Weight loss and the Biggest Loser: What you really need to know about the NY Times article

Patients, Facebook friends, and friends of friends contacted me in horror after reading the NY Times article on the Biggest Loser. Weight re-gain is inevitable. Most if not all of it.  And metabolic rate is screwed too. The control you believed you had? Doomed to dissolve. The hope you were given that you'd finally made it to your goal size or weight—or were getting closer—shattered. Overweight, obese, underweight or average size—the feelings knew no size boundaries. Fear. Anxiety. Hopelessness. Panic.

The pain of regain extended well beyond the 14 Biggest Loser contestants studied and their loved ones. It was felt by those of you who shared their struggle and their joy and sought inspiration from this outrageous, extremist show. 

The NY Times summarized the research: by 6 years after the show’s end, all but one participant studied had either regained some weight or gained beyond their starting weight; 4 contestants are now heavier than before they tortured themselves with this unsettling weight loss regime.

I know how you're feeling.

Nearly all have slower metabolisms now than at program’s start—over 600 calories less on average— with the biggest loser, Cahill at a loss of 800 calories burned per day; he now has to eat 800 calories less per day to maintain the same weight compared to at the start of the program. Many reduced their weights enough to improve their health, but the struggle to maintain the loss was constant and painful—physically and psychologically.

Where’s our anger at this abuse?

Four to 6 hours daily exercise was commonplace, with Cahill reporting 7 hours/day while on the show. Two or more hours included intense cardio workouts. And their intake? 1000-1200 calories was not unusual—an outrageous restriction even if the obese individuals were sedentary. That’s right. Just breathing or being at rest they would lose weight at that calorie level given average heights and starting weights. The degree of starvation was shameful and irresponsible. A set up for failure for sure. And did I mention there are now reports by participants of taking stimulants (provided to them by the program) to accelerate the weight loss—like ephedra and Adderall? 

It is simply abusive to lose weight the way they were directed to for the public’s entertainment. The extreme calorie deprivation resulted in a hormonally induced hunger and subsequent binge eating. No doubt, great shame and embarrassment resulted from their regain as they blamed themselves for their “failure”. Unfortunately, people replicate this self-abuse with crazy diets all the time, believing they can just jump-start their weight loss and then sustain it. Wrong, wrong wrong. 

What can you learn from this Biggest Loser study?

Yes, metabolic rate does slow with weight loss. This is not news. You knew it. You knew that when you were dieting and the weight loss you’d hope would continue simply didn’t happen. Your weight would plateau even though you were doing just what you were doing before. Even though you were “being good”. And so you made an adjustment. You’d eat a little less or exercise a little more or use behaviors like purging. And what resulted? More frustration, less “success” with weight loss. 

It may be time to be more realistic.

And for many if not most of you, rebound overeating or binge eating occurred. Because you’re a failure? Surely not! Because it wasn’t sustainable. Because you felt deprived—hungry, unsatisfied, fatigued, unfocused, vulnerable. Because hormone levels fought against you, as leptin levels—which helps us feel satiated—dropped with weight loss.

While the number of study participants—a mere 14 individuals—was small—the results were enormous. All but one regained significant weight. Yet the big news from this piece was the extent of the metabolic rate drop and the duration that it was sustained—observed when last checked 6 years after the end of the show! Now that’s scary.

What does this really mean for you?

While we don’t have all the answers, it appears that the degree of restriction impacts the outcome. Meaning, more rapid loss, more rapid gain. The “biggest loser”, Danny Cahill, had the greatest drop in metabolic rate—down 800 calories/day. He also regained the fastest, based on the NY Times graph accompanying the article. Deny your body and it’s gonna do what it needs to preserve yourself—it’ll try to slow the engine down, to conserve, to save some fuel for another day, to burn fewer calories. Yes, it does appear proportional. More moderate reductions in rate of weight loss, less drop in metabolic rate. 

Is my metabolism ruined forever?

The degree and duration of metabolic drop reported in the Biggest Loser research is simply not seen in other studies—a drop of 3-5% is more common. And most studies show that this drop reverses with increased food intake. 

Living with anorexia? 

