people [27-33].

Finally there’s type II diabetes. Here there is a strong correlation, as expected, because a major factor leading to type II diabetes is insulin resistance. Insulin resistance is worse in sedentary people. The best known treatments for diabetes are physical activity and eating better (e.g. less refined carbs, more plant foods) even if no weight loss occurs: [34-38]. Further, insulin resistance has been shown to occur before weight gain [38]. There’s a case to be made that the insulin resistance causes the weight gain, not the other way around. Finally, weight loss by itself does not improve insulin resistance, as is easily proved by studying people who lose weight through liposuction [39]. I think this information needs to be shouted from the rooftops. We definitely do have a type II diabetes crisis. When I was younger it wasn’t called type II diabetes, it was called adult-onset diabetes. Now we can’t call it that because it has become prevalent in our children too. But the fix is straightforward. Get people moving more, and eating healthier food, instead of stigmatizing them about their weight. I don’t have proof of this but I suspect making kids feel bad about their weight makes them less likely to do physical activity, not more.

Focusing on Health Tips

This is a compilation of tips from my own experience or other books I’ve read over the years, tips from Body of Truth, and tips from Health At Every Size. There are two aspects, physical activity and healthy eating. The tip for physical activity is what I’ve been recommending all along, finding activities you enjoy and increasing your NEAT.

Healthy eating involves cutting back on “junk” (overly processed commercial foods), and adding more healthy choices like fruits and veggies. It does not involve intentional caloric restriction because that can trigger the set point mechanism and make it harder to sustain healthy eating. Dr. Bacon also highly recommends mindful eating so you’ll notice the flavors of the foods you’re eating more, and also notice the full signal instead of mindlessly inhaling food till you’re stuffed (as I have been known to do many times in the past). She was very careful in explaining phasing in healthier food and phasing out the less healthy: many people will have experienced diets in the past, probably multiple times, and are apt to fall into the “forbidden food” mindset. Nothing is forbidden, just cut back on the less healthy food and try to eat more good food. This seems like a good candidate for Steven Guise’s “mini-habits” approach, discussed previously .

The next tip from Dr. Bacon was surprising to me at first because it seems like something dieters are also taught to do: portion control. But it makes sense in the context of mindful eating, if you look at Dr. Brian Wansinck’s work, which we’ve talked about. The average dinner plate size in the US has drifted up considerably in recent decades, and is significantly bigger than those used in Europe. And people tend to clean their plates, so this make us automatically overeat. Just go back to using smaller plates and it controls portions. No need to count calories. Eating slowly to help the sense of fullness to get from your stomach to your brain is also recommended. The objective is to get to intuitive eating where you don’t have to count calories, and just eat delicious healthy food till full and don’t worry about it.

Hopefully you’re convinced that even if you feel (or have been told by someone in authority like a doctor) that you are overweight, the best thing you can do is to concentrate on your health and not worry about your weight. You’ll feel better and your health will improve, and ironically this is actually the best long term approach to possibly lose weight and sustain it. But your attitude needs to be that you’re ok if that doesn’t happen because it’s secondary.

I take this concept of focusing on health first very seriously. For this reason I have audited my entire site, and put updates in to correct places where I had incorrectly listed weight as a health risk instead of physical inactivity or poor diet.

Answering the Critics

The picture in my previous post with the caption “health at every size” came from the acefitness website. Aceftiness is a reputable organization for certifying personal trainers. I, in fact, became Ace-certified a few years back though I never practiced as a trainer. I was encouraged when I read this article because it was pretty positive, and from a mainstream organization. And the fact that they used that picture in their article makes me think they “get it”. But they did include arguments from critics:

“HAES critics have two main opposing arguments. First, they argue that there is ample evidence that shows excess adiposity is related to chronic disease, especially in those who fall under class II (moderate-risk) or class III (high-risk) obesity. Second, that the concept of listening to internal hunger and satiety cues is challenging in our obesogenic environment. They further argue that the HAES studies showing positive outcomes have utilized small sample sizes with individuals who are overweight or with class 1 obesity, excluding those with class II or III obesity, for whom weight loss may be more beneficial (Penney and Kirk, 2015).

While they acknowledge that the HAES approach may be useful, they insist on more evidence with larger and more diverse sample sizes to assess if the approach is truly beneficial for both individual and population-level health.”

I’ve included the Penney and Kirk article below as ref. 40. The first issue is that excess fat is correlated with chronic disease at more than mild obesity. And I’d add that even in Dr. Flegal’s studies, the risk of all-cause mortality does go up for class II obesity and higher. We’ve already discussed “correlation is not causation” above, and shown that the biggest risk factors are really inactivity and poor eating, and argued that the evidence shows focusing on directly addressing those risk factors rather than weight is the most effective approach to improve health outcomes. It’s true that the sample size in the HAES studies have been small [8,9] but they are statistically significant. We have small studies that show HAES works well, and many large studies that show weight-loss approaches don’t. I think the best evidence we have is to go with HAES now. But by all means, shake loose some funding for larger HAES studies.

Another criticism is that an intuitive eating approach may not work in our
“obesogenic” environment. I shared that concern and addressed it in my previous post, it was my reason for still advising minimizing junk food eating: I said that with intuitive eating, “You want to wake up your body’s mechanism that senses when you’ve eaten the right amount. But it will have trouble doing that if you eat a lot of food that was intentionally designed by scientists at commercial food companies to be hyperpalatable”. So it’s intuitive eating of healthy foods that’s the key,

There remains the point about high-risk obesity. The best estimate I could find is that this is just under 5% of the US population. It seems logical that people in this category would still benefit from more activity and healthier eating. But do they also need to take specific measures to lose weight? I don’t know the answer to that and don’t feel qualified to answer it. I’d like to hear what an expert like Dr. Bacon would say about it.

The acefitness article ends on this positive note (I added the italics):

“Whether or not HAES resonates with you, your clients can benefit from a training approach that focuses on more than just weight. It may never have occurred to your client that there are benefits of exercise and healthy eating besides weight loss.

Armed with this information, there are two powerful ways you can encourage healthy behavior change. First, educate your clients. Let them know that their behaviors matter in regards to their health and quality of life, whether or not those behaviors lead to weight loss. Second, help them build an expanded view of the benefits of exercise. Rather than only setting a weight-loss goal, encourage clients to track changes related to blood biomarkers, reduced stress or anxiety, better sleep and energy, or improvements in sport and activities of daily living.

Once clients realize the powerful life-enhancing benefits of exercise, they’re more likely to make it a sustainable habit, regardless of weight outcomes.” Yes, I think they get it.

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