Weight control – a new framework takes shape

Stepping Stones

Stepping Stones (Photo credit: Rich Jacques)

Is it Time to Change the Default First Option?

If so, what would that be?

Satiety-Focused Weight Health is a conceptual framework that can be used to organize one’s approach to weight control, in the aftermath of the era of reliance on calorie restricted dieting.

I think that as of now we have the knowledge and interventions to make satiety-focused weight health preferable as the default first option to consider for the majority of those whose health is being affected by excess body fat and/or by fat within the abdomen (including, that is, people within the normal weight range who are “metabolically obese”).

First solve the hunger – then consider the weight.

The core conceptual shift – Calorie restriction can block weight control success.  For many people, the path to their weight control goals requires fully letting go of calorie restrictive diets and behaviors, at least for a period of time.

The line of thinking goes like this:

  • If you want to reduce the amount of food energy eaten (relative to energy requirements), there are only two options. You can try to work with or influence the functioning of the appetite/satiety system so that it signals for less food, or
  • you can try to impose your will power over your response to the appetite control system – that is, refrain from eating despite hunger – also known as calorie restriction.
  • Research has confirmed that calorie restricted dieting, although useful for some, is not a productive strategy over the long term for most people. Imposing control has not delivered on its theoretical promise.
  • This leaves us with the strategy of looking for ways to reduce the hunger drive and/or improve the satiety value that comes from the amount of calories consumed. This is now the available path. Since the only other path is to impose calorie restriction, a person’s best hope is to use all available and personally-acceptable means to achieve this – to the degree that this is practical and sustainable.
  • With a person’s best weight control asset recognized to be the best understanding and balanced functioning of their innate appetite/satiety control system, all things that interfere with that are counter-productive. A person can’t learn to understand and work with their appetite/satiety control system while at the same time acting in ways that disrupt or provoke that system – such as skipping or skimping meals, using caffeine or stress hormones to suppress appetite or refraining from eating when hungry.

“Solving” the hunger is not possible while the focus is on immediate weight loss.

Satiety-focused strategies have come from behind to emerge as a powerful set of tools. We now have enough knowledge base to make a satiety-focused approach to weight health a successful approach for many people. When it is not enough on its own, the next step is to consider moving on to level 2 and level 3 interventions, while still valuing the central importance of avoiding excess hunger and optimizing satiety.

The value of a satiety-focused approach has been under-recognized in large part because of the pervasiveness of calorie-restrictive dieting and behaviors, which have been adopted by large numbers of the population as ingrained chronic behaviours.  Therefore, it is not possible to evaluate the true usefulness of satiety-focused strategies for an individual unless there has been active, intentional, informed avoidance of calorie restriction in all it’s forms.

This entails a fundamental shift in thinking. Hunger and cravings when trying to eat less are seen, not as an unpleasant nuisance, but as fundamentally disruptive to the process of achieving weight control goals.

Your body intends to be in charge of how much you eat. You have an incredibly  complex, multi-layered and redundant fundamental body management and survival system referred to as the body weight control system, which is expressed through the appetite/satiety control system. We are barely scratching the surface in understanding this system and how it works. (You can find preliminary descriptions of this system and diagrams of our current concepts of how it works – but be advised that these are all early “sketches”, no matter what other impression you might be given.)

It turns out that your hunger drive can be pushed up by many things, some of which you can take control of and change. Your ability to feel adequately fed with the food you’ve eaten is also something that can be influenced by many things other than the energy (calorie) amount of the food itself.

Calorie-restricted dieting, with it’s inherent hunger, has been the default treatment recommendation for weight loss. We now know that this approach, although helpful for some people, in general has been stunningly ineffective. There is also reason to be concerned that it might, in some people, actually be harmful in that it can cause disrupted eating patterns, lowered metabolic rate, (unjustified) feelings of personal failure, distrust of medical/nutritional advice, and so on. (See link below to the previous post on this topic.)

You cannot win a fight with an ancient, extremely complex basic body system that is wrapped into every part of your functioning – it’s better to make nice.

