Why Imposed Extreme Rapid Weight Loss Always Fails
And What To Do About It
In the first week of May 2016 dozens of friends, family members and clients independently forwarded us a New York Times article about an extreme weight loss show winner who ended up subsequently regaining weight and how his was a typical outcome. For people outside the fitness industry this was news. For those of us inside, it's old hat; and there are genuine physical reasons why it's so common. There also happen to be ways to counter it.
One of my very first clients about 12 years ago was a young woman who had done gastric bypass the year before we met. She lost 80lbs within the first two to three months after the surgery. In the three months prior to meeting me she had gained back all 80lbs plus an additional 25lbs. I thought this was an anomaly, but over the course of time I discovered that 10+ year post-op fail rates on medically directed extreme weight loss are nearly 100% (if we define "fail" as significant weight regained and the patient still at an obese to super obese BMI).
There are statistics that sound better than a 100% fail rate, but scrutiny doesn't bear them out. The most promising rigorous long term study on extreme weight loss via bariatric surgery, conducted by doctors at McGill University Health Center, pegged long term fail rates as low as 20.4-34.9%. This seems a lot better than 100% until you read the article carefully. Only 83.8% of the proposed sample population was followed, over 3% of patients died before the study ended, not one patient reached a normal body mass even at the lowest post-op weight, and all participants ended up still obese. Pay close attention to what's happening here. This is an internal study. The McGill University Health Center is loathe to collect or showcase data in a way that reflects badly on its outcomes. These are essentially the most promisingly-interpreted statistics on weight loss surgery capping out at a 79% or 65% success rate, but only when the authors have included exclusively the survivors, the most successful participants, and defined "success" as a BMI anywhere lower than pre-op. That's abysmal. Imagine that a participant started at a body weight of 450lbs, lost 50lbs of muscle, tendon, ligament and bone and another 50lbs of fat, then subsequently gained 99lbs of fat (this is a typical body composition outcome for most extreme weight loss participants). According to these authors, as long as that person is still the same height or taller, he would be considered a "success" at 449lbs despite netting a 99lb fatter and less lean body composition simply because his BMI is less.
It's called padding the numbers. Caveat emptor. Health centers aren't the only ones who do it. Stock analysts, mutual and hedge fund managers craftily choose the lowest price in a quarter and the subsequent highest price to outline their "incredible performance." Certain Buddhist monasteries make would-be students suffer for days outside in order to ensure that only the most dedicated will enter. The most elite schools require only the most motivated kids, because they haven't the first clue how to help the unmotivated. There are surgeons who only take the most promising patients, because they want to tout good numbers. I know coaches who only take the most self-motivated clients to begin with. In fact, any time a program emphasizes "success stories" above brand and methodology, they forever have a sampling bias in future customers. They obtain customers who would've succeeded just as well or better without any of their guidance. It's a great racket for a business, but only if you want to develop zero troubleshooting skill and eternally be incapable of helping the Everyman. Sadly, the very people most capable of helping tough cases will, by definition, be the least well-known. Thus, the most popular "experts" are an easy target to dismantle. The real experts developing pertinent wisdom are doing so by suffering in the trenches. By virtue of being in the trenches, they are not filming infomercials, creating reality shows, writing best-selling fad fitness books and uploading a selfie every twenty minutes.
If you've ever been online or watched any television, you've seen countless 30, 60, 90 day transformations and testimonials. They're a dime a dozen. People get lucky. People get motivated for 4-12 weeks. There's absolutely nothing special or particularly enriching to be learned from these. Now think to the 5 year, 10 year, 15 year transformations. You probably can't name one. They do exist, but they seldom start out in an exciting manner.
The incorrect but typical explanation levied is that the person on the extreme weight loss program never built the mental, psychological and emotional apparatus to become a thin person; thus, they're destined to fail once the strictures of external imposition are loosened. Surgically altered stomachs eventually distend. Lap bands eventually yield. Sooner or later people have to live in the real world, and not on a retreat or television show with a questionably-experienced celebrity trainer and medical doctors looking for some sort of fortune or fame by virtue of ignoring the best parts of their training.
It's an incorrect explanation, or at least insufficient, as I'm sure there's something to it. We all know people who just haven't ever learned to manage themselves in any aspect of their lives, whether it's academic discipline, work ethic, eating, exercise, practice in their chosen art, sport or music, relationships, or just good 'ol follow through on what you say you're going to do. We're humans after all. So, yes, I agree: we have an epidemic of lack of internal integrity and self-discipline. However, that's such a weak offloading of responsibility to the very people who are busting their butts trying to lose weight and struggling. They're working hard; and we owe them a more satisfying explanation than "pick yourself up by your bootstraps," when they haven't boots, or straps or hands.
