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Over the past few weeks I’ve put together an extensive (and I hope valuable) series on training clients with obesity.  In Part I of the series I described the categorization and classification of obesity.  In Part II I shared some resources and very important concepts about obesity management.  In Part III I discussed how I would go about training those with a BMI greater than 35.  In Part IV I talked about the training I would use for those with a BMI below 35, but still above 30.  And in Part V I presented a summary of the various types of bariatric surgery that are most often sought by those with obesity.  Today I want to finally bring the series to a close with a final piece about nutrition for those with obesity.

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What We Know About Diets

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I think some of the largest trials comparing diets in the real world (such as the famous A to Z Study) have demonstrated that while low carb diets generally get the lead for early weight loss, after a year they aren’t really that much better than moderate or higher carb diets.   Granted, there was a statistically significant difference in the A to Z Study, but is it really significant in terms of what it means to you or your clients?  Here are the results from the paper.

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Mean 12-month weight loss was as follows: Atkins, −4.7 kg (95% confidence interval [CI], −6.3 to −3.1 kg), Zone, −1.6 kg (95% CI, −2.8 to −0.4 kg), LEARN, −2.6 kg (−3.8 to −1.3 kg), and Ornish, −2.2 kg (−3.6 to −0.8 kg). Weight loss was not statistically different among the Zone, LEARN, and Ornish groups.

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So basically, the Atkins group lost an average of 10.3 pounds, the Zone group lost 3.5 pounds, the LEARN group lost 5.7 pounds, and the Ornish group lost 4.8 pounds after one year!!!  In this case the “best” diet yielded an average weight loss of approximately 0.2 pounds per week.

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What I feel this study really tells us isn’t that one type of diet is superior to another for weight loss, but that our biggest issue with diets is compliance.  In fact, what I think you’ll find if you talk to any client with obesity is that many of them have tried numerous diets for weight loss in the past and some of them may actually have done VERY well (losing even 100 pounds or more) only to put it back on.  The key here is not to find some magical diet that will elicit the most rapid fat loss possible, but to find a nutrition plan that the client will be able to maintain for life.

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Wait a Minute…

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Isn’t that what I usually say for non-obese clients too?  Gee willikers.  Could we be on to something here?  Does this mean there is no magic diet that will instantly result in ripped abz for only $39.99?  Could it also be that if we simply identified and address the barriers that prevent us from being able to adhere to ANY diet we’ve selected that we’d get better results?  Nah…couldn’t be.  That would make too much freakin’ sense.

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Anyway, the biggest nutritional factor that is required to result in weight loss success is a moderate calorie deficit.  As simple as it sounds, the key is to make sure the calories consumed by the client are less than those that are burned.  I should reiterate again that this should be a MODERATE deficit and your client need not lose weight rapidly and you must resolve to teach them the proper way to lose weight despite their insistence that they’d like it to go faster.  The more severe the plan, the less likely the client is to stick to it for life which (as we discussed above) the single MOST important element of any nutrition plan.

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I should note that in some medical obesity management programs very low calorie diets (VLCD) consisting exclusively of nutritional protein shakes totalling 800-900 calories per day are sometimes used for rapid weight loss.  You should NOT follow this practice with your clients.  Programs like these MUST be medically supervised as there are risks associated with gall stones from rapid weight loss (possibly leading to pancreatitis), low sodium levels, and life threatening blood sugar crashes if the person is on insulin (as many with obesity who have Diabetes are).

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Aside from that, the diet should contain enough protein for muscle maintenance, fiber, and plenty of fruits and vegetables.  But I need to state again that creating a moderate calorie deficit and finding a nutritional lifestyle program that will stick (along with identifying and addressing barriers to compliance) are the two biggest concerns.  Without these, you can pretty much forget about everything else.  And, of course, since these clients often struggle with sudden change and making it stick in the long term (as do most clients actually), it is important to implement progressive behavior change to get the client onto the plan rather than an instant jump to super strictness.  Doing this will empower the client and make them more willing to take further steps as their confidence grows.

