DebraSY

Thoughts on a Peptide YY Study (with a digression on the “N” word)

In Weight-Loss Maintenance on November 5, 2010 at 8:39 am

I read a comment yesterday from a woman who has lost 100 pounds, yet she’s frustrated and feels betrayed by her own body.  I understand that frustration.  She devotes great time and effort to weight management – three hours daily on the exercise component alone.  This is so much more than magazines and other purveyors of cultural mythology (even our doctors) tell us will be required for our zippy weight-loss and maintenance “lifestyles.”   Moreover, her trimmer body has not magically cured all of her health issues (something else the magazines and doctors imply will happen), and new ones have emerged.

Her struggle reminds me how important it is that we do our research on the science of weight loss and maintenance and try to better communicate with our doctors just how complicated and difficult it is.

I don’t think doctors are mean spirited, but they are overworked and must keep current on hundreds of medical issues.  Weight management, for many reasons, has been simplified down to useless advice:  calories in/calories out, eat less/exercise more, walk thirty minutes a day, eat fresh produce and control your portions.  Blah, blah, blah.  When patients fail to lose weight or maintain weight loss on such simplistic recommendations, doctors chalk it up to “patient noncompliance,” common medical parlance that translates as “blame the victim” to those of us not wearing white coats.

I understand the term “noncompliance” serves mostly for legal purposes.  It helps protect doctors when “noncompliant” patients try to sue for a bad result.  Sadly, it often hovers like a dark cloud over the doctor – patient relationship, and it is particularly troublesome with regard to weight management.  Instead of fostering an atmosphere of support and collaboration in a very difficult pursuit, it fosters condescension and suspicion.   When the patient insists that she is doing as instructed, if her weight doesn’t support her story, she’s assumed to be lying, noncompliant.  If she complains about how hard it is and admits to some backsliding, she is simply noncompliant.  “Bad girl!  Just try harder.”  That’s what she hears.  It makes me wince that in my doctors’ offices I may be held up as an example to shame her.

I ran across the “N” word in the study I want to talk about today:  Essah, et al.  It made my blood run cold.  I apologize that I can only get you through to the abstract.  I gain access to full studies through friends with paid subscriptions, or I drive to various branches of the mid-continent library and read hard copies.

At any rate, without violating “fair use” rules, I share the following sentences from the Subjects and Methods section of this study:

Subjects were responsible for preparing their own meals.  They presented to the General Clinical Research Center weekly for a weight determination.  Compliance was assessed by interview and degree of weight lost, with less than 1 kg loss over a 3-week (sic) defined as noncompliance.  Noncompliant patients were required to meet individually with a dietician.

At least participants weren’t summarily kicked out of the study, though two dropped out.  Later, in the Discussion section, the “N” word pops up again.

The fact that some subjects did not achieve weight loss as expected with a 500 kcal per day deficit suggests noncompliance.

Despite the cold language, the study is useful, and we should look at it. But first, some background.  Peptide YY3-36, along with the hormone Leptin rises after meals.  It is presumed to have a role in regulating our food intake by communicating satiety.  I have read that PeptideYY may be the “long-range” satiety chemical, if Leptin is the short-term communicator.  Now, I invite experts to jump in and correct me, but as I understand it, in the chemical cotillion in our bodies, Leptin dances with Ghrelin and PeptideYY3-36 dances with Agouti-Related Protein.  The former couple does a quick step and on a day-by-day basis lets us know when it’s time to start a meal or snack and when we should drop the fork and dance away ourselves.  The latter couple dances a long-stepped waltz and monitors whether our body’s weight is in homeostasis, and presses us to return it to that place if it leaves (and Essah, et. al., as we will see, confirms this theory, without the dance imagery).  In practical terms, if Leptin (along with other chemicals) makes you feel a bit icky after a too-big meal, then PeptideYY (along with others) may be the bugger making you feel like crud on January 2nd, after more than two months of holiday indulgences. 

Obviously, PeptideYY is of great interest to maintainers.  It is a key player in quietly keeping non-weight reduced people at the same weight for weeks, months or years at a time – unconsciously, subtly and elegantly.  How can we get her on our side to do the same thing?!

In Essah et. al. the doctors compared PeptideYY levels in a small sample of people who were guided to lose weight on a low-fat diet to a small sample of people who were guided to lose weight on a low-carb diet.  Total calories on the diets for both groups were individually reduced by 500 per day, based on food journals the participants had turned in at the beginning of the experiment.  Participants agreed to maintain their normal exercise regimens.  There were only 30 participants in all. 