Millions and millions of people had made repeated efforts to control their food intake by using their will-power to over-ride the signals from their body weight control system.  This often results in short-term wins that are tantalizingly misleading. Over the longer term, your body fights back. Research has shown repeatedly that the short term weight losses are a false promise, for most people. Although some people have made this approach work for them, for most people this approach brings poor results after the first weeks or months. The false promise of the weight loss in the first weeks or months has been wrongly interpreted as a valid indicator of how the weight loss could be expected to proceed over time. For most of the people most of the time, it is more realistic to see this initial weight loss phase as a temporary situation that the body will muster its resources to fight against.

Calories control the skirmishes, but satiety ultimately determines the winning or loosing of the game.

Satiety-Focused Weight Health – overview

“Satiety-focused Weight Health” is a conceptual framework on which to build an approach to:

  • supporting each individual’s efforts to attain and maintain a body composition and weight
  • that is most compatible with their long-term health,
  • in the context of their goals, their choices, their individual circumstances and their inherent body tendencies.

General health, individual circumstance, over-all quality of life and individual goals take precedence over total body fat when considering body composition targets.

If reduction in body fat stores is desirable and this is not occurring, interventions are chosen that are designed to facilitate achieving satisfactory satiety and freedom from sustained hunger while undergoing weight loss. Failure to see improvement in body fat levels over time is a valuable feedback from the body that more needs to be done to reduce appetite drive and facilitate satiety. Any attempt to impose a calorie cap will ruin this essential feedback and sabotage progress towards a successful long-term strategy (which will actually be composed of a combination of strategies).

The same model is applied when the goal is stabilisation of weight in the face of a trend to weight gain. This model can also be used when the target goal is “food peace” – that is, relief from chronic struggles with hunger and cravings.

In this model, sustained or excess hunger is regarded as a symptom requiring attention, investigation and problem-solving.  Sustained or excess hunger is also regarded as counter-productive, and something to be responded to by eating.  Therefore, when eating according to one’s appetite, the determination of whether hunger/appetite is excess is made principally by tracking changes in body composition as accurately as possible with today’s limited tools.

Of course, as part of general weight control recommendations coming from agencies and health practitioners, every effort is already being taken to help with hunger as much as possible during weight loss interventions. The shift is in the concept going from (1) the calorie cap being the prime and beneficial intervention, with hunger being addressed secondarily as much as possible within the calorie cap to (2) the achievement of satiety while body energy stores remain stable or intentionally decrease as the prime and beneficial target.

The key to unlock the great potential of this approach is the recognition that calorie restrictive dieting and behaviors can severely undermine or fully block success.

All those involved in the field of weight control have been increasing their focus on appetite and satiety.

The writing has been on the wall now for some time about the failures of the calorie restriction (go hungry) approach. More and more attention has been given to understanding the things that affect body weight control. There has been a lot of research into what things push people’s appetite up (for example, certain medications, sleep deprivation). Research also is aimed at understanding which foods or eating habits or patterns result in the most feelings of satiety for the least amount of calories consumed. For example, when people take in a lot of calories as sugary drinks, their bodies tend to not “notice” those calories fully in terms of how much else they consume afterwards. Obesity management medications and obesity management surgeries are also oriented to helping people feel less hunger (appetite) and more satiety from a given amount of food energy consumed (or consumed and absorbed in the digestive tract).

Experts in obesity management are moving away from the focus on calorie restricted dieting. However, this has not trickled down much yet from the realm of the “obesity experts” to the doctors, nutritionists, nurses and so on that most people see as part of their health care team. And you’ll still see endless books and magazine articles describing diets that are one form or another of calorie restriction (often cleverly disguised).

This major shift within the field of obesity medicine* is reflected in a ground-breaking program released in Canada in 2012. This program is called “The 5As of Obesity Management”. (Links below)  One core of the new approach that this program teaches is the focus on finding ways to reduce excess “drivers” of appetite and identifying and correcting factors that disbalance the appetite/satiety control system. The purpose of developing this program and a set of educational materials is to get this message out to the general community of health care providers and the public. The old days of “give diet sheet first, ask questions later” are gone, or should be.

This program is a remarkable development and I highly recommend that you have a look at the video at the bottom of this post and consider learning more. It is a bold statement that we really are in a new era and it is past time to ditch old ways.

