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Obesity Myth #2: Importance of Realistic Goals



The second myth in the New England Journal Paper on obesity myths, is described as,

“Setting realistic goals in obesity treatment is important because otherwise patients will become frustrated and lose less weight”.

The authors point out that there is little data to support the notion that people with unrealistic goals will lose less weight than those with realistic goals and note that there are even a couple of papers suggesting that those with the most optimistic (but unrealistic) goals may achieve the greatest weight loss.

While I agree that the data to support this “myth” may be lacking, I remain wary of the idea that setting unrealistic goals (or making unrealistic promises) is a helpful practice or should be encouraged.

Given the number of “all or none” thinkers, I see in my practice, I have often seen patients despair and even give up because their efforts got them nowhere close to their “dream weight”.

I also consider it a simple matter of ethical practice to not promise or support patients to pursue unrealistic goals, although I know that some readers and practitioners may prefer to “keep the hope alive”.

Myth or no myth, I will certainly continue counselling my patients to focus on realistic and sustainable goals rather than aim for targets that are unachievable and unsustainable.

This is certainly a ‘myth’ that I’d like to hear my reader’s opinions on – I realise opinions are not data – but they do make for interesting discussions.

AMS
Edmonton, AB

27 Comments

  1. the Italian Obesity Society (SIO) started today a debate on the NEJM paper. I’ll keep you informed

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  2. I remember how I felt when I KNEW I would never see 135lbs or even 150lbs again and it felt so demoralizing. Having been over 360lbs, now being a steady 190lbs and maintained this weight for over four years is a HUGE success. Yet, there is this part if me that feels like a failure. That I could do better. I should also add that I wear a size 8-10, finished Ironman Canada triathlon in under 15hr last year and set a personal best of a sub 2hr half marathon last year too. My LIFESTYLE is immensely more active and my eating is much more under control yet those numbers on the scale hurt me….why? I set a goal to be 165lbs and thought to myself I would beat it. Then reality set in and my body went down to a low of 168lbs and bounced to be where I am today. No matter how much I exercise or restrict my eating, the scale doesn’t move more than 2 or 3 pounds. It is a daily struggle to feel good about where I am and what my body can now do, rather than how much it weighs.

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  3. Hi Dr. Sharma:

    I think we should adopt a philosophy of “working with the body” (whether the goals are realistic or unrealistic when making attempts to lose weight).

    Even if we set realistic ( which is probably better) weight loss goals, if we go about fighting the body ( e.g. huge caloric deficit from severe dieting, plus ungodly amounts of exercise) then it becomes really bad. The body will fight us unbelievably forcefully and it is a battle we will lose.

    It is setting us up for failure to work against the body.

    Some may get great results setting unrealistic goals . I realize unrealistic goals are not ideal. Those who do not get great results should , above all, not be disappointed in themselves. They are battling biology.

    Perhaps we should “let it fly and see what happens.”

    So, in summary, I think we need to make it a top priority ” to work with nature” regardless of if we make realistic weight loss goals or unrealistic.

    Above all, work with the body all the time- never against it.

    Take care,
    Raz

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  4. I am profoundly grateful that no one tried to discourage my goal of overcoming a lifetime of obesity and reaching my “dream weight”. I believed I could do it. I did it. And I’ve kept more than 100 pounds off for 12 years (with no obsession, by the way!) No doubt I would have been told that this was an “unreasonable goal” and I should settle for losing say, 30 pounds (and remaining obese). Sorry, no. Dare to set “unreasonable”, “unsustainable”, and “unrealistic” goals” — and then achieve them. I truly believe that the naysayers who preach that large, long term weight loss simply isn’t possible are creating a self-fulfilling prophesy. Sure, it may be hard and most definitely you must be mindful for the rest of your life, but hard isn’t impossible. And no one should be discouraged from reaching for the stars.

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  5. “I know that some readers and practitioners may prefer to “keep the hope alive”.”

    When keeping hope alive is perpetuating a lie, then it violates the hypocratic oath.

    Also, too, why would health professionals encourage patients (with only a few extreme exceptions) to set weight goals, anyway? Except at the extreme ends, weight is not, in itself, a health hazard, it is mostly a symptom of health problems. It occurs to me, you MDs don’t tell your patients that they should set a goal of having a fever below 100 degrees before 2 pm today (then turn them loose with bottles of medicines to get to that goal any way they might). You work with the patient by prescribing and dosing and you monitor what the fever does, and regard it as a symptom of other issues.