Fear not—you have not permanently messed things up. The famous Minnesota Starvation Experiment demonstrated what those who treat eating disorders know from practice—that metabolic rate rapidly increases with re-feeding. (But continue to starve yourself and yes, your metabolic rate will be suppressed.) It requires a lot more calories than we’d expect for underfed individuals to restore weight. Ask any parent who is helping to renourish their child with anorexia. 

So please don’t be too quick to assume your fate. How do we know metabolic rate increases in this population? In addition to the Starvation Experiment and inpatient studies using indirect calorimetry—a  measure of resting metabolic rate or calories burned at rest, we also can see it indirectly—from increases in heart rate, body temperature and hormone levels.

I don’t have anorexia. I just diet to lose weight.  What does this mean for me?

“Just dieting” still lowers metabolic rate. If you are as extreme as the contestants, you may need to acknowledge your fate. If you are expecting rapid loss to be maintainable, think again. Torturing your body with hours of exercise each day as many of them did (or any amount, quite frankly, that leaves you starving) and/or restricting your eating and denying your hunger will fail you. 

Banning these? Time to change your approach
 to weight management.

Feeling deprived by omitting foods that satisfy you will lead you nowhere. Besides the reduced metabolic rate, the resulting deprivation leads to binge eating. And binge eating contributes to significant excess in calories and weight regain. Hopelessness follows, leads to the “what the heck effect” and eating recklessly. It all adds up to significant weight regain. And with chronic restricting, there’s also a loss of muscle mass which further reduces metabolic rate.

So now what?

Using more sensible, less extreme, more behavioral approaches to take charge of eating may seem less sexy, but has my vote. An 8 year study on lifestyle change resulted in long term weight loss (in 73% of overweight participants)— but not to the degree you might be hoping for. A 5-10% drop in weight was maintainable without losing sanity, and improved health. 

While the Biggest Loser participants tortured themselves dropping huge amounts of weight, and suffered as it rapidly increased, those with practical lifestyle changes lost less to start and after some initial regain, stabilized for years, suggesting better long term outcomes. The Biggest Losers? The study ended at 6 years, but based on the charts most seem to be likely to continue their weight gain trend.

So what can you do?

• Accept more realistic weight goals.  Modest paced weight loss (assuming weight loss is truly needed) may be most sustainable. 
• A 5-10% weight loss is enough to have a signifiant impact on your health—on blood pressure, blood sugar blood, cholesterol, fitness level and overall well being. 
• Focus on fitness goals. Regardless of your weight, find ways to move more, setting realistic goals.
• Address the quality of your intake for health. Include plenty of whole foods including grains, fruits, vegetables, nuts and lean protein sources—as well as fatty fish. But allow room for other foods you enjoy—yes, that includes cupcakes.
• Work on your eating behaviors, as I’ve addressed throughout this blog (see posts labeled mindful eating and binge eating)
• Cover your ears when your doctor says you must drop to the average BMI if you haven’t seen that place in decades, or ever. Clearly more harm than good will be done.
• Oh, and stop blaming yourself. Take charge of what you can control without physical or mental distress. And take some steps to love yourself as you are.

Thanks for reading. And sorry it's taken so long for a blogpost. Please take the time to share your thoughts--and share this piece with others.

So you think you're recovered from an eating disorder? Take this quiz to find out.

1) Recovery is about weight gain. Period.

The simple answer? 

It just might not be going the way you planned. 

False. Now don't let your eating disorder get all excited, saying "See! I told you so!"

Weight restoration is surely a must for those who have fallen from their usual weight or in the case of kids, their weight for age and BMI curves. That is, their expected pattern of gain based on their age and their weight history. For kids, falling off their usual growth curve suggests a problem. It shouldn't be praised or rewarded, but evaluated. (Pediatricians, did you read that?!) But if someone's weight was high due to unhealthy behaviors such as binging, emotional overeating, or general disregard for satiety, and weight dropped with improved eating and coping, weight gain is likely unnecessary.

Simply reaching a healthy range based on the charts also isn't enough. Perhaps your restrictive eating and suppressed weight began as a young teen, and you've lived for years with eating disordered behaviors. Did you rely on cigarette smoking or other substances? Was your appetite suppressed by ADHD meds? As you recover, weight gain may be essential regardless of what the BMI charts say. Focusing on the weight is misguided!

