This isn't surprising. BMI increases bring reduced insulation sensitivity, which in turn is what causes the issues. The fix is to diet and exercise. At the end of the day we don't care about BMI, we care about insulin sensitivity - but it is easier to measure BMI than blood insulin. BMI isn't a perfect indicator but it's a pretty good one.
"The fix is diet and exercise" is not correct at all. There is no evidence on population level data or studies that diet and exercise produce durable BMI loss on a population level. From a "calories in calories out" perspective it is naively true, but in practice it doesn't work at all. The issue is that when people have BMI>30, their bodies endocrine system gets pretty messed up and their bodies will basically request 3500 calories per day. There have been a number of breakthrough medicines in the past few years that disrupt this cycle and reliably produce weight loss on a population level through hormonal changes that reduce appetite and delay gastric emptying. Some examples of these drugs are Tirzepatide and Semaglutide.
A caloric deficit will produce weight loss. If you're arguing that this isn't sustainable due to the amount of calories being "requested" by people's subjective desires and experiences, that's a completely different (and also incorrect) argument.
There are many double blind studies on this. On a 2+ year time horizon, the huge majority of obese people who follow a "eat less exercise more" regime lose weight and then gain it back. This happens because the people never stop being hungry due to the disruption that obesity puts on their endocrine system. There are a number of medicines (saxenda, liraglutide, ozempic, mounjaro, wegovy) that produce reliable robust weight loss on a 2+ year time horizon. These medicines work best with a change in diet and exercise habits, but reliable weight loss on a population wide scale is not something you treat with "diet and exercise" advice.
Yes a lot of crash diets fail, for obvious reasons, but once a diet has stabilized the cravings will go away.
It does for many people mean they will need to cut out or dramatically cut down the eating out, drinking and instant meals. Most people don't want to do that.
Substantial weight loss is possible across a range of treatment modalities, but long-term sustenance of lost weight is much more challenging, and weight regain is typical1–3. In a meta-analysis of 29 long-term weight loss studies, more than half of the lost weight was regained within two years, and by five years more than 80% of lost weight was regained (Figure 1)4. Indeed, previous failed attempts at achieving durable weight loss may have contributed to the recent decrease in the percentage of people with obesity who are trying to lose weight5 and many now believe that weight loss is a futile endeavor6.
Obesity is a problem of modernity and specific cultures made up of people who didn't used to be obese generations ago. Are the populations around the world in which people aren't generally obese just filled with a large subset of the population constantly starving...or we agree that no such large subset is simply destined to obesity.
If we agree on this, then your argument isn't that people are destined to obesity, but rather that once they're obese, they have patterns of behavior that are extremely hard to break over a long term basis. That isn't the same as saying that weight loss is a futile endeavor, it's just saying that people who are obese are very often going to fail to stick to the patterns of behavior that resulted in weight loss.
My argument is that in 2022, the medical advise and consultation of “diet and weight loss is the solution to obesity” is not true on a population level. We now have other tools to address obesity that are both pharmacological (GLP-1/GIP acting) or surgical (bariatric surgery). We should stop admonishing patients for not following treatment guidance (eat less, exercise) and instead provide them with solutions that actually work reliably. I have nothing to add to the causes of obesity, and eating properly and maintaining a high level of activity are clearly good at preventing people who have never been obese from becoming obese.
Sure a caloric deficit will produce weight loss. Obviously. But reducing calorie intake alone does not guarantee a calorie deficit. While there is of course some level of unavoidable caloric expenditure, the average person has a fair bit of expenditure that is quite avoidable.
It is not hard for the body to discourage unnecessary caloric expenditure in response to a notable caloric deficit. Indeed, doing just that is a basic famine survival instinct.
Now given the decidedly non-famine conditions, eventually things should restablize, but it does mean for a person at caloric equilibrium, reducing caloric intake by say 500 Calories, will often not result in a 500 calorie deficit, but a smaller one for for quite some time until the body adjusts to this being the new normal.
In the mean time, the person likely feels like shit. Furthermore, If there actually is food available, the body and subconscious mind is doing everything it can to encourage the person to eat more.
This substantial resistance of the body to attempts to run meaningful caloric deficits for an extended period are a not insignificant portion of why "dieting" often fails. People don't stick with it, since it majorly sucks.