    The only patient goals that can reasonably be expected to succeed are behavior goals that the patients themselves embrace: “I will eat at least one serving of cruciferous vegetables a day.” “I will exercise for 45 minutes, six days a week.” Then the doctor monitors what happens with regard to health, including ALL the numbers: cholesterol and other fats in the blood, iron, sugar, etc. Weight should be way down the list and regarded as a bonus, mostly.

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  6. There is research to support that healthy lifestyle goals be made without weight loss loss as the main focus, including the health at any size movement http://www.haescommunity.org/

    People who are motivated to eat healthier and increase exercise to receive many of the other benefits such as more energy, stress relief, better mood, fewer colds, etc are more likely to continue with the habits even if weight loss does not occur or plateaus. Also, people who are aware of how difficult even maintaining a stable weight is may feel better about themselves compared to the primarily unrealistic weight loss goals in the media.

    As you report Dr. Sharma, most studies show diet and exercise programs at best create sustainable weight losses of 5-10%. Any programs that promise more than that are setting people up for disappointment.

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  7. The goal should be “to follow the food plan for today”, then reset tomorrow. Measurable, attainable, short-term.

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  8. I think setting “unrealistic” long term goals might be motivational for some people. Losing 75 pounds to get within the “normal” BMI range certainly sounded unrealistic when I started, but I’m not sure if a more “realistic” goal like “lose 7% of body mass to reduce risk factors for diabetes and heart disease” would have been nearly as motivating. Also, when I achieved it, I might have stopped. More generally, if all I set were realistic goals, I would achieve much less in my life. That’s my personality; I can see how setting unrealistic goals can be discouraging for some people. I wonder if any research has been done comparing efficacy of different weight loss goals to some personality traits (eg type A/B).

    I think what can’t be unrealistic is the short term goals: rate of weight loss, calorie restriction, exercise, etc. Explicitly failing at a goal *is* discouraging. Long-term goals are more difficult to straight-up fail at.

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  9. When I asked a doctor for help about my weight she severely overreacted & told me to lose 100 pounds. Patted my head & sent me on my way. “Lose 100 pounds & call me in the morning.” Lol. I’m not, nor was i100 pounds over weight.
    If this was a way of setting big goals, thinking I would under achieve, it completely sabotaged me. Realistically, I needed to lose 60 pounds & that was devastating enough. Overstating it made me inactive. Stating it made me inactive. The only way I could motivate myself was to think in terms of single pounds. I’m gonna lose one pound. I’m going to keep my weight lower by one pound for a week. That was a victory. I didn’t need more reasons to feel like crap. I’m now 40 pounds over weight. Not that I feel like I’m in a position to train anyone, I just know that unrealistic goals devastated me.

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  10. I am a psychologist that specializes in disordered eating in Calgary. I absolutely concur with your statements regarding realistic goals. We are socialized to believe that more is better and that we are failures if we do not succeed at the extremes that are depicted in reality shows and magazines. Keeping the hope alive in my observations only serves to devalue the individuals accomplishments and to distract them from the current joys of living.

    Also, I find one of the most realistic goals I coach clients on with their weight loss is to learn how to sustain it. I asked clients to work on a small amount of weight loss and then spend time sustaining it. We all know how to lose weight (healthy or otherwise) but rarely do we learn how to sustain it. That is a realistic goal that should be a priority at various stages of weight loss.

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  11. I had a VSG in June and while I’d love to eventually be my so-called perfect weight I’ve already met most of my personal goals at about the halfway point. I’m still losing, and expect my weight to settle where the amount of exercise I enjoy (not force myself to do) intersects the level of eating I can enjoy. (not grit my teeth and suffer with)

    If that means I only lose another 20# – I’m ok. 🙂 Real life includes birthday cake. (A small piece, but a piece)

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  12. Susan Miller

    That is EXCELLENT. You are a rare individual. How did you do it? I am very interested to hear what you did.