The results?  The low carb dieters lost six times more weight than the low-fat dieters on the same calorie reduction.  Interesting in itself.  Both sets, after their diets, saw a ten percent decrease in serum PeptideYY measured both after fasting and after meals.  Even more interesting.  The study references another study, Sloth et. al., which also reported lower PeptideYY levels and increased appetite scores after low-energy weight-loss dieting.

The take-away message to print up on a three-by-five card and hand to your MD:

As lower PYY levels are associated with increased appetite, we speculate that reduced PYY levels following diet-induced weight loss represents a physiological homeostatic mechanism to preserve baseline body weight.  Reduced PYY levels would indirectly stimulate hypothalamic neurons containing neuropeptide Y and agouti-related protein, which in turn would stimulate appetite and food intake.                        –Essah, et. al.

It’s setpoint theory, summed up by someone your doctor may respect, if he or she doesn’t respect you.  When we consider that both PeptideYY and Grehlin are dancing in the wrong direction after we have lost weight, our doctor’s silly recommendations ring hollow in our ears.   The cards are stacked against a diet of mere “portion control” because our bodies demand bigger portions after weight loss.  The idea that weight management is just calories in/calories out is complicated and made horribly difficult by a body screaming for more calories in.  Most importantly, “Noncompliance” is an insulting cop-out.  People do comply, but to their own bodies’ powerful messages, not their doctors’ simplistic and lazy advice.  That, my friends, is why 97% of people regain lost weight.   Not because they suddenly remembered that the “fat lifestyle” was a bang-up way to live.

This kind of science makes me cynical about the current popularity of “intuitive eating,” especially for maintainers.   Our intuition is merely an amalgam of messages sent from our chemical cotillion, and when we are weight-reduced those messages have changed and may have a different mission from our own to maintain our losses.  This is not to say that intuition is useless.  In a future post, I will talk more about intuition-assisted eating.  I invite your thoughts now on that topic, or on anything you’ve read here.

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  1. As noted in a previous comment, I tend to eat a diet much higher in fat than typically recommended, as much fat as I want, in fact. That is the intuitive part of my eating style. Tracking my intake over several months helped me understand what my body (apparently) *wants* in contrast to what my mind (and nutrition *research*) says I *should* eat.

    In nursing school I felt sad and angry, often, about the kinds of *client education* that nurses are urged to provide regarding weight loss, proper diet, exercise, and so forth. The social construction of paradigms, which professionals practically worship in most cases blindly (such as science, scientific research, medicine, economics, politics, etc.) left me sick at heart. I came to believe that any healing which occurs between *care* providers and *patients* is as much a mystery related to *love* as to evidence-based practice. The dominant health beliefs remind me of ancient superstition, with all *positive outcomes* attributed to the correct medical interventions but most *negative outcomes* are due to *patient history*, genetics, anomaly, or *noncompliance*.

    So, when the witch sinks like a stone, there is a slight chance she may have been innocent, alas dead but gone to her just reward, yet if she flails about in the pond attempting to swim before sinking (AHA!) it was *proof*. Ahem.

    “The fact that some subjects did not achieve weight loss as expected…suggests noncompliance.” Are they doing literary analysis here or so-called scientific research? Can anyone say tautology?

    Forgive me if my comment is less than coherent. I find it difficult to communicate in words these days when facial expressions and hand gestures could do a much better job.

    Thanks Debra for another provocative blog offering!

    • Hey, RN. Love your stream-of-consciousness thoughts. That’s how wisdom starts, methinks. Structured paradigms, as you point out, can be cages that stop productive thinking.

  2. I believe you are correct. I have dabbled in intuitive eating and read a blog from a group. It does seem to me that success following that plan isn’t very evident.

    I’ve been maintaining a 50 lb loss for three years now. It is still not easy. I’ve started following a primarian eating plan. It is helpful. I had quit drinking the suggested( by most people) (Eight 8 oz. cups a day) amount of water and have recently started having the water. The difference in how I felt was remarkable and very noticeable. I do not drink water otherwise. Never have liked it.

    mo

    • Welcome, Mo. I’m not entirely primarian, but I find I’m getting closer and closer to that. I love Barbara. She’s not a “know it all,” but she sure knows more than most. And she approaches this process as a discussion. She is a rare MD. People who live in Cleveland are lucky. Those of us elsewhere just have the book and her blog. I pick nits with her in a few areas — her book doesn’t deal adequately with exercise, for example, and it makes me nervous how she pushes for more pharmaceutical tools (I’m gun shy after the Fen-Phen and Redux debacle), but, regardless, I’m a huge fan. Cannot lie.

