Table of Contents
At this point we’ve gone over the vast majority of the most important topics to eat healthily and work towards a healthy body composition. We’ve discussed metabolism, calories, a strategy for gaining or losing weight if desired and how to track progress when doing so, macronutrients, micronutrients, food groups, the timing of when we eat, various dieting schemes, and how to overcome barriers related to cost and time.
Yet, even knowing all of this there are still additional barriers to long-term success. Many people feel guilty and/or shamed about their perceived “weight problem”, and with a negative mindset it can be really difficult to begin any new journey and build sustainable, healthy habits. On the other end of the dieting journey, most people who are able to lose weight eventually gain it back. In this lesson we’ll discuss these issues in more detail.
Guilt, stigma, and stress associated with obesity
It’s very easy to simply say someone with obesity should eat less, exercise more, and then their obesity will disappear. Problem solved! However, if it was that simple then obesity wouldn’t be so incredibly difficult to treat on a population and individual level, there wouldn’t be so many fad and gimmicky diets, there wouldn’t be such a large supplement industry for weight loss, and there wouldn’t be so many books and literature written on this topic. So why is this something that so many people struggle with while others do not seem to have as much of an issue? This has been summarized well in the literature but I will highlight various points of interest here.(Busetto, 2021b; Grannell, 2021; Vallis, 2021)
Genetic and non-genetic influences
We actually already talked about this to some degree in Lesson 1 when discussing how resting metabolic rate & non-exercise activity thermogenesis can vary between individuals. The underlying mechanism triggering these and other differences discussed below are not clear. They are frequently attributed to genetics, epigenetics, and environmental exposures. Another possibility is underlying infection; for example, adenovirus 36 infection is associated with obesity.(da Silva Fernandes, 2021)
In addition to this, there seems to be significant appetite/taste differences between people with and without obesity, with differences seen in gene expression of taste buds(Archer, 2019), differences in taste sensation in response to high fat & sugary substances (even prior to the onset of obesity)(Yokum, 2019), differences in hunger & hunger hormone responses to the same meal(Goltz, 2019; Farhadipour, 2021), differences in appetite disinhibition that would lead one to give in to cravings(Brunner, 2021), and differences in brain reward region responses to palatable food as well as prefrontal region activation that may make overeating more likely.(Hall, 2014) As recently reviewed, it seems people with obesity have impaired taste, and one method of compensation is to overeat a given flavor to make up for the decreased taste sensation.(Harnischfeger, 2021)
While we know there are many differences between individuals with respect to hunger, appetite, and satiety, pinpointing the underlying physiologic mechanisms to explain these differences is difficult, largely due to the complexity of the regulation of our drive to eat.(Montégut, 2021) The image below gives an indication of this complexity from a nutrient signaling perspective.(Berthoud, 2021) There are additional factors not shown in this image (ie, leptin produced by adipose tissue), but the point is that there are many variables at play beyond our direct control.
Additionally, there seems to be a “food addiction” phenotype, potentially affecting 10-20% of the population.(Yekaninejad, 2021) It is debated whether this should be considered an addiction but can describe some individuals who have tremendous difficulty staying away from the temptations of processed foods that constantly surround us.(Gearhardt, 2021) This is likely in part due to the factors described in the prior paragraph as well as potential upregulation of neural pathways associated with addiction; this can particularly be seen with sugar.(DiNicolantonio, 2018) All of this can make people more prone towards eating tasty, calorie-filled foods.
There are other factors specific to obesity itself. In one review of appetite control it was noted that increased fat-free mass tends to drive increased energy intake (individuals with obesity will generally have more fat-free mass as this helps support the additional fat mass).(MacLean, 2017) The authors here also note that increased fat mass actually seems to inhibit energy intake in individuals with healthy weight, but in individuals with obesity the fat mass does not inhibit energy intake. They also note that decreased insulin sensitivity (commonly seen with obesity) decreases postprandial satiety. This will make people with obesity more prone to eating excess calories.
Additionally, there seems to be a very large genetic influence on obesity and related traits.(Qasim, 2018) One review discussing this noted heritability estimates of 32-49% for variance in energy intake, 20-78% for preference of different food groups, 63% for satiety responsiveness, 75% for food cue responsiveness, and 45-74% for rate of consumption.(Reddon, 2018) There also seems to be a very large interplay between genetic heritability and one’s local environment; one study of twins at age 4 found heritability of BMI was much higher in the higher obesity-risk homes (86%) compared to the lower obesity-risk homes (39%).(Schrempft, 2018) This can manifest if someone with a sweet tooth lives in a home with many sweets available; with sweets available they will be prone to overeating, but if they were to live in a home without sweets available they would not overeat.