    Take care,
    Raz

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  13. I believe in one day at a time and being mindful in the here and now. Every day when I wake up I have to make a choice to eat well and be active, each time a menu is in front of me I have to make the choice again. Focusing on “being thin by….spring/the wedding/the high school anniversary….” doesn’t help me focus on what I am doing right now. Neither does “I’ll start Monday/after exams/after my trip…” Reasonable or unreasonable, long term goals just don’t work for me.

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  14. One of your statements is a crucial point in this: it is “a simple matter of ethical practice” to help patients set reasonable goals.

    Tell them to shoot for the moon, but in my bariatric surgery practice I’ve seen many long-term patients in GREAT health who feel like failures because “my surgeon told me I should be 120 pounds” and a quick mental calculation tells me the patient’s surgeon is targeting a BMI of 22. Ridiculous for many morbidly obese patients, and ultimately damaging.

    Does it motivate someone to control their blood pressure BETTER if you give them a goal of 95/60? Do we shoot for a fasting blood glucose of 70 in diabetics? There is a risk:benefit ratio in all we do. Careful about the damage you may cause by going beyond a healthy goal.

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  15. What fredt said, focus on the now.

    Also I think making targets is pointless. People will do what they can do. Its like, anyone can have the will and motivation to run a marathon. But not everyone can actually do it because of poor physical conditioning etc.

    Human judgement should be ignored in cases of reality.

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  16. All of the papers in their supplementary appendix were relatively short term – the longest one was 92 weeks. Although that is pretty long for weight loss studies, it is extremely short in comparison to the human life span. It seems reasonable that any harms from unrealistic weight loss expectations would not come in the short term, but over 5, 10, 20 or more years as people become disillusioned.

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  17. ‘Realistic goals’ is a subjective and arbitrary assessment made by some one who may be an expert in obesity, but has no expertise in the individual. Realistic for me is what I think I can achieve, not what my doctor or other health practitioner thinks is realistic. There is so much bias in making such an assessment it is better to just stop doing it. Ask me what I think is a realistic goal, don’t tell me, and don’t judge me for having goals that do not match your judgement of me. Sorry Dr S, considering it ‘unethical’ to support a patient’s goals seems way out of line to me. Patients deserve more credit and more respect. Don’t think a patient’s goals are realistic? Remain neutral and non-judgmental. Calling it a matter of physician ethics is misguided and paternalistic.

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  18. When I started the weight wise education modules, I had no idea of wht a good weight lose goal was let alone how to reach it. I had less of an idea how many calories I was consuming because I was using `the about that much method of measuring`which turned out to be way too much. When I did resort to measuring to see how much I was eating my jaw dropped. Shortly after that I sat and pondered what good goals were for me. I finally decide to get off my cholesterol medication and get out of the obese BMI. Well I got off one of the two cholesterol medications (I chose the most expenive one which the tax payers would like because they pay for my medications), but I did not get below 200 lbs.

    I know that I am much healthier now than I was before I started but figuring out what goal was best for me to set was a true challange. I do think that difficulty setting a goal may be related to my depression, and adding exersize is related to my arthritis which makes the 30 lbs of weight lose the best I can do.

    Life does have pot luck dinners, holidays, trips, and times when I am aren`t able to manage you weight easily; but that is life. for me I measure success as not going back one the second cholesterol medication, and staying in size 18w clothing. Most GP`s couldn`t care less about the later but it helps me keep my lose versus regain–in short life like weight gain happens each one of us have to find a way to keep from regianing that weight whether we are one who can handle unrealistic goals or not.

    Each patient needs to know himself or herself well enough to know whether realistic or un realistic goals are best for them.

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  19. I agree with Susan Miller. Thankfully, when I started losing weight – the last time round – I hadn’t heard about the statistics on regain. If I had, I probably would have been discouraged before I’d even started.

    Assuming I could reach my goal (I was shooting for a dress size, rather than a goal weight) I started dieting with no idea that I wouldn’t be successful. I overshot my goal and ended up a size smaller. (And no, vanity sizing didn’t come into play as I had to give away a lot of old clothes.)

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  20. Different people have different psychologies, so one piece of advise won’t fit all.

    For me, it has to be attainable. I am currently 350 pounds and “ought” to be around 130. But I think that is totally unrealistic so I have set my goal as losing 100lb. To me, that “feels” attainable. I don’t give a damn that I’ll still be 120 lb overweight, or stay that way the rest of my life, because life at 250 is going to be a lot better than life at 350.

