Certainly not! But unfortunately we need to look a little more closely.
It's been a while since I've posted on hard-core woo, and I miss it, so here's a little tip for you: if a diet sounds too good to be true, then it is. Weight loss is very hard, unless you are very sick. In fact, a colleague of mine ran into a friend who had lost a lot of weight and said, "You're OK, aren't you?" As an internist, when I see dramatic weight loss, my first thought is cancer, not a wildly successful new diet. But all of us overweight types wish there were an easy way.
There isn't. A friend of mine heard about a diet that involves extreme calorie restriction along with injections of human chorionic gonadotrophic hormone (hCG). My first thought was if you restrict yourself to 500-800 calories per day, it doesn't matter what you inject---you're going to lose weight. But as is the usual pattern with woo, each time you try to rebut it, there is a new claim. For example, when you point out that starvation diets will always make you lose weight, they say that this one makes you not hungry. When you say that it sounds dubious, they say that it not only makes you not hungry, it causes you to somehow lose weight where you want it, and keep it where you like it.
So what experts are behind this revolutionary diet? Well, the biggest proponent appears to be Kevin Trudeau, the infomercial guy who keeps going to jail for fraud. What kind of claims is he making?
Now, for the first time in fifty years, this revolutionary breakthrough discovery, which permanently cures the condition of obesity, is being released to the public.
Richard Dawkins has a great statement about claims like this one:
If you are in possession of this revolutionary secret of science, why not prove it and be hailed as the new Newton? Of course, we know the answer. You can't do it. You are a fake.
Strangely enough, scientists have actually investigated this "miracle cure for obesity".
Not only is the diet no more effective than calorie restriction alone, the hCG also doesn't affect hunger or other more subjective factors of dieting.
Look, no one likes being obese, and despite what fake experts like Sandy Szwarc say, it's bad for you. But there is no magic. To lose weight, energy in has to be less than energy out, and when you do that, you will feel hungry. It sucks, it's hard, but at this point, it's all we've got.
(Please excuse the unconventional citation format---I'm playing with some new software)
"A clinical study of the use of human chorionic gon...[J Fam Pract. 1977] - PubMed Result," http://www.ncbi.nlm.nih.gov/pubmed/321723?ordinalpos=1&itool=EntrezSyst….
"Chorionic gonadotropin in weight control. A double...[JAMA. 1976] - PubMed Result," http://www.ncbi.nlm.nih.gov/pubmed/792477?ordinalpos=1&itool=EntrezSyst….
"Human chorionic gonadotrophin and weight loss. A d...[S Afr Med J. 1990] - PubMed Result," http://www.ncbi.nlm.nih.gov/pubmed/2405506?ordinalpos=40&itool=EntrezSy….
"Ineffectiveness of human chorionic gonadotropin in...[Am J Clin Nutr. 1976] - PubMed Result," http://www.ncbi.nlm.nih.gov/pubmed/786001?ordinalpos=1&itool=EntrezSyst….
"[Risk-benefit analysis of a hCG-500 kcal reducing ...[Geburtshilfe Frauenheilkd. 1987] - PubMed Result," http://www.ncbi.nlm.nih.gov/pubmed/3609673?ordinalpos=1&itool=EntrezSys….
So is the idea to try to induce an artificial morning sickness so that you won't eat so much? It sounds like it might work in theory--many women lose weight during the first few months of pregnancy--but even disregarding the fact that it doesn't work in practice, is intentionally making oneself nauseous a good idea? And if so, wouldn't just adding Ipecac to the diet regimen be simpler?
As an internist, when I see dramatic weight loss, my first thought is cancer, not a wildly successful new diet.
The problem is that diets are practically useless for long-term weight loss. Almost everyone who loses weight on a diet gains it back within a few years. Surgery seems to help somewhat, but it is pretty risky and thus not suitable for any situation less extreme than morbid obesity. Anecdotally, the few people I've seen who have lost weight and kept it off for long periods of time (>5-10 years) have done so by making permanent lifestyle changes. Not an 800 Calorie diet for a month, but a 1800 Calorie diet for life. And increased exercise, also for life. Has anyone studied whether this works on the population level?
