A New Obesity Study About the Difficulty of Permanent Weight Loss

A new Obesisty study, involving a follow-up on contestants of the TV show, The Biggest Loser, highlights several startling truths about why it’s so hard to lose weight and keep it off for the approximately 71 percent of American adults who are overweight or obese. Here are some lessons anyone should take away from the study:

Don’t lose hope.

It would be tempting to read the findings of the Obesity study and throw your hands up. If people who are the best at losing weight are at risk of gaining it all back, what’s the point? 

But that would be the wrong message to take away from the findings, said Morton. A full continuum of obesity care is out there, and these weight loss methods include dietary counseling, medication, temporary gastric balloons and bariatric surgery. The sooner you reach out for help, the more chance you have of losing the weight for good.  

“If you do have an issue with your weight, please don’t wait, and please don’t despair,” he concluded. “There’s a lot of solutions out there that can help folks, and what this study shows is that people can be helped if they seek out treatment sooner and they have lifelong maintenance help.”

Obesity is a chronic condition that requires lifelong maintenance.

 A few key components to help maintain weight loss include a new way of eating that you can stick to for life, a sustainable exercise routine that doesn’t put you at risk of injury, at least seven hours of sleep a night and stress management strategies, said Dr. John Morton, chief of bariatric surgery at Stanford Health Care. Finally, following up with a professional as you figure out your new life are crucial — at first on a monthly basis, and then down to quarterly meetings if you feel you’re getting a handle on things.

It takes a village of medical professionals to help a person lose weight safely, says Dr. Lawrence Cheskin of the Johns Hopkins Bloomberg School of Public Health. But the work doesn’t end once you hit goal weight: Cheskin’s weight loss patients continue to check with their clinicians at least once a month for an extended period of time so that they can iron out any post-program bumps in the road.

“The more frequently you follow up with people, the better their chance of sustaining weight loss,” he said. “As far as I know with ‘The Biggest Loser,’ when you’re done with the show, you’re done.”

Perhaps we should focus on health and weight maintenance, not weight loss.

The danger in waiting to take action against weight gain is that your body’s weight control processes are like a thermostat, explains Roseberry. Set it too high (by gaining weight) and you run the risk of that temperature becoming your new normal. If the room manages to get colder (through weight loss), that thermostat will kick in and work to get those temperatures up again.

“Your body actually fights you to go back to that weight you were at,” says Roseberry. And as “The Biggest Loser” study suggests, that “fight” can go on for at least six years.

It’s probably best to think about obesity as a something akin to high blood pressure, which can go down with the proper medications but will shoot back up if you stop taking the medicine, Morton added. Or think of obesity in terms of cancer: it’s better to nip it in the bud when the problem is small, instead of stalling treatment and letting the tumor spread.

“Don’t let yourself get too far,” Morton said. “If your BMI is about 30, it’s time to do something about your weight.”

While weight loss should be the goal if your BMI starts to reach unhealthy levels, even taking steps to maintain your weight accomplishes a great deal, because it prevents your body from getting used to that higher “set point” weight that could soon become its metabolic norm, Roseberry added.

“If we can find new ways to prevent more people from gaining weight and becoming overweight and obese, that would be a huge step forward,” he said. “And if we can focus more on health parameters than weight per se, I think whatever you can do to help increase your overall health is more important than your absolute weight.”

Losing weight can lower your metabolism — but that shouldn’t stop you.

Most people regain at least some of the weight they’ve lost. There are many possible reasons for this, like returning to one’s previous unhealthy levels of exercise and eating due to fatigue or boredom with the new healthy routine. But as the Obesity study illustrates, the more weight you have to lose, the more your metabolism rate and leptin levels decline. These two factors alone, along with other physiological processes that are not captured in the research, are relentless forces essentially trying to pull your body back to its previous unhealthy weight.

These physiological processes are relentless forces essentially trying to pull your body back to its previous unhealthy weight.