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In short, there is no magic but consistant and slow behavior change and a reasonable diet.  Anything else is just setting your client up for failure.  And if you doubt it, I’ll leave you with this.  Below is an image of the weekly weight values of a client I’ve worked with for the last nine years.  The first year averaged a 2-3 pound per week weight loss and beyond that it was much slower.  But the point to be really taken is that weight loss is easy.  Long term maintenance which is where the truly gifted trainer aims to shine.

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As usual, if you have any questions, comments, or random insults you can leave them below and I’ll make sure to address them.

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Also, if this article has been useful to you please don’t hesitate to share, “like”, tweet, +1, or whatever funky social media thing you can do to spread the word.

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Recently I started writing a series on training obese clients that has evolved into much more than I had expected.  In Part I of this series I described the categorization and classification of obesity, in Part II I shared some resources and very important concepts about obesity management, in Part III I discussed how I could go about training those with a BMI greater than 35.  In Part IV I talked about the training I would use for those with a BMI below 35, but still above 30.

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Today I want to begin talking about nutrition for those suffering with obesity.  However, discussions about nutrition and the obese client would be lacking without at least a brief mention of gastric bypass surgery.  So today I will cover that, and then I should have only one more post on nutrition related stuff that should wrap things up.

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Now before you tune out because you think gastric bypass has nothing to do with you or your clients, trust me when I say you need to hear this.  Even if you are not a believer in this type of surgery, chances are that if you train obese clients long enough you’ll run across one that is considering or has had some form of bariatric surgery.  If or when that happens, you should be informed with the best possible information so that you can provide appropriate guidance and support.

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And even if you never happen to personally train someone who has had this surgery or wants to have this surgery, it will help to inform you that this surgery is by no means “the easy way out” that some may perceive it to be.  I feel that fitness professionals should make an effort to at least understand the basics bariatric surgery as this is part of weight management for many (even if you don’t agree with it).  So…let’s get at it!

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Laproscopic Banding

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The first and least invasive type of bariatric surgery is simply called laproscopic adjustable banding (popularly known as the Lap-Band).  With this surgery, a small adjustable band is inserted through very small incisions and placed laproscopically around the top of the stomach.  This limits the amount of food that can enter the stomach and thereby causes people to lose weight.  This is called a restrictive surgery because of this limitation.  People that have had this surgery also have a port below the skin in the abdomen that allows them to have saline added or removed to make the band tighter or looser depending on their needs.  Of all of the bariatric surgeries available, this is the least invasive and it has the smallest surgical risk.  It is also removable so if some decides it isn’t right for them, the band can be removed.

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From the data I’ve seen at conferences and from hearing surgeons talk about this procedure, it seems as though the weight losses seldom meet the expectations of the patient, weight is almost fully regained in many cases, and the band is frequently removed.  As a result, it seems that gastic banding is losing favor in some circles.  One of the things that strikes me as most interesting about banding is that we’re basically providing a removable (temporary) treatment for what I’ve suggested is a chronic condition.  If removing treatment results in the return of the condition, it might be wise to question the use of temporary solutions.  Of course, I’m not saying that there isn’t a place for banding (they often use them when they feel such a surgery is warranted in children – don’t even get me going here), but the data I have seen on them is generally not promising.  I won’t ignore that some have great success with these, but I think this is the exception rather than the rule.

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Sleeve Gastrectomy

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The sleeve gastrectomy is also a laproscopic procedure in which part of the stomach is actually cut off and removed.  The remaining section of the stomach is actually quite small which limits the amount of food a person can consume and allows them to lose weight.  This too qualifies as a restrictive procedure and it is only slightly more risky than the laproscopic band, but it is permanent.  This surgery generally has greater weight losses than laproscopic banding and (from what I’ve seen) is better in terms of preventing weight regain.  However, the results aren’t as great as with the “gold standard” gastric bypass surgery we’ll talk about next.

