The New York Times recently reported on a study following contestants from the NBC television show, The Biggest Loser. According to the small study as the body loses weight, even small amounts, it fights to get back to that weight by slowing the body’s metabolism and lowering leptin levels (the body’s satiety hormone). Dr. Janine Kyrillos, the Director of Jefferson’s Comprehensive Weight Management Program at Bala Cynwyd weighed in (pun intended) on the subject. Dr. Kyrillos is an internal medicine physician, board certified in obesity medicine.
What are your thoughts on this study?
Firstly, I am thrilled that this kind of research is making to the lay press. It’s so important that people finally realize (especially health care providers) that obesity is so much more complicated than just calories in-calories out.
There are a lot of studies that show people develop a set point: a certain weight at which their body wants to stay. If they forcefully lose, the body fights to get back to the original weight. Metabolism slows, and people become more tired and seemingly “lazy.” They get hungrier and crave higher calorie foods. Basically, our bodies still think we live in the stone-age where we had to hunt and gather our food. We are designed to eat food and store it so we are prepared for famine and starvation. Weight loss is perceived as starvation, and the body fights to rebuild its energy stores for the next time.
How would one find their metabolic rate?
The method used in the study was indirect calorimetry. The participant breathed through a machine that measured oxygen going in and carbon dioxide going out. This allowed the researchers to see how much oxygen was metabolized during a specific period of time. The machines to do this are very expensive and are not used routinely in the general public.
There are other ways to measure fat mass with DEXA scanners or biometric impedance (a scale with a tiny electric current). These assume the body burns a specific number of calories based on how much muscle, water, and fat a person has. We have one of these body composition scales in our Bala Cynwood location. Evaluating muscle mass and energy expenditure help guide our patients’ treatment and helps track progress.
Can any doctor test your Leptin levels?
Leptin levels are very tricky to interpret. Most people with obesity have leptin resistance, so they may have high levels of leptin, but their body doesn’t use it efficiently, so it doesn’t work as well. At this point, it’s not a useful measurement in general practice.
What does this mean for the average dieter? Can they expect to never stop dieting?
I cringe when I hear people say “going on a diet” or being called “a dieter.” We have to reframe how we think about maintaining weight. You can’t just restrict calories for a finite amount of time and expect the weight you lose to stay off. A restrictive diet is like holding your breath: you can only do it so long before your body takes over and forces a breath.
This is what happened with the Biggest Loser contestants. They took drastic measures to restrict their caloric intake and increase their energy expenditure. In response, their bodies took over by lowering their metabolism and making them more hungry.
The key is to make sustainable changes in lifestyle including more sleep, less stress, better quality food, and regular activity. It’s not about weight loss necessarily, but being healthier. There are many studies that show that losing 5-10 percent of your body weight has many positive effects on health (improved BP, blood sugar, sleep apnea, arthritis pain, and more).
Actually, the Biggest Losers did a great job. If you look at the data closely, on overage, they have maintained 12 percent weight loss, and 57 percent of them maintained at least a 10 percent weight loss which is more than twice the number of people we would have expected based on other studies.
Jefferson’s Comprehensive Weight Management Program is a medically supervised liquid diet. What does that entail?
The supervised meal replacement program is one of the more popular interventions we offer. Our patients usually stay on the meal replacements (shakes, soups, and bars) for 12 weeks. Some ask to continue, but we don’t recommend more than 16 weeks. Basically, they take a break from food – almost like “food rehab.” It temporarily narrows their options, allows them to break some ongoing habits, and helps them identify eating cues that may not be related to physical hunger. The key to the program is the weekly classes. There is so much for people to learn about behavior, physiology, and nutrition. They develop new habits and skills to use long term, and they get support from other people with similar struggles. At the end of the 12 weeks, the participants then go into a 12-week transition phase where they slowly reintroduce food in a way that builds healthier habits and new routines. After that, we encourage them to come to periodic maintenance classes on a long-term basis.
How important is the follow-up for patients who go through your program, or any weight loss program?
Follow up is everything. Obesity is a chronic disease. Treating it takes long term management and lifestyle changes. It’s not much different from many other diseases. Take asthma. Asthma is a combination of your genetic makeup interacting with the current environment (allergens, pollution, air quality, etc). You wouldn’t expect a person with asthma to use an inhaler for a few months and never come back. And you certainly wouldn’t tell them, “Well, maybe if you didn’t breathe so much you wouldn’t be wheezing.” And you wouldn’t call them weak if they used medical treatment to control it.
What kind of weight maintenance do you recommend for your patients?
If they can maintain a 5-10 percent weight loss…even three percent, that’s a big victory. Sometimes, just not gaining weight is a success.
My philosophy is to treat obesity as aggressively as possible using intensive lifestyle modification which includes improving sleep, managing stress, increasing activity, and improving the quality of food; medical evaluation to look for underlying factors contributing to their weight; medications and surgery when appropriate; but most of all, having realistic expectations and compassion!
How important is research like this for combating the stigma of obesity?
I wish more people would have the realizations that the contestants [in the story] verbalized. Most patients blame themselves and say they should be trying harder. Many are resistant to medical interventions like medications and surgery. And it’s a learned attitude. There is so much shame and blame toward people with obesity that is counterproductive and just plain mean-spirited. Additionally, it may take several generations to reverse the momentum obesity has gained over the past 50 years.