I'm never one to sweep aside the psychological component. Healthy behaviors are not as exciting or sexy as "extreme rapid weight loss." We give ourselves the errant expectation that who you will be is the product of a past action. It's foolhardy. Claiming today that you are doing cardio has no bearing on who you will be in five years. You are what you do, not what you did. You will be what you will do. Yes, a single decision can change trajectory. But the accumulated baggage on the current path determines the current status.
There is a more fulfilling explanation for the recidivism, because there are real physical and physiological reasons why most extreme rapid weight lost must be regained:
1.) Physics - Newton's Third Law
For every action, there is an equal and opposite reaction. Homeostasis, an equivalent idea, is this broad term. When applied in human biology it refers to our organism's internal checks and balances continually seeking to maintain roughly our exact tissue makeup. Simply put, our body works hard to be the same mass, the same composition, NO MATTER WHAT. Some in the fitness world have proffered the solution: "shock the body." Wrong. You absolutely never want to shock the body. Have you ever heard the saying, "you can sheer a sheep many times; but you can skin him only once"? If you sucker punch your body, you are going to get dragged into a street brawl that there's no surviving. You have to coax, cajole and embezzle your way to the top, just like the Rothschilds and Rockefellers. Take a penny a day. Don't get greedy and skin yourself. Empires aren't built on a lottery ticket. "Shock and awe" didn't work on Iraq. It's not going to work on human biochemistry.
2.) The Human Animal Is A Threat-Survival Machine
Every time you signal your body that it is under threat, keep in mind that it is the most resilient survival machine known to us. It is going to grow into a bigger animal so that it can better dominate the threatening environment. The deepest centers of our brain haven't the first clue whether we are losing weight rapidly because of war, famine, pestilence, some "well-intentioned professional" slicing up our innerds with cutting weapons... I mean surgical tools, or a "well-intentioned professional" enslaving us... I mean guiding our food choices on a reality show.
When we are under threat continuously and intensely we are either going to break while trying to become a bigger animal or we are going to actually become a bigger animal. Going back to Newton's Third Law, if the perception of threat is low, the survival desire to become a bigger animal will be equally low. If the perception is great, the survival desire will be great.
On the flip side, simply reducing your perception of stress reduces the survival need to become bigger. People with better management of stress tend to be leaner. There is data on this. Anecdotally, I can tell you that, from tens of thousands of clients and members, those who manage stress well have very little difficulty losing weight and maintaining. Clients who refuse to face the negativity and stress in their workplaces, relationships and personal habits fruitlessly adhere to one diet and exercise plan after another.
One of my case studies involved an older gentleman whose work and social responsibilities were taking an obvious toll on him. My first recommendation was to stop any overt exercise. Everything in his program for the first 12 weeks revolved around improving sleep, gaining a feeling of dominance in his mornings, streamlined simplicity during the workday and purposely eating white rice, sweet potatoes, ice cream, cereal, etc. before bed at night. I never allowed him to do a single workout until he effortlessly dropped 25lbs of body fat just by lowering his psychological burdens.
3.) Extreme Rapid Weight Loss Relies on Extreme Hormonal Imbalances
Optimal hormone balance will eventually result in optimal body composition. Besides being evident common sense, I've run the experiments. This approach requires more patience and a much greater understanding of why you're doing what you're doing; but then there is no maintenance transition. The client is already in maintenance mode before reaching her goal. It's so effective that a whole movement has cropped up in recent years among brilliant innovators and laypeople alike, known by or associated with a variety of monikers: quantified self; quantified medicine; citizen medicine; anti-aging and life extension science.
With extreme hormone imbalance, on the other hand, you enter a tailspin from which there may never be an exit. Thyroid will be suppressed. Stress hormones are ignited in order to break down fat, which reduces the amount of DHEA and total testosterone [T] that can be made AND weight loss commensurately increases sex hormone binding globulin [SHBG] which will bind to whatever little T is left and make the free T (the usuable testosterone) negligible. DHEA and T work on a tipping balance with cortisol, so without them, your stress hormones get little oversight. This itself is likely viewed by our bodies as an attack, the proper response to which is grow bigger and fatter.
