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Will Losing Weight Make You Fat?

I often joke that the easiest way to gain 25 lbs is to lose 20! Unfortunately, this may not be much of a joke, as there is mounting evidence that intentional weight loss may indeed be an important driver of long-term weigh gain. New evidence in support of this hypothesis comes from a Finnish twin study by Kirsi Pietiläinen and colleagues from the University of Helsinki, published in the latest issue of the International Journal of Obesity. Subjects included 4129 individual twins from the population-based FinnTwin16 study (90% of twins born in Finland 1975–1979). Weight and height were obtained from longitudinal surveys at 16, 17, 18 and 25 years and examined in relationship to the number of lifetime intentional weight loss (IWL) episodes of more than 5 kg at 25 years. A single IWL episode increased the risk of becoming overweight by age 25 almost three-fold in women and two-fold in men. In fact, women who reported two or more IWL episodes had an even higher (5-fold increased) risk of becoming overweight at age 25. In monozygous twin pairs discordant for IWL, co-twins with at least one IWL were 0.4 BMI units heavier at 25 years than their non-dieting co-twins despite no differences in baseline BMI levels. Similarly, in dizygous pairs, co-twins with IWLs gained progressively more weight than non-dieting co-twins (BMI difference 1.7 units at 16 years and 2.2 units at 25 years). These findings not only confirm previous studies that dieters may be more prone to future weight gain but also provide evidence that, this obesogenic effect of dieting is apparently independent of genetic factors. All the more reason to warn against the widespread obsession with ‘cosmetic’ weight loss – as I have said before, all weight loss attempts should be medically indicated and anyone attempting to lose weight needs to be warned that they may in fact be increasing their long term risk of becoming (even more) overweight or obese. On the other hand, in cases where weight loss is indeed medically indicated, considerable effort and long-term follow up will be required to prevent relapse – not only is weight loss not a ‘cure’ for obesity but, in many cases, losing weight can actually make the problem worse! Imagine if all diet and weight loss products and programs had to come with a  clear ‘warning’ that use of these products or programs may increase the risk of obesity! Clearly something for… Read More »

When To Recommend Weight Loss For Obesity

Obesity medicine, which I define as the medical care of someone living with obesity, should approach patients holistically with the aim of improving their overall health and well-being. Advice to lose weight may or may not be part of obesity management – much can be gained for someone living with obesity by promoting their health behaviours, getting them to feel better about themselves, improving their mental health, and helping them better managing their health issues.  Much of this can be achieved with no or very little weight loss. Thus, we must consider the question of when weight loss would specifically need to be part of the treatment objectives. In my own practice, I approach this problem by considering the following three questions: Is this a problem unrelated to abnormal or excess body weight? Is this a problem aggravated by abnormal or excess body weight? Is this a problem caused by abnormal or excess body weight? From what I hear from my patients, the most common mistakes in medical practice fall into the first group – trying to address unrelated issues with weight loss recommendations. There are endless stories of patients going to see their health provider with problems clearly unrelated to their body fat (e.g. a broken arm, a sore throat, the flu, depression, migraines, etc.), who simply get told to lose weight. Indeed, there is evidence to suggest that patients with obesity are less likely to undergo diagnostic testing, most likely based on the assumption that their problems are simply related to their excess weight. This is not only where grave medical errors can be made (late or misdiagnosis), but also where the advice to lose weight is clearly wrong. If the presenting problem has nothing to do with excess weight, then no amount of weight loss will fix it. The second category deals with issues that are not causally related to abnormal or excess body fat but where the underlying problem either causes more symptoms or is more difficult to treat because of the patient’s size or fat distribution. There are countless medical problems that fall into this category. For e.g.  a heart or respiratory problem entirely unrelated to excess weight (e.g. a valvular defect or asthma) can become worse, cause more symptoms, or be much more difficult to treat simply because of the patient’s size. This group also includes issues like neck or joint pain from a trauma… Read More »

If Oprah Can’t Why Do You Think You Can?