"Almost everyone who loses weight on a diet gains it back within a few years."
That's because the term diet implies a beginning and end. As in "I'm going on a diet to lose 20 pounds, after which everything will be better and I'll go back to the eating habits that got me 20 pounds overweight in the first place." And we're suprised diets don't work?
"Surgery seems to help somewhat, but it is pretty risky and thus not suitable for any situation less extreme than morbid obesity."
Surgery is actually quite effective. Following Roux-en-Y gastric bypass, patients will generally lose 50% of excess body weight in 1 year, and will dramatically reduce (if not eliminate) their need for diabetic medications and antihypertensives. For gastric banding, the results are not quite as dramatic (40-45% of excess body weight at 1-2 years) but are still significant. When you say that surgery is "pretty risky", just what do you mean? Risk of perioperative mortality? Major complication (anastamotic leak, sepsis, prolonged hospitalization)? What are risk statistics? Or are you just throwing out a generic "pretty risky" and applying it to both of the currently predominant weight-loss procedures?
"Not an 800 Calorie diet for a month, but a 1800 Calorie diet for life. And increased exercise, also for life. Has anyone studied whether this works on the population level?"
I'd argue that, given increasing rates of obesity, it has been shown not to work in this country. Yes, that's due to dropout rate (failure to maintain an 1800 Cal diet in the long-term), but that's the crux of the issue. As PalMD pointed out, it's calorie balance: calories in minus calories out.
Yes, that's due to dropout rate (failure to maintain an 1800 Cal diet in the long-term), but that's the crux of the issue.
Exactly. If a few people fail to maintain a diet that will keep them in the "normal" (can you call it normal when it is below average?) weight range then the problem is probably with them. If virtually no one can maintain it then there is a problem with the recommendation. Why can't most people maintain a diet that will keep them in the healthy weight range? What, if anything, can we do to shift that curve? Simply lecturing people isn't enough.
I don't know how common this is, but semi-anecdotally, when I've spoken with obese patients who desire help in losing weight, one very common theme is overwork. Almost all of them work 2 or 3 jobs, don't sleep enough, and don't get enough exercise or recreation. I couldn't prove that an increase in the minimum wage would decrease the obesity rate, but I have a certain suspicion that it might.
When you say that surgery is "pretty risky", just what do you mean?
I blush to admit that it was a strictly anecdote based statement. I'm an internist. When I see a post-surgical patient it is because something has gone wrong. Usually terribly, hideously, disgustingly wrong. Bad outcomes of roux-en-Y or banding procedures are some of the worst. Non-healing wounds in the abdomen are something that I could happily go my entire life without ever seeing again. However, I don't remember how common this sort of problem is. My impression from what I remember from reading on these procedures years ago was that in general, the risk/benefit ratio was pretty decent for patients with severe or morbid obesity.
However, I would be much less confident that the numbers would come out well for an overweight patient, particularly one without other risk factors (i.e. normotensive, no diabetes, normal cholesterol.) Particularly given the risk that they might end up with malabsorption sydromes from the surgery. And while obesity is--pardon the pun--a huge problem in the US, there are far more people who are overweight than obese and I don't think that surgery is a good way to address their weight problem. At least not at this time.
"If a few people fail to maintain a diet that will keep them in the "normal" (can you call it normal when it is below average?) weight range then the problem is probably with them. If virtually no one can maintain it then there is a problem with the recommendation."