Following the path of reductionism to understand why extreme weight loss is regained, we could go all the way down to cation exchanges, chemical affinities and alterations in the ability of receptor transposition across stressed cell membranes. Observing what's happening at the organ and hormone level and thereabouts, however, we have all the ammo we need for now. Marked suppression of testosterone plays a major role, as obese men and women already have supressed T prior to losing weight, thus having one less androgenic (e.g. - making one leaner) stimulus in the arsenal to start. The pituitary gets a good ribbing while you're at it; and I think we can fairly state that you will have shortened the life of your adrenals and kidneys with such intense demand, along with the liver attempting to keep up with the cholesterol, energy and steroidogenesis precursor demands. Insulin is controlled; so the pancreas possibly gets a break. Leptin and ghrelin are part of the short term explanation. But when looking for a cause of cumulative difficulty, most intriguing to me is LPL.
LPL, or lipoprotein lipase, is a marker for body fat regulation. As the name indicates, it's an enzyme involved in breaking down fat. When we break down a little fat, LPL is stable. When we drastically plummet our body fat, LPL skyrockets, as one would expect. The problem, however, is that LPL also signals its countermeasure: the restoration of fat. There's supposed to be a balance in the body. And when we take LPL off the charts, the signal for fat restoration is undeniably imbalanced. We don't know the exact mechanism yet. But the double whammy is that LPL stays elevated for many months after the lost weight and possibly several years. Hence, the signal to regain fat is equal or greater than the signal you sent to lose the weight in the first place.
Not enough is known about LPL-related receptors. However, it's a safe assumption that, like when any other compound gets introduced in massive quantities, the related receptors become desensitized. When the body receives caffeine all the time, caffeine doesn't work so well. When the body receives alcohol all the time, alcohol loses potency. When LPL is constantly elevated, fat loss doesn't happen. This in part explains why heavier individuals have higher LPL to begin with, despite not naturally losing weight more easily than thin individuals. The lipolytic (i.e. - breaking down fat) action of LPL is blunted. Simply put, with extreme elevation of LPL and other extreme changes during rapid weight loss, they become less effective. More simply, it becomes a lot harder to break down stored body fat. Though we'd hope the countermeasures' related receptors would also get burned out, that just doesn't seem to be the case when you follow individuals who've had extreme weight loss. Their systems become steadily and increasingly incapable of lipolysis while readily regaining fat with very little or no new stimulus.
What To Do
It is not super exciting to lose a half, one or even two pounds of fat every one to two weeks. It's also not exciting to practice scales in music. It's not exciting to practice conjugations in a foreign language. It's not exciting to make tiny contributions to your retirement fund. In general, worthwhile long-lasting accomplishments are the result of consistent and non-exciting work. We can't proxy the hare in place of the tortoise. Whatever excitement people have at the outset of their programs is perfectly fine, and, to a certain extent, ought to be encouraged. In order to help ourselves and our fellow man, however, we must reevaluate the weight loss journey. Rather than one of excitement, it has to be the natural outgrowth of optimal-health-engendering behaviors.
The most difficult part of the road will begin after the weight is lost. New "boring" behaviors must be implemented as an obligatory path to real maintenance. When people experience difficulty and relapse, it's not a character flaw. It's a natural response to hormone imbalance. At some point, when the excitement wanes, we must put the emphasis on optimal health and hormone balance. When we do, all of a sudden, "character flaws" magically disappear. I used to think that as people neared their goals, it was time for them to begin loosening the reigns. The fact is, instead, that's the very time people need to double down and commit to additional measures, whether it's increased guidance by trainers, nutritionists and coaches or supplemental hormone therapy and fitness community external accountability. In the end, people have to find a sustainable program that works.
If your weight loss relied on extreme hormone imbalance, the transition to maintenance should be two to four times the amount of time it took to lose the weight. If it takes three months to lose the weight, it's going to take six to twelve months to enter maintenance mode. The same could be said about the energy and financial resources committed.
Now, well into my second decade in the fitness industry, I've met with over 10,000 gym members, prospective members or coaching clients. All of them have experienced weight loss at some point for 4-12 weeks. Guess what: if you're an adult human in the Western world, you've experienced weight loss at some point for 4-12 weeks. That can't be the goal. It has zero staying power. The goal has got to be deep internal change, both physiologically and mentally. Monitor hormones. Do testing. Do a mental check as a way to get additional insight into hormone balance. If you consistently find yourself dwelling on disempowering thoughts, there's a good chance your T is across the board too low, your diurnal cortisol curve is suboptimal, and your physical capacity to be motivated is low. This isn't a character weakness. It's a neurological and endocrinological reality that won't be solved by increased threat and trauma. Address this. Return to realistic consistent fundamental healthy behaviors. Don't be a flash in the pan. Remember Newton's Third Law - you're only going to more strongly seek unhealthy rewards if you further traumatized yourself. Reach out to those who can help. Avoid those who judge and shame you out of their abject ignorance on the subject. Practice the skill of listening to yourself. Then, in 10+ years, be one of the real success stories.