There are no doubt long-term “success stories” out there – people who just by making (often radical) changes in their diet and activity behaviours have lost a substantial amount of weight AND are keeping it off. However, there is also no doubt that these people are rare and far between – which is exactly what makes each one of them so exceptional. I am not speaking of all the people we hear or read about who have lost tons of weight – we hear about their spectacular weight loss – cutting carbs, cutting gluten, going vegan, going paleo, alternate day fasting, running marathons, training for iron man competitions, going on the Biggest Loser or eating at Subway. What we don’t hear about is the same people, when they put the weight back on – which, in real life is exactly what happens to the absolutely vast majority of “losers”. We hear of their “success” and then we never hear from them again – ever. Oprah is different! Different because, we have had the opportunity to follow her ups and downs over decades. When Oprah “succeeds” in losing weight, she does not disappear into the night – no – she puts the weight back right in front of our eyes, again and again and again and again. Now, comedy writer Caissie St.Onge, in a comment posted on facebook, pretty much summarizes what it is we can all learn (and should probably have learnt a long time ago) from Oprah: “Oprah is arguably the most accomplished, admired, able person in the world. She creates magic for other people and herself on the regular. So, if Oprah can’t do permanent lifelong weight loss, maybe it can’t be done. Oprah is also crazy rich. If Oprah can’t buy permanent lifelong weight loss, maybe it can’t be bought.” “I’m not saying you should give up on your dreams of having the body you want. I’m just asking, if you never get that waist, will your life have been a waste? (I see what I did there.) Every day we are bombarded with media, content and products. Special foods and drinks. Programs and plans. None of this shit has ever worked for Oprah and it probably isn’t gonna work for me or you.” “I know the reason isn’t because you’re weak. If you’re carrying around 10 or 20, or 50 or 150 pounds more than the tiny… Read More »

Did Dieting Make You Fat? Blame Your ‘Proteinstat’

Yesterday, I posted on the intriguing finding (now documented in 15 prospective studies) that dieting can make you fat – especially if you start out with a normal weight. In the paper by Dulloo and colleagues published in Obesity Reviews, the authors attribute part of this effect to the so far elusive “proteinstat” – a system, similar but different from the “adipostat” – that is designed to protect your lean body mass. As the paper nicely delineates, the problem with post-dieting weight regain is that the fat comes back first but that the drive to eat does not cease till you have also regained the lost lean body mass (muscle). It appears as though there are two complimentary biological systems that regulate weight regain. The better known system is the “adipostat” that worries about protecting and restoring fat mass – the neuroendocrine players include leptin and perhaps other signals derived from fat tissue that signal fat stores to the brain. This system works (primarily through dropping metabolic rate but also through effects on appetite) to very quickly and effectively restore the depleted fat mass after dieting. The less known system is the “proteinstat”, that apparenty worries about restoring lean body mass. The system works slower than the “adipostat” but continues its activity (often reaching its peak) even after all the lost fat has been regained and you are back to your original weight. In fact, it continuous working (primarily through appetite and cravings) till lean body mass is restored, even if this means gaining even more fat in the process. In their careful reanalysis of starvation studies, Dulloo and colleagues also come up with an explanation why this process of “weight overshoot” results in more gain the skinnier the individual is to begin with. “…the lower the initial adiposity, the greater the proportion of energy mobilized as body protein (referred to as P-ratio) during weight loss. The steep part of the negative exponential curve lies between 8–20% body fat, and a shift from the upper to the lower values in this range, generally considered to reflect a ‘normal’range of adiposity for men living in affluent societies, results in 2.5- to 3-fold increase in the P-ratio; the latter constitutes a proxy of the fraction of weight that is lost as FFM since protein belongs to the FFM compartment. This extremely high sensitivity of the P-ratio with regard to the initial body… Read More »

Will Dieting Make You Fatter? Only If You Are Skinny!

At the recent European Congress on Obesity, I had the occasion for a long chat with my friend and colleague Abdul Dulloo, from Friburg in Switzerland, who has worked extensively on the issue of weight regain. I asked him how much evidence there is to support the common notion that losing weight makes you fatter – something many dieters claim to have experienced. Indeed, both in animals and humans, weight loss, as a rule, is followed by a more rapid regain of body fat than lean body mass (i.e. preferential catch-up fat) than of lean body mass, as a result of which body composition post-weight regain results in a greater proportion of fat mass than before. But does this increased “fatness” persist over time? This is where Dulloo made me aware of a recent paper he published in Obesity Reviews that examines this question. What his analysis of prospective studies on this issue revealed is that paradoxically, people within a the normal weight range appear much more prone to weight gain over time with dieting than people who already have overweight or obesity. Indeed as he points out, “…it is dieting to lose weight in people who are in the healthy normal range of body weight, rather than in those who are overweight or obese, that most strongly and consistently predict future weight gain.” The reasons for this rather unexpected finding are unclear and some have argued that repeated dieting to lose weight in normalweight people may represents unsuccessful attempts to counter genetic and familial predispositions to obesity – these people are genetically prone to weight gain, which is why they are dieting in the first place. Thus, rather than a causal relationship, the association between dieting and subsequent weight gain is just what would have happened to them anyway. Others have argued that the metabolic effects resulting from the psychological “fear of fatness” (which prompts dieting) per se may increase the risk for weight gain hence a contributing factor to the obesity epidemic. However, as Dulloo and colleagues discuss at length, based on their reanalysis of a wide range of human studies of weight loss and refeeding on body composition data on fat mass and fat-free mass (FFM) losses and regains, there is increasing support for the biological plausibility that dieting predisposes lean individuals (rather than those with overweight or obesity) to regaining more body fat than what had been lost… Read More »