Correcting Misinterpretation in the Public Dialogue on Weight-Loss Maintenance

Correcting Misinterpretation in the Public Dialogue on Weight-Loss Maintenance

July 14, 2016

Co-signatories: Obesity Action Coalition, Obesity Medicine Association

Supporters: The Academy of Nutrition and Dietetics

Overview of Position

Public dialogue concerning metabolic adaptations that occur with weight loss has only partially addressed the scientific evidence on this topic. This is clear in the 2016 public dialogue on the research published in Obesity based on participants in the television show “The Biggest Loser”.1 This paper reported that 6 years after a substantial intensive weight reduction most of the contestants on this program were hypometabolic and had regained some or all of the weight they had lost.

Persistent reduction of metabolic rate both during and after weight loss (i.e., adaptive thermogenesis) has been shown following even relatively small (10% or less) degrees of weight loss.2-4 This hypometabolic state is exacerbated by hyperphagia reflecting changes in pathways regulating appetite and energy balance (delayed satiation, increased hunger), interrupting communication between adipose (fat) cells, gastrointestinal (stomach, intestines, pancreas) cells, and the brain (increased responsiveness to food in neuronal reward pathways, decreased activity in restraint pathways) that usually maintain energy balance.5, 6

These scientific findings make clear that there are physiological mechanisms beyond volitional control that serve to oppose the maintenance of weight loss and to promote weight regain. It is important to bring public attention to the underlying biology that favors weight regain. Understanding and increasing awareness of this underlying biology should help serve to dispel the myth that the two-thirds of the U.S. population with obesity or overweight simply lack willpower. It is also critical to identify obesity as a lifelong disease with manifestations remaining evident even after it supposedly has been “cured” by weight loss.

While accurate publication of the science behind the metabolic, behavioral, and biological adaptation to weight loss should reduce fat bias, misreporting on the topic can be harmful - particularly if it is falsely reported (or implied) that any attempt to lose weight of any amount (and sustain its loss) is futile. Such mistranslation can have repercussions beyond simply a poor understanding of obesity and weight loss; it can potentially cause people living with obesity or overweight to forgo any action to improve their weight and health.

Numerous studies have demonstrated that persons with obesity can lose 5 – 10% of their initial weight and many of them successfully maintain this new, lower body weight. In addition, reductions of this size (5 - 10% initial weight) are associated with improvements in hypertension, sleep apnea, mood, physical mobility, and the development of type 2 diabetes (or controlling it in those already affected).7-10. Programs such as those reported in the Look AHEAD study show that approximately 70% of individuals are capable of weight-reduction of at least 5% and that over half of these individuals are able to sustain weight loss of >5% at the 8 year mark.11

Recommendations

In summary, despite the misinterpretation of research to conclude that long-term reduced weight maintenance is futile, there is much evidence that points to the contrary. People with obesity and overweight should continue in their weight-loss journeys with evidence-based resources and support from the obesity research and treatment community, the media and others. Thus, we call for the following recommendations:

  1. Elucidation of the metabolic and biological mechanisms at play in obesity and overweight should be viewed as positive developments. Therefore, The Obesity Society calls for basic, clinical, and behavioral scientists to leverage these opportunities to design personalized individual treatment plans integrating existing therapies with those yet to come.
  2. Media outlets and reporters play an active role in shaping public perceptions of health and healthcare in this millennium.13, 14 Given this increasing influence, The Obesity Society calls for the media to take greater responsibility for shaping accurate public dialogue about the implications and consequences of new scientific information regarding weight loss.
  3. The Obesity Society urges healthcare providers to better understand obesity and overweight, and treat patients affected with accurate, evidence-based information and treatments, while also relaying the benefits (and challenges) associated with weight loss and its impact on health. 
  4. The Obesity Society calls for more research to identify additional treatment options to support meaningful weight loss and weight-loss maintenance. 
  5. The Obesity Society calls for broader recognition and understanding of obesity as a chronic disease.

Statement of the Problem

An inaccurate interpretation of studies on metabolic adaptation is that weight loss is futile. The magnitude of the metabolic adaptation to extreme weight loss presented in the Biggest Loser, may not apply to the less extreme degrees of weight loss that can be achieved, at least transiently, by many individuals. For example, the degree of decline in resting energy expenditure noted in the Fothergill study1 is much larger than that reported in studies of humans after lesser degrees of weight loss.4, 12 While it is true that there are distinct biological, and physiological changes that occur with weight loss and which resist weight-loss maintenance and facilitate weight regain, these changes represent challenges that require increased efforts to maintain weight after weight loss rather than indications to presuppose that such efforts are fruitless.

In fact, many people are successful at losing weight and sustaining that loss at levels that may be associated with significant health benefits, even if they do not conform to a societal cosmetic ideal. Presentation of long-term weight reduction as a futile process discourages individuals who are overweight or obese from even attempting weight loss, preempting the potential success of many. Furthermore, this viewpoint works against the necessary provision of the financial and social network support for individuals who do attempt weight loss and denies those who are successful at sustaining even a small degree of weight loss the respect that they deserve. It should be noted that for other chronic diseases, treatment is neither discouraged, nor denied to individuals, regardless of prognosis.