I don't call it normal (because it's no longer the statistical norm); I call it healthy. I don't think we can throw out the recommendation because so many fail to meet it; (do we stop counselling smoking cessation, even though only 1 in 4 succeeds?) BMI recommendations are made because evidence shows increased risk of disease and decreased life expectany associated with being overweight/obsese. I haven't seen any data regarding obesity rates and socioeconomic strata (Admittedly haven't looked either), but the term "Fatcat" came from somewhere, so I don't think it's strictly a lower-class problem. I did recently run across an interesting study showing an inverse relationship between hours-slept per night and BMI. Certainly our society is trending toward increased workweeks, energy-saving conveniences (ever circle the parking lot looking for a space closer to the store?) decreased time for recreation, decreased manual labor, all of which contributes to the epidemic, but that doesn't change the fact that as BMI rises above 25, health risks increase. To tell our patients anything different is a disservice to them.
"Bad outcomes of roux-en-Y or banding procedures are some of the worst."
Umm, no. But that's a whole other topic.
"My impression from what I remember from reading on these procedures years ago was that in general, the risk/benefit ratio was pretty decent for patients with severe or morbid obesity. However, I would be much less confident that the numbers would come out well for an overweight patient, particularly one without other risk factors (i.e. normotensive, no diabetes, normal cholesterol.) Particularly given the risk that they might end up with malabsorption sydromes from the surgery."
Well, we don't perform weight-loss surgery on people who are overweight (BMI 25-29), with or without comorbidity. With regard to risk-benefit ratio (at least the risk side of things) 30-day mortality for roux-en-y is 0.5%, much less for gastric banding.
Specific complications for banding: erosion into the stomach = 0-3%, slippage = 2-14%, esophageal dilatation < 10% (resolves with deflation of balloon.
For r-n-y: DVT/PE = 0-3.3%, anastamotic leak = 2-3%, bleeding (Rarely requires reoperation) = 0-4%, wound infection = 10-15% (open) or 3-4% (laparoscopic), marginal ulcer = 0.6-13%. Incisional hernia = 24% (open) or <2% (laparoscopic).
"Particularly given the risk that they might end up with malabsorption sydromes from the surgery."
This is pretty much a non-issue for gastric banding. For r-n-y, it is a malabsorptive procedure, which accounts (in addition to the restriction of gastric pouch size) for its effect on weight. I'm not sure what "syndromes" you refer to. Iron and B12 deficiency are common, so patients (ours at least) are informed of the need for life-long iron, B12 and MVI supplements. I've had far worse malabsorption syndromes in crohns or mesenteric ischemia patients with SB resections than with bariatric patients.
* All specific stats obtained from up-to-date online.
Well, we don't perform weight-loss surgery on people who are overweight (BMI 25-29), with or without comorbidity.
This is the critical point as far as the average American, who is probably overweight but not obese, is concerned. A surgical procedure with a 0.5% 30 day mortality is ridiculously dangerous for a condition that has an essentially nil 30 day mortality. Less radical surgeries, such as liposuction, have not been demonstrated to have any effect on mortality or long term weight loss. So surgical interventions are not an option for the typical overweight patient.
Which means that they're stuck with the diet option, which doesn't really work. You mentioned smoking cessation and its poor outcomes. But the percentage of patients who stop smoking has increased over the years because of improved interventions (wellbutrin, nicotine patches, behavioral therapy) and social changes (banning smoking in bars, higher taxes on tobacco). I haven't seen similar efforts going forward in the area of weight loss. At least not successfully. This is a failure of the medical profession, not a failure of the patients.
Certainly our society is trending toward increased workweeks, energy-saving conveniences (ever circle the parking lot looking for a space closer to the store?) decreased time for recreation, decreased manual labor, all of which contributes to the epidemic, but that doesn't change the fact that as BMI rises above 25, health risks increase. To tell our patients anything different is a disservice to them.
Pardon the double post. The other was getting long and link heavy.
Certainly most health risks increase with BMI (there are a few exceptions, but that's a different post.) Health risks increase with smoking as well. But we would do our patients a disservice if all we told them about smoking was, "so stop already". Because they won't in the absence of other interventions. Multiple interventions and social changes have helped reduce the number of people who smoke and so, if the lung cancer rates are anything to go by, have reduced the number of people dying due to smoking related illnesses. I suggest that we need to do something similar with obesity, that is, that "how do we undo the social changes that have led to increased obesity" is an important public health question. One example might be to improve public transportation. Public transportation is associated with a small but measurable increase in daily caloric usage as well as a decrease in greenhouse gases. Simply telling individual patients that they need to lose weight, while necessary, is not sufficient.