> Results: Despite heterogeneity across studies, we observed reductions in pooled effects for overall food cravings (-0.246 [-0.490, -0.001]) as well as cravings for sweet (-0.410 [-0.626, -0.194]), high-fat (-0.190 [-0.343, -0.037]), starchy (-0.288 [-0.517, -0.058]) and fast food (-0.340 [-0.633, -0.048]) in the meta-analysis. Baseline body weight, type of intervention, duration, sample size and percentage of female subjects explained the heterogeneity.
>
> Conclusions: Calorie restriction is associated with reduced food cravings supporting a de-conditioning model of craving reductions. Our findings should ease the minds of clinicians concerned about increased cravings in patients undergoing calorie restriction interventions.
Substantial weight loss is possible across a range of treatment modalities, but long-term sustenance of lost weight is much more challenging, and weight regain is typical1–3. In a meta-analysis of 29 long-term weight loss studies, more than half of the lost weight was regained within two years, and by five years more than 80% of lost weight was regained (Figure 1)4. Indeed, previous failed attempts at achieving durable weight loss may have contributed to the recent decrease in the percentage of people with obesity who are trying to lose weight5 and many now believe that weight loss is a futile endeavor.
Appetite changes likely play a more important role than slowing metabolism in explaining the weight loss plateau since the feedback circuit controlling long-term calorie intake has greater overall strength than the feedback circuit controlling calorie expenditure. Specifically, it has been estimated that for each kilogram of lost weight, calorie expenditure decreases by about 20–30 kcal/d whereas appetite increases by about 100 kcal/d above the baseline level prior to weight loss31. Despite these predictable physiologic phenomena, the typical response of the patient is to blame themselves as lazy or lacking in willpower, sentiments that are often reinforced by healthcare providers, as in the example of Robert, above.
You risk alienating people by focussing on BMI though. Weight has been moralized in the US (being fat is seen as a moral failing). People do not easily accept advice that is given through a moral lens.
The data shows that there is a better measure than BMI which doesn't carry all the stigma, so why not use that one?
Taking any of the more accurate measurements of body composition requires effort, unlike BMI. It's easy and lazy and not yet acknowledged as an ineffective practice so doctors do it. It's also not always wrong, just because BMI and obesity do correlate.
My understanding is the argument is not whether to use someone's fatness as a measure of health if there's a much better, specific metric besides being fat (ie. resting insulin levels) to prescribe exercise and diet over.
I don't think it'll reduce stigma or whatever of fat people, but I do agree that if someone is fat but their insulin is normal maybe a doctor can pay attention to something else like if they came in for an allergy test or something they may not need the diet/exercise spiel. Similarly if someone's thin but their insulin is crazy its time to talk diet/exercise.
There is a rare, rare, rare chance you can some weird diseases that mess up insulin sensitivity, so you can be skinny and have issues. Those are rare and not solved by diet and exercise.
Otherwise if your insulin is high, you need to diet and exercise. Measuring blood insulin is a lab procedure - you go to a collection lab, you get jabbed, they mail it for testing.
Measuring BMI requires stepping on a scale and knowing how tall you are.
> Measuring BMI requires stepping on a scale and knowing how tall you are.
There are contradicting posts in this very thread that say high BMI and obesity aren't necessarily the same thing, because apparently you can be tall and be only mildly into lifting and suddenly you have a high BMI. If that's the case [I'm not a lifter] then it makes total sense to me to track resting blood glucose, not obesity, because it's simply the more accurate measurement.
> because apparently you can be tall and be only mildly into lifting and suddenly you have a high BMI.
Very unlikely. BMI is a standardized model. Unless you are dramatically out of the parameters (you're 7'2" or you are an olympic lifter) it is pretty accurate.
You can also use calipers in that case - you need someone to help you because you can't reach it yourself but it's very fast and accurate.
Again, insulin testing is expensive, invasive and time consuming. You might get insulin tested once a year.
I'm merely pointing out that it's apparently not as simple as stepping on a scale because no one can get their heads straight about high BMI's causation to begin with or what to do about it.
It just seems much simpler to me to take an actually accurate test once a year and prescribe purely based on the accurate testing. That way we also get skinnyfat people.
Imagine if once a year, your boss sat you down and went "Hey, you did a terrible job this year. No promotion."
You might ask him why he didn't give you any feedback earlier so you could have fixed the issue. "Oh, well I only give feedback once a year since it is hard to do".
You need regular (weekly, biweekly) feedback on your diet.
