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From a colleague:

"People can and do maintain weight loss. For example, look at the National weight Control registry in the USA"

My response:

The National Weight Control Registry is a list of people (10,000 in the US, so the equivalent here would be 750 people out of Australia's population) who have enrolled themselves after losing 14kgs or more and keeping it off for a year. It relies on self-reported data and people who regain weight are removed from the registry. It is not representative of the population or of the usual experience and was never meant to be such. However, it does tell us a bit about the statistical unicorns who consider their weight loss important enough to enrol on the registry, and who's bodies have thus far allowed weight suppression. The behaviours these people maintain are: 60+ minutes of exercise every day, a strict (usually low fat) diet every day with no exceptions (not even Christmas), they eat breakfast every day and they weigh themselves weekly to daily. They have made maintaining their weight loss one of the most important things in their life. How many of us tell our clients that if they want to lose weight and keep it off that they need to develop this degree of rigidity forever and with the caveat that those behaviours will also not necessarily result in weight suppression? And for questionable longevity benefit when compared with behaviours alone.

Their response:

"Weight loss is not necessarily temporary. The National Weight Loss registry as you mentioned doesn’t have the massive numbers you desire, but they shouldn’t be dismissed as anomalies or outliers. For a start, not many people actually know about it to register themselves in the first place."

I did not respond as the conversation moved on but what I would have responded would have been:

They are literally outliers. That is literally what outlier means.

The wonderful Ragen Chastain of 'Dances with Fat' has a great blog post on this too: www.danceswithfat.wordpress.com/2012/12/27/national-weight-control-registry-skydiving-without-a-chute/

And from fellow dietitian Glenys Oystan from 'Dare to Not Diet': www.daretonotdiet.wordpress.com/2016/05/31/the-nwcr/

From a fellow dietitian:

"I do believe there are significant risks for mortality with increased BMI, irrespective of diet. I have seen studies supporting that, so I don’t think it’s a slam dunk for embracing any level of obesity. See the latest BMJ systematic review for example:

http://www.bmj.com/content/bmj/353/bmj.i2156.full.pdf"

My response:

My fingers get twitchy when I see this kind of research used to justify recommending weight loss, but I see it all the time and I think it's important to unpack the details.

The meta-analysis you've posted is a good one and can tell us many things. Mainly it shows that a group of larger people is, on average, likely to have a shorter lifespan than a group of smaller people. Interestingly, this one shows that smoking appears to be worse for you if you have a high BMI. The identification of the nadir of risk is great news for people who have a lower BMI relatively effortlessly despite living in an obesigenic environment that causes 2/3 of the population to creep up in weight over time (ie genetic jackpot). The recent influx of big BMI and mortality meta-analyses interestingly comes in response to Flegal's paper from 2013 which found that being overweight conferred the lowest risk of death in an NHANES dataset, thus suggesting that larger bodies might not be as bad as originally thought. Anyway, I digress. There are far more interesting things for dietitians in this study.

Firstly, where are our intentional weight losers (ie including our clients)? Well, we don't know. Unless they are running separate analysis for those who intentionally lost weight into a lower BMI category we cannot tell whether they have the same risks as so-called 'never-fat' people and so we cannot say that weight loss delivers on it's promise. This study found that using highest adult BMI when analysing mortality resulted in even lower risks for the lower BMI categories. So this might mean that all weight loss is bad, or it might mean that there are so few healthy people losing weight, keeping it off and not dying early that the disease-related weight loser stats drown them out. Think about that for a bit: there are more people actively dying from disease to the point that they are losing weight than there are people who have successfully, permanently lost weight. Probably a bit of both is true. Bottom line: population studies showing how bad obesity is do not justify recommending weight loss; they just show that being overweight/obese confers risk. They say nothing about the merits of no longer being obese or about the risks of becoming obese. Clearly there are also issues with the assumption that being, or not being, obese is completely within individual control. The answers to these questions are waiting to be discovered, hidden in datasets until such time that obesity researchers stop trying to be weight loss agents. https://www.cambridge.org/core/journals/nutrition-research-reviews/article/a-review-and-meta-analysis-of-the-effect-of-weight-loss-on-all-cause-mortality-risk/26226C6DF1BA32BEB00AAC87FC416667" target="_blank">Here is another paper looking at the mortality risks related to intentional weight loss (spoiler: overweight people who intentionally lost weight had an 11% increase in mortality). 

