Want to lose weight?

yoda_2“Ready, are you?”

Last week, there was a lot of focus on abuse. This is not the easiest thing to read about, but given how clear it has become that childhood abuse is probably our #1 cause of disease, disability and death, this is not a topic we can continue to ignore. We all have a responsibility to help prevent future cases of abuse, and therefore there really is no not-getting-involved-in-that option. I choose to get involved, and try to do something about it, and spreading awareness is one way of being part of the solution, I hope.

I was not particularly surprised that very few from the media were interested in publishing a story about a study showing an increased risk of obesity in those who suffered childhood abuse. All the media want these days is to sell the latest fad diet, one more extreme than the other, and hopelessly ineffective to boot, see a new study in JAMA on this topic. There have been so many studies on the futility of dieting that it is quite simply mind-boggling that the media obsession with dieting continues. As things currently are, the large media corporations are certainly not part of the solution, which is really sad.

If 15 years of research on weight loss and obesity treatment has taught me anything, it is that dieting generally does not work. And, yes, I have the data to back up that statement. Sure, the outcome will depend on the individual, and what caused the weight gain to begin with, so it is not an entirely black or white scenario. If you, for example, are one of those who experienced weight gain as an adult as a result of entertaining too many business clients, then you can probably have some small success with a diet and exercise program, with the caveat that you have to stick to it, or you will regain all the weight you have lost.

Obesity, however, is usually established at a very young age, and this is almost like a different disease compared to adult-onset obesity. Going on a diet for someone with childhood-onset obesity is very unlikely to succeed, although it could happen of course. It depends on how long you can adhere to the diet (whatever than diet is), but there is also a lot more to this particular story. What is of paramount importance for those of you who were overweight already as children is to try and figure out why you gained the weight to begin with, and this is where it gets tricky.

I have recently published a new 6-step model on how weight gain occurs from childhood (Obesity Reviews, 2014, September issue) and it looks like this:

 

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What this model suggests is that we have to go much, much deeper than merely going on a diet (or have bariatric surgery for that matter) in order to reach any lasting success. This means addressing things like your thoughts, i.e. core beliefs (e.g. pessimistic or optimistic), and issues related to self-esteem and self-worth. It also means looking at emotional issues and triggers like fear, frustration, anger, hopelessness, shame and guilt. Finally, you need to understand how and when you feel stressed and worry, as they will both wreak havoc with your emotions. And, as you may be aware of by now, when it comes to how we shape our lives, emotions trumps rational thought every time.

The thing you also need to understand is that all, if not most of these internal factors, are usually established at a very early age as a result of your family environment and upbringing. This does not mean that you can’t do anything about it now as an adult, not at all. There are many things you can do to improve things like self-esteem, core beliefs, negative emotions and stress, but it will take both time and effort on your part. Do it one small step at a time. Awareness is the first step.

And once you start to understand where your negative thoughts, emotions and stress come from (we all have them, it’s a tough planet…), and what triggers them, you will probably not have to enforce a restrictive diet and punishing exercise regime in order to get the results you want. Eating a healthy and balanced diet, as well as exercise, will come much more naturally once you start to feel better about yourself on the inside. Change is certainly possible, but I advice you to skip the dieting, as it only tends to increase frustration when the weight comes back on, and instead look more closely at your thoughts and emotions. This is where the real potential for improving weight loss outcomes truly lies.

 

Erik Hemmingsson

 

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“In my end is my beginning” TS Elliot

ACE pyramidThe ACE study pyramid.

Today I am saluting what I consider to be absolutely groundbreaking research which modern medicine has been ignoring for far too long. The work I am referring to is the ACE study (Adverse Childhood Experiences). This is a large study from the US that convincingly showed that difficult early-life experiences is arguably our leading cause of death, disease, disability, drug use and smoking.  

Let me be a little specific because this subject really fires me up. The researchers measured things like childhood abuse, violence in the family, drug addiction, mental illness, and criminal behavior in the family. Then they performed an analysis to see how such experiences were associated with a wide range of outcomes, including obesity, but also attempted suicide, numerous diseases, smoking, drug use and alcoholism. 

More than half of the participants reported at least one such adverse exposure, a quarter reported more than two, and six percent more than 4. And these were not people from a deprived area, they were predominantly white, college educated, middle class Americans.

Not surprisingly, there were very clear associations between number of adverse experiences and health outcomes. For example, when comparing those with 4 or more adverse exposures with those who had none, the odds ratio of being a smoker was 2.2 (i.e. an increased risk of 120%), 4.6 for depressed mood, 7.4 for being a alcoholic, 10.3 for injecting drugs, and a truly staggering odds ratio of 12.2 for attempted suicide (it’s very rare to see such high odds ratios in medicine, it’s like smoking and lung cancer). In terms of common medical diagnoses, the odds ratio was 1.6 for obesity, 2.2 for ischemic heart disease, 1.9 for any cancer, 1.6 for diabetes, and 3.9 for chronic bronchitis.  

I hereby challenge anyone to find another exposure that comes even close to these risk estimates for the leading causes of death where there is also a very high proportion of the population that is exposed, i.e. population attributable risk. But because of the stigma, shame and taboo surrounding this difficult topic, there is also a staggering lack of awareness of these facts, and hence very little help avaliable.

This has to change and can change if enough people become involved. Please take the time to watch this 13 minute youtube video by the first author Vincent Fellitti (give him and his coworkers the Nobel Prize, I say) on the truly remarkable ACE study findings. 

I wonder how much longer we can go on ignoring this topic and the fundamental role our childhoods play in determining our future health and well-being. Yet modern medicine would have you take next to meaningless drugs, where we sometimes have to treat hundreds for preventing one single case of myocardial infarction or diabetes, with numerous safety issues attached.

