How Can You Say Weight Loss Doesn’t Work?

Success and DietsThis is one of the most common questions that I get.  For people who’ve been steeped in diet culture – even if they’ve personally had the experiences of short term weight loss, long term weight regain, and yo yo dieting – it can be really difficult to believe that successful long-term weight loss is something that almost never happens.  That’s certainly how I felt when I first started to read through the research.  I had a really tough time believing that the idea that I could and should become thin to be healthy – which was promoted and sold to me more aggressively than any other concept or product in my life – was not only not based on research, but actually directly contraindicated by it.

The issue here is two-fold. First even if we believed that weight loss would improve health (though Mann and Tomiyama 2013 suggests that it doesn’t) there isn’t a single study in existence where more than a tiny fraction of people were able to achieve long term weight loss using any method. Statistically the most common outcome of intentional weight loss attempts (whether they are “diets” or “lifestyle changes” or any thing else that is an attempt to manipulate body size through diet and/or exercise) is weight regain.  The thing that seems to cause the most confusion is that almost everyone loses weight short term, and we mistakenly believe that if we can lose weight short term then we can lose weight long term and maintain that weight loss.

The truth is that the vast majority of people regain their weight and the majority gain more than they lost (see Mann and Tomiyama 2007) So even if we think that being fat is a problem, given the current research, recommending weight loss is the worst advice we can give. Weight loss simply does not meet the ethical requirements of evidence based medicine since we don’t have any evidence that suggests that it will work for more than a tiny percentage of people and we don’t have any evidence that is able to link decreased weight to better health, controlling for behaviors. In fact when people decrease weight without changing behavior (as in the case of liposuction for example) we don’t see changes in health.

In fact, what we see over and over is that when people change their behavior, their health often improves and often they lose weight short term. We then inexplicably credit the weight loss with the improved health rather than crediting the behaviors. When studies control for behavior we find that people of different sizes with the same behaviors have the same health hazard ratios and risks of all cause mortality (see Wei et al, Matheson et. al, and the Cooper Institute Longitudinal Studies to start.)

Given the fact that we have no evidence that supports a weight loss intervention either for change in body size or a change in health, but we have a great deal of evidence for increased health through behaviors regardless of starting weight or weight change associated with the behaviors, the ethics of evidence-based medicine require that we prescribe healthy behaviors to those interested in improving their health, or that if we give a weight loss intervention we practice informed consent and let them know that almost everyone who attempts that intervention has the exact opposite of the intended result, and that we have no evidence that, even if the person is in the tiny minority who succeed, their health will be improved.

We should also be very clear that neither health nor healthy habits are an obligation – nobody owes anybody health or healthy habits by any definition.  Everyone gets to choose how they prioritize their health and what path they want to take to get there.  Also, regardless of habits, health is never guaranteed and never entirely within our control.  Finally health is not a barometer of worthiness, and our health isn’t anybody else’s business unless we make it their business.

People are allowed to disagree with this, but let’s not pretend that disbelief, however indignant or authentic or well meaning, is the same thing as evidence-based conclusions. The idea of weight loss creating health is what I call a Galileo Issue – it’s widely believed, fervently supported, it’s heresy to suggest that it’s not true, and yet it is not supported by evidence. We have to start basing our interventions on evidence over “everyone knows” if we hope to actually give people accurate information.

UPDATE: Awhile ago I told you that a screenwriter had written a screenplay based on my time dancing.  Well, you know that game where you try to decide who should get to play you in a movie about your life?  That game just got very real for me.  The screenplay has been optioned and, per one of the members of the team “we are going to make the hell out of this movie!”  And it all started with a connection made by a blog reader (Thanks TS!) It’s super exciting, and a little weird, and super exciting.  I’ll keep you updated as there are more details!

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15 thoughts on “How Can You Say Weight Loss Doesn’t Work?

  1. The biggest problem is the decades of indoctrination by the diet and beauty industry that has been perpetuated. Even once someone accepts the fact that diets don’t work, it is so easy to fall into the trap over and over again.
    I have tried and tried to educate my mother on these facts, but she just can not grasp the truth so ingrained is her indoctrination. She will follow one diet guru after another, wasting hundreds and thousands of dollars on one quick weight loss scam after another, and projecting her beliefs on every one around her, namely me and my children, and my grandchildren. She blames her health issues on the roughly 20 “extra” pounds she carries rather than on a life time of unhealthy behavior, and yo yo dieting. Because she has always lost weight, to her that is the proof that the diets work, the fact that she gains it back and more, to her that is proof that she failed not that the diets failed.
    It makes me nuts that she has spent the majority of her 74 years trying to reach some unattainable goal, and never being happy with the body she has. Never accepting that she was good enough, just the way she is created.
    Fighting against her perpetuating that same fallacy toward me and my children and grandchildren is difficult at best. The first question she asks about anyone in the family is whether or not they have lost weight, when she wants to tell someone they look nice she does so by telling them that they look like they have lost some weight, She shows her concern about others by being concerned about their weight.
    My mother is not a bad person, it is just that the indoctrination into the diet cult was complete decades ago,
    All I can do is to keep pointing to the evidence and using logic to battle against not only my mothers influence but that of a great many others including but not limited to the first lady of the united states, and the mass media.