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Roux En Y Gastric Bypass

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While there have been many versions of this surgery over the years, the roux en y gastric bypass is now the gold standard against which all bariatric surgical procedures are compared.  In this surgery, like the sleeve gastrectomy, part of the stomach is removed to limit the amount of food that can be consumed except that with the sleeve the stomach can hold 150ml of food while this procedure typically limits food to about 30ml (two tablespoons).  Then, the small intestine is cut part of the way along and attached to the new stomach pouch.  This prevents much of the food that is ingested from being absorbed by the body resulting in even greater weight loss.  For this reason, this procedure is classified as a restrictive and malabsorptive procedure.  It is obviously not reversable.

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The highlights of this procedure is that the weight loss is typically greater than the two previously mentioned.  It also does have some greater weight loss maintenance than the other two as well.  What is more important though (and probably why this procedure gets so much appreciation from physicians and patients) is that it can be an almost instant cure for Type 2 Diabetes.  In other words, you could be a Type 2 Diabetic today, get the surgery, and then you’re pretty much off your meds.  There is even some talk about doing this procedure on non-obese Diabetics whose disease is really difficult to control, but I’m not sure whether this will pan out.

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I want to be clear here with my own perspective in that I don’t think the data on this is 100% reliable as the follow up isn’t the best in many of these studies and some are not randomized controlled trials.  The big issue with follow up is that the people that are probably most likely to make themselves available for this are those that are doing well.  Those who aren’t probably don’t want to be followed up.  For this reason, I think that perhaps this surgery may be good for some Diabetics, but I’m cautiously optimistic.

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I also want to be clear about some of the downsides.  First, the surgical risk is higher with this than the other surgeries I’ve mentioned.  I don’t think it is terrible, but worth noting.  And because the surgery is malabsorptive, there are some major nutrient deficiencies that occur with many patients.  Of course, they are typically told to take certain vitamin and mineral supplements for the rest of their lives following surgery, but some are non-compliant with this and they end up with serious issues.  There are also other issues like increased rates of suicide, divorce, addiction, and other issues following this surgery that make it important to weigh the risks and rewards of this procedure.

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Biliopancreatic Diversion with Duodenal Switch

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This procedure is the most intensive procedure of them all and it is only usually considered for the very obese patient.  Generally it begins with the restrictive component where the stomach is reduced very much like the sleeve gastrectomy.  From there, it becomes difficult for me to describe so I’ll just use a video to illustrate for those who are interested.

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This procedure can be done in two parts with more severely obese patients.  In the first procedure, the restrictive part is done to reduce the size of the stomach.  Then, after the patient has lost some weight and is less of a surgical risk, the surgeon can go back in and add the malabsorptive element to continue the weight loss.  While the roux en y is the gold standard, the duodenal switch can also be used for those who have regained weight after this procedure as it is pretty much the only thing left in the surgical arsenal.

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As you might guess, the risks for this surgery are higher than those associated with any of the previous, but the results are also usually pretty darn good too.  Ultimately, the more risky the surgery, the greater the potential weight loss.  However, with all surgical procedures you really have to look at the pros and potential cons of this operation.  Similar to gastric bypass, there are many possible issues that can present.

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I honestly can’t tell you what to do in the case of a client that has had any of the above surgeries because they’ll all present differently.  My primary goal with this post was to bring a basic understanding of surgical weight management to the fitness world in the hopes that it will begin to build a bridge between fitness and physicians as we attempt to understand each other’s methods.

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I can tell you that without lifestyle modification any of the above surgeries can result in weight regain and the reappearance of obesity related issues like Diabetes, hypertension, and so on (remember what I said about obesity being a chronic condition?).  So even if we don’t agree with the methods, it is important that we be prepared to partner with people that have had them (and their physicians) because many family doctors are at a loss for what to do with these patients.  By having at least some understanding, you will be in a position to help.