The term "fatcat" is historical. Currently, low socioeconomic status is a risk factor for obesity at least in developed countries.
From a sociological perspective, this is an important consideration. Just a few generations ago it was considered a sign of wealth and status to have a deep suntan and carry a few extra pounds because this was an indicator of the ability to afford good food and vacations in warm places. In time we learned of things like skin cancer and heart disease, and the social seesaw tilted in favor of floppy hats and aerobics. It's never enough to attack an issue like this purely from a medical standpoint - science begets denialism in a way that social factors don't, so clearly the solution lies in a marriage of the two.
a deep suntan is a fairly new popularisation, go back a hundred years or so and it was considered a bad thing (meant you had to work in the fields for a living).
"A surgical procedure with a 0.5% 30 day mortality is ridiculously dangerous for a condition that has an essentially nil 30 day mortality."
Please keep that in mind the next time you refer someone wiht DJD for a knee replacement (0.6% 30-day mortality) or hip replacement (0.7%)
"chorionic gonadotrophic hormone"
Anyone who injects this stuff hasn't thought about what 'gonadotrophic' might mean.
Thanks SurgPA and Dianne for your ongoing discussion.
As someone who has managed to go right past overweight in the wrong direction, I have to say that my weight change is strongly correlated with the amount of routine exercise I fit into my life. Going to the club or going for walks helps, but commuting on bicycle is a more consistent method of getting the pounds to shed. Diet? Sorry, I quit smoking, and, yes, that is when my weight began to increase, but so did my sedentary living.
I know many people who are slightly to moderately overweight who get a lot of exercise and appear to be in good shape. I also know a few people who are slender, but look ill, because their weight control is completely related to limiting calories and completely unrelated to exercise. At what point does being in shape get overwhelmed by excess weight?
Sorry, my last post sounds snarkier on re-read than I intended it to be. My point is that bariatric surgery is not the high-risk, low-impact gamble it has been perceived by many to be. It carries a perioperative risk comparable to other abdominal surgeries. However, I don't think we can minimize the long-term health risks of obesity (diabetes, vascular disease, djd, depression, sleep apnea, GERD) which must be weighed in the balance. With currently 1/3 of US adults qualifying as obese, that is a sizable population.
"I suggest that we need to do something similar [to smoking cessation] with obesity, that is, that "how do we undo the social changes that have led to increased obesity" is an important public health question."
Now here we probably have some common ground. Absolutely, we need to reverse the collective belief that exercise is a penance to be suffered for some vague future benefit, rather than a joy to be savored now, that any convenience to reduce manual labor is a good thing, that bigger is better (restaurant portions, car size, home size, bank account), that we must earn more money (and thus work harder,longer) to buy the bigger house with more unused rooms, a fancier car/tv/clothing like the one the Jones family has, and that paying 20% credit-card interest so that we can have that widget now is a HELL of a lot more expensive than saving money (and earning a couple percent) until you can pay cash (or do without the widget). All we have to do is convince people of that, so they can work a little less, get a full night's sleep, eat quality food because they're hungry (not because they're stressed/depressed/bored/in-a-hurry), go for a walk/bike-ride/hike or just go dancing with a loved one. While we're at it I guess we'll have to redesign our communities (that's ok, they're falling apart anyway) so that the daily commute isn't 30-60 minutes (each way), the grocery store isn't 10-20 minutes (by car), and our kids can walk/bike to school (rather than spend an hour on the bus every day.) It's really quite simple, see? If we can just do that, the rest will fall into place. (Sorry, I'm kind of a pessimist on the whole societal change thing.)