Post script of hope:
For those of you who have incredibly suboptimal hormone balance, you can tip the scale in your favor. Even with the cards stacked against you, even with elevated LPL, even with zero thyroid function, even with immeasurably low T, DHEA, DHT, androstenedione, androstenediol, and whatever other challenge you face, you can do it. It can be done. Start with two things:
A.) Don't Guess. Test.
There are a lot of entry points here, but one of the weakest is the CBC/CMP. If you talk with your general health care provider about fatigue, inability to lose weight, lack of drive, and concerns about hormonal function, she will do nothing or pull a CBC/CMP. There has never been a more pointless set of labs for wellness than the CBC/CMP. This will tell you absolutely nothing useful unless you are in the throes of kidney failure or Dengue Fever. Don't be distracted by the 30 different values in the tests. They are telling you almost nothing about long term health. Just so you know, almost every time a doctor has said, "well, your labs look perfect," they are referring to this incredibly shortsighted set of tests which tell us little more than you are currently breathing and don't need IV fluids. It's a cheap set of tests for a reason. Perhaps it can be a starting point to determine that you aren't actually at critical impending risk of death. But it can only be a starting point.
If your health care provider is particularly motivated, she may run a thyroid screen. Again, unless you are way off the testing range, you're going to hear nothing more than, "you're in normal ranges." You could be at the dead bottom of normal T3, and, if they even bother to check TSH, you could be at the absolute top, and they are still going to tell you you're "normal." Even good endocrinologists won't usually add TPO into a thyroid screen. So, even if you do come up as hypothyroidic, or, if you're working with a fully evolved clinician who will use the term "borderline," we don't have an answer for one of the biggest culprits in causing suboptimal thyroid function without checking TPO.
That's to say nothing about the fact that your lab values change depending on time of day. Most health experts are oblivious to this. And steroidal hormones, though they can tell us a lot, are too complex for your general practitioner.
To get more than "good/bad," "normal/abnormal," look into wellnessfx, life extension lab testing, my former employer (Life Time Fitness) or go to an actual HRT specialist clinic. If that's too involved for you at this point, I'd encourage you to begin with testing your own blood sugar ( http://www.elev8wellness.com/wellblog/lose-15lbs-for-15-in-2015) and orthostatic blood pressure. From these, you can get a pretty good starting feel for what's going on. Until you regularly pull 85 or less on glucose, you aren't losing body fat even if you're losing weight. When you stand up and recheck blood pressure, if your systolic number doesn't go up 20 points, you are exhausted from the perspective of organ reserve, and a salivary diurnal cortisol test kit can confirm it.
Once you're ready to expand the testing roster, look into some fundamentals you can change right away, like B vitamins and vitamin D. The vast majority of non-Equatorial people are extremely deficient in vitamin D. The only way to get the dose right is check your levels at least quarterly. I have a colleague who is active and outdoorsy, spends a good part of the year in Central America, but discovered through testing that he had to supplement 15,000 ius per day year-round to be in optimal ranges. Generally, people take 500-2,000 ius per day and think they're changing the landscape. If you don't test, you don't know.
B.) Revise Your Idea of a Plan
When people say they want to lose 20lbs, for example, they create a "plan" to workout and diet a certain way. The reality, however, is that "plan" is actually a goal and you have no strategy on how to hit the goal. An actual plan includes how you will perform the behaviors. An actual plan is not a checklist of foreign behaviors that most likely you won't ever do.
One of my favorite questions to ask is, "on your worst week, when you're about to lose your job, your best friend dies, your health is compromised, you hurt your ankle, your car breaks down, you've been going to sleep too late, and there's a snowstorm outside, what is the greatest number of workouts you'll get in and the greatest nutritional compliance you will execute?" Whatever those numbers are, that is your realistic average execution going forward, because all that and then some is going to happen some day, possibly today. Make the plan based on that. Do not make a "plan" based on some Pollyanna week that's never even existed. The moment you face a non-Idyllic week, you will implode, unless you have worst case scenario plotting in place. Remember, we are looking for sustainable lifestyle, not imposed restriction.
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