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If you want more information on this topic I would highly recommend you take the time out to read Dr. Sharma’s series called Why I Support Bariatric Surgery.

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There are 5 parts and they are all fantastic.  They can be found here. 1, 2, 3, 4, 5.

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But before you think I’m totally going to allow only the positives to be highlighted here, Dr. Sharma wrote a 5 part follow up series called Why Bariatric Surgery Can Fail which I think is also solid and provides more information than I can possibly cover here in this single post.

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You can read this series here. 1, 2, 3, 4, 5.

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In the end, I guess I didn’t teach you much about how to handle these clients, but being aware of them, what they’ve had done, and the potential issues can only point you in the right direction.  If nothing else, you probably just learned something you never thought you’d learn in this industry. 

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If this article helped you in any way or you think it may help others you know, please share it on Facebook, Twitter, Google+, or whatever social media outlet is your addiction.  Or if you’re lazy like me just hit the “like” button or +1 button.  Thanks.

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PS: I know I possibly covered a lot of unfamiliar ground here so if you’ve got questions, drop ‘em below.

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PPS: Check out Part VI of this series HERE.

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In Part I of this series I described the categorization and classification of obesity, in Part II I shared some resources and very important concepts about obesity management, in Part III I discussed how I could go about training those with a BMI greater than 35.  Today I want to talk a little bit about training people with obesity whose BMI is less than 35, but still over 30 which is pretty much the standard criterion for obesity in most places in the world (except for a few places that I mentioned in Part I).

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Within this category I find that there are often two different types of people.  The first are those who are inactive, have less than average muscle mass, and are generally out of touch with all that is fitness.  The second type I generally see within this category are those who are regularly active, lift weights, and are fairly muscular.  They are often everyday gym rats, off season bodybuilders, and even trainers and coaches.

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While those in the first group tend to accept that they are obese, those in the second group often having difficulty truly accepting this and often  point out that BMI does not take into account their muscle mass.  For this reason, it is important to remember that while you CAN have a BMI greater than 30 and not be over fat, males with a body fat percentage over 20% and females with a body fat percentage over 30% are considered obese regardless of their BMI.

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I won’t get into it too much here, but you can see how working with those who are already active could warrant more intense training programs and different exercise variations.  However, I find that these people are most difficult to reach in terms of establishing long term realistic behavior changes as they tend to see themselves in the different category than those who are starting from ground zero.  In my experience, this group tend to think that they are able to handle more “hardcore” dieting and training practices to bring about rapid fat loss and they struggle to come to terms with the fact that while they certainly train hard, they need to address the root causes of their excess weight in much the same way as those who are less experienced with training.  In short, carb and calorie cycing, refeeds, and all of the other advanced nutritional practices are secondary to slow, progressive behavioral change.

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I would also add to this discussion the importance of remembering a point I made in Part I.  It isn’t as important to know the classification of obesity (how heavy you are) as it is to know about how obesity is impacting your health.  In short, you could have class 3, stage 0 obesity (BMI over 40, but no obesity related health problems) or you could have class 1, stage 2 obesity (BMI over 3o with significant obesity related health problems).  So weight (over even body fat percentage) doesn’t give us the whole picture anyway.  If you exercise you MAY be in better health because of the simple fact that exercise is medicine, or you may be suffering from metabolic changes associated with obesity despite the amount of exercise you’re getting.  So whether you exercise or not, I think the two groups here both need to consider changes to their behaviors in the interest of long term health.

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Goals

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Before we go forward I want you to consider something before you outright reject it.  What if we suggested to people that instead of losing weight that they just focus on maintaining weight?  I’m not body composition change or anything fancy.  There is no trick here.  But what if instead of working towards fat loss, we just stopped the gain?  Is that success?