The recent public dialogue on the topic of metabolic adaptation in obesity following the publication of a study based on Biggest Loser contestants1 highlights several issues of interpretation of the science and the need for clarification of some salient points.

  1. Excess weight and obesity have serious health implications. Therefore, weight loss should be attempted, as appropriate, using evidence-based treatments. This is much like many other incurable and chronic diseases, where the prognosis is less than ideal, but treatments are offered with expectation of improved health outcomes.
  2. Many persons with overweight or obesity can lose 5 - 10% of initial weight by participating in a comprehensive lifestyle modification program.
  3. Patients should be made aware that actual weight loss achieved does not always coincide with their desired weight loss. Nonetheless, less-than-desired weight loss may still significantly improve health and quality of life.
  4. Maintaining weight loss, however, is harder for most people than losing weight. Weight-loss maintenance varies across individuals.
  5. Physiological and biological mechanisms that are beyond volitional control may resist weight loss and favor weight regain. Hence, it is challenging for most people to maintain all or some of the weight lost.

References

 

  1. Fothergill E, Guo J, Howard L, Kerns JC, Knuth ND, Brychta R, Chen KY, Skarulis MC, Walter M, Walter PJ, Hall KD. Persistent metabolic adaptation 6 years after "The Biggest Loser" competition. Obesity. 2016; doi: 10.1002/oby.21538
  2. Müller MJ, Bosy-Westphal A. Adaptive thermogenesis with weight loss in humans. Obesity. 2013;21:218-228
  3. Rosenbaum M, Leibel RL. Adaptive thermogenesis in humans. International journal of obesity (2005). 2010;34 Suppl 1:S47-55
  4. Rosenbaum M, Hirsch J, Gallagher DA, Leibel RL. Long-term persistence of adaptive thermogenesis in subjects who have maintained a reduced body weight. The American journal of clinical nutrition. 2008;88:906-912
  5. Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, Proietto J. Long-term persistence of hormonal adaptations to weight loss. The New England journal of medicine. 2011;365:1597-1604
  6. Rosenbaum M, Kissileff HR, Mayer LE, Hirsch J, Leibel RL. Energy intake in weight-reduced humans. Brain research. 2010;1350:95-102
  7. Wing RR, Bolin P, Brancati FL, Bray GA, Clark JM, Coday M, Crow RS, Curtis JM, Egan CM, Espeland MA, Evans M, Foreyt JP, Ghazarian S, Gregg EW, Harrison B, Hazuda HP, Hill JO, Horton ES, Hubbard VS, Jakicic JM, Jeffery RW, Johnson KC, Kahn SE, Kitabchi AE, Knowler WC, Lewis CE, Maschak-Carey BJ, Montez MG, Murillo A, Nathan DM, Patricio J, Peters A, Pi-Sunyer X, Pownall H, Reboussin D, Regensteiner JG, Rickman AD, Ryan DH, Safford M, Wadden TA, Wagenknecht LE, West DS, Williamson DF, Yanovski SZ. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. The New England journal of medicine. 2013;369:145-154
  8. National Institutes of Health/National Heart L, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults--the evidence report. Obesity research. 1998;6 Suppl 2:51S-209S
  9. National Institutes of Health/National Heart L, and Blood Institute. Executive summary: Guidelines (2013) for the management of overweight and obesity in adults: A report of the American College of Cardiology/American Heart Association task force on practice guidelines and the obesity society published by The Obesity Society and American College of Cardiology/American Heart Association task force on practice guidelines. Based on a systematic review from the the obesity expert panel, 2013. Obesity (Silver Spring, Md.). 2014;22 Suppl 2:S5-39
  10. Jensen MD, Ryan DH, Donato KA, Apovian CM, Ard JD, Comuzzie AG, Hu FB, Hubbard VS, Jakicic JM, Kushner RF, Loria CM, Millen BE, Nonas CA, Pi-Sunyer FX, Stevens J, Stevens VJ, Wadden TA, Wolfe BM, Yanovski SZ. Guidelines (2013) for managing overweight and obesity in adults. Obesity. 2014;22(S2):S1-S410
  11. Look AHEAD Research Group. Eight-year weight losses with an intensive lifestyle intervention: The look ahead study. Obesity (Silver Spring, Md.). 2014;22:5-13
  12. Leibel RL, Rosenbaum M, Hirsch J. Changes in energy expenditure resulting from altered body weight. The New England journal of medicine. 1995;332:621-628
  13. Centola D. Social media and the science of health behavior. Circulation. 2013;127:2135-2144
  14. Yoo JH, Kim J. Obesity in the new media: A content analysis of obesity videos on youtube. Health communication. 2012;27:86-97