    When I get to 250 I will regroup, and set a new goal.

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  21. I think it depends on how “goal oriented” a person is, and whether they tie their self-worth to whether or not they achieved some arbitrary goal they set for themselves. Some people are motivated by big goals, others are not.

    When I started my fitness/weight-loss program (back in ’96) I didn’t set “SMART” goals (ugh, I hate that term), I just tried to live by some basic principles on a daily basis (call them goals if you want). Was I motivated when I started to see the weight coming off? Heck, yeah! The only time I actually set a weight-loss goal for myself was when a surgeon told me she’d prefer that I lost 25 pounds before she operated on me (I managed to lose 40-lbs in 5 months). Today, 80 pounds lighter (and 15 years older), I am motivated more by what my body can DO (3x Ironman, 6x marathon, plus countless other races) than how much it weighs.

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  22. This was the most problematic of the ‘myths,’ in my opinion, because it doesn’t really matter how much weight someone loses if they’re just going to put it back on again. Hell, people are probably better off losing less weight if they’re going to yoyo. Did this article ever address the issue of long term maintenance? For people who are determined to be significantly lighter, maintenance is all that really matters. Anyone can starve themselves for a while and lose weight. Very few people can happily starve for the rest of their lives.

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  23. In a large observational multicenter study we found an association between higher BMI loss expectation and attrition.

    DALLE GRAVE, RICCARDO, SIMONA CALUGI, ENRICO MOLINARI, MARIA LETIZIA PETRONI, MARIO BONDI, ANGELO COMPARE, GIULIO MARCHESINI, AND THE QUOVADIS STUDY GROUP. Weight loss expectations in obese patients and treatment attrition: an observational multicenter study. Obes Res. 2005;13:1961–1969.

    Objective: To investigate the influence of weight loss expectations (expected 1-year BMI loss, dream and maximum acceptable BMI) on attrition in obese patients seeking treatment.
    Research Methods and Procedures: Obese subjects (1785; 1393 women; median age, 46 years; median BMI, 36.7 kg/m2) seeking treatment in 23 medical Italian centers were evaluated. Baseline diet and weight history, weight loss expectations, and primary motivation for seeking treatment (health or improving appearance) were systematically recorded. Psychiatric distress, binge eating, and body image dissatisfaction were tested at baseline by self-administered questionnaires (Symptom Check List-90, Binge Eating Scale, and Body Uneasiness Test). Attrition and BMI change at 12 months were prospectively recorded. Results: At 12 months, 923 of 1785 patients (51.7%) had discontinued treatment. Compared with continuers, drop- outs had a significantly lower age, a lower age at first dieting, lower dream BMI, a higher expected 1-year BMI loss, and a higher weight phobia. At logistic regression analysis, the strongest predictors of attrition at 12 months were lower age and higher expected 1-year BMI loss. The risk of drop-out increased systematically for unit increase in expected BMI loss at 12 months (hazard ratio, 1.12; 95% confidence interval, 1.04 to 1.20; p

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  24. When I went through the weight wise program a few years ago, I can remember having a discussion with the nurse about what I thought I should ideally weigh. At the time I was 290 pounds. “I think I should weigh 135 pounds.” She asked me when I last weighed that much. “When I was 13.” And then she asked me if I thought that having the body of a 13 year old was a realistic goal for a woman of 35 years. It really opened my eyes, because I’d had that magic number in mind my entire adult life. I refer back to that conversation in my mind each time I set a new goal … is this realistic?