To be continuedFirst, solve the hunger. (Part 3 of this series)

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* obesity medicine is also called “bariatric medicine” – note that’s not the surgeons, who practice bariatric surgery.

Related Resources:

The Canadian Obesity Network developed the tool kit “The 5As of Obesity Management”. This excellent set of resources is presented on their web site on their Resources page, on the tab “5As”   LINK

On the page, click on “View 5As Presentation (pdf)” for much more information than is presented in the video.

The set of resources is sold for a modest fee and is intended for use in clinical offices.

Video introduction to “The 5As of Obesity Management” (5 min.) Highly recommended.  This is a great video to share with your doctor and all members of your health care team.

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Hunger Therapy – Or?

How to Make Low Calorie Apple Breakfast Cut th...

How to Make Low Calorie Apple Breakfast Cut the Apple (Photo credit: admiller)

What is Hunger Therapy?

You know if it is Hunger Therapy by asking yourself this question:

“If I have eaten my meal (and waited some minutes), or am waiting for my next meal time, or have eaten all my “allowed” food for the day, and I’m still hungry – what am I “supposed” to do?”

If the answer is – - “go hungry”  then what you are doing is a form of Hunger Therapy.

I first published this April 9, 2012. I’m posting it now because it is still topical and because this was originally published as a page “Which Way to Weight Loss?”. As a page it is often not noticed by people in the way a post would be. I’ve made some minor editing to provide context and improve readability.

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What is the most promising strategy to try first for most people seeking to reduce high total or belly body fat:

  • calories are controlled by intent - capped at a prescribed level in spite of hunger

OR

  • calorie are controlled by the appetite/satiety control system - the task is to help the appetite/satiety control system function appropriately so that weight can trend towards normal without sustained hunger?

CONTEXT

No-one has a lock on what the best way forward is. I am bringing up some concerns 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 striking and unexpected absence of substantial long term benefit other than for small numbers of people, a full re-evaluation is warranted. I am with those many who feel that one vitally important aspect of this is to assess and consider the potential harmful effects of not only the occurrence for individuals of sustained hunger as a side-effect of the recommended restricted-calorie eating, but also the potential harms from the very existence of professional advice that it is advisable and desirable and “good behaviour” 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:

  • Option 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.

or,

  • Option 2: calorie balance is monitored 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.

The Theory – In the calorie restriction model, the idea is that as long as the individually-adjusted calorie cap is not exceeded, then loss of body fat will proceed. The idea is that hunger will not itself prevent this loss of body fat, it is just an unpleasant nuisance. It is agreed that 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. Note that this set of ideas must be based on an assumption that it is safe and smart to ignore and disrupt your body’s basic maintenance and survival signalling system.

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 (OK, the standard of care) 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.

How do you recognize a calorie-restricted approach? Curiously, by the same criteria I have outlined at the top of this page regarding Hunger Therapy.

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 ingrained 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 self-imposed and possibly even automatic 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 standard 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. No-one can lay claim to knowledge of a medical treatment for reduction of excess body fat that is scientifically proven in a large population of people to be both safe and effective in the long, long term – none exist.

For all these reasons, 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.

Hunger? What of that?  Aren’t we supposed to ignore the hunger and “stick to the diet plan”.  Isn’t that the advice that pervades society, from agencies and health practitioners alike, repeated over decades?  Isn’t the hunger little more than a nuisance, to be ignored or managed as best as possible? Conquered, even? A test of one’s character?

There is the outcome on the individual directly of the attempt to endure sustained hunger (and of “failing” to do so). There is a whole extra set of problems when the professional/agency advice to put up with sustained hunger becomes incorporated into a general societal attitude that expands and gets passed down over generations.

There are rumblings (angry screaming?) that the persistent, excess hunger (and the other outcome of this professional/societal attitude that hunger can be safely ignored and, in fact, you are displaying approved behaviour if you do) is an unsuspected, slow-onset, toxic bomb that goes off in the individual and in society over the course of months, years, decades.

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”.

To be continued …

Related articles:

  • They Starved, We Forgot  LINK to post on Ancestral Weight Loss Registry
  • Nov 21/12 LINK to new post by Gary Taubes, “What would happen if…? Thoughts (and thought experiments) on the calorie issue.”