I think this last point is key for explaining a large part of the reason why we have the obesity epidemic in the first place. Over the last several decades there has been an increase in readily available sources of calories(Vandevijvere, 2015), as seen with larger portions sizes, more fast food restaurants, and an ever-expanding array of food choice options. Thus, our entire society has become a higher risk “food environment” for people who are prone to obesity, and those with genetics inclined towards obesity will simply have a more difficult time as a result.
Note: “Heritability” can be a tricky term to understand. It describes how much of the variation in a given trait can be attributed to genetic variation. If curious, an overview of some of the misconceptions is presented here. As it relates to the above topics, a simple question some may ask is “If heritability for obesity and related traits is so high, why did the obesity epidemic only begin in the last several decades?” To understand this, consider the below BMI distribution curve, taken from here:
This is an updated distribution curve from 2020, and we know that the rates of overweight and obesity have increased over time. Thus, 60 years ago the mean value would have been considerably less than 27.5. Over time the curve has essentially shifted to the right. However, heritability refers to the variability of the trait, not the mean value. Thus, shifting the whole curve to the right will not influence the heritability directly. Heritability indicates the genetic influence of where along the curve someone may fall. Thus, even if the heritability of obesity was the same 60 years ago (it is not, see the next paragraph), the difference is that with all of the environmental changes that have taken place our population now consumes more calories than previously and on average gains more weight. So we can have the same heritability but much higher levels of overweight and obesity.
However, as described above, many individuals have trait thats lead to overeating in an obesogenic environment where lots of food is available. Thus, the heritability of obesity has likely increased over time as the changes in environment have allowed the genetic trait differences to manifest and lead to many people overconsuming calories.
This is an oversimplification, but a more detailed understanding is not important to understand the main concept. The key point is that the change in the environment over time (likely mediated primarily by the availability of highly palatable sources of calories), has led to most people gaining weight; heritability more so describes to what degree this varies between different individuals as opposed to the magnitude of weight gain of the population as a whole.
Tip: By getting all of the snack and junk food that you do not wish to eat out of the home it is much easier to avoid it. Many people will have a hard time resisting snacks that are present in the home 24/7. It is generally much less likely for people to develop cravings so strong that they feel the need to run out to a store to purchase snacks. Optimizing your food environment can make it much easier to stick to a healthy eating plan. If you do want to include treats occasionally that is fine to do, but if keeping them in the home is going to prove problematic then consider purchasing small quantities (ie, an individual piece of candy instead of a bag of candy) so you cannot binge on them regularly.
Stigma, guilt, and shame
In addition to the genetic influences, many people with obesity experience weight stigma, which generally makes adopting healthier habits and working on body weight management even more difficult.(Rubino, 2020; Lee, 2021)) This is true not only for adults but also for adolescents as well as children.(Schvey, 2019; Pont, 2017) Many of the negative psychological effects of obesity in youth are mediated by weight-based victimization, and several studies show bias begins as early as age 4 and an impact on children with obesity as early as the 1st grade.(Puhl, 2020a) Stigma even occurs readily in the medical profession.(Ananthakumar, 2020; Puhl, 2020b) Stigma seems to be prevalent in many different countries as well.(Puhl, 2021)
This is yet another source of stress, and stress itself has been found to worsen obesity and weight management through a variety of mechanisms.(Geiker, 2017) This includes worsening sleep, which generally decreases willpower to resist temptation and can lead to increased caloric consumption. Stress also makes it harder to start a diet or any lifestyle change successfully. Additionally, highly palatable foods can help relieve stress, which can then generate a feedback loop where the brain begins to desire these foods to a greater degree.(Tomiyama, 2019)
Thus, there are many contributing factors to obesity, some of which are outside of an individual’s control. By no means does this make it impossible to engage in healthier habits and lose weight, but it does seem like this will be harder for some individuals than others. For these reasons, blaming somebody for their own obesity seems short-sighted, and it may be more appropriate to actually blame the increased food availability in our society as well as the increased technology leading to less physical activity overall. As stigma has generally been shown to be harmful as opposed to helpful, and increasing stress makes any lifestyle change harder, I do not believe there is an evidence-based rationale to attempt to shame people with obesity into losing weight.
Tip: For any healthcare professionals reading this, there is a growing body of literature discussing different terminology to use when speaking with patients.(Puhl, 2020) In general neutral terms such as “weight” and “unhealthy weight” are preferred. There is contrasting data regarding preferences for the word “obese”. One recent study suggests we should use the terms “weight” and “unhealthy weight”; the term “BMI” was also acceptable (and was preferred by parents when discussing a child’s weight).(Brown 2021) Some adults actually preferred the term “overweight”. The use of exacerbating words (ie, “high BMI” vs “BMI” or “very overweight” vs “overweight”) was found to elicit further feelings of disgust.