Your weight may be technically in the normal range, but your behaviors may indicate a problem. You know, like restricting, binging, purging, laxative abuse, compulsive exercise.

Weight is just one component of eating disorder recovery.

2) If I get a period (and I'm not a guy) then my body is healthy.

False

Surely losing your period when you're of age and sex to be getting a period is cause for concern. But getting your period is not evidence that all is well and you have recovered. You may get what seems like a period when you're on the pill, or start to get periods back without all the hormones being back to normal. Or maybe like one adult patient I used to see, in spite of her struggle with anorexia, she managed to conceive and deliver 5 children, never missing a cycle. Similarly, weight may be restored to the appropriate place, but it may take several months for menses to resume. For guys, low testosterone level is a more silent red flag that things are amiss; is resolves with adequate eating.

3) If I can take in enough calories, then I've recovered.

False

Can you eat foods you used to enjoy?

Sure, you will need enough calories to get your body bad to normal function--with a healthy heart rate and blood pressure, without major drops in pressure when you go from lying down to sitting or standing; with normal body temperature and energy level; with better sleep and mood. But full recovery means eating a range of foods and nutrients. It requires eating enough carbohydrates and fats-- not just protein. Recovery, true recovery, demands you include foods that seem scary, foods that you used to love, so that you aren't controlled by them. Like eating some pizza or an ice cream if the spirit moves you.  It means eating bread that may be whole wheat, or white, sourdough or french, without relying on ‘sandwich rounds’ or high fiber, low calorie flatbreads, or “Ezekiel” bread. If you’re truly recovered you can eat foods even if you can't justify them for their nutritional value, even if you don't think of them as "good for you".

4) I've stopped using laxatives, vomiting, and I'm eating better. I'm healthy now that I'm exercising every single day. So surely I'm recovered.

False. Replacing one behavior with another-- in this case, having to exercise to allow yourself to eat-- is also not healthy. Be careful that you aren't just swapping one behavior with another-- even a 'socially acceptable' behavior like exercise. If you feel you can't eat if you don't exercise you have work to do!

Ok. So I am doing fine with all that. But I need to be the one preparing the food. I'm still recovered, right?

I know. This is a scary idea. I will
settle for nourishing you
with words.

Not quite. Full recovery includes some flexibility and acceptance of what you can't control.

It means eating meals out without having to look up the calories before hand, and without having to modify the entire meal according to ED (that said, being vocal about your preferences doesn't have to be disordered. While Sally didn’t have an eating disorder in "When Harry Met Sally" this scene is worth viewing for some comic relief. Recovery is being able to eat a meal without watching the food be prepared, fearing the secret addition of ‘toxic’ ingredients.

Recovery acknowledges that people you know diet or overexercise or are losing weight, and it is what it is. (see husband triggering) And that you stay the course with eating and avoiding behaviors because it simply has to be; because you can be a great dieter-- but it didn't serve you very well being in that place before. And because you simply deserve to feel better.

Not as far along as you hoped? 

Then move your frustration to action. If you've just started on this path, hooray for improving your intake and taking steps toward recovery! Perhaps you're finding other ways to cope, so you're freeing yourself from unhealthy disordered behavior. Maybe reading this post helps you realize that more recovery pieces are in place than when you started. Progress! The point of this piece is to raise your awareness to help you keep going and reach fuller recovery. And to shake up some denial that stands in your way.

Yes, there's hope. See some of the links below.

Any changes to your thinking or eating you still need to make? Perhaps the post below will help to motivate.

Please share your thoughts!

And thanks for reading.

http://dropitandeat.blogspot.com/2011/09/beyond-calories-learning-to-embrace.html

http://dropitandeat.blogspot.com/2012/09/lessons-from-my-final-day.html

http://dropitandeat.blogspot.com/2013/05/do-you-believe-recovery-just-isnt.html

http://dropitandeat.blogspot.com/2012/03/normalizing-eating-and-hiking.html

Spouses, partners, parents of loved ones with eating disorders--I need you to keep reading. Really.

