A feature article in today's New York Times chronicles the unfortunate fate of participants in The Biggest Loser after the spotlights dim, the TV cameras stop speeding, and some time goes by. They regain the weight. Some of it, most of it, all of it, or even all of it plus some.
The article cites the work of Kevin Hall, a researcher at NIH and leading expert in the dynamics of energy balance whose important work I have profiled before. I have tremendous respect for Kevin, and share his penchant for reality TV, although in my case, that's mostly limited to singing and dancing. I have never enjoyed weight loss as entertainment.
In my case, that's a bit ironic, because I actually "starred" in a weight loss reality show. VH1 asked me to be one of the judges on Celebrity Fit Club, at a time when The Biggest Loser was just a twinkle in NBC's eye. I agreed, thinking I might genuinely help the "celebrities" struggling with their weight and health, both on camera, and off. I declined to go back after a successful first season, for two reasons. First, the back and forth to Los Angeles for weekends of filming, with red eye flights on Sunday night, and back to work on Monday morning, were pretty taxing. Second, there was clearly, and perhaps predictably, more interest in titillation and drama than sensible approaches to losing weight and finding health. So, one season was ample.
Other than that, I have never watched "weight loss TV," because I think it tends to sensationalize, and mislead. It turns the prevailing struggle with weight into spectacle, and I personally don't care for that. It also implies to the viewers at home, all too many of whom are struggling with their own weight: you can do this, too! But the main reality about reality TV is that it's a whole lot of TV, and very little reality. What you can do in front of millions, with coaches, and trainers, and cooks, and sponsors, and so on -- you can't necessarily do on your own, at home. I think the insinuated "try this at home!" is an invitation to failure, shame, and self-recrimination.
What the New York Times tells us today, no surprise to those of us who have worked directly with severely obese patients over the years, is that failure overtakes the show participants, too. Those of us in these trenches have known all along that though challenging, weight loss is rarely the rate-limiting problem. Sustaining the weight loss is where most efforts fall down.
Dr. Hall's work on energy balance has shed light on this before, and the new work apparently dials up the illumination. What it shows, in essence, is that the sequence of severe obesity followed by fairly drastic weight loss activates the body's primitive defenses against starvation, which is, in effect, what it is experiencing. Metabolism slows, fuel efficiency is enhanced. In the context of Stone Age privations, these are highly adaptive responses, and we are likely here today only because our ancestors had them. In the context of willfully addictive junk food, and the bountiful ubiquity of it -- it is a metabolic disaster.
The most welcome part of this story, and such high profile attention to the matter, is the relief it may provide the "victims," reflected in quotes incorporated throughout the article. Our society has a shameful tendency to blame the victims of this obesity epidemic we have contrived, largely for profit. In that context, weight regain after loss with such fanfare must feel like ignominious failure. Dr. Hall's work, and this attention to it, say loud and clear: it's not your fault! That's a vital message that participants and spectators alike need to hear.
I can do little to add to the Times' excellent discussion of the physiologic implications of all this. Yes, we need to understand better the body's native responses to such weight loss. Yes, we need to devise new ways to help ensure the weight stays off for more such people, more of the time.
But I think the Times neglects the principal implication. Severe obesity can almost always, and should almost always, be prevented in the first place. If ever an ounce of prevention was worth many pounds of cure, this is the time.
Participants on The Biggest Loser have severe obesity. Severe obesity is the fastest growing segment of the modern epidemic. A TV show can make spectator sport of a problem our culture is fomenting, but it cannot fix it.
Why? Because in our culture, food literally is willfully devised to be, for all intents and purposes, addictive. Because in a society that feigns to be cutting sugar, after cutting carbs, after cutting fat- the best available evidence suggests we never actually cut anything. We just kept adding more calories, from new varieties of junk food exploiting the current nutrient fixation. Because we lament the prevalence of obesity and its often dire complications, especially in children, but blithely continue- as you have likely heard me say before- to market multicolored marshmallows as part of a complete breakfast. We peddle soda as a source of happiness, rather than diabetes. We pretend that fruit roll-ups have anything to do with fruit. We market ever bigger pizzas, with ever more cheese in ever more places; and ever bigger burgers, with ever more bacon.
Let's not mince words here: marketing obesity is big business, and a wide array of businesses are feeding on it. They include, but are not limited to, Big Food which profits from causing the problem; Big Pharma, which profits from treating the problem; Big Tech, which profits both from causing and combating the problem; and Big Media/Publishing, which profit from telling us about the problem in the customary manner: afflicting us when comfortable, comforting us when afflicted.
There is one more crucial consideration here, a product of our new and rapidly evolving understanding of epigenetics. We are creating newborns already predisposed to be obese.
Consider that the egg that made you formed in your grandmother's womb! How so? Well, your mother, obviously, formed in your grandmother's womb. When your mother was born, her ovaries already contained all the eggs they would ever house. Those ovaries, and the eggs in them, thus formed in your grandmother's uterus- and one of those eggs provided half the genes that produced you.
Those genes, per se, were not directly altered by your grandmother's behaviors, environment, or weight. But most of our chromosomal real estate is not our genes -- it is the epigenome, large expanses of molecular "switches" that determine what genes do. These switches absolutely are influenced by lifestyle, environment, and weight. So the native position of epigenetic switches, including those affecting insulin responses, metabolic rate, and weight -- is set not just before birth, but before the birth of our parents.
The good news is that epigenetic switches can be altered by our own behavior -- we have aggregating proof of that. But the switch positions we are born with have early and obvious implications for our health and weight. The current generation of obese, young adults are offspring of parents and perhaps even grandparents already caught up in an obesity epidemic going back enough decades to transcend generations. It would not be a great stretch to say: they never had a fair chance.
We will be dealing with the consequences of this for a long time to come, and should do so with considerable compassion, along with the insight and understanding derived from work like that of Dr. Hall. But it is past time to acknowledge that all of our ex-post-facto responses to obesity are a bit like efforts to put Humpty Dumpty together again, and cannot begin to compare favorably to prevention.
We know that obesity can be prevented, because most of history prevented it. We have seen history in fast forward in places like China, where obesity was rare just a matter of years ago, and is skyrocketing with adoption of all the cultural practices we are so adept at exporting. Salutary cultures, like those of the Blue Zones, defend both health and healthy weight, but are losing ground, too, to the relentless predations of Big Food, and Big Soda.
I am hopeful Dr. Hall's work, and attention to it by the New York Times, will cultivate both scientific advances, and empathy. But this will all be a squandered opportunity if we allow ourselves to believe the implications are limited to physiology, as we keep running on profitable junk.
Human physiology is the same as it ever was. The metabolic defenses against starvation are the same as they ever were. As we work to understand them better, we should not overlook the modern culture, all around us, that is the same as nothing in our prior history -- and that exploits our native vulnerabilities for profit as a matter of routine.
Director, Yale University Prevention Research Center; Griffin Hospital
President, American College of Lifestyle Medicine
Senior Medical Advisor, Verywell.com
Founder, The True Health Initiative