The metabolism decline makes sense; a person who loses weight is smaller than they used to be, and so requires fewer calories to fuel their body’s processes. But the researchers note that the study participants had a resting metabolic rate that was about 500 calories lower than you’d expect based on their body composition and age. And in fact, over time, that metabolism kept getting slower, especially in people who maintained the most weight loss. This is because the participants started off at very high weights (the average BMI was almost 50).

“We expect patients to have a reduction in their basal metabolic rate,” said Dr. Holly Lofton, an assistant professor of medicine and the director of the medical weight management program at NYU Langone Medical Center. “This is congruent with other studies that have looked not only at metabolism but changes in hormones that affect appetite, desire for food and hunger in people who have lost weight from diet and exercise.”

One thing the study does illustrate, poignantly, is that weight problems are not simply a failure of will but instead a chronic medical condition. These “Biggest Loser” contestants have heart and drive in spades as they demonstrated on the show, and if weight loss was only a matter of self-control, they would have no problem maintaining it. 

Re-gaining some lost weight isn’t necessarily a failure

If a crop of “Biggest Loser” contestants who participated in the study is representative of the entire alumni, the show’s intensive diet and exercise resources weren’t for naught: While all but one regained weight in the intervening six years, it was also true that 57 percent of the 14 participants maintained at least a 10 percent weight loss, noted the study researchers. This is a significant amount of weight loss for anyone to sustain, but this number is all the more impressive considering that participants in this study started off with an average BMI of almost 50. 

Past research about other weight loss groups show that only about 20 percent of overweight people maintain at least a 10 percent weight loss after one year. Another study that followed up with weight loss participants eight years after an intensive lifestyle change found that only 27 percent maintained a 10 percent weight loss. 

“The good thing about [“The Biggest Loser”] is that these individuals did manage to keep a significant amount of their weight off,” said Aaron Roseberry, an assistant biology professor and a member of the Center for Obesity Reversal at Georgia State University. “Yes, they did gain weight back, but they are still lighter and ultimately healthier than when they started the show.”

True as that may be, not every doctor agrees with the show’s methods.  

“From what I’ve seen of clips of the show, I have concerns about ‘the support’ — if you will — that is offered to the patients,” said Lofton. “It seems at times to be punitive, which is not what I support when I try to induce weight loss in my own patients.”

While all but one regained weight in the intervening six years, it was also true that more than half of participants maintained at least a 10 percent weight loss.

We know that hormones control hunger cues, but there’s not much we can do about it right now.

The more weight you lose, the lower leptin levels get, leaving you hungry. The study notes that leptin levels in “Biggest Loser” participants plunged from a starting average of 41.1 nanograms per milliliter to 2.6 ng/mL at the end of the contest. Six years later, those decimated leptin levels had recovered somewhat, but only up to 27.7 ng/mL.

Currently there are five FDA-approved medications on the market to aid in weight loss, but none of them is a replacement for leptin, one of the key hormones that create feelings of fullness. The New York Times notes that the pharmaceutical company Pfizer is conducting animal trials for a medicine that imitates leptin, but they’re still ongoing. If scientists achieve a replacement for leptin in people who have lower levels due to genes or weight loss, it would be an obesity gamechanger, says Lofton.

“If we had a medication that would help patients who have leptin deficiencies, that would be a breakthrough,” she said. “And then for the rest of us, who lose weight and have lower leptin, it would be something that could improve our weight maintenance results.”

Gary Taubes: Why We Get Fat

Now on order for me at Amazon.

Science writer Gary Taubes, author of Why We Get Fat and possibly the country’s most prominent critic of the reigning theories on the obesity epidemic, has founded a non-profit research outfit of his own, he writes in the journal Nature.

Under the headline “Treat obesity as physiology, not physics,” he argues that the idea that obesity is simply a product of overeating and “calories in, calories out” has gotten us where we are today: Overweight or fat, many of us. He backs an alternate theory:

The alternative hypothesis — that obesity is a hormonal, regulatory defect — leads to a different prescription. In this paradigm, it is not excess calories that cause obesity, but the quantity and quality of carbohydrates consumed. The carbohydrate content of the diet must be rectified to restore health.