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The basic premise is that each of us tends to slowly gain weight as the years go by and that if we could just stop the gain we’d be miles ahead.  I’m not suggesting that you’ll have an easy time convincing clients that this is the way to go, but sometimes perspective is the key here.  How many times have you (or someone you know) pulled out a picture from 10 years ago and thought “Damn…I used to look like that?  And I thought I was fat?  I would KILL to look like that again!!!”.  Hindsight is 20/20.  Add to that the physiological and psychological effects of losing and regaining weight repeatedly and you can see why maintaining weight might be a good option.  In this case, I think many would do well to maintain their current weight and work towards preventing future gain.

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I’m not saying that you’re going to get clients to buy into this off the bat.  But if you’ve worked with a client for a long time and they’ve failed change their behaviours to the point where they’re able to lose weight (if you’ve been in the industry for a while you know you’ve seen this even if you’re unwilling to publicly admit it) it might be a good time to reiterate this point so that they can see the smaller version of success that they ARE achieving.  Further, I find it helps in cases like these to reiterate successes like adding exercise and the benefits it provides to keep the client motivated to maintain the changes that they have made.  At one point in my career I used to “fire” clients for being non-compliant and failing to get results with weight loss.  Had I had this perspective then I certainly wouldn’t have made this embarrassing mistake and they’d probably be healthier for it.

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Back to reality though.  If a client comes in and you tried to sell them on this they’d be out the door before you could blink.  I think that mentioning the concept is a good idea, but suggesting a weight loss of no greater than 1-2 pounds per week is probably a good idea.  Truthfully, we all know that when starting a program it’ll come a little faster at first anyway (business tip: under promise, over deliver), but if the weight loss keeps moving much faster than this it could be a good sign that you’re overly depriving your client and that the changes won’t stick.  You don’t have to take my word for it, but I’m right. 

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But here is the real key.  Measure multiple things and create goals for each.  Track weight, measurements, body fat percentage, health markers (get their physician on board and make sure to educate them on obesity), cardiovascular fitness, and so on.  That way, if there is little progress on one, there will be others to highlight at any given time.  And MOST importantly, define weekly BEHAVIORS that you want to change (no more than 1-2 at a time) and focus most heavily on these goals.  Behaviors become habits which lead to outcomes.  Even if the client is able to deviate from plan and lose weight, the reinforcement should be focused on the behaviours as opposed to the outcome.  Because, in the end, if the behaviors don’t change, the results will eventually come undone.  So…the instead of behaviors leading to the goals…the behaviors ARE the goals.  Or to phrase it another way, the results are YOUR goals, the behaviors should be the goals of your client.

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Training

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I was thinking I’d write a detailed explanation of the training I use for people in this category, but frankly, it isn’t really much different than the training I outlined in Part III with only a few exceptions.

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I will do a full movement assessment on people in this category provided that they are not overly limited in any specific way.  Most are not so I proceed with a full breakdown of posture, mobility, stability, flexibility, and strength on this crowd.  If the client can, we do foam rolling.  And I certainly don’t have any issues with doing mobility work specific to the needed determined in the assessment for this group either.

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In terms of resistance training, I’ll generally follow the same template as I would do with heavier folks with the exception of the fact that this group will probably be able to handle (both physically and psychologically) more volume so I might do 2-3 set of each exercise instead of starting with 1.  That said, in the beginning pretty much anything you do will bring about results so I don’t push the envelope too much.  Make the person enjoy exercise and they’ll come back.  Of course, if I get one of those I mentioned earlier who already trains like a beast I’ll make them hurt.    Let’s be honest, they’ll enjoy that.  But they’re still going to have to make behavior changes too as this is the component upon which long term results are dependent.

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For cardio with this group it all comes down to what they prefer to do.  Now that doesn’t mean that if they prefer to sit on the couch and watch television that they aren’t going to do cardio.  But if they would rather do moderate intensity cardio for a longer time I’m good with that.  I don’t think cardio is that important for fat loss when combined with a solid diet anyway.  I use it for health and other benefits so I don’t care how they get it.  If they prefer more intense stuff, they can do that.  Of course, the idea is always to be increasing in intensity over time regardless, but I don’t freak out if people don’t want to do intervals.