Overall this is a sensitive topic with lots of variable preferences; I advise using the terms “weight”, “unhealthy weight”, and “BMI” initially and then you can actually ask the patient/family what their preferred terminology is when discussing these topics moving forward.
Note: I’m sure some people may have read the above and scoffed to some degree, thinking we should be shaming people into losing weight. To be clear, anecdotally there are some people who do not develop any motivation to lose weight until they undergo some sort of shaming experience. So for some people being shamed does seem to spur motivation and lead to positive changes. However, for many people this is not the case, and to my knowledge there is no evidence-based method to determine which subset of people may turn shaming into positive change.
Regardless, while shaming may provide motivation for some people, there are tons of people who do want to make changes and have been unsuccessful in doing so. For this group of people I cannot conceptualize any possible benefit of shaming; they already have the desire to make change but lack the knowledge or means to do so. Further shaming them will not fix those two issues, but it will likely increase stress levels and make things even harder.
Thus, in general, I am not a fan of fat-shaming.
So what should you do if you suffer from guilt, stigma, and stress associated with your weight status? Hopefully the above rationale of the underlying genetic and environmental influences beyond an individual’s control can help alleviate some of the guilt. Additionally, if you develop a plan of action, stick with it, and start seeing results, this should help increase motivation and positive feelings regarding the entire process. Some people will benefit from therapy regarding these topics; if you think this may apply to you consider discussing with your healthcare provider. If there are specific people in your life who are making things difficult attempt to engage them in an honest conversation about how they can be more supportive. Lastly, if you can find a peer or peer group to join you on a journey to a healthier lifestyle that can be very motivating and beneficial.
Habits to aid weight maintenance after weight loss
Many people diet and lose weight to some degree but then ultimately gain it back, with several different factors contributing to variable weight regain between different individuals.(Aronne, 2021) This is still a very active area of research, with various mechanisms of weight regain being proposed(Busetto, 2021a) though counterpoints to many of these proposed mechanisms exist as well.(Martins, 2021) Regardless of the underlying mechanisms, in one systematic review (SR) of studies in adults with at least 3 years follow-up after an obesity intervention, all eight of the studies showed significant weight regain with seven showing continually increasing weight at every follow-up time point.(Nordimo, 2020) This is undesirable for several reasons. The obvious ones are that one’s self-esteem may take a hit when progress is lost and any health benefits of getting the extra body fat (“BF”) off may reverse to a degree when weight is regained.
However, there are additional reasons as well. If people diet successfully and become relatively lean prior to gaining the weight back it can lead to fat overshoot where the resultant BF percentage becomes higher than it was prior to dieting in the first place.(Jacquet, 2020) Repetitive weight cycling has also been associated with decreased muscle mass and a higher risk of developing sarcopenia.(Rossi, 2019)
Note: The underlying mechanism for fat overshoot seems to come from the concept of “partitioning”, where as weight is lost a certain percentage will be lean body mass (“LBM”) and a certain percentage will be BF. The leaner one becomes the greater the percentage is LBM. When weight is regained, BF increases more quickly than LBM, and thus for the body to reach the prior levels of LBM there can be “fat overshoot” where the amount of BF regained actually surpasses the amount of BF there was initially. This is one of the reasons I’ve emphasized the importance of resistance training, eating sufficient protein, and losing weight at a reasonable pace, as all of this will help you maintain your LBM while losing fat and thus fat overshooting should be much less likely to occur.
While studies do show that most people gain weight back, there are obviously some people who successfully keep the extra weight off. What separates these individuals from everyone else? There have been many studies evaluating this, some recent ones include a SR & meta-analysis of randomized controlled trials implementing behavior change techniques(Ashton, 2020), a study evaluating people who were able to successfully maintain weight loss for five years(Lawlor, 2020), a SR of studies of successful weight loss maintainers in weight control registries(Paixão, 2020), a SR of qualitative studies demonstrating perspectives of successful weight loss maintainers(Spreckley, 2021), as well as analyses in children(van der Heijden, 2018; Jones, 2019).
When reading through this literature a few themes & habits emerge that many successful individuals implement. These include:
- Self-monitoring. This can be done with regular self-weighing, tracking food intake to some degree, paying attention to the way clothes fit, keeping a step counter, developing “relapse” protocols if needed, pre-planning for events, or a variety of other methods. Self-monitoring has been found to be very helpful for active weight loss(Harvey, 2019) and avoiding weight gain over the holidays(Kaviani, 2019) in addition to long term weight maintenance after weight loss.
