Exercise Resistance

Recently I blogged about how few people actually take up the advise to be physically active, even when delivered by a health professional (e.g. click here).

A new study in the Lancet now shows how difficult it is, even with the greatest effort, to get a substantial proportion of people moving.

In this study by Kinmonth and colleagues from the General Practice and Primary Care Research Unit, University of Cambridge, 365 sedentary adults with a parental history of type 2 diabetes were randomly assigned to either receiving just a brief advise leaflet in the mail or a 1-year behaviour-change program, delivered either by trained facilitators in participants' homes or to the same program delivered by telephone. The program was designed to alter behavioural determinants, as defined by the theory of planned behaviour, and to teach behaviour-change strategies.

Surprisingly, at 1 year, the physical-activity ratio of participants who received the intervention, by either delivery route, did not differ from the ratio in those who were simply given the brief advice leaflet.

The bottom line of this relatively large randomised trial is clear: A facilitated theory-based behavioural intervention, even when delivered with professional home trainers and individual counseling is no more effective than simply providing an advice leaflet for promotion of physical activity in an at-risk group.

I can only imagine how disappointed the investigators must have been having to conclude that health-care providers should remain cautious about commissioning behavioural programmes into individual preventive health-care services.

This seems very much in line with the large body of evidence that states that people will either exercise or they will not - those who like activity and have done it before will do it again - those who don't - will refuse to do it (in the long term), no matter what.

Of course there will always be some exceptions, but these are likely to be few and far between - the majority is simply resistant to change.

Having predictors of who is likely to adopt exercise and who is not may be important in order to target advise (and resources) to those most likely to actually do it (and persist).

Once again - one-size is unlikely to fit all.

AMS

Food Cravings and Weight Loss

OK, here's a new piece of research from Tufts University whose results I would probably have predicted:

1) People crave energy-dense foods low in fibre and protein

2) Losing weight increases those cravings - the more weight you lose, the greater the cravings

3) People who give in to these cravings lose less weight (or gain it back)

Carrot sticks will simply not replace chocolate cake. The question is, how much chocolate cake can you still eat while trying to lose/maintain weight?

I guess the answer is: how ever much chocolate you need to still or manage those cravings.

If you are not a complete control freak those cravings will drive you nuts and you'll probably give in sooner or later.

Rule of Thumb: if you feel you are depriving yourself you are unlikely to stick with it (or feel unhappy and frustrated).

Let's never forget that food serves biological, psychological and sociological purposes that have nothing to do with maintaining energy balance, nutrient intake or good health.

The powers that regulate the hedonic aspect of food intake are always lurking and ready to sabotage any weight loss attempt.

Ignoring these "powers" is doomed to failure - let's embrace them and find creative ways to work around them.

AMS

Obesities and What to do About Them

Over the last couple of days I have been reading a new 160 page report on "Tackling Obesities: Future Choices" produced by the UK Government's Foresight Program which is run under the Government Office for Science.

The report was prepared by some 200 experts (mostly from the UK) and ends with several "what if" scenarios that model the outcomes of possible policy decisions.

The first point of note is that the title of the work refers to "Obesities" rather than "Obesity", thereby formally recognizing that this is a heterogeneous entity and that there are many forms of obesity.

Over all the work is impressive and discusses obesities in all their complexities - the biological and environmental system map is enough to let anyone serious about trying to understand the causes of the epidemic throw up their hands in despair and flee the room.

Nevertheless, the work is useful in that it contains a lot of interesting bits that are "quotable" and deserve discussion.

Sentences like:

"The forces that drive obesity are, for many people, overwhelming."

are notable because they depart from the usual idea that obesity is essentially a consequences of individuals' choices and decisions and all anyone has to do is to be "smarter" about their health.

This obviously we know is not true - in fact, if, as stated elsewhere in the report,

"People [in the UK] today don't have less willpower and are not more gluttonous than previous generations."

and

"...for an increasing number of people, weight gain is the inevitable - and largely involuntary - consequence of exposure to a modern lifestyle."

we need to be careful not to blame the victims.

It will rather be changes in social values and the way society as a whole chooses to respond to this epidemic that will make a difference. Amongst the experts, there was clearly no expectation of any spontaneous reversal of obesity trends.

The report is a challenging but fun read. I will probably be posting more on stuff I find in it over the next few weeks.

For those wanting to read the full report, you can download it by clicking here.

AMS

Young Mothers: Lose Weight While You Sleep!