    1. Obviously your mother is not a bad person – she seems to have raised a wonderful daughter! Many blessings to you and your family.

  2. Yeah, it’s tough getting people to believe that long-term, carefully controlled studies are better evidence than ‘my best friend’s cousin’s accountant’s dog walker’s aunt lost fifteen pounds on the turnip and blueberry cleanse, and now she doesn’t have high blood pressure… which she didn’t have before, so weight loss totally makes you healthy!’

    When something is as stigmatized as being fat is in our society, people go to extremes to avoid/change the supposed problem. It’s closely related to other futile efforts to change something that wouldn’t be a problem if society didn’t make it one, like the number of women of color who have harmed themselves using skin lighteners to be ‘less ethnic’ and therefore acceptable in a racially prejudiced world.

    In both cases, the wrong ‘problem’ is being addressed. There is nothing wrong with being fat. There is nothing wrong with having lots of melanin. The real problem – the one that needs fixing – is prejudice. The problem that needs addressing is hate based on a random visual cue.

    But it’s always easier to convince a person that the troubles they face are their fault, because most of us believe that we can change anything if we just try hard enough… as long as it’s on the personal level. Once we start thinking in societal terms, we all too often shrug in despair.

    The thing is, society is made up of individuals, and individuals can actually be changed in more rational directions. Those on the front lines of the first wave won’t usually see society as a whole change, but once enough individuals change, so does society.

    It’s all a matter of water on stone. Sure, a drop of water doesn’t wear through a stone, but enough drops of water over enough time do erode the stone.

    The trick is to be the water.

  3. Very awesome about the movie! Just wanted to drop a quick note to confirm that I would (will) watch the hell out of this movie!

  4. If one walks into a doctor’s office for a six month checkup massing twenty or thirty pounds less, the response from the doctor should be concerned, not congratulatory.

  5. Congrats for the movie! That is amazing!

    I think that the biggest issue with the small percentage of people who actually achieve long term weightloss is that people think it’s still worth it. They hope that they’ll be The Chosen One and surely that cabbage soup and nothing else for 1 week will do the trick.

  6. Brilliant news about the movie :o)

    Imagine trying to be true to the evidence about the futility of “going on a diet” and the lack of proven benefit of weight loss while working in an environment where the vast majority of other practitioners chant the mantra about losing weight being good and where all the patient information leaflets push “weight loss” and “healthy BMI”. I get people who have serious medical problems bawling their eyes out about not being able to lose weight when trying to lose weight is the very last thing they should be doing.

    With friends and family, it’s quite straightforward because I’ve always been keen on personal boundaries, or the Underpants Rule. I can say, “Your health, your underpants; Auntie Jeanie’s health, Auntie Jeanie’s underpants; my health, my underpants.” But at work, it IS my responsibility to give people good advice about their health, irrespective of what other choices they make about looking after themselves. So when I get asked for a prescription for orlistat, or a referral for a gastric band, or a signature on a form to say I’m happy for a patient to do Lighter Life or the Cambridge Diet (or for a child to go to Weight Watchers/Slimming World) people often don’t get the consultation they were expecting.

    On the other hand, sometimes people are very relieved when I say, “From a medical point of view, it’s better if you don’t try to lose weight.” Or, “When you leave my office, take a walk down into town. You’ll see plenty of fat old people doing exactly the same things that thin old people do.”

  7. It disgusts me how the Anti Fat Brigade and the diet industry make their false promises about how everyone’s lives will become magically perfect if we would all just only lose some weight.

    1. (Hmm, guess that proves there are a lot of fit plus size dancers out there for them to pick from to play you… or are they going to just use a fat suit so people can say that was the only way it could happen…)

  8. It’s like the X-Files:”I want to believe…”

    Because we’ve been taught by our families, communities, advertising, entertainment, doctors, etc., that the only way to be acceptable to society is to be thin. So to move on from that means you will never be accepted or worthy of acceptance. If you don’t try to fit in, you deserve rejection. That’s too scary for a lot of people.

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