- Goal setting. Setting small, specific, realistic goals and then achieving them can be very motivating and provide evidence that what you are doing is actually working. These goals can work towards larger, long-term goals. Consider setting both “process” goals and “outcome” goals. The former regards building habits (ie, “I will start at least 5 minutes of exercise daily” or “I will not buy any junk food the next time I go to the store”). The latter regards outcomes (ie, “I will lose 2 pounds in the next month” or “the next time my doctor checks my cholesterol levels they will be improved”). For weight maintenance, goals can still be set to maintain your weight, improve your exercise performance, continue your healthy habits, etc.
- Social support. This is very important both in the home and in the social setting. In the home it is difficult to make significant healthy changes (ie, cut out cookies) if everyone else is eating cookies in front of you. If you can get everyone in the home to be on the same page and buy in to starting healthier habits together, and thus support each other, it can be much easier to be successful. Regarding social settings, when out with people who are understanding and not trying to push unhealthy foods onto you it is much easier than if you are with people who are going to try to throw you off of your healthier habits. There is no need to avoid going out with others but try to ensure the people you are with will be supportive.
- Meal preparation. This was discussed in Lesson 14, but preparing meals in advance and having healthier options that you can quickly pack and take with you if you need to eat out will make it much easier to stick with your nutrition goals.
- Distraction strategies. If you are hungry you can consider if you really need to eat now or if there are other things you can do to take your mind off of hunger, such as drinking fluids (as sometimes thirst presents as hunger), walking, reading, etc. Many people find they get hungrier when they are bored; using various distraction strategies will help prevent this from leading you to eating more than you wish. This can also help deal with cravings.
Tip: While distraction strategies are great when they work, at times you may simply be hungry and nothing will work other than eating. In this situation you can consider eating a meal early, but if you really need a snack consider choosing a more filling option. One study developed a “satiety index” for common foods, where foods were ranked by how satiating they were.(Holt, 1995) They tested 38 foods and assigned them a score in reference to white bread (assigned a default score of 100). The 5 most satiating foods were:
- potatoes at 323 (they tested Russet potatoes that were peeled, boiled for 20 minutes, and stored in a refrigerator overnight prior to reheating in a microwave)
- ling fish at 225 (stored frozen, then steamed, stored in a refrigerator overnight, and reheated in a microwave)
- porridge at 209 (made from raw rolled oats cooked in a microwave with reduced fat milk)
- oranges at 202 (fresh, peeled)
- apples at 197 (fresh, skin was included)
While most people are not going to have ling fish laying around their home, the other foods are all reasonable options to prepare in snack-sized quantities and can be good options if hungry. There is likely some individual variability regarding satiety of different foods so consider trying different options and see what works best for you. You can also consider manipulating the texture or consistency of foods you consume; studies on average indicate this makes a small impact on food intake but in individual cases this may prove quite helpful.(Appleton, 2021) For example, you can consider making potato soup rather than simply eating a potato and see if this is beneficial for your hunger levels.
Additionally, a recent study suggested that adopting a healthy mindset regarding food options can lead to one naturally selecting smaller portions.(Veit, 2020) While more research needs to be done regarding this, when really hungry consider viewing snack intake as “a way of giving your body what it needs” as opposed to “failing with your dietary goals”; this may help you not “fall off the wagon” and start binging or engaging in other undesirable behaviors.
- Continued motivation. This is really important after losing weight. When actively losing weight and seeing the results on the scale or in the mirror it can be very motivating to continue pushing forward. After weight loss is complete that initial source of motivation can vanish. Finding some way to continue to stay motivated is critical; utilizing support from peers and healthcare providers can be helpful. This is one of the reasons it is very helpful to adopt healthy lifestyle changes as opposed to following any sort of a crash diet; if you make an actual lifestyle change and it becomes ingrained in your habits then continued motivation is not as necessary if you can continue your new lifestyle indefinitely.
- Physical activity. While not the topic of this course, continued physical activity & exercise is likely helpful for maintaining weight loss and further improving health.(Melby, 2019; Bosy-Westphal, 2021)
Thus, there are several strategies that will help aid weight maintenance after weight loss. Most of these strategies are also beneficial for initial weight loss. Building all of this into a healthy lifestyle with support from family and peers that can be carried forward indefinitely is ideal for sustained success.
There are many contributing factors to obesity, several of which are outside of one’s individual control, and thus some people will have a much more difficult time dealing with this than others. The negative stigma regarding obesity in our society and the associated stress make dealing with obesity even more difficult. Nonetheless, adopting a healthier lifestyle and losing weight is not an impossible task, and many people are able to do this successfully. By planning things out and adopting beneficial habits there is usually a path forward towards accomplishing one’s goals. Finding the right individual path is imperative; no two people have the same shared set of experiences and thus helpful tricks, triggering situations, and definitions of success will differ between everybody.
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