A new perspective to long term weight management

Is there a better way?

Dr Rick Kausman. Published in the Australian Family Physician, Vol. 29,

No. 4, April 2000, pp 303-306.

Background To manage the increasing rate of excess weight and obesity, individual health
care providers and many health promotion programs have focused on encouraging people to
lose weight, and/or achieve a certain weight, for optimal health. The focus has been on the
person’s weight, in other words, on the ‘end point’.
Objective This article provides a theoretical background of the need to think of the issue of
weight management in a new way.
Discussion In an environment that has been described as ‘obesogenic’, past and current
strategies have not succeeded in creating positive change. The time has come for a new
‘process oriented’, more holistic focus.

During the past few decades, there has been a significant increase in the percentage of the
population who are above the most healthy, comfortable weight that they can be (1). We also
know that, across a population, people who are over their most healthy weight have an
increased chance of associated health problems (2). However, despite millions of dollars being
spent by governments on health promotion, and an enormous number of individuals spending
millions of dollars in an attempt to lose weight (3), these efforts have been largely ineffective
(4).

What are people doing to try to lose weight?

Many people have tried, or are in the process of trying, to lose weight. However, many people
attempt to lose weight by following short term weight loss diets in an attempt to achieve and
maintain a healthy weight (5). Three basic types of weight loss dieting strategies have been
identified:
• avoiding eating for long periods of time
• refraining from eating certain types of food
• restricting the total amount of food eaten (6).

Australian figures show that 92% of young women and 44% of middle aged women have dieted
to lose weight at least once (6). Paxton also showed that 47% of people had tried to lose
weight in the 12 months before her survey (7). Importantly, of this group of dieters, 45% had
tried to lose weight once, 43% between 2 and 5 times, and 12% had tried to lose weight six or
more times!
So weight loss dieting is common. But what about its effectiveness and the consequences of
dieting?

Consequences of dieting

Worldwide statistics show that weight reducing diets and restrictive eating plans do not help
people achieve their goal, that is, to lose weight and keep it off. A summary article in the
Annals of Internal Medicine states:
In controlled settings participants who remain in weight loss programs usually lose
10% of their weight. However, 1/3 to 2/3 of the weight is regained within one year, and almost
all is regained within 5 years (8).
The article, ‘Position of The American Dietetic Association: Weight Management’ states:
Traditional intervention programs are built on the premise that persons can
control their own weight and redesign their bodies regardless of physiology or genetics. These
programs set weight goals according to standardised tables and use restrictive diet plans to
assist persons in their attempts to reach what usually prove to be unmaintainable weights (9).

In fact, many people not only regain the weight they lose, but actually end up heavier than
before they started the diet.

What are the dangers?

There are short-term physical side effects of weight loss diets, such as impaired concentration,
with subsequent negative effects on work or study (10).
Recent studies show that there may also be long term physical side effects if people have
swings in their weight (11,12).
Dieting has been seen to be associated with an increased chance of depression (13), and has
been shown to be a risk factor for eating problems and for eating disorders (14,15,16).

In his 3 year study, Patton showed that female adolescents who dieted at a moderate level
were 5 times more likely to develop an eating disorder, and those who dieted at a severe level
were 18 times more likely to develop an eating disorder, compared to those who did not diet
(17).

There are also significant emotional and psychological risks that come from regaining weight
that has been lost on a diet. Rather than questioning the failure of the method, people often
blame themselves. Self esteem decreases with almost every failed attempt, and this has a
negative impact on many areas of life. Many people enter a ‘vicious cycle’ (18) of going on and
off weight loss diets, which can be very challenging to exit.

Some people develop a sense of feeling ‘out of control’ with food and their eating behaviour.
They feel disempowerment as a consequence of dieting. These feelings can pervade many
areas of a person’s life, and it can be an enormous drain on their emotional energy. But can
disempowerment and feelings of being ‘out of control’ affect a person’s physical health? We
are seeing some research that suggests it can.

