Dr. Sharma's Obesity Notes

Continuing my discussion of the paper by Julia Temple Newhook, Deborah Gregory and Laurie Twells from the Memorial University of Newfoundland, St. John’s, published in the Journal of Social, Behavioral, and Health Sciences, on what causes some people to gain weight, we turn to what the authors describe as, “Gradual Processes”.

Thus, in their extensive interviews with individuals seeking bariatric surgery, although most interviewees focused on explanations with a considerable sense of self-blame, many did report social structural factors as playing an important role in their weight gain, without using these as “excuses”.

“Zoë pointed out that outdoor exercise was too difficult for her in winter conditions, and indoor exercise in a gym was out of her reach financially, and gave specific policy recommendations: “They’re always telling people to lose weight, that we’re an overweight province. Well, help out a bit. Make gym memberships a little more cheaper, make it a little more accessible to people.”

Other barriers included occupational and domestic work schedules:

“When you’re sitting at a desk 40, 45, or 50 hours a week, you’re trying to establish yourself so that people are looking to you, so you get promotions as opposed to someone else, so you’re putting in those extra hours and you’re coming home tired. You’re sitting down for supper, and then it’s 7:00 at night.Okay, when do I do anything now?”

“Wanda explained, “I got the two kids. I have a gym membership, a family gym membership; it’s just that we never get there. I work all day. When I get home I’m tired. … Just finding the time is hard.”

As the authors note, leisure time distribution is a social inequality that particularly affects those with less income as well as mothers of young children.

Furthermore, social inequality related to the risk for occupational injuries with subsequent weight gain are likewise often not seen as related to the social determinants of health.

Finally, built environments and the cost of weight-loss programs were seen as contributing factors that made weight management efforts difficult or unsustainable.

I am sure that readers will have their own social determinants to contribute to this list.

AMS
Berlin, Germany

Obesity fact #7 in the New England Journal of Medicine paper on obesity myths, presumptions and facts, states simply that,

“Provision of meals and use of meal-replacement products promote greater weight loss.”

This “fact” is not surprising, as obviously if all you eat are the meals that are provided as part of a hypocaloric meal plan, then this is going to result in more weight loss than trying to compile those plans on your own.

Thus, as the authors rightly note,

“More structure regarding meals is associated with greater weight loss, as compared with seemingly holistic programs that are based on concepts of balance, variety, and moderation.”

While this may well be the case, the question ultimately is not just one of efficacy but also of effectiveness.

In other words, how likely, in the real world, is someone going to stick with a highly structured diet that essentially consists of meals delivered to your doorstep or even to meal replacements (rather than “real” food)?

While there are no doubt people who would fare well with such a regimen and would be willing to sacrifice variety for a plan that requires no effort in preparation and little effort in terms of decision-making, this may well be a minority of individuals.

While such strategies may well work to lose weight – the question really is whether such strategies results in long-term behaviour change that continues once you go back to eating “normal” foods in “normal” settings. Both cost and monotony could well be limitations of such approaches in the long term.

Nevertheless, I am certain that some of my readers will have their own experience with weight loss plans that either provide meals (e.g. Jenny Craig, Nutrisystem, etc.) or plans that involve replacing meals with bars or shakes (e.g. Slim-Fast).

That both strategies can be highly effective and promote weight loss is without question – they definitely work – whether such strategies are effective in the long-term (beyond the confines of a clinical trial) is perhaps less certain.

Obviously, any diet plan only works as long as you stick with it and there is probably nothing simpler or more convenient than having someone else prepare your meals for you.

AMS
Chicago, IL

We all know people who have apparently “conquered” obesity by losing weight and keeping it off (many go on to become personal trainers, motivational speakers and authors of bestselling miracle diet books).

Who, you may ask, are these people and wherein lies their key to success?

Researchers who have turned finding answers to this elusive question into a considerable enterprise (in the form of the US National Weight Control Registry), in a paper published in OBESITY, now describe four distinct clusters into which these successful maintainers tend to group.

One fictional but rather prototypical representative is Mark, who belongs to (what I would call) the “Golden Boys & Girls of Weight Loss”.

As it so happens, Mark is a 52 years old college graduate, married and unencumbered by a family history of obesity. In fact, Mark, did not begin gaining weight till well into his mid-thirties. Discovering on his 40th birthday, that despite maintaining relatively good health, his BMI was now a portly 32, he decided it was time for a change.

Although he had never made any attempt at losing weight before, he embarked on a diligent self-directed program of regular exercise (about 400 Cal per day) and caloric restriction (to about 1400 Cal per day), as a result of which he dropped 56 pounds to a BMI of 23.

This was almost 11 years ago. Today, Mark continues to maintain his weight loss and finds this relatively easy. He weighs himself regularly, has no problem following his daily exercise routine (about 90 mins of rigorous workouts), does not obsess about what he eats (despite limiting his intake to 1400 Cal), has few cravings and is generally happy with his life (and weight). He seems relaxed and his mood is excellent.

When it comes to his success, Mark does not understand what all the fuss is about. He found a problem, he fixed it, end-of-story! No big deal!

