Low Carb, Low Fat, Whatever — Let's Study Stick-With-It Diet Behavior

This post is not about low-fat diets versus low-carb diets. Or Jenny Craig versus Weight Watchers. It's about just the opposite: a provocative paper just out in a leading medical journal that argues that we should "end the diet debates" and move away from doing research comparing various diets altogether.

Instead, the authors say, researchers should focus on how to help people change their eating behavior long-term, the real key to controlling weight and reducing disease. It begins:

As the obesity epidemic persists, the time has come to end the pursuit of the “ideal” diet for weight loss and disease prevention. The dietary debate in the scientific community and reported in the media about the optimal macronutrient-focused weight loss diet sheds little light on the treatment of obesity and may mislead the public regarding proper weight management.

It's hard to imagine abandoning our second-favorite national pastime — pitting the Atkins diet against the Paleo diet against the South Beach diet. And what would the American diet and weight-loss industry, estimated at $60 billion, do without "the latest study" to tout?

But the paper just out in the Journal of the American Medical Association argues that there’s already been plenty of research on the question of which sort of diet helps people lose weight best --- many dozens of studies, even studies compiling and analyzing other studies.

And all these millions of dollars of research basically come down to a big fat draw. The different diets help people lose weight pretty much equally well — with maybe a difference of a couple of pounds in one direction or another.

We have to understand what’s affecting our ability to make healthier decisions and really drill down into that conundrum.

So if which diet you follow doesn’t much matter, what does?

The key word is adherence — sticking to healthier eating for a long time. (I'm reminded of pet adoption appeals seeking a "forever home;" we need "forever eating habits.") The paper’s lead author, Sherry Pagoto, an obesity researcher at the University of Massachusetts Medical School, says that what we most need to study now is behavioral change, what makes people stick to healthier eating and exercise habits.

"We have to understand what’s affecting our ability to make healthier decisions," she said, "and really drill down into that conundrum."

What makes one diet easier to stick with for one person than for another? It varies for different people, she says. "Some people say, 'Oh, it’s very easy for me to follow a low carb diet.' Other people say, 'Oh I could never do that. I need to go low fat or Mediterranean.' It may have to do with what they’re used to eating, their food preferences, their family traditions. So there are a lot of factors that go into whether you can stick to a diet."

"And so that’s what we’re saying: We really need to understand those factors. We need to understand the key to adherence and it does not appear to be the content of the diet. It’s more the context of the dieter."

In essence, Sherry Pagoto and her co-author, Bradley Appelhans of Rush University Medical Center in Chicago, are talking about a shift of focus: the idea that the most important aspect of dieting is not nutrition — not the balance of carbs or fats or proteins — it’s behavioral change, and how to make it last.

A couple of other points she made when we spoke:

"Obesity is a chronic health care issue and it needs chronic care. And one thing we point out in the paper is that we don’t have reimbursement policies right now for chronic care for obesity, and that’s the big challenge. We do have effective interventions that involve behavioral modification, but we don’t pay for them, clinicians don’t have access to them."

The most common thing a patient will say is, ‘I want to lose weight, but life is getting in the way.’

"I am a clinician in a [clinical weight loss] program, but patients actually have to pay out of their pocket for it. So it’s not something that’s easy to bill for and get third-party reimbursement for right now. There is a piece of legislation called the “Treat and Reduce Obesity Act 2013” that was put forward by a bipartisan group of Congresspeople in June that I’m really excited about, because it does expand reimbursement policy for counseling for obesity."

On the research that's needed now:

"I think it’s a behavioral science question. So we need to understand all of the factors that go into behavioral adherence, and there are biological factors. We do know, for example, there are neurobiological differences across people in terms of your affinity for certain types of foods. There are environmental factors — food availability, neighborhood characteristics. We live in a toxic food environment right now, so helping people figure out how to navigate that, because it’s working against them, is important."

"Then there are also psychological factors like stress. Stress is a huge factor in undermining adherence in any diet, undermining adherence to an exercise program. So there are the factors we really need to be focusing on."

"The most common thing a patient will say is, 'I want to lose weight, but life is getting in the way.' And what they mean is, “I am struggling with figuring out how to make these changes last and stick given everything else I’ve got to do.' And that’s what they need help with. That’s a behavioral science question. It’s not a nutrition question per se."

Readers, if you controlled a weight-loss research budget, which questions would you most want your researchers to ask and answer? Personally, mine would be: Why is eating healthfully so easy for me in the morning and so close to impossible as the day wanes?