Adherence is the question without an answer
Published 9.6.2016Kevin Hall Ph.D, who researches obesity at the National Institute of Health (NIH), and Yoni Freedhoff, MD, who operates a bariatric center, wrote an editorial in The Lancet. The full text is available for free, but you have to register at The Lancet site to gain access.
Freedhoff reprinted the editorial in total (with accompanying graphs) at his own website, if you want to avoid the registration. Some points to note before I begin my commentary on the editorial:
- Both men accept obesity as a disease, I do not.
- Neither man considers movement as a primary means of dealing with obesity, I think this is a mistake.
- Neither believes that there is one "diet to rule them all." Here I agree.
- Maintenance of weight loss comes down to long term adherence.
The editorial points out that even in the DIRECT study that lasted two years and showed that a low carbohydrate diet (low carb) resulted in higher weight loss than a low fat diet, over the longer term, both diets saw followers begin to put back on weight.
Adherence is the issue with ALL diets. Adherence is poor even in short term diets, which is why I designed my “diet” the way that I did. As I've written numerous times here, I started by eating at maintenance. And then determined whether or not I could live happily eating at that amount.
They also note that food diaries and surveys are basically worthless. People lie. Everyone assumes metabolic adaptation is why diet results get reversed, when the reality is that it’s lack of adherence.
Basically there is no ONE diet that is best for everyone. First, you have to recognize that the energy balance is the reality and that you must find a way to eat fewer calories. Second, you must realize that you have to do this for the rest of your life. If you can’t accept those tow facts, no diet is going to work for you. Movement can be part of solution. Exercise sure, but also NEAT (non-exercise activity thermogenesis). Essentially all movement matters, not just that at the gym.
Their conclusion is that adherence should be the focus of diet science, not which diet should be crowned “king.”
Vox also covered the editorial, and described the graphs in it.
What you see in the first chart is a steep drop in weight within the first six months on the low-fat and low-carb diets. Then the weight slowly edges up and plateaus. At the two-year mark, the low-carb dieters look almost undistinguishable from the low-fat dieters: there’s only about a 4-pound difference in weight loss between the groups — a difference that's too small to have an impact on health.
The large curve in the second chart is a mathematical model of how energy intake changed over the course of the two-year trial. Put simply, you’ll note that dieters can’t sustain a steep drop in calories, and slowly eat more until their energy intake plateaus along with their weight. (The other two slopes in the graphic show self-reported data about what people were eating, which the authors point out are clearly flawed since they don’t align with the observed weight regain in the trial.)
The author agrees that researchers should be looking to see why different diets appeal to different people— but WHY?? Rather, people’s time would be better spent calculating maintenance for the size the person would want to be, and then seeing if eating that way (in the way that THEY want to eat) and at that amount is something they would be willing to do.
Hall seems to think that the individual's physiological reaction to a way of eating can be modeled and predicted from first principles, but I'm not convinced of that at all. Worse is the fact that over time an individual's tastes change. And nothing, alters the reality of the energy balance. I've seen people wish their was research to determine why people overeat, as though that's some deep dark mystery.
Please people, the reason for overeating isn't really complex. Eating and drinking are fun, social activities that all humans do. Even if you have nothing else in common with the human across from you, you both have to eat and drink. That's why it's so common for food to be associated with human milestones. Everybody eats. And eating a bit too much is easy to do.
Most people do not gain weight rapidly (though there are illnesses and drugs that do cause that). Most people eat a bit more than they expend for an extended period of time and slowly add weight to their frame. Worse than that, larger bodies need more food, and so eating that excess becomes normal, rather than excessive. Reversing that process and losing weight is nowhere near as much fun. Why does it need to be any more complicated than that? I know why I got fat, and I know why I'm maintaining a lower weight now.
I've said before and I'll repeat myself here: The NIH's model for calories and weight is the best one available. If that was Hall's only contribution, he would be worthy of note because you can't adjust your diet unless you know how much you need to be eating given the amount that you move. And I'll be thrilled of there is some sort "adherence" gene that can be activated. But my best guess is that it will always and ever be a matter of realizing how much (number of calories) you can eat to be the size you want to be.
Sparring
In other news, Hall and David Ludwig continue to argue over the meaning of Hall's results showing that fat loss slowed in a very low carb diet. Ludwig faces continuing criticism from Stephan Guyenet as well. Ludwig is a full on Taubesian, even as the evidence mounts that Taubes is simply wrong about obesity and its cause. I placed these two links here because in recent (well, relatively recent) writings Taubes and some of his followers have changed their tune to, "It's really adherence that needs to be studied."Taubes et al. would still insist that very low carb dieting is earlier to adhere to— but this is clearly not the case for everyone, or there wouldn't be so many rotund low carbers posting online. There is no magic here, if you begin to eat more than you expend (even if none of those calories are carbs) you will add weight.
No one wants to hear it
This rant at GQ is a good illustration of why this site exists. I am fascinated by nutrition and health research, but plenty of people (who would include the majority of my family) are not. Hence, I write and pontificate here in my own little web space. Though I should note, for the record, that I do not preach about my choices regarding diet and exercise, but I do answer any questions if asked. Once asked,Disclaimer
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