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.