Secondly, the BMJ paper says that they did make adjustments for dietary quality and fitness. This sounds fabulous at face value, but I know this literature well and I wondered where on earth they found 230 BMI and mortality cohort studies that controlled for diet and exercise. So I nerded out in the supplementary material. Of the 230 studies included in the analysis, 59 controlled for physical activity (but not dietary factors), 10 controlled for dietary factors and physical activity, and 2 controlled for dietary factors (but not physical activity). People in these studies represented 7.7%, 3.8% and 0.062% of the total people studied respectively. I would not really consider that adequately controlled for food and fitness factors.

Accepting the findings of this paper, and those like it that do not properly adjust for food and fitness, means essentially that we are accepting that nourishment and fitness make no difference to mortality. Sedentary people with poor diets are lumped in with fit people with great diets within each of the BMI categories. Most of the studies included did not adjust for SES either. Does that seem fair or accurate? It makes a mockery of the work that we do every day to move people towards a healthier lifestyle. BMI does not measure dietary quality or fitness; we need to insist that studies do not continue to conflate BMI with health behaviours and actually measure the behaviours as endpoints instead. Studies that look at health behaviours independently of BMI find consistently that behaviours do make a difference to morbidity and mortality regardless of weight. Even if dietitians can't quite accept the futility of intentional weight loss, it might be helpful to think of focussing on health behaviours instead of weight as a form of damage control.

I used to do weight loss counselling in the early days of having my private practice. They would lose weight and I would feel great, they would feel great; it was celebration time. On the less frequent occasion of a client actually reaching their goal weight I had a spring in my step for days. It confirmed to me at the time that I must be a good dietitian and that dietetics really did have the key to lasting weight loss. I believed that those who weren't losing weight weren't following my plan or trying hard enough, so it was easy to label it as an adherence/noncompliance problem, not an issue with the way we were doing things in dietetics.

Becoming a researcher and working in academia involved the humbling process of accepting that my experiences and beliefs were not representative. Only seeing the 'honeymoon' phase of weight loss and devaluing the importance of my clients' previous (failed) weight loss attempts had lead me to have a distorted view of the effectiveness of dietetic counselling for weight loss. Unless a dietitian is following all of their clients for 5+ years it is likely that they suffer this same confirmation bias. In the absence of good quality research showing the 5 year outcomes of dietitian-delivered, individualised weight loss counselling, we have to accept that we are probably the same or worse than the well-funded, multidisciplinary, beautifully designed weight loss studies described in the literature which were used by the NHMRC in their review to conclude that long-term weight loss for the majority of people is unattainable.

In Australia we have the Australian Guide to Healthy Eating, which is essentially a pie chart version of MyPlate, but at least uses pictures of actual food to demonstrate the sorts of foods which belong in each food group. The guide is basically a summary of the observational studies which link diet with adequate nourishment, longevity and chronic disease. The serve sizes I explain as a unit of measurement, a way for nutrition scientists and dietitians to 'count' and describe someone's diet, a way to estimate whether someone is receiving adequate nourishment, not a magically perfect portion that a real person needs to eat at any given time. I explain the jaw-dropping scope for measurement error in nutrition science, both pre and post swallow, and the difference between risk and prediction of disease or longevity in a population vs an individual, and that there is no diet which can guarantee any individual longevity or reliable protection from disease.

Interestingly, dietary quality studies where they assess dietary intake against national food guides using one score for 'core' foods and another score for 'junk' foods (please forgive my non HAESy shorthand) find overwhelmingly that it is in fact not the 'junk' food which increases risks but the lower amount of 'core' foods. In other words, if the 'core' foods are consumed in patterns consistent with what is represented in the guide, the consumption of 'a little' or 'a lot' of 'junk' food makes no difference. Kurotani and colleagues have an excellent summary of this literature in their paper: http://www.bmj.com/content/352/bmj.i1209.full (open access yay!) This body of literature is also nice in that it is the food selection guides for the country that are used to assess the population ie it is sensitive to the value of cultural eating patterns within a population.

To distill the literature even further (if people are interested in experimenting with their diet) it seems that eating a variety of fruit and veg does your body good (so experiment with fruit and veg prep ideas which you find delicious, practical and feasible for you), eating a variety of grain based foods is probably helpful for some (let your body be your guide), dairy food is neither helpful or unhelpful (let your body be your guide) and eating charred meat frequently probably isn't a good idea.

Also important to remember is that the recommendation for low fat dairy foods was reverse engineered on the basis that it would keep energy intake down and thus prevent obesity although there is no evidence to support that this is useful for inclusion in population guides or effective.

So in summary, a population, proportion based food guide can be a useful tool (albeit blunt) for probability based nutrition assessment and as a way to deliver nutrition education about adequate nourishment for human bodies (of all shapes and sizes), but when it is used in a prescriptive way it's definitely then not HAES practice but it also massively oversteps its own evidence base.