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  25. I had VSG in Oct 2008 and I have lost 267lbs with eating healthy and working out.
    Since I was the first Canadian patient undergoing this surgery in Canada there was some media interest in it. I believe it played a partial role in my success as people “watched” me and I know for a fact some were waiting to see me “fail” but I said to myself: NO WAY – I am getting & staying healthy. This is my only second chance I have and I do not want to rely on a third chance….
    In the beginning I only worked out 3x / week with less intensity to not damage any joints as per my trainer’s recommendation. As I kept losing my weight I increased the amount & intensity of my work-outs as I have a very competitive nature and always compete against myself and try to strive for improvement & betterment.
    I did not set a specific goal at the beginning of my journey as to where I want to be but after a few months I said it would be nice to be below 220lbs – lets try.
    I announced this goal to many people and received support, however I was (am) the one who has to put in the hard work daily. I did reach my goal in Dec 2010 and I was rewarded with a nice present from a friend for a new found hobby of mine. I lost another 40+ lbs in the following months but then it stopped…in the last 18 month I have only lost about 8lbs however I did lose 3 dress sizes in those 18 months which is very nice 🙂
    Yes, there are days when this drives me crazy but most days I am OK and keep telling myself “your health is so much better now and you can do whichever activity you want and ultimately I am successful in maintaining”. I still have that “hope” to lose my last 25lbs and I gave myself time til the end of Oct – but after all, it is just a number on the scale and if I can fit in a size 6 dress, which I am close to, I don’t really care what the number on the scale is.
    I am extremely well trained (confirmed by my trainer) and I will participate (& finish !!!) my first half marathon this summer. I am on track to run a full marathon in a couple years and live up to the bet a friend & I took when I had some reconstructive surgery done for the loose skin.
    This all being said, I do work-out every day (different exercise & intensity to give my muscles rest & recovery time) before I go to work, I eat healthy about 90% of the time and I do measure all my food (except in Restaurants) I eat every day and I do brown bag lunch from my home cooked meals from scratch. And yes, I do work: full-time.
    This all being said: if I would have set my goal at the beginning to fit in a size 6 dress I would have probably not even started trying as it sounded so unrealistic. But as I worked on it my goals got adjusted and loftier and I do not consider myself a failure even though I might not reach all of them – the dream and trying was worth it and I learned so much about myself in this journey.

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  26. Hi Dr Sharma,

    My name is Cristina and I am one of the dietitians at EatRight Ontario. I enjoyed this blog posting about Myth #2 Importance of Setting Realistic Goals and wanted to share with you the new “My Goals” tool available to the people of Ontario. http://www.eatrightontario.ca/en/eaTracker.aspx

    “My Goals” is part of a larger tool called eaTracker, which has other functions like helping people track their eating habits.

    What’s new to eaTracker is the My Goals enhancement developed by EatRight Ontario. With the My Goals tool, individuals in Ontario can:

    – Choose from an expanded list of ready-made SMART goals, or write a custom goal for themselves.
    – Get weekly motivational emails from EatRight Ontario with tips to keep them on track with their goals.
    – Get support with setting or achieving their goals by talking to the dietitians at EatRight Ontario at 1-877-510-510-2.

    There are over 100 ready-made SMART goals to choose from that focus on how to make healthier food choices, plan and prepare meals, get more or less of a certain nutrient, stay active or manage one’s weight.

    Some examples of the goals available include:

    – Go for a walk with a friend for 15 minutes two times this week.
    – Avoid second helpings during meals and snacks every day this week.
    – Pack my lunch 3 days this week rather than eating out.

    Over 500 people have signed up since our launch in January 2013. eaTracker is available nation wide, but the enhanced My Goals feature is for Ontario residents only since EatRight Ontario is provincially based. Thanks again!

    Link to My Goals tool: http://www.eatrightontario.ca/en/eaTracker.aspx

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  27. It’s very difficult for emotional eaters to separate goals from, for lack of a better term, “tools that I use to beat myself up so I can stay in the familiar place that’s less scary than success.”

    It’s also very difficult to identify a realistic goal for an individual. What has worked, is setting SMART goals that get adjusted after every time increment, like 2 weeks, and goals that get bigger over time. Now that I’ve been consistently tracking my activity and eating, I know where I’m really at, and realize that I have multiple issues. Giving myself permission to focus on just one at a time until I feel solid in that change helps me not set myself for failure.

    I just don’t have enough information at 290 pounds to know whether I’ll be able to get to 185, much less 135, especially at my age. But I *do* know from experience that I can get weight off one pound at a time, and am setting goals around the skills to keep me from putting it back on: exercise, portion control, tracking consistency, better food choices, taking steps to resolve the emotional issues that make me feel like eating a lot is my best or only option.

    I don’t know if realistic vs. unrealistic is the issue, or a failure to acknowledge just how many pieces to the puzzle there are.

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