You may have no idea how they're suffering. Your wife, or mother, or partner or son. It's about shame. And fear. That's why they can't tell you. That's why it's so hard for her to ask for help. I'm not placing blame, but I'm asking you to start to listen like you never have before. Because it's hard for those living with anorexia, bulimia and binge eating disorder to say what needs to be said.

Don't be fooled by his size or his weight. People with eating disorders come in all sizes. And don't be fooled by how well she had been doing. Slips happen. That's normal. But recovery requires acknowledgement that things are amiss, and that support is available. Right there. In person. Not just virtually through this blog, or a virtual support group or a friend across the world.

Yes, they need to know that you are there for them, unconditionally. Even if you really don't understand. Even though you wish they'd just 'get over it'. Struggling with an eating disorder is something they simply did not choose.

She may not discuss it with you, seeming as if all is well. And he may deny that he's restricting or over exercising. Besides. It's so much easier to see what we'd like to see.

So if you suspect that there's something not quite right, please start a discussion. And use open ended questions, ones that can't be dead-ended with a simple yes or no response.

You just might have your blinders on to
what's really going on--right before your eyes.

Do you know how trapped she's feeling?
Like there's no way out of her misery?

Sometimes we're a bit too close to the situation to
see the whole picture.

FB and your diet, weight, fitness & happiness: A cautionary post about comparing.

Everyone is so happy. And doing so well, always having a great time. They’re all eating amazing food and managing their weight. They all look so healthy, too. And their kids are always smiling—they have the perfect families. Everyone else is so good at exercising—Map My Ride/Run and other apps prove they’re doing so much better than you running and cycling and walking. Yes, by comparison you hardly rate.

Hardly his happiest or his best mug shot.
Posted with permission.

Or so it seems.

It was quite timely that my patient whom I’ll call Beth, described her frustration having spent too many hours on Facebook. (Imagine that. Spending too much time on social media.)  She saw far too many ‘friends’’ photos displaying beach-bound bodies with a confidence she doesn’t possess. Like those ‘before and afters’ from diet ads from Diet Center and Weight Watchers (where the print too small to read confesses that these images are of rarely occurring weight loss that normal people don’t usually experience nor maintain in the real world) they showed what everyone else was capable of—except for her. These photos of Beth’s friends and acquaintance were beautiful—looking slimmer, happier and more fit than her for sure. 

Or so it seemed.

These pictures of friends struggling
 hardly get seen.

Ok. Raise your hands if you post pictures of yourself that you'd rather destroy. Right. We only post our best shots, the ones that get the ‘likes’, right? And we surely don’t see people throughout the day, at all times, when they may be looking their worst—like we see ourselves. No early morning “I-just-rolled-out-of-bed” shots posted on FB.  And did you know that some ‘friends’ even use apps which photoshop their pictures, like they do in magazines with airbrushing? Yes, it’s even possible that some pictures you’re thinking are real have been touched up. 

Comparison is a tricky business. You only see a small slice of a person’s life, of what’s really going on. The rest, no doubt, is projection. They ‘seem’ happy, or healthy, or content. But maybe it’s just how it appears. Their exercise level may be awesome, or excessive or a rare event advertised to their Facebook friends.

No, these imperfections don't make
it to FB.

Your friend who’s lost all that weight may have cancer, or may be struggling with anxiety and depression, causing her to feel anything but happy. Or fit. Or relaxed. The bikini clad acquaintance may be so preoccupied with what she believes she can and can’t eat that she hardly enjoys herself at the beach, or when she dines out, or even when at home deciding what she could possible have for lunch.

Yet another recent study showed that using social media can have a negative impact on our eating behaviors including binging, purging and using diet-pills. “Both online physical appearance comparison and online fat talk were associated with greater disordered eating” the study by Dr. Bulik and colleagues showed. Without the comparing, however, greater Facebook use was associated with decreased disordered eating behavior. So it’s all how you use it. "Comparison is the thief of joy"--I can't agree more with this quote attributed to Theodore Roosevelt.

Looking neither happy, nor energized.
I was actually quite miserable here.

Maybe it’s time to challenge your Facebook and social media friends. Are they capable of posting a picture where they don’t look so awesome? Can they post the ride or run where their speed was less than impressive?  I doubt that most can bring themselves to do so—but wouldn’t that change things?