    • It does seem to me that success following that plan isn’t very evident.

      I feel like I should point out that intuitive eating isn’t a weight loss plan – unless you’re defining “success” in some other way?

      • Ah, Dee, I think HAES wishes it owned “intuitive eating” but it really doesn’t. There are diet books and classes that claim it too. In the early 1990s I took an Intuitive Eating Diet class.

      • Huh. I never would have guessed. Intuitively (ha, ha) it’s pretty obvious that it wouldn’t work as a weight loss plan, unless you were previously ignoring satiety signals – which can’t be all that common. It’d be uncomfortable.

      • That was their point. They told us we were out-of-touch with both hunger and satiety, and as soon as we got in touch with those things (on a scale of one-to-ten), we would gradually find our way into the BMI chart’s happy range. This was a hospital-based program. Yeesh.

      • Oh, of course. The ol’ “your body really wants to be skinny and you are foiling it with your stupidity/greediness/weakness/craziness. If you can make yourself into a better person, you will automatically become thin.” meme. Gag. I’d forgotten that a lot of people (including medical professionals!) still believe that crap.

      • Oh, of course. The ol’ “your body really wants to be skinny and you are foiling it with your stupidity/greediness/weakness/craziness. If you can make yourself into a better person, you will automatically become thin.” meme.

        THIS! YES! And, as you suggest, it has become a MORAL issue in the sense that the quality of one’s spiritual beliefs/practices/life are assigned a cause-effect relationship to your eating behaviors and/or weight. Supposedly with the *correct* spiritual practices, you will end up at your *ideal* weight. O lordy does this ever smack of the socialization required for people to swallow capitalism and the accompanying serf mindset: work hard, obey the rules, save for a rainy day, and thou shalt be rewarded with fiscal security. LOL. Yeah, the diet industry, spiritual gurus (aka life coaches) and the shrinks who eat this intuitive eating stuff up, hehe, are those assured of the fiscal security while their victims, er, clients, grow poorer of pocket and richer in shame and self loathing. Rinse and repeat.

        Okay. Too many mixed metaphors, I know. I’m a poet in my other life. This science-y stuff gets me all dis/cum/bobulated. 🙂

  3. Over the last 5 or 6 years I’ve gone from a size 22 to my current 12 (I’m 5’2″). The first 75lbs were from altering my diet alone. I gained back 10lbs in a year of externally inflicted chaos, started working out and lost another 20 for a total of 85lbs. In fact I’m still losing, maybe a pound a month or so. I don’t know if that counts me as a “maintainer” or not but I am not actively on a diet or trying to lose — it’s just what happens when I eat what I eat and move how I move.

    OK, I do track my weight, but I also refuse to calorie count, food journal, deny myself any foods, or consume anything I don’t want to. I know which foods are healthful and which are not, which foods make me feel satiated and which do not, and how big of a portion size is appropriate for a given food. If I exceed my internal guidelines it’s usually on purpose (burrito! pumpkin pie! yum!), and I don’t guilt myself, just try to eat healthfully in the interim before the next pizza craving kicks in.

    But it is HARD, which I think derails a lot of people who so desperately want to intuitively eat. It’s a daily struggle. Frankly, I want to gorge myself past the point of being comfortable more days than not. If I could eat nothing but nachos for the rest of my life I’d be a happy girl. And I can’t single out THE reason why I can intuitively eat while so many others need to food journal forever. It’s a combination of factors that are highly personal and wouldn’t translate well to anyone who isn’t living my exact life.

    I wish everyone trying the intuitive eating path the best of luck, but some people just need to employ other measures. IT DOES NOT MAKE YOU A FAILURE.

    • Punkin sprout (cute name), welcome to the blog!

      If you’re still losing a pound a month, your body hasn’t completely put the brakes on you. You would be well advised to think of yourself in the process of “changing skis” from downhill to cross country. During the downhill slide, I ate whatever I wanted to too. I would brag that most of the time I just didn’t want a donut or a cheeseburger, but when I wanted one I had one, and I wasn’t lying. I did that.

      When you are deeper into maintenance, you’ll find yourself putting more and more time between pizza slices (and you may only eat the toppings and skip the dough), regardless of your cravings, and you’ll find that you’ll have to get by on half a burrito, or a quarter, when the urge hits. That, or you’ll see a weight slide. You’ll probably also need to find some external controls that work for you. Your intuition will listen to your suppressed leptin and peptideYY, and your elevated ghrelin and the other chemicals that communicate to you. And they will likely be communicating more insistently than would be indicated by the studies I’ve begun to quote here in the blog. These studies are measuring endocrine differences after a very short period of weight loss. You think it’s hard now? Gear up for the work ahead, but also keep heart. You CAN circumvent weight regain, binge impulses, etc., in a number of ways — diet composition, food timing, exercise microbursts, etc. — and I plan to talk about that more in posts to come. And I hope enough maintainers are following to add their voices to this complicated process. I’m listening as much as I’m talking.