This conclusion is based on endocrinology that has been understood for 50 years: insulin regulates fat accumulation, and blood levels of insulin are effectively determined by carbohydrate intake. The more easily digestible are the carbohydrates we eat (the higher their glycaemic index) and the sweeter they are (the higher their fructose content) the higher are our blood insulin levels, and the more fat accumulates.

If this is true, it suggests that the obesity epidemic was caused at least in part by the research community’s failure to understand the nature of the disease, and by the food industry’s exploitation of that failure.

But is it true? Or is it the case, as conventional wisdom has it, that these competing hypotheses of obesity have been rigorously tested, and the energy-balance hypothesis has simply won out?

That’s what Taubes and colleague Dr. Peter Attia will be trying to figure out at the Nutrition Science Initiative (NuSI) in San Diego. So far, they’ve found a lot of flaws in previous research, and are aiming to organize some studies of their own.

Curry Lowers Diabetes Risk, Study Finds

Here's a more recent spice/insulin resistance article. As always the scientific jury is out, and this might be another case of popular journalism "junk science," but I figure why not try it?

Curry Lowers Diabetes Risk, Study Finds

by Jessica Berman

August 03, 2012

According to a World Health Organization study, the number of people with Type 2 diabetes around the world will reach 366 million by 2030. People with this condition have trouble processing dietary sugar which, instead of providing energy, builds up to dangerous levels in their blood.  Now, a small study conducted in Thailand suggests that an ingredient found in curry dishes may reduce the risk of developing the chronic disease.

A new study suggests curcumin may lower the risk of Type 2 diabetes in people who are pre-diabetic, a condition that precedes full-blown diabetes. The substance is found in turmeric, the spice that gives curry dishes their characteristic flavor and yellow color.

Researchers at Srinakharinwirot University in Bangkok recruited 240 people who were all pre-diabetic.  The participants were educated about the condition and how to manage it with proper diet and exercise.  None was on any medication to manage their condition.

For nine months, half the participants took six capsules of curcumin every day, while the other half was given a placebo, or dummy pill.  By the end of the study, 16 percent of patients in the placebo group developed Type 2 diabetes. None in the curcumin group did.

Constance Brown-Riggs is a dietitian and diabetes expert with the US Academy of Nutrition and Dietetics.  While the study was well done and in her view significant, Brown-Riggs says curry should not be viewed as a replacement for a healthy diet and exercise when it comes to managing diabetes.

“People tend to look for a magic bullet.  They are always looking for the quick fix as I call it, which is the 'magic bullet.'  The fact is that it is generally not one supplement that is going to prevent someone from going on to develop Type 2 diabetes," noted Brown-Riggs.

For now, she cautions against using herbs and spices in a concentrated form, even though Brown-Riggs acknowledges research is beginning to show they may have healthful, anti-oxidant properties that counter the effects of inflammation, which can lead to heart disease and cancer.

"Until we get a much larger body of research to support that, eating Asian cuisine is a good way of getting this particular spice - turmeric - in the diet," she said.

Type 2 diabetes is the most common form of the disease, often seen in obese individuals.  It usually begins with elevated blood sugar levels that are not high enough to be considered diabetic.  Commonly, people who begin eating better and losing weight can prevent the condition from progressing to full-blown diabetes.

In the study, people in the cucumin group also lost weight, while those in the placebo group did not.  Weight loss seems to reduce insulin resistance, the hallmark of the disease. Insulin resistance occurs when cells in the body no longer respond to the hormone which helps convert glucose from food into energy.  Blood sugar then remains elevated and, over many years, people with Type 2 diabetes can develop a host of complications, including poor blood circulation and blindness.

The Thai researchers speculate that tumeric has anti-inflammatory properties as well, that help protect insulin-producing beta cells in the pancreas from damage, improving their efficiency.  In addition to insulin, beta cells produce a hormone that regulates blood sugar.

