Lasting weight loss comes from the inside, not the outside

It’s quite remarkable just how much we continue to search for well-being and happiness from outside sources, such as a new job, new relationship, new car, hairstyle, watch, suit, dress, shoes, and the list goes on. If you take a step back and look at our general way of life, it kind of feels like we are conditioned to run around the treadmill of life constantly in need of outside things and gadgets to make us happy. Of course, we rarely get any lasting fulfillment in getting those new shoes, or whatever we long for, yet we keep doing it over and over again.

Einstein

The same can definitely be said of dieting. The pattern of weight loss and regain will be very familiar to all those who struggle with weight problems. A very large part of why dieting fails is that we don’t get to the bottom of why the weight gain occurred to begin with, and, even though there are different ways of looking at this, my view is that the vast majority of weight gain comes from the inside in the form of negative thoughts and emotions. The origins of those negative thoughts and emotions can be very complex but there is no doubt that they usually make their debut during childhood and stay with us as adults, consciously or not.

Negative thoughts and emotions have a huge influence on our health and well-being, and obviously our weight, both in terms of regulating stress, metabolism and inflammation, but also lifestyle choices and habits. This is why I am convinced that any lasting weight loss is very unlikely to come from outside sources, it needs to come from within. Once you start to understand more about your thoughts and emotions, you can shed the weight in a very natural way, because, in a sense, your body will no longer have its fat storage programs activated (set-point theory) as a result of psychological and emotional distress.

Obviously it could take a while to go through such an internal cleaning process, but I also believe that it does not have to take years or decades, it’s really up to you how hard you work at it. And you should certainly get qualified support if you need it.

But if you skip working on your internal issues and instead go for what you perceive to be the easy way out, i.e. trying a solution from outside sources such as a diet, you are not likely to be successful long-term since those fat storage programs will still be activated, and the weight will likely come back on. Or you will need to be super disciplined in terms of what you eat and how much you exercise for the rest of your life. Some people manage this, but not very many (I know I wouldn’t).

get-skinny-on-fad-diets_e

 

In terms of losing weight long-term, I believe it’s about time we stopped fighting against our bodies and instead realized that we need to work with our bodies instead. If you are carrying excess weight, it probably means that your body has activated fat storage programs as a result of your internal distress (fat is basically a survival mechanism, and your body is reacting quite naturally to stress). Your best bet in deactivating those programs will be to find out why they are activated to begin with, and then gradually turn them off by releasing those internal distress factors.

Erik Hemmingsson

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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:

 

obr12197-fig-0001

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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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.

Why is long-lasting weight loss so hard?

Losing weight is not easy. Not at all. But keeping it off is even harder. This is not new knowledge, but it is only recently that we have started to find out why it’s so hard to keep it off. Last year, I was working with some colleagues on a meta-analysis that evaluated different strategies for keeping weight off after a period of rapid weight loss using a very low calorie diet (<1000 kcal/d). We evaluated different types of diets (low GI, high protein, and so on) and supplements, exercise and finally anti-obesity drugs.

What we found was pretty depressing: none of the strategies were very effective at helping people keep the weight off. This much we were able to conclusively prove.

This got me thinking about how the body defends against weight loss. I concluded that there are at least three types of primary defenses against weight loss, all of them powerful and hard to dodge for anyone wanting to lose weight long-term. Moreover, the defenses operate according to the rubber band principle: the more weight you lose, the more defense activation, and hence weight regain, you are likely to experience.

First, once weight loss occurs the body will increase circulation of appetite increasing hormones and peptides, such as ghrelin (increases hunger) and leptin (increases satiety). Sure, you can override this cognitively, at least for a while, but you are basically swimming upstream from now on. It’s doable, just not very easy.

The second line of defense is called adaptive thermogenesis. This means that your body goes into calorie saving mode once you have shed some weight, and you will now burn a lot fewer calories during both rest and exercise. This reduction in metabolism is a lot lower that what we would normally expect as a result of having a lighter body.

The third line of defense is behavioral relapse into old habits. Some habits are formed early in life and are manifested in the brain. By losing weight you needed to change your old eating and exercise habits and form new ones. But those “highways” in the brain didn’t just go away, they are still there. And we are indeed creatures of habit, and after a period of fighting those first two defenses, those old habits can easily make a comeback when you feel tired and stressed.

And there also appear to be more defenses, not least psychological and emotional ones. One such example is that many overweight individuals identify with having extra pounds, usually established already in childhood. This means that they are used to a looking heavier than others. Once they lose weight, some individuals will struggle to identify with their new appearance, and consciously or not, they can can feel uncomfortable and regain for that reason, no matter how much they want to appear thinner.

My suspicion is that children who grow up overweight will have a harder time losing weight that adult-onset weight gainers for this very reason, since adult-gainers do not identify with being overweight to nearly the same extent.

The highly visual nature of obesity could in fact be one of the reasons it is so hard to treat long-term, at least with current reactive methods, such as drugs, diets and exericse.

I can understand if you feel a bit depressed reading this but in order to make real progress we have to understand why we have been failing for so long. Now we at least know a bit more about what does not work and why. I say that is at least partial progress. Real tangible progress will happen when we find methods that do not trigger these defenses in the same way or perhaps even avoid them altogether.

If you feel particularly nerdy and want to read the meta-analysis we did, please see Johansson K, Neovius M, Hemmingsson E. Effects of anti-obesity drugs, diet and exercise on weight loss maintenance after a very low-calorie diet or low-calorie diet: a systematic review and meta-analysis of randomized controlled trials. Am J Clin Nutr 2014;99:14-23. This paper was published open-access meaning that there is no fee for downloading it.

Erik

Ps. I will be holidaying for 2 weeks now, have a great summer everyone! Ds.

Bild 2013-05-31 kl. 09.27 #2