But drugs is where the money is, and medicine has shaped itself to a truly gargantuan business model. In many ways, this is an absurd way to practice medicine, especially given the very toxic role of early-life adversity, and the potentially huge beneficial impact of therapy and other holistic methods to overcome such hurts. 

Erik Hemmingsson

If you liked this post, you will have my thanks if you help to spread awareness even more by re-sending it to family, friends and colleagues.  

 

Reference

Fellitti et al. Relationship between childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse life experiences (ACE) study. Am J Prev Med 1998;14:245-258.

New study: Childhood abuse and adult obesity

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This post will be about a very difficult topic: childhood abuse. Along with colleagues Dr Kari Johansson and Dr Signy Reynisdottir, I have just published a study that I hope will provide some much needed insight into a much-overlooked topic: how childhood abuse leads to an increased risk of weight gain and eventually obesity.

Having been an obesity researcher for 15 years, I have been fully aware since very early days at work that many (if not most) of our patients have had very difficult childhoods. Too many for it to be a coincidence. But for years I was very reluctant to look into this, the topic was just too much for me, too demanding, too hard. Then one day just over a year ago I decided enough was enough, I had heard one depressing story too many. I decided to follow my intuition and really have a look at the published literature to see what was out there.

I quickly came to the conclusion that there was more than enough data for a solid systematic review and meta-anaysis. I enrolled the help of some willing colleagues, and we started collecting everything that had ever been published, and then we quantified the risk of being obese as an adult in individuals who had experienced childhood abuse or not. Reading those papers and extracting the data was enough for me to go into some kind of reclusive state, it was definately a major emotional challenge.

What we found was a consistent elevation in risk of obesity in adults who had suffered childhood abuse compared to those who did not suffer abuse. Moreover, the pattern was very consistent, across all different types of abuse, such as emotional, physical and sexual, including a positive dose-response association, i.e. the more abuse, the greater the risk of obesity. These are clear signs of causality. Finally some vindication for all those who talked about this uncomfortable subject, including patients, but were pretty much ignored year after year.

The mechanisms behind why abuse leads to weight gain are multifaceted but include increased psychological and emotional distress, negative self-belief, low self-esteem, insecurity, shame and guilt, reduced metabolism (oh yes, stress substantially lowers your metabolism and lipid clearance, more on that soon), inflammation, HPA-axis dysregulation, appetite up-regulation, cognitive decline, sleep disturbances, maladaptive coping responses, and so on and on.

Modern medicine is thankfully starting to wake up to the fact that negative life experiences have markedly adverse effects on health. And yet the media and many others who should know better keep piling the guilt and shame on overweight and obese individuals by saying that they need to exercise more and eat less, when there is so much more to the story.

Reference:

Hemmingsson E, Johansson K, Reynisdottir S. Effects of childhood abuse on adult obesity: a systematic review and meta-analysis. Obesity Reviews 2014, epub 14 August.

There has got to be a better way

GaryLarson_2001

I have seen many times how bariatric surgery can help people with severe obesity have a better and healthier life, at least in the short term. The benefits of surgery over other methods such as diet and exercise programs are also quite clear – in the short term. Does this mean I support surgery over other methods? No, it most certainly does not.

Here are some of my personal issues I have with bariatric surgery. It has become clear that there are serious risks to your health involved with the surgery. Examples include increased risk of alcoholism, depression and many forms of malnutrition. There is also likely to be an increased risk of suicide. I think you will agree that these adverse events are quite serious, and these are just examples. If any type of drug or other form of treatment was associated with such serious risks, it would probably never be approved.

The majority of people and colleagues I speak with also appear to have this notion that surgery is the only method that does not lead to long-term weight regain. This is wrong. I would argue that the long-term effectiveness of bariatric surgery to maintain a very large weight loss is very poorly understood. The landmark publications on the effectiveness of surgery have mostly come from Sweden as it happens (the SOS study). Slightly less than 300 individuals underwent gastric bypass in this study but the follow-up of body weight development some 15 years later was only done in 13 individuals, i.e. less than 5% of all starters, meaning a dropout rate of 95%.

And when you do a study of this kind, who do you think drops out? Those who generally do worse of course. So, by now I hope you realize that there are some pretty dark clouds hanging over bariatric surgery, including a very large risk of weight regain. Indeed, many patients who have had the surgery are now coming back having regained all their weight loss. And yet bariatric surgery has increased exponentially in Sweden and elsewhere in the last 5 years: it went from about 2000 per year to 8000 within 2 years.

I understand that people are frustrated and need more effective methods than what we currently have in the non-surgical arena, but this does not mean that there is a license to go overboard with a very drastic method with serious safety issues. Moreover, we also know that there is minimal screening before surgery, for example of factors like drinking habits and mental health. But surely, you think, there must at least be a massive follow-up after surgery to make sure that the patients are all right, coping well and not malnourished? Unfortunately no, apart from a tiny minority of centers. Many patients are left more or less completely on their own.

So what do I mean by saying that there has got to be a better way? I mean it’s time we invested some time and effort into understanding more about what caused the weight gain to begin with – this is obviously unique to each individual – and then try to reverse the situation through much safer means. This is likely to include counseling, therapy, diet, exercise, stress management, mindfulness or whatever is needed to steady the ship.

Who knows what will happen to all those patients who suffer long-term damage after 10, 20 or 30 years down the line as a result of their surgery. And bear in mind that, if you do suffer adverse events, that this surgery is not easy to reverse.

Yes, I still think surgery is called for in extreme cases, but this calls for much enhanced screening and follow-up, not to mention many more long-term safety studies, including a proper intention-to-treat analysis of body weight. But the current thinking, at least here in Sweden, is to start operating younger and lighter individuals, even children.