"But the percentage of patients who stop smoking has increased over the years because of improved interventions ... and social changes (banning smoking in bars, higher taxes on tobacco). I haven't seen similar efforts going forward in the area of weight loss. At least not successfully.
Australia is currently considering a junk-food tax. As for banning fat people from bars and restaurants, well...
My inner frat boy is all for it, but my sense of fairness demurs.
While we're at it I guess we'll have to redesign our communities (that's ok, they're falling apart anyway) so that the daily commute isn't 30-60 minutes (each way), the grocery store isn't 10-20 minutes (by car), and our kids can walk/bike to school (rather than spend an hour on the bus every day.) It's really quite simple, see? If we can just do that, the rest will fall into place.
Actually, a lot of people are moving into areas where they're rediscovering walkable urban design and human-scale (as opposed to "car scale") neighbourhoods. Check out some online information about transit villages sometime. Of course, you're probably always going to have some people who prefer the McMansion in the middle of Sprawl Acres Gated Community, but there's really no accounting for taste. (You can blame Robert Moses and William J. Levitt for that, and the auto industry for the rest.)
Getting urban design that works for people instead of cars is, actually, simple. People did it (using 19th Century technology, even) for the better part of a century and had it pretty much down by the time it was supplanted. It's simple. It's just not easy.
Speaking as a member of the carless cohort (I live in a city centre and can walk to work when there isn't a -30C wind chill and ice all over the place), I'm pleased to see that being so gives me a slight exercise advantage over the great wheeled masses.
My point is that bariatric surgery is not the high-risk, low-impact gamble it has been perceived by many to be. It carries a perioperative risk comparable to other abdominal surgeries. However, I don't think we can minimize the long-term health risks of obesity (diabetes, vascular disease, djd, depression, sleep apnea, GERD) which must be weighed in the balance. With currently 1/3 of US adults qualifying as obese, that is a sizable population.
Not sure anyone's still reading this thread, but just in case...
I think I may have expressed myself badly in prior posts. I agree with the quoted statement entirely--for people with moderate to morbid obesity. Surgical interventions have been clearly demonstrated to be effective in aiding weight loss and improving health in obese patients. And yes there are a lot of obese people in the US who could benefit from bariatric surgery. In general, I'd probably recommend a trial of weight loss through behavioral interventions first, unless there were clear reasons not to (obesity so severe that it is endangering the person in the short term, inability to exercise for reasons other than weight, etc). However, in the majority of cases, that isn't going to work and the next step is to talk to the surgeons. Bariatic surgery can work very well and most patients are happy to put up with weekly B12 injections (do you even need weekly for bariatric surgery induced B12 deficiency or is monthly enough?) if it means being able to dump their daily insulin and CPAP.
However, I have serious doubts about whether bariatric surgery is an option for people who are overweight or even borderline or mild obesity. At some point, the risks of surgery, plus the risks of having to take iron and B12 forever, are going to start outweighing the benefits of weight loss and I'm not sure where that line is--a BMI of 35? 30? 25? On the other hand, the surgery is likely to be less risky in overweight patients compared to obese patients (fewer overweight people will be diabetic or have cardiac disease, less risk of poor wound healing and pressure sores, probably better mobility sooner after surgery), so it isn't clear that the 0.6% 30 day morality would hold for overweight patients.
Obviously, you don't do bariatric surgery on a patient with a BMI of 27. it's not standard of care. A trial of bariatric surgery in overweight patients might be an interesting study, if the IRB would approve, but I would expect that you'd need a huge number of patients to show any significant benefit in terms of lower long term mortality.
Be that all as it may, a person who is overweight at 20 or 30 is at risk of becoming obese at 50 or 60. So interventions, whether public health or individual, to aid in weight loss or even just weight maintanence are needed for overweight and even healthy weight patients. I understand your pessimism about the possibility/effectiveness of social change, but I don't think that it is entirely justified. Change doesn't happen overnight, but it can happen. Thirty years ago would you have expected bars to ever ban smoking?
