For most people seeking to reduce high total or belly body fat, what is the most promising strategy to try first:
- calories are controlled – capped at a prescribed level
- calorie balance is monitored by following changes in body composition
No-one has a lock on what the best way forward is. I am bringing up in these pages some concerns of mine that I feel warrant some consideration.
Many people have spent their long efforts doing their best to support the health and well-being of people who would like to improve their health by loosing weight. Much effort has gone in to pursuing many different approaches to treatment. Given the unexpected degree of limitation of long-term benefit, a full re-evaluation is warranted. Part of this re-evaluation is the basic nutritional structure of the eating plan (i.e. considering low or at least moderated carbohydrate quality or type). I am with those many who feel that another aspect is to assess and consider the potential harmful effects of not only the occurrence of sustained hunger as a side-effect of restricted-calorie eating, but also the potential harms from the existence of professional advice that it is advisable to engage in sustained hunger for medical benefit.
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There is a fundamental choice at the core of any eating plan designed for loss of body fat:
- (1) set a limit on the total daily intake of food energy (calories)
- (2) do not set a limit on the total daily intake of food energy (calories)
These two options are mutually exclusive. You can’t have both those choices at the same time. Either there is a limit set or there is not. If the limit is “sort-of-set”, there is not actually a limit – as in, “the total calories for the day is to be no more than (for example) 1400 calories — well, unless you are really, really hungry, then have more to eat if you want”.
This choice could be expressed another way:
- (1) stay below a set limit of total calories for the day, whether you become hungry or not. Calories are capped, and this is the path to success, with hunger being a nuisance side-effect to be ignored or managed. Weight/fat mass is tracked over time and the calorie cap is adjusted up or down until a calorie level is found that permits weight loss at the desired pace.
- (2) calorie balance is monitored, but indirectly by following any changes in body weight/fat mass over time. Sustained or excess hunger is regarded as a threat to long-term success and is to be avoided. The path to success is through taking steps to achieve the absence of excess hunger (adequate level of satiety) while eating an amount of calories that permits slow weight loss.
In the first situation, excess hunger is regarded as not of direct importance to the outcome. In the second situation, excess hunger is considered to directly interfere with long-term successful outcome.
In the first situation, the idea is that as long as the individually-adjusted calorie cap is not exceeded, then loss of body fat will proceed. Hunger will not itself prevent this loss of body fat. Hunger can indirectly prevent success, if the person responds to the hunger by eating more than the set limit of food. Hunger can also indirectly interfere with the effectiveness of this approach by leading the person to abandon the treatment plan and/or by discouraging future attempts to follow similar treatment plans.
Because excess hunger can lead to the person “breaking their diet”, a growing amount of medical attention and research is being paid to the science of hunger/appetite/satiety. It is also understood that the study of hunger/satiety will shed light on the factors that are promoting the current obesity crisis.
For the past many decades, overwhelmingly the common (or even the standard) approach to body fat loss has been to advise or prescribe a set limit on total daily food energy (calorie) intake. This limit may be expressed as a calorie number (for example, 1500 calories per day) or as serving amounts of various foods, which is just a less obvious way of counting calories.
The mathematics of the approach is so convincing, and it all appears so logical, that it has pretty much been taken as a given that:
- the benefits were plainly obvious
- the risk of harm was plainly low
- the balance of benefit to harm was plainly so great as to not require specific investigation
So, why this long article? What is the point of this discussion?
There is a shaking, dust and confusion at the very foundation of what has been the standard approach to weight loss. Each of the above three points has come under serious doubt:
- the long-term effectiveness of limited-calorie dieting seems to be amazingly less than anticipated
- the long-term safety of limited-calorie dieting has increasingly come under doubt
- the net benefit versus harm is in doubt and has not been proven scientifically
To be clear, these statements are not limited to limited-calorie dieting, but are true for weight loss diets in general. However, I would contend that the attitude favouring calorie-restriction is so pervasive in the culture that any research on over-weight/obesity is going to be studying calorie-restricted eating unless a very concerted effort is expressly made to avoid the behaviours of calorie restriction in the study population. Therefore, are we actually totally sure what we have in the way of weight-loss/control studies (on obese people, otherwise they don’t count anyway) that are completely free from the contaminating effect of calorie-restricting behaviours. In other words, have pretty much all research studies in the past decades been, in actuality, studies that at least reflect, in some part, the effects of imposed calorie-restriction (even when that has not been intended or there has even been an attempt to avoid it)?
Under these circumstances, perhaps it would be useful to revisit the core decision as to whether to impose a calorie limit or not. Or, more to the point, the choice whether to use a diet approach where excess hunger is a nuisance to be tolerated, or a diet approach where excess hunger is considered a threat to success and is to be avoided (and excess hunger is primarily considered as a symptom of something more needed to be understood or changed for that person).
One might term the first choice “Hunger Therapy”. As tempting as that is, that delicious term would be misleading as there is actually no intent to cause hunger, hunger just happens to be the usual outcome. On the other hand, I suspect it is a term that many people who have been through multiple cycles of limited-calorie diets would instantly relate to. There is some merit, though, to the use of a term like “Hunger-Inducing-Treatment”. This would yield the acronym “HIT”.
This might seem like just having some fun with words. It might also seem like an attempt to be nasty or to pick a fight and throw names at people who have been doing their best to provide the best care they know to people who have a real medical need to reduce their body fat. Neither is true. Nobody knows the right way(s) forward anymore and no-one can lay claim to knowledge of a medical treatment for reduction of excess body fat that is scientifically proven to be both safe and effective in the long term – none exist.
For that reason, the conversation must be opened up. Things that have been taken for granted, assumptions that have been made, things that “every-one knows are true” all have to be brought out and looked at from the ground up. I think that naming hunger as an under-considered harm is one aspect of the broad re-considering that must be done. There are many people who have made this point long before me.
If “Hunger-Inducing-Treatment” is in doubt as a promising way forward, perhaps it is time to give the alternate approach (option 2 above) at least a good try.
Perhaps a useful term would be “Satiety-Focused Weight Health”.