We’ve had a few weeks of recipes and other fun, light content. Now I want to share something more serious.
When I went back to university to study nutrition in 2003, weight loss was accepted without question as both achievable and a central part of the dietitian’s role. I went on to work in cardiac rehabilitation for nine years, where the majority of my consultations were with people who were seeking help with weight loss.
I participated in professional continuing education to support weight management, from the American Academy of Nutrition and Dietetics’ Certificate of Training in Adult Weight Management to Obesity Canada’s Learning Retreat for Dietitians. I heard obesity expert Dr. Arya Sharma speak so many times I think I had his slides memorized. I helped start the first Obesity Canada local chapter here in Calgary and was on the executive committee for two years.
But at every step in this journey, the more I learned, the more I practiced, the more my weight loss expectations were lowered. I told Dr. Sharma once that our cardiac rehab program (like others) was struggling to help people lose weight, and he said, “Just focus on behaviours — exercise, healthy eating. Don’t focus on weight loss.” I shifted to that focus years ago, but people (and their doctors) continued to measure success in pounds lost. About a year ago I stopped taking individual clients, in part because I was tired of disappointing people, so misaligned were expectations and reality.
Since then I’ve been speaking, writing, and learning more every day about the Health at Every Size ® approach, about Intuitive Eating, and about what a non-diet, weight-neutral, weight-inclusive practice would look like. I’ve been inspired and enlightened by leaders in these movements, including Calgary dietitian Vincci Tsui, who is well ahead of me on this journey and has patiently answered my questions and shared her expertise.
I’m ready to start offering individual consultations again, but I want to set expectations up front: If weight loss is your goal, I’m sorry to say I can’t help with that. To help you understand why, and what we can achieve instead, I’m sharing this excerpt from my Sweet Spot Guide to Eating Well After a Heart Attack (sign up here if you want a free copy). Most of it applies whether you’ve been down that road or not. I hope it’s helpful. With love, respect, and hugs, here goes.
If your body mass index (BMI) is over 25, you’ve likely been told to lose weight by a doctor or two, especially since having your heart attack.
(BMI is simply the ratio of weight to height squared. It’s useful in population studies but doesn’t say anything definitive about the health of an individual. There are much better ways to assess your cardiac risk.)
Anyhow, if weight loss is the prescription, I suggest you ignore it. Why? There are lots of good reasons, but as a dietitian, my chief concern is that we don’t have a safe, effective way to lose weight and keep it off. Furthermore, repeatedly failing at weight loss, which nearly everyone who attempts it eventually does, poses serious risks to your long-term health and happiness.
That might surprise you. You’ve probably heard weight loss success stories – in person, on TV, in a magazine, or online. When people are losing weight, they’re more than happy to talk about it. The rare few who keep it off for more than a year or two love to tell their story.
But weight lost is almost always regained, even for people who stick to whatever diet or exercise regimen caused it. Human bodies are remarkably effective at defending our size. The redundant mechanisms that help us avoid starving to death kick in when we start losing weight.
A panel of experts convened by the National Institutes of Health in the United States found that for participants in controlled weight loss studies, “one third to two thirds of the weight is regained within 1 year, and almost all is regained within 5 years”. As the more recent Australian guidelines also acknowledge, most weight lost “is regained within a 2-year period and by 5 years the majority of people are at their pre-intervention body weight.”
In my thirteen years as a dietitian, I’ve seen those statistics in flesh and blood, working with countless people who’ve tried one diet after another. Even highly motivated, knowledgeable, and otherwise competent dieters find long-term weight loss elusive, and it’s frustrating and discouraging. I don’t go into a consult without a box of tissues.
Photo by Kelly Sikkema on Unsplash
(Weight loss surgery can be more effective, but it isn’t without risks and side effects. For some the benefits may outweigh the costs, so talk to your doctor if you want to learn more.)
If weight loss is so unlikely, why do doctors keep recommending it? Surprisingly, physicians get very little formal training on weight science. And there are plenty of short-term (6-12 month) studies showing weight loss. Most of the major guidelines recommend it.
And doctors hear more dieting success stories than struggles. People are proud to report weight lost. But when it starts creeping back, as it inevitably does, people are more likely to avoid the doctor (/dietitian/personal trainer), for fear of shame and blame. The result: health and fitness professionals end up with a lopsided view of weight loss.
But isn’t my weight a risk factor?
Extra weight is associated with heart disease, diabetes, high blood pressure, and other health problems, but as the saying goes, “association isn’t causation.”
If living in a larger body doesn’t cause these conditions, why do they so often coexist? One theory is that the same factors that drive disease risk, like socioeconomic status and limited physical activity, also cause weight gain. Another is that weight stigmatization and discrimination contribute to many health problems. Both are unfortunately all too common.
Both heart disease and weight gain are caused by the interplay of numerous contributing factors, so simply blaming weight (and by extension, the patient) is unhelpful and erroneous.
In fact, it may surprise you to learn that people whose weight puts them into the overweight or obese BMI categories do as well or better after getting a stent or undergoing bypass surgery. This finding is actually consistent with extra weight increasing survival in people with other conditions.
But what’s the harm in trying?
Despite this, you might think, “Why not try? Maybe I’ll beat the odds and lose the weight. It would be good for my health, right?”
Certainly short-term studies show improvements in biomarkers like blood pressure and cholesterol when weight is lost, but because the weight loss is typically accompanied by a change in behavior, we can’t be certain whether the improvements are the result of weight loss, or simply the increase in exercise, or the dietary changes.
It wouldn’t matter as much if there weren’t such serious downsides to a focus on weight loss. These are some that may be most relevant to you now, so soon after your heart attack:
- Studies show that many people eventually regain more weight than they lost.
- People who repeatedly lose and regain weight don’t live as long and are actually more likely to have a heart attack, a stroke, or develop diabetes. They’re also more likely to have higher LDL cholesterol and blood pressure. Studies can’t prove that weight cycling like this causes those problems, but it certainly doesn’t seem to help.
- The futility of dieting can weaken your motivation for exercise and healthy eating, both of which actually have been shown to improve heart-related outcomes even in the absence of weight loss.
Apart from impacts on heart health, there are other downsides of weight cycling that can impact your quality of life and well-being:
- Reduced self-esteem and emotional distress
- Higher risk for eating disorders, such as binge eating disorder
- Preoccupation with food and body.
That’s a pretty high price to pay for something so ineffective, wouldn’t you say?
So what now?
I know this can be difficult to hear. The weight loss narrative is strong and popular for a reason: If you just figure out the right diet, exercise, or other solution, and really stick with it this time, you’ll get your blood pressure down, feel better, fit into your old clothes. I don’t blame you a bit for hoping, trying, persevering.
Image credit: Obesity Canada.
I’m definitely not saying don’t bother with exercise. I’m not saying not to eat more salads. What I’m saying is don’t do these things for weight loss. Many of the secondary prevention studies have shown health benefits without weight loss, including the Lyon Diet Heart Study. The DASH diet lowered blood pressure without weight change. Lifestyle changes can lower cholesterol and insulin sensitivity, even in the absence of weight loss.
If your goal is to reduce your chances of having another cardiac event, by all means, let’s do that. Just don’t define success in terms of pounds lost.