(This, of course, is all according to Mark – the data in the NWCR is self-reported and should therefore perhaps be taken with a grain of salt.)

As it turns out, Mark is a member of a rather elite segment of the NWCR – making up just 13% of registrants. It is not surprising that Mark is male, as this segment is the only cluster of NWCR registrants, where men are well represented (42% to be exact).

Of note is that Mark, like others in this cluster, did not require much help from anyone to turn things around. He may well have glanced at the occasional diet or exercise book, but that’s about it. Mark is certainly not the diet industry’s dream client, largely because he has no need for their services.

But then again, Mark is a rare bird when it comes to “conquering” obesity – only slightly more common than Gertrude, who we will meet later this week.

I have not seen too many Marks in my practice (why would I?). In the rare cases, where I have met folks like Mark (outside my professional life), they tend to be well-adjusted, not too bad to hang out with, and their general attitude seems to be, “I got over my weight, now you get over it too, like, what’s the big deal? – Eat Less – Move More – easy peasy!”

Congratulations Mark – I am sure many out there wish they could just be like you – sadly, you are special indeed!

If there is a Mark out there who happens to read this (although I doubt that Mark would have much interest in a blog about obesity), please feel free to leave a comment.

If you know of a Mark (male or female) – perhaps you can share their story here.

AMS
Edmonton, AB

Ogden LG, Stroebele N, Wyatt HR, Catenacci VA, Peters JC, Stuht J, Wing RR, & Hill JO (2012). Cluster analysis of the national weight control registry to identify distinct subgroups maintaining successful weight loss. Obesity (Silver Spring, Md.), 20 (10), 2039-47 PMID: 22469954

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While I am still figuring out what exactly to do with my Saturday posts (they used to be my “Hindsight” series), I will be putting up the odd link(s) to anything that tickled my funny bone over the past week.

I am particularly delighted to kick this off with a list of ridiculous weight loss fads meticulously compiled by a Pauli Poisu for cracked.com, which includes diet sunglasses, diet dinnerware, ear stapling, toe rings, flavour spray and pregnant lady pee.

If you know of similar innovative products please drop me a line.

And if you happen to have actually used any of these miracle solutions – please feel free to share your story (I promise not to laugh).

AMS
Edmonton, AB

As I often talk about in my lectures, many obese individuals appear to be waiting for their life to start – dreaming of all the things they will eventually do (next week, after their final exam, after Christmas, on January 1st, next Summer, etc.) after they finally get the weight off.

Canadian Obesity Network bootcamper Nicole Glenn, from the University of Alberta, has now published an exploration of just this issue in a paper titled, “Weight-ing: The Experience of Waiting on Weight Loss”, in the journal Qualitative Health Research.

In this phenomenological exploration of what it means to wait for weight loss, Nicole examines the weight wait through experiences gleaned from interviews, blogs and other sources.

As is typical for this type of work, the analysis is deeply personal and subjective and makes no claims to ‘saturation’ or universality of the interpretation or experience. Yet it provides deep insights into an issue that concerns millions of people living with excess weight.

“Phenomenological research aims for a certain effect, one that can lead us to suddenly see or grasp a human phenomenon in a way that enriches our understanding of everyday life experiences. Such seeing may transform our being and thus our practices”

As she writes,

“Waiting on weight loss shows itself through the promise of starting over, through repetition and resolution. The journey begins again, and again, and again. Or at the very least, the possibility of the wait for weight loss rebeginning is ever present.

‘It is January 2nd. I face the scale: Get on, get off. Repeat. I spend the rest of the day telling myself that I will do better, that things will change. Nevertheless I find myself cutting up the leftover ham, mindlessly stuffing the sweet, brown sugar goodness into my mouth. I can literally feel my rings tighten and ankles swell. I start to sob. I told myself last year I would not be in this position next year. In fact, I’ve made pretty much the same promise to myself for the past 20 years.’”

And yet, weight loss, even when it occurs is not the end of the wait – it may now be a wait (fear) for the weight to come back:

“I am somehow unsafe in this my new, thin body. Here I cannot let my guard down. I cannot dwell as I would in a place that is truly my home. So I am left to wonder if the waiting has really ended.”

As for the clinical implications of her findings, Nicole states:

“Recommendations for weight loss are commonplace in contemporary culture, with infomercials and commercials on television, and print and online advertising constantly offering up the newest ways to slim down…..I do not seek to confirm or refute the effectiveness of weight loss as a treatment, but instead strive to shift the focus to how such recommendations might manifest in an individual’s lived experience.”

As I have often said before, simply throwing out “weight loss recommendations” or even just linking numbers on the scale to “health” contains a message of “value” that is hurtful, damaging, and does harm.

Hopefully this paper will be read both by those interested in health promotion as well as everyone involved in obesity management.

AMS
Edmonton, Alberta

photo credit: openDemocracy via photopin cc

Glenn NM (2012). Weight-ing: The Experience of Waiting on Weight Loss. Qualitative health research PMID: 23202478

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