Actually, a lot of people are moving into areas where they're rediscovering walkable urban design and human-scale (as opposed to "car scale") neighbourhoods.
I grew up in suburban Dallas. I now live in Manhattan. I miss my car not at all.
In general, many of the cities considered most livable are "human scale" rather than "car scale". A car is not needed in Zurich, even suburban Zurich and it is consistenly rated one of the best cities to live in. Amsterdam, another high ranking city, is also very easy to navigate without a car. (In fact, it is entirely possible, even easy, to live in rural Holland without a car...the key is bikepaths).
My husband and I are currently on this diet. Before starting it, we were encouraged by our physician to do as much research about it as we could, which we did. So I can give you the facts as they relate to us.
Yes, you do feel hunger, but it comes and goes and is regulated by the approximate 1 gallon of liquids (coffee, tea, or water) per day that you drink plus the appetite suppresents you take if you do this diet under medical supervision, which I recommend. Many days you feel no hunger, particularly if you stick to eating the 10AM, Noon, 3PM, and 6PM division of the foods. Even if you do feel some hunger, it's only a couple of hours until you can eat.
True, nearly anyone can lose weight on 500 calories per day, but you aren't living on 500 calories per day; you are taking in only 500 calories through your mouth, but the rest is coming from your body's fat. A pound of fat weighs 3500 calories. (Think of a pound of butter and you have an idea of what that looks like inside your body, crammed into your thighs, belly, etc.)
And yes, you will lose weight. The minimum average weight loss I've heard about is 1/2 pound per day. I have been losing closer to 3/4 of a pound per day, and my spouse has been losing double that. That is weight loss success that keeps you going when on any other diet by now, I'd become discouraged and given up.
While most other diets seem to claim their success at least in part by having you do heavy exercise, this diet tells you to only do light exercise if you do any at all. Heavy exercise tends to damage muscle (that's how it then builds it up), which causes your body to want to store anything extra in the way of calories that it might have, and to be stingy about giving up what it has stored. Thus even moderate to heavy exercise works against the program instead of with it. (Should you exercise? Of course. But don't go for heavy cardiac or muscle building exercise until you stop the diet.)
You only do the diet for 3 or 6 weeks at a time, and then have to be off it for the same length of time before you can do it again if you need to.
There is a lot of untrue information out there. And yes, this isn't an FDA approved use of the hormone. But it works for many, many people. I've been unsuccessful at losing any permanent amount of weight, and have continued to add to my weight gain over the years until I'm now at an unhealthy weight and at risk for all kinds of diseases. Not to mention that I don't feel well. But this diet is working for me, and it is resetting my eating habits to a much healthier program and level.
For those who have a lot of negative things to say about this program, please consider that pharmaceutical companies spend millions of dollars and use thousands of people every year as test subjects for new drugs that most often have unpleasant to deadly side effects. And those drugs are approved for testing by the FDA, and later scripted to patients by thousands of medical professionals.
Stop being in denial and open your eyes! I hate to be the one to break it to you haters out there, but you are all full of shit! This product works. I lost 120 lbs of FAT using this diet and the HCG drops and I was not hungry, had no cravings and felt just fine without having to do any exhausting excersizes. I am now 1/2 of the body weight I originally was before I used this diet and am no longer worrying about having a heart attack because I am no longer FAT and my eating habits have been reestablished with good eating habits that were attributed to the hcg diet. If you look at the ingredients on the label on the bottle of hcg drops, you will see that there are more ingredients than just the HCG hormone. That is the last one listed on the label.
Millions of people who have used this product and lost weight cannot ALL be wrong, be paid actors/actresses, be lying, be employees working for the companies or have cancer! Geez... What a bunch of jackasses!
A fatal flaw was that they failed to have any representative posts ready to go up when the blog went live.
Had they done so, and had the content been surprisingly acceptable, the reception might have been better.
Instead we get this "Hi! Welcome to ShillBlog!" (crickets) and everyone, quite reasonably, expects the worst.