      I think you joined this conversation at a good time. During my yo-yo days I wish I had the internet.

  4. This is what always comes to my mind about intuitive eating discussions: “You can’t solve a problem with the same mind that created it.” Albert Einstein

    With full disclosure in mind, the sentence which comes before that quote is:
    “The shortest but perhaps most accurate description to see a therapist that I have ever seen.”

    I was also glad you mentioned secondary conditions. Because most all of US (maintainers) have them. The most common seem to be – galbladder, asthma, knees, lower back, GI track, migraines. I think many of these are sort of lost in the crowd when we are at our full weights. As we lose, some of them go away as the pounds leave and the habits improve. But I think most of us are left with something rather significant with which to DEAL. Sometimes these are self made (high weight and poor food and no exercise caused them) and sometimes they would have been there without the higher weight history. But I think part of maintaining is being able to COPE with these secondary, chronic conditions.

    Good post. I followed a link from Debby over earlier in the week and have been enjoying your archives.

    • Welcome, Vickie.

      Amenorrhea is also common among maintainers, and that is likely caused by the weight-loss itself. Lynn wrote about it on RTR and her own blog. What a horrible side effect, especially for those who lost the weight primarily to increase fertility!

      It gets down to the nasty reality that weight loss and maintenance have been oversimplified and marginalized by the medical community, and I’m not sure what to do about it other than cathart about it on this blog. In my 12-minute meetings with my own docs, I haven’t gotten through.

      You are so right that much of maintenance is figuring out how to cope.

    • It’s my understanding that gallstones are also caused by weight loss.

  5. Yup. Some say it’s the loss, some say it’s the yo-yoing.

  6. I’ve been reading your blog with great interest. As an 8 year maintainer of a 90ish pound weight loss I can certainly relate to the struggle. I’ve gone through so many different issues over the past 8 years. At my lowest weight I was down over 100 pounds, but that was at a point where my marriage exploded and I couldn’t bring myself to eat. As soon as I started eating again I was back to 90ish lost. I feel like I turned a corner about two years ago when I stopped weighing myself and focused on habits not the scale. I spent some time working as a personal trainer and found that weight-lifting was much more my speed than aerobic exercise. In fact, there is some evidence that overdoing the cardio can backfire and make weight-loss and maintenance harder. These days I walk briskly from the bus station to and from my work each day and try to get some heavy weight-lifting in regularly. I didn’t lose weight by restricting calories or fat (I am firmly in the whole-foods low-carb camp) and am able to maintain while eating plenty of juicy steaks and crispy chicken skin. What I don’t eat is sugar, grains, and most starchy carbs. I do find that I can’t eat quite as much as I’d like to and I try to eat normal (or slightly smaller) portions even though my appetite would have me eat larger ones. I don’t count calories or carbs but I could probably tell you roughly how many of each are in everything I put in my mouth. Just like I could probably tell you exactly how much I weight even though I no longer step on a scale.

    Thanks for your blog! It’s nice to know that I’m not alone in my struggle to maintain.

    • Welcome, Sweet Tart. Interesting about the weight lifting over the cardio. From what I understand, you are unusual but not alone. Many people, especially women, find it harder to embrace than cardio, at least to the degree that radical weight-loss maintenance requires. At minus 90, you’re 50% more radical than I am. I tip my hat.

  7. I actually just had a run-in with this homeostatic system in the last few weeks. I was sick for 10 days and lost ~5 lbs due to a loss of appetite, but as soon as I started feeling better my appetite and cravings increased dramatically. Now that I’m back close to where I started, my appetite has slowed back down to its normal level.

    As for intuitive eating as a diet plan, I remember running into that back in the 80s, through a diet plan I was in through my HMO as well as in Weight Watchers. The idea was that emotional eating was the root of the problem, and if you only listened to your body and ate only when truly hungry, all your extra weight would melt away. Yeah, sure…

    Regarding noncompliance, that reminds me of how people discuss metabolisms of skinny vs. overweight people. A skinny person who can eat anything is lucky to have a fast metabolism, but someone who is overweight despite dieting and exercise doesn’t have a slow metabolism, s/he is just lazy and probably lying. They seem to forget that most traits are distributed +/- normally on a population scale, and a normal distribution has tails on both ends (i.e., variation both above and below normal).