The Whitehall Studies, which looked at risk of coronary heart disease in the workplace, have
highlighted the importance of being ‘in control’ (19,20). Low control in the workplace has been
shown to be a significant and independent risk factor for coronary heart disease (20,21). For
many people, particularly women, the home, and especially the kitchen, is a workplace in its
own right.

In its Darwin Declaration, The Royal Australasian College of Physicians said:

… the health of Aboriginal and Torres Strait Islander Australians is disastrously poor compared
with other Australians, and the fundamental cause is disempowerment.. (22).

Clearly, being in control of important life issues is vital to emotional and physical wellbeing.
Eating behaviour and weight management is one of these important life issues.

A change in perspective

Many people in the general public are not aware of this information. This is not really surprising
given that it is relatively recent, and that there are many groups with a commercial interest in
maintaining the status quo. Thus, the general perspective or paradigm in the community about
being overweight and weight loss strategies is as follows:

• The amount of ‘overweight’ for an individual can be measured on a chart, and the cause of
‘overweight’ is straightforward and simple - it is either gluttony, laziness, or a combination of
both.
• The solution to ‘overweight’ is to go on a diet and simply stop eating so much, and
discipline oneself to take more exercise.
• We can all be slim if we try hard enough and ‘think slim’ and to reach and maintain our
optimal health and personal happiness we all need to be thin.

This perspective has not created an understanding of the complexity of the issues for both
health professionals and non health professionals, and has not supported positive change.
Importantly, this perspective does not distinguish at all between weight and health.

Thomas Kuhn in his book ‘The Structure of Scientific Revolutions’, says:

Paradigms gain their status because they are more successful than their competitors in solving
... problems (and) The success of a paradigm ... is at the start largely a promise of success ...
(23).
The prevailing perspective has failed to solve problems, has failed to create solutions, and has
proved unsuccessful.

Is there an answer?

We are faced with a huge dilemma. On the one hand we have increasing levels of people who
are over their most healthy, comfortable weight. On the other hand, the methods that have
been used to try to make a difference are not helping, and in many cases are making things
worse. So what can we do? How, as health professionals, can we encourage people who are
above their most healthy weight to achieve optimal health, and as a result, be the most healthy,
comfortable weight they can be in today’s environment? And how can we do this without
causing negative sequelae?
Unfortunately, there is no single answer. We certainly need to be aware that the environment
we are living in has changed drastically over the last 50 years or so. In many parts of the
Western world there are a tremendous number of labour saving devices, from motor cars to
battery powered lollipops (the lollipop spins around in your mouth so you don’t even have to
bother to turn it). Twenty-four hours a day, seven days a week, high fat, high sugar food is
available. It is enormously challenging for all of us to be as physically active as we would have
been a century ago, and not overuse food for any number of complex and individual reasons.
We have also come to rely too much on external advice, and have forgotten to be aware of our
own body’s cues for weight management (ie. our own physical hunger signals).
We need a new cultural perspective with respect to eating behaviour and weight issues to
replace the old unsuccessful one. This position might include the following:

• That a healthy, comfortable weight is relative to the individual.

• That the cause of being above a healthy, comfortable weight for any one person is complex
and multifactorial, and the solution includes setting realistic, individual, sustainable,
behavioural goals.
• That the solution also takes into account that we need wider society change to help the
individual achieve and maintain their goals (ie. planning and promoting safe environments
for physical activity).

The new perspective would include that the process needs to be empowering for the individual,
and involves working on why specific issues have become a problem for that person. It does
not deny that we should take care of ourselves by being physically active and eating healthily,
but it promotes the message that health and vitality come in all shapes and sizes, and we can
aim to be healthy at our own natural weight rather than thin at any cost. And it also says that
we can lead happy, healthy productive lives without being the current culture’s idea of an ideal
shape.

We are now in the early stages of this shift in vision.

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