OK, here is another interesting observation on weight and sleep:

Erica Gunderson and colleagues from the Kaiser Permanente Research Foundation, in an observational study of 940 young mothers, found that mom's lack of sleep at 6 months post partum was directly correlated with weight retention. (click here for reference)

Mothers, who at six months post partum reported five hours of sleep or less, had a three-fold greater risk of substantial weight retention at 12 months than mothers who reported sleeping seven hours (lucky them!).

The authors conclude, and I concur, that we now need an intervention study to see if "prescribing" more sleep to young moms leads to less weight retention.

Looks like we're going to need young dads to take on more of the "night shift" and let the poor moms sleep.

Wonder though if this will then lead to weight gain in young dads?

AMS

Please Pay Attention - You May be Obese

There are over 50 recent publications in PubMed on the possible link between Attention Deficit Disorder (ADD) and obesity. In my own anecdotal experience I continue to be surprised on how many patients presenting with obesity have clear signs of this disorder.

They are usually the patients who show up late for appointments because they locked their keys in their cars, did not fill the last prescription for their metformin because they lost it, started filling out food records but never got past the first day, used their new bike only once because they never got around to fixing the flat tire from their first ride, take a packed lunch to work but forget to eat it, enthusiastically start a new diet but lose interest three days later because weight loss is too slow - I could go on forever - you probably get the picture.

In my practice I have come to recognize that ADD is probably one of the most common and frustrating barriers to obesity management. By definition, individuals with ADD lack the ability to plan ahead and to follow through on their plans, easily lose interest, and are constantly sabotaged by their impulsiveness when it comes to making healthy choices.

There is now evidence to support the notion that alterations in the dopaminergic reward system may be common to both ADD and hedonistic hyperphagia. Not surprisingly there is some work showing that methylphenidate (ritalin) can sometimes reduce cravings for sweet and fatty foods.

It does not surprise me that someone with ADD is probably more prone to "mindless eating" and thus more likely to gain weight than someone with proper impulse control.

One of the most remarkable cases I recall was a patient, who after being started on ritalin, at his next visit for the first time brought in and proudly presented meticulously completed food records (he was also a couple of pounds lighter).

In medicine it is always easiest to blame the patient - not motivated, not interested, not focused, not following instructions, not compliant, not adherent, etc.

Recognizing that this behavior may be due to ADD and providing proper treatment for this condition may in these cases be the first step to obesity management.

AMS

To Have is Not to Be

Would you refer to someone with atherosclerosis as an "atherosclerotic"?

Would you refer to someone with renal failure as an "uremic"?

Would you call someone with osteoarthritis an "arthritic"?

I know that it is common to speak of diabetics, hypertensives, psychotics, etc. but it is not polite. In fact many journals emphatically forbid the use of these terms - the proper language would be diabetic, hypertensive, or psychotic patient, but even that may not be polite enough.

This issue is particularly relevant when speaking of obesity. There is a subtle but important difference between someone "being" obese or "having" obesity - Mr. Jones "is" obese vs. Mr. Jones "has" obesity.

Why is this important? When we use terms which have negative connotations like "obesity" it is important that we do not define our patients based on this condition - obesity is not a character trait - it does not define who our patient is - it is something our patient has and is seeking our help to get rid of.

Mr. Jones "is" Mr. Jones irrespective of whether he has obesity or has lost the excess weight.

I suggest that we do not speak of obese patients - let us show our compassion by speaking of patients who have obesity (as they may have atherosclerosis, uremia, osteoarthritis, diabetes, hypertension, or psychosis).

AMS

New Near Resolutions: Why Bother?

What could be more expected than a call from a local TV station today asking for my take on New Year resolutions? What should people do who want to lose weight and be more healthy?

Well, readers of this blog would already predict my answer: do not resolve to do anything that you do not enjoy and are unlikely to stick with.

There is absolutely no evidence that two weeks of avoiding fast food or four weeks of daily exercise will do you any good in the long run - except perhaps increase your experience of just "failing" again when you fall back into your old lifestyle.

People are too smart to stick with doing things they don't enjoy, especially if it takes an effort to do so. This is especially true if the rewards are distant, uncertain and vague.

But even experiencing the benefits is no guarantee for adherence. How many people do you know who have lost weight, felt fantastic - so full of energy - just great, only to gain the weight back?

So here's my two bits on New Year resolutions: if it's not sustainable don't bother.

Drastic and radical changes are rarely sustainable - remember: the benefits of even miniscule daily bouts of exercise are incremental - the health benefits of running a marathon once in a lifetime are irrelevant!

Happy 2008!

AMS