    Finally, as a PhD student I have access to most medical journals. I’m guessing you can “see” my email address – if you ever are unable to get hold of an article, feel free to email me.

  8. “Non compliance” is the medical profession’s defence mechanism. They’ve set themselves against the fact they have no answer to fatness, instead of admitting this they insist on introducing fault and that is highly suspect.

    Because of that they have to blame fat people or the focus would be back on them, its literally fat folk or them, and they’ve made their choice, I’d say that’s mean enough.

    I sympathize with your aversion to ‘intuitive eating’ in essence I feel it’s an overreaction to role assigned to the conscious mind in dietary restriction. Rather than rebalancing that part of the mind’s very important role in eating it seeks to behave as if it can be bypassed, it cannot and I don’t see it as desirable either. I had to do this when I unexpectedly hit WLD burnout years ago and I instinctively (yes) sought to get out of it as quickly as I could.

    I also think you touch on something important and that is the aftemath of a career of WLD. Bodies vary, but it often doesn’t end when you stop dieting. A lot of people don’t realise their ‘IE’, is just their body preparing for another famine-and by that I mean, feasting.

  9. Oops, should have read the comments first, you are talking about another version of intuitive eating. From what you’ve described, it’s like taking a smaller (imaginery) cookie cutter to your hunger/appetite and eating according to that, except you’re supposed to chanel your ‘true(r) signals’ like a medium.

    The problem is that doesn’t feed back into where the signals start as, fewer signals needed. IOW, it seems to create a positive feedback loop, rather than a negative one, so either signals remain, or increase.

    I find that fascinating and feel it must tell us something more about the nature of eating than ‘it mistakes calorie restriction for a famine’.

  10. Thanks, Viajera, for your offer. I may need you at some point. I do prefer to go back to original research. Even when the mainstream presses are quoting accurately, they’re incomplete. They don’t look at funding conflicts of interest, they don’t look too carefully at methodology, sample size and other important factors.

    And your comment on the “emotional eating” thing. Garsh, is that exasperating! I heard that reasoning in my hospital-based program too. And it seems to be making a resurgence. I haven’t read it yet, but I may force myself to read the new Geneen Roth screed that Oprah loves so much. Ms. Roth has found a way to make herself a lot of money by tying our emotional insecurity to weight loss. Woof.

    Wriggles, for the internet unsavvy, am I translating right? WLD = Weight-Loss Dieting and IE is short for Intuitive Eating. I picked it up by context, but context has led me astray before.

  11. Yep, that’s right.

  12. I may be mistaken, but I think leptin is more of a long-term regulator-hormone for fat storage/energy, which is why it often isn’t a noticeable barrier DURING weight loss, but may become one much later, during maintenance. Another interesting point, if I may, these dancing friends at the cotillion switch partners when folks aren’t watching! 🙂 Thus, surges in CRH and other stress related hormones influence the rhythmic influences of a vast array of vagus nerve mediated endocrine partners. One way to help reduce *risks* of regain, therefore, may involve learning ways to “accept” (as individuals) our dysfunctional and harmful social systems when we cannot change them–or, as you have aptly expressed it: becoming more stoic. 🙂 Of course, this kind of transformative learning doesn’t negate the need for (or the power of) social activism. In fact, activism (through solidarity as you have shown many times) may also soothe our battered internal neurosystems. Love you.

  13. You may be right, Hopeful. Research marches forward, slowly, and Leptin may, indeed function long term. I would note tooo that many hormones function in more than one way (insulin comes to mind). It wouldn’t surprise me if someone found that Leptin functioned differently in non-weight-reduced people than in people who are weight loss maintainers.

    Since I wrote the “chemical cotillion” metaphor, I have changed my mind on how Ghrelin works. I don’t think its dance partner is Leptin at all, but I think it dances to its own rhythm — set over time by an person’s feeding and exercise schedule. I accept Katarina Borer’s more recent premise too that it works on the reward center of the brain. When Ghrelin is kicked off its rhythm (by episodes of sustained moderate intensity exercise), it may influence Leptin to rise, but it’s not a direct relationship where one tangos forward while the other tangos back and vice versa.

    My thought today: We still know very little about the chemical cotillion that defines weight regulation post-weight loss, but we DO know that there is a cotillion happening, and it’s a big stinking farce that political people and behavioral scientists (like the NWCR) keep promoting the idea that it’s all just a matter of simple portion control and making good choices. Shame and blame.

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