Paper: Ross, R., Blair, S., de Lannoy, L., Després, J. P., & Lavie, C. J. (2015). Changing the endpoints for determining effective obesity management. Progress in cardiovascular diseases, 57(4), 330-336.
I can do a handstand. But I never set myself a goal of being able to do a handstand. Handstands have merely been a by-product of a healthy yoga practice. And weight loss is the same. I don’t believe it should ever be a goal. Only a by-product of a healthy lifestyle. Trouble is, there is so much focus on weight that, even if you are eating well, moving more and feeling great, many people still feel like a failure if the scales don’t go down.
But emerging research is challenging the assumption that we need to focus on weight loss in order to be healthier. Instead studies are suggesting that putting weight goals on the backburner and instead focussing on creating healthy lifestyle habits is far more effective in helping people reach a naturally healthy weight. And some studies are even showing that weight loss isn’t even necessary to enjoy the benefits of living a healthier life.
Ross et al’s (2015) paper encourages us to change our ideas of what ‘success’ looks like when it comes to obesity management. Instead of setting outcome goals (weight loss), we need to focus on process goals (healthy eating, movement…).
As an aside, I know some people feel ‘obesity’ is a stigmatising term that encourages fat phobia. In the context of this post, I am using it in the same context as the researchers of this paper have used it – to represent a person with a BMI of over 30. It has no more meaning than that and there is no judgement involved in my use of the term. There is a very fine line between motivating healthy behaviour change and weight stigma and, as professionals, we need to be mindful of how we use terms such as ‘fat’ and ‘obese’ and whether they are helpful or harmful to the people we are working with. Equally, we need to be able to have these conversations openly and inclusively, using the language we have available instead of holding back for fear of accidently creating stigma or for being shamed for doing so.
Here’s what we know…
- Seventy percent of US adults are overweight or obese. That’s 78 million Americans.
- Obesity prevalence is increasing despite 33% of US men and 46% of US women reporting that they are attempting to lose weight.
- Obesity is associated with an increased risk of type 2 diabetes, cardiovascular disease, various cancers, and mental health disorders. Whilst this is correlational not causational, even when we are working from a weight-inclusive, health at every size paradigm, it is important to accept that there are health consequences associated with being obese.
- Most overweight and obese adults are not able to sustain the behaviour changes required to sustain weight loss long term (according to several randomised control trials).
‘Effective’ Obesity Management
Currently, obesity programmes are deemed effective if someone loses over 10% of their bodyweight. Failure to lose this weight can mean they are withdrawn from obesity reduction programmes, and often the healthy behaviour changes they began to make are discontinued too. However, improvements in diet and increased physical activity have been shown to improve health even without any weight loss. So, surely improved health despite no weight loss, is effective?
Benefits Of Focussing On Diet and Exercise Instead of Weight Goals
We know that weight loss is not necessary to achieve health benefits from lifestyle changes (e.g. reduced abdominal fat despite no overall weight loss – possibly due to an increase in muscle mass). Therefore, it makes sense to put weight loss to one side and view ‘success’ as the adoption of healthy behaviours. This increases motivation and reduces the feeling of disempowerment people often feel when they don’t lose weight.
Reducing Obesity vs. Preventing Weight Gain
The paper highlights how obesity itself is less of a health issue than the process of weight gain when already overweight or obese. Therefore, shifting the focus away from weight loss and towards the prevention of weight gain is a good first step.
This is for a couple of reasons:
1 – By shifting the focus away from weight loss, it reduces the body’s defence mechanisms to negative energy balance (e.g. adaptive thermogenesis). This energy restriction can cause extreme hunger and reduced metabolism leading to greater weight gain long term. Read: How Dieting Makes Us Fatter.
2 – It allows for smaller, more sustainable behaviour changes. For example, the general advice for weight loss is to reduce calorie intake by 500-750 kcal a day and to increase activity by 200-300 minutes per week. Even for the most motivated person in the world, this is a big ask. In contrast, to prevent weight gain, it’s recommended to reduce calories by 100-150kcal per day and increase activity by walking an extra 2000 steps per day. It may seem like a tiny change but this is the benefit of the small change approach. As you meet the goals you set (e.g. improving nutrition and increasing activity), you feel more empowered, your self-efficacy improves, you reduce the urge to overeat, and you feel motivated to make more changes that contribute to a healthy lifestyle.
We can apply the suggestions of Ross et al (2015) in a couple of ways:
- When working with clients, we can shift the focus from outcome goals (e.g. weight loss or gain) to process goals. For example, if a client comes to us wanting to lose weight, we can explain to them why it’s far more effective to take the focus off weight goals and instead focus on day-to-day habits by encouraging them to go to their favourite Zumba class on a Tuesday evening and their weekly personal training sessions, suggesting they enjoy country walks with their partner at the weekend and meditate for five minutes when they wake up, and advising them to always have a selection of fruit and vegetables in the house to snack on… By focussing on the behaviours instead of the weight, we will help clients see their health (and their worth) is based on much more than their weight.
- This is also applicable when we’re working with people who have an unhealthy relationship with food. For example, instead of focusing on a goal of ‘being binge free for four weeks’ which can create unnecessary pressure, we can shift the focus to the process of daily self-care, nourishing meals, healthy movement, and meeting their needs – physically, psychologically, emotionally, and spiritually, to reduce binge urges.
- Clients often think they need to make huge changes to their diet and lifestyle in order to see any progress so they join a gym, start running, sign up to a weight loss club, cut out carbs, track calories, get a personal trainer… and they end up exhausted. And because they are exhausted, they go back to unhealthy habits (because this is what the brain does when it has run out of neurological energy. Read: Self-care: What It Is and Why It’s So Important). Therefore, a small change approach is usually far more effective. For example, for the first fortnight, you might encourage your client to focus on what they do in their lunch hour. Instead of sitting at their desk and eating from the canteen, you might encourage them to go for a 20-minute walk to the local supermarket to grab a pick’n’mix salad box instead. For the following fortnight you might encourage them to add in a weekly exercise class (something they enjoy) whilst maintaining the changes from the first two weeks. And then once they feel empowered by those changes, you might start to look at their morning routine – could they get up 15 minutes earlier to meditate and have some fruit or porridge breakfast instead of fuelling up on coffee and biscuits? It’s important to remind clients that there is no rush. This is a process. A daily practice. This is about creating healthy habits that are going to last a lifetime.
I’d love to know your thoughts! And if you would like to read the full paper, please drop me an email.