Yes, But Is Weight Loss the Be-All and the End-All?

What is your dream weight?
What is the weight at which you'd be happy--not as ideal as dream weight but still something you'd be glad to achieve?
What is the weight you'd find acceptable--not something you'd be terribly happy with but which you could live with if it were your current weight?
What is the weight at which you'd feel disappointed--it's less than you weigh now, but it would still leave you feeling very unsatisfied?
Researchers at the University of Pennsylvania asked these very questions of a group of obese women beginning a weight-loss program. The average dream weight amounted to a loss of 69 pounds--32 percent of the women's current body weight. The weight loss the women would have found merely acceptable was 55 pounds a--25 percent weight change. And the weight loss that would have been disappointing was 37 pounds--17 percent of their body weight.

After 48 weeks, almost an entire year, half the women did not achieve even their "disappointed" weight.

Heather Bell, MPH, RD, a nutrition therapist at the Tufts-New England Medical Center, isn't surprised. "In reality," she says, "it's hard for some people to lose even 10 percent of body weight, never mind being able to keep it off." Granted, as most people have heard by now, even small changes in weight, say, 5 to 10 percent of body weight--and sometimes less than that--can often produce significant improvements in cholesterol levels, blood sugar, blood pressure, and other medical indices of health. But that can be small comfort to people who have a certain body size in mind.

The problem, Ms. Bell says, is that "we frequently focus on weight to the exclusion of everything else. Particularly in this culture, there is a temptation to over-focus on weight." And that means that even clients who lose enough weight to become healthier but still weigh more than what they consider ideal "are likely to feel frustrated, likely to feel disappointed, likely to feel like they've failed, which means they may then give up on all those health-enhancing behaviors because they didn't accomplish what they were 'supposed' to."

To get around that, Ms. Bell says she works to "reframe success" for her patients. To find out exactly how she gets people to focus less on weight in a culture that relentlessly puts weight front and center--and more on health and healthy attitudes about food--we sat down with Ms. Bell for an in-depth interview. Her outlook and approach upend a lot of commonly held beliefs about weight management.

Q: If it's so hard for many people to lose and keep off even small amounts of weight, what do you say to someone who comes into your office and tells you be or she wants to lose 50 or 100 pounds?
Heather Bell: I start by asking the person what's the highest weight they were ever at? And for how long? What's the lowest weight they were ever at--as an adult? And how long were they there? Because if someone identifies a goal weight that they've never been at in their life, or if they were there for only a short time after a really strenuous diet, then just by getting them to speak those numbers aloud, I have kind of prepared them to hear that it may not be possible. I tell them that I can't determine for certain what their body weight is going to be but that I wonder whether their aim is possible.

Q: But can't people lose the amount of weight they want if they just eat fewer calories and exercise more?
HB: That's an overly simplistic perception, and one that has become moralistic, too--that the relationship between weight and eating or weight and physical activity is very direct and straightforward and that if people would just eat less and get more physical activity, they'd drop down to goal weight.

Q: Well isn't that true? Aren't a lot of people just not trying hard enough?
HB: In many cases, that's not what's going on. There are plenty of people who, upon following a 1,500-calorie diet and engaging in a reasonable amount of physical activity, will not lose weight, or will not lose much. Not everybody's body snaps to. I had one 300-pound woman who was doing all the right things. She wasn't as active as she would have liked, and her diet could have been tweaked here and there, but she had no major dietary indications that the amount of food she ate was what was responsible for keeping her weight where it was.

With some people, once they have gained a lot of weight, there could be something in their physiology that vigorously defends that higher weight in the face of significant behavioral changes. This woman had to deal with her daughter's getting teased because she had a fat mother. She contended with people who didn't want to sit next to her on public transportation. She felt defeated and demoralized and she worked very hard to do everything "right," but healthy habits were simply not getting her thin, or even dramatically thinner.

Q: Does the medical community recognize that many people's bodies won't let them lose large amounts of weight? After all, a lot of patients are sent to dietitians such as yourself by their doctors, right?
HB: Some healthcare providers are happy to let weight move at whatever pace and to whatever degree it will. They are just focused on improving the clinical bottom line--labs, vitals, medication dosages, etc. And if those indices improve as a result of the patient seeing me, they are satisfied. Others, in the face of a patient's doing the best that they can, will say, 'I don't care. I want to see a 15-pound weight loss.'