A study on curcumin’s potential benefits in reducing the risk of Type 2 diabetes is published in the journal Diabetes Care.

Spices and Insulin Resistance

I've been using cinnamon in my coffee for some time. I also use cayenne pepper and ginger. I'm going to add some turmeric and cumin into my dinner meals. Seems easy enough.

Here's an older web article I found on spices and diabetes.

by Ryan Bradley, ND

July 2006

Is it just chance that many cultures have traditional dishes that have been passed down generation after generation and are still eaten today? Have you ever considered whether these foods, or food combinations, may have health benefits?

While dietary research largely overlooks the possible health benefits of traditional foods due to its focus on fat content versus carbohydrate content, clinical research on specific foods and food ingredients demonstrates food as more than fat and carbohydrates, but contains compounds that improve health.

In diabetes, these healthful qualities include improvement in blood sugar, reduction in inflammation, improvement in cholesterol and lipid status, and perhaps reduction in blood pressure.

So far in the medical literature, the herbs and spices from the Indian continent seem to be among the most active for improving blood sugar. Clinical and basic bench, i.e. test tube, research has demonstrated benefit of the spices: cinnamon, fenugreek, ginger, tumeric, and cumin.

Cinnamon and Diabetes

At least three clinical studies have been performed to test the blood sugar lowering and insulin-sensitizing affects of Cinnamon (Cinnamomum cassia). In one of these studies, different doses (1, 3, or 6 grams) of cinnamon were given in capsules to people with diabetes for 40 days (Khan et al. 2003); this study demonstrated improvements in both fasting blood sugar and in LDL (“bad”) cholesterol at all doses.

Similar findings were observed when an aqueous (water-based) extract (equivalent to 3 grams of powdered cinnamon) was administered to people with diabetes for four months; these people were not using insulin (Mang et al. 2006). 

However, recently published research by Vanschoonbeek et al. contradicts these reports, finding no improvement through supplementation of cinnamon at a dose of 1.5 grams per day. As is always the way with science, conflicting evidence frequently emerges -- and ultimately we learn more from these discrepancies.

Is cinnamon effective?

At least three clinical studies have been performed to test the blood sugar lowering and insulin-sensitizing affects of Cinnamon.

And if so, how should I take it? The short answer is, we do not know. Much of the groundbreaking research from the lab of Richard Anderson, PhD at the USDA (research funded by Diabetes Action) suggests the water-soluble phenolic components of cinnamon are the most effective (Broadhurst et al. 2000). Supplements are available containing just these components and these supplements may prove to be more effective than whole cinnamon.

Studies have not been performed comparing cinnamon in food versus whole cinnamon in capsules or versus the water-extract of cinnamon in capsules. Unfortunately we still know very little about the safety of all forms of cinnamon when taken as a supplement, although the data on water-extracts of cinnamon suggests safety when administered to lab animals (Onderoglu et al. 1999). I discourage taking large doses of whole cinnamon until we know more its safety.

Fenugreek

Research on the spice fenugreek (Trigonella foenum-graecum) is also promising in diabetes. Clinical research in people with diabetes has been performed on both a fenugreek extract and on soaked fenugreek seeds showing improvements in fasting blood sugar and insulin sensitivity (Gupta et al. 2001 and Madar et al. 1988).

Ginger

...ginger has demonstrated promising results in basic science and animal research testing its ability to improve insulin sensitivity...

Ginger (Zingiber officianlis) has been used as a staple ingredient in Indian and Asian food for hundreds of years. In western herbalism, it is known for its action as a digestive, an anti-inflammatory, and as an anti-nausea medicine. However, recently ginger has demonstrated promising results in basic science and animal research testing its ability to improve insulin sensitivity, reduce oxidation, and improve cholesterol (Bhandari et al. 2005 and Akhani et al. 2004). We still do not know much about the impact of ginger on these parameters in humans, however the preliminary research is very promising -- and ginger tastes quite good.