I’d love to hear what you think. So please leave a comment! And thanks for reading.

What doctors must know about eating disorders.

I want your input. I need to hear your voices. For EDAW 2015, I have volunteered to present to two medical residency programs—one in Boston, MA and one in Providence, RI on what doctors need to know about eating disorders.  I've incorporated recommendations from twitter responders and from Aspire, but I welcome more input. Here's what I have to share with new doctors so far:

• Avoid the ‘Don’t ask, don’t tell’ approach. Patients rarely volunteer behaviors they feel ashamed of—bingeing, purging, diet pill and laxative abuse.  So providers need to ask. Nicely. Casually. Non-judgmentally. Include basic ED screening questions at routine visits.

• Early action is not just for college admissions. Eating disorders are best identified early and treated promptly. We wouldn’t simply wait it out to see if blood sugars simply turn around in a patient with type 1 diabetes. Take eating disorders as seriously as you would cancer, or

  

  The time is now for improving medical management
  of eating disorders.

  diabetes, or heart disease. Because like these medical conditions, they cause physical damage, and impact emotional wellbeing. And did I mention that left untreated they can be fatal?
• Relying on size is a seismic mistake. People of all sizes suffer from eating disorders. And because eating disorders in those of “normal” weight are often missed, they may be more chronic and challenging to overcome. Patients with anorexia can have high BMIs; they severely restrict their intake, are ruled by food rules and fear weight gain; their restriction impacts their ability to function, their mood, their blood pressure, body temperature, blood counts and thyroid level, fertility, bone density, and GI function.
• ED sufferers want help. People with eating disorders ultimately want to be free of their disorder. They are not just being difficult. They may also be struggling with depression, anxiety and OCD making recovery more challenging. They are
  
  suffering with their symptoms making day-to-day life unbearable. In fact, the risk of suicide is higher in those living with eating disorders and is a major cause of death in this population.
• Be careful what you ask for. Before recommending that your ‘overweight’ patients lose weight, do some assessing.  Has their weight or weight percentile been normal for them? What behaviors might be better addressed versus focusing on their weight? Diets can be the tipping point, precipitating an eating disorder. Striving to achieve and maintain a lower than usual weight contributes to maintenance of eating disorders.

  

  You can't simply tell by appearance that
  someone is suffering.

• Guys (yes even straight guys) get eating disorders. Seemingly healthy, fit, guys, and overweight boys and men live with eating disorders. Like girls and women, they may restrict and be fearful of gaining, binge eat, purge, and compulsively over exercise. EDs have no gender limits.
• Eating disorders may start in preadolescence, or at age 20, or in the 40s.  Eating disorders don’t expire when kids reach adulthood, or when adults mature. Individuals with EDs may first present for care after decades living with their ED or may have a late adult onset during a transition period in late adult hood.
• Read between the lines and ask the right questions. Please don’t praise a patient’s weight loss. Would you say great job if they lost due to cancer? Do focus on reinforcing healthy actions, not numbers. Rather, ask:
•  "What kinds of changes have you made?" 
• "How do you feel?" 
• "What percentage of your thoughts are spent thinking about food and eating?"
• "How’s your energy level?" 
• "How are you managing with these changes?"And note that healthy eaters are not always so healthy. Ask why your patient became a vegetarian/vegan. Why are they following a gluten-free or low carb diet?

Families play a critical role in
supporting a child's recovery.

• Parents are necessary supports for recovery. Overwhelmingly, parents need to be brought in to assist recovery. And the only thing we can blame parents for when it comes to eating disorders is their genes. 
• Eating disorders are serious mental health conditions. They have genetic, environmental and nutritional underpinnings. They don’t just “run their course” or become “out grown”. They require treatment by experienced providers. ASAP. Waiting may be lethal.
• If you don’t know, please ask! Check out AEDs medical resource guide and this. Seek out providers to collaborate with who are part of national or regional eating disorder organizations like AED, NEDA, iaedp and MEDA.

Please share this with your medical providers. And with your friends. And twitter followers. And with your Facebook friends.

Eating disorders require education and a break from the commonly help practices and beliefs. And you can help make it happen.

Thanks again to those who have already shared their ideas that were incorporated into this post.