I think it's hard for clinicians. They live in the wider culture, too. So an overweight patient may remind them of their own struggle with food and body image. We're told over and over, explicitly and implicitly, that obesity is a character flaw; it can be hard to shake, even if you know that a small weight loss can lead to a significant drop in blood cholesterol, blood pressure, and triglycerides--improve the overall clinical picture.

Q: What about the fact that small amounts of weight loss in a very overweight person, while they might lead to changes in blood cholesterol and other metabolic indices of health, often cannot address other aspects of excess weight--osteoarthritis of the knee or hip joint, for instance?
HB: It's true. Things like arthritis are structural rather than metabolic aspects of obesity. So some people who are not able to lose a lot of weight are not going to be able to resolve certain weight-related conditions by virtue of better eating habits or getting a little more exercise. And then it becomes a very individual decision as to what someone's going to do about his or her weight. Some people will make peace with their medical condition, and some may consider another avenue, such as gastric bypass surgery. Sometimes even then a problem may not be resolved. I had a client who underwent a gastric bypass and still has sleep apnea. Overweight isn't always an independent cause of a condition.

Q: In the face of the various limitations of a weight-loss plan--the fact that a lot of people are not going to be able to lose as much weight as they would like, the fact that very overweight people may still be left with conditions related to their weight no matter how hard they work to change their eating and exercise habits--how do you get people even to consider sticking to health-enhancing behaviors like eating better and incorporating more physical activity into their lives?

HB: I try to shift the focus a little bit. I try to broaden their perspective on what it is to see positive changes so that they can look forward to weight loss, but if the weight doesn't change as much as they hope, they have other ways of gauging success, and they have other ways of appreciating all the changes that they're making. If you point out to somebody what an accomplishment it is that they were able to lower the dose of, say, a blood pressure medication--or even go off a medication altogether--that can have a big impact.

Q: So you're not really helping them with a weight-loss diet? It's more like a health-improving diet?
HB: That's right. But it's not just about particular food choices. As a nutrition therapist, it's my role to understand, appreciate, and be able to work with people's thoughts and feelings as they relate to food and physical activity. It's very much about people's relationship with food.

There are a lot of people who, for a variety of reasons, cannot commit to behavioral changes that might result in weight loss or that would at least be healthy for them. There are tremendous stresses--domestic violence and Poverty and lack of resources and substance abuse. And then there are those who have a very emotional relationship with food and use it to take care of themselves, to cope, for gratification. As a result of that, there can be an awful lot going on that gets in the way of people making healthful choices.

They may also have lost touch with when they're truly hungry or sated, which can keep them from eating amounts appropriate to their bodily needs. They may be afraid of experiencing hunger because of past diets that were too strenuous and led to hunger that was so severe it caused extreme levels of discomfort. I try to get people comfortable with a level of hunger that allows them to have a healthy appetite for a meal they're heading into so that they can enjoy it and won't overeat as a result of having let themselves get too hungry.

Q: Do you find with those people that if they can develop a more constructive relationship with food, they actually drop significant amounts of weight?
HB: For some people, definitely. But not always. It depends on to what degree their lifestyle habits are defining their weight and to what degree their weight is being defined by their own particular physiology.

Q: To what extent do you discuss with your patients actual foods and dietary patterns to shoot for?
HB: You know, a lot of people come in already knowing the nutrition component. They know about five fruits and vegetables a day and more whole grains and low-fat dairy products. They're familiar with the lifestyle prescriptions. We certainly talk about those things to some degree, but much of what I do is help people decompress, get to their anxiety around food, and get a particular goal weight that they've set for themselves on the back burner. Once they manage that, it allows them to take advantage of the information they already have about how to eat a balanced diet. What I mean is, if I can get them to a position of what I call centeredness, they can make the healthful choices they're already aware of. And they can individuate them to their own preferences and proclivities rather than follow some cookie-cutter approach that's supposed to work for everyone but couldn't possibly.

Q: So is that what it comes down to--getting the person comfortable with the idea that eating right is about many things, not just about a certain number on the scale, and then letting the chips fall where they may?
HB: That's right. You know, if you do your job right, your client will be able to make choices that lead to better eating and perhaps some more physical activity no matter what the outcome in terms of weight. But if I can get a client to have a greater degree of comfort and confidence around those choices, then the two of us have really been successful.

Did you know...
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PHOTO (COLOR): Heather Bell, MPH, RD, nutrition therapist, Frances Stern Nutrition Center, Tufts-New England Medical Center

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