Turmeric

Turmeric (Curcuma longa) is sold in most grocery stores ground as a yellow-orange powder, or sold in many Asian and specialty markets as a whole orange root. Turmeric has been used in traditional Chinese and Ayurvedic herbal medicine for thousands of years as a detoxification herb (as it appears to protect the liver) and as a potent anti-inflammatory. 

...[Turmeric] improves the action of disrupted insulin-response pathways in diabetes.

Modern science has been applied to the use of turmeric, and has shown its reputation is based on solid science -- turmeric is a potent anti-inflammatory. Although no long-term studies have been done specifically in people with diabetes, the bench research shows that turmeric does reduce many of the inflammatory signals known to be overactive in diabetes (i.e. cytokines IL-6, IL-1, and TNF) and improves the action of disrupted insulin-response pathways in diabetes (i.e. PPAR-gamma) (Shishodia et al. 2005)!

Other herbs

Other herbs and spices that exhibit anti-diabetic action include: cumin (Le at al. 2004 and Rchid et al. 2004), garlic (Ashraf et al. 2005 and Ahmad et al. 2006), and red chili pepper (Tolan et al. 2001 and 2004).

Food or Supplement?

I see many people with diabetes in my clinical practice already burdened by the numerous bottles of medications and supplements they take daily. I am challenged to refine their treatment plan into a manageable number of bottles and pills that effectively treats their current health concerns and is preventive of future complications.

Because this process is already so challenging, my approach is to always bring healthful foods, herbs, and spices into the diet rather than taking as a supplement whenever possible. However, as I mentioned with cinnamon above, there are still many unanswered questions about using these herbs and spices in food versus taking them as a supplement.

As it may not be possible to bring each of these herbs and spices into your diet every day, a combined approach of supplementation and diet is reasonable. If you were going to use cinnamon as a food, one gram of cinnamon is approximately one-half teaspoon and can be easily sprinkled on whole-grain toast, steel-cut oatmeal, or brewed into a mild tea (add ginger for even more benefit and aid digestion).

If you were going to take cinnamon as a supplement, I would recommend a supplement that contains the water-extracted components. Consider trying both ways for three months, self-monitor your blood sugar, and ask your doctor to recheck your fasting blood glucose and hemoglobin A1c to see if cinnamon helps you.

What’s the bottom line?

Although definitive statements are difficult to make regarding the exact action and effective “dose” of each of these herbs and spices, in my opinion there is enough research available to suggest these long-standing traditional herbs and spices have health benefits for people with diabetes and eating these foods should be encouraged by physicians and nutritionists.

...there is enough research available to suggest these long-standing traditional herbs and spices have health benefits for people with diabetes...

While these flavors may take some getting used to, many people enjoy them and even crave them once they try a few dishes. If you cook at home, look around for an Indian, Asian, or Middle-eastern cookbook that includes recipes with these ingredients. Ask the employees of local ethnic groceries about the herbs and spices in their shops and how to use them. Many specialty groceries now offer cooking classes in ethnic cooking. If you eat outside of home, try Indian or Thai fare next time instead of American-style family restaurants. (After all the classic American cheeseburger and fries is used in research as a standard way to induce inflammation.)

If you do try eating Indian fare or Asian fare outside of the home, consider skipping the white rice and rice noodles with your meal to further improve its health benefits.

Add spice by learning and enjoying new foods and recipes and you may be adding life!!
For those readers interested in learning more about the technical aspects of the anti-diabetic and anti-inflammatory actions of these herbs and spices, I recommend finding the following excellent review articles at a local medical library:

• Aggarwal BB, Shishodia S. Suppression of the nuclear factor-kappaB activation pathway by spice-derived phytochemicals: reasoning for seasoning. Ann N Y Acad Sci. 2004 Dec;1030:434-41.

• Srinivasan K. Plant foods in the management of diabetes mellitus: spices as beneficial antidiabetic food adjuncts. Int J Food Sci Nutr. 2005 Sep;56(6):399-414. Review.