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Summary

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In short, I think the biggest difference between these folks and those with a BMI greater than 35 is how you frame their goals.  The training is simply a matter of matching the level of exercise progression/regression to meet their needs and not making them hurt so bad that they don’t want to come back.  While this group is often easier to work with in terms of what they are physically capable of doing, their nutritional shortcomings are often just as difficult to overcome as those at higher body weights.  In the next article of this series, I’ll be talking about nutrition and how it applies to these groups.

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If you have any specific thoughts or questions about these articles, please drop them below.  And don’t forget to follow me on Twitter and Facebook if you’re not already.

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Check out Part V of this series HERE.

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I hope this has been of help to you.  If so, please “like” or share this article so we can spread the word.

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Okay…in Part I of this series I talked about the categorization and staging of obesity and in Part II I dropped a few fundamental thoughts (and some great resources) for preparing to train clients with obesity.  If you haven’t read these I’d suggest you go back and read them first.

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Goals

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Today I want to move forward and actually get into details about how I train people with obesity.  More specifically, I want to focus today on how I train clients with Class 2 and Class 3 obesity (BMIs over 35 and 40 respectively), but first I just want to touch on the subject of goals.  I read somewhere recently that when those with the higher classes of obesity are asked to define their weight loss goals it is common for many to desire and expect weight losses of as much as 50% of their current body weight.  In other words, if you’ve got a 500 pound man, his goal might be to reach 250 pounds.  If you’ve got a 300 pound woman, her goal might be to reach 150 pounds.

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Frankly, I don’t have any studies to back up this assertion, but based on my experience I can only say that there is certainly some truth to this.  As a human, I can certainly understand how someone with class 3 obesity might just want to be “normal”.  However, as a fitness professional I feel it is my responsibility to temper this belief with a delicately put explanation of reality.  The very real truth is that weight loss will likely be much less.  Even with bariatric surgery (eg: gastric bypass) the average weight loss is around 20-30% so the likelihood of weight losses this great with non-surgical methods are not great.  That certainly isn’t to say that they can’t happen (I’ve seen it with a couple of my own clients), but I think it is more prudent to emphasize the medical benefits of weight losses as small as 5-10%.  In fact, even without a body weight change, the addition of exercise alone can improve health markers, mobility, and wellbeing.

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I think the key here is to not prevent clients from making these goals for themselves (good luck if you try to do that), but to stress the benefits of lesser weight losses and applaud them as they achieve them.  Further to this point, with these clients in particular I would generally focus less on the outcomes and have them focus heavily on weekly behavioral goals instead.  As it will take a long time to lose this much weight, clients will get more consistent feelings of accomplishment from achieving small goals instead of looking at the overall goal (which can be discouraging).

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It is important to remember that two of the biggest predictors of long term adherence to an exercise program are the reality of their expectations and self efficacy (belief that they can do it).  Expecting too much and falling short obviously makes us want to give up which is why I try to emphasize realistic goals.  And giving them small weekly steps increases the belief that they can achieve the activity required which only sets them up for success.  Of course, you can probably see how this could work for non-obese clients as well…which it does.

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Side Note

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I chose to distinguish the training of Class 2 and 3 obesity from Class 1 or even just people in the overweight category because I think that goal setting should be different and the programs could actually be different between these groups to some degree (depending on the level of impact their obesity has on their movement).  I’ll talk more about this in my next post, but for now, I’d suggest employing the goal setting practices above for higher BMI clients.   But now that we’ve got that taken care of, let’s get into the training.

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*Note that the training I’m discussing here is if I am personally working with a client.  This is NOT the same as I’d recommend to an unsupervised person with obesity trying to get started on their own.*

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Assessments

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As many of you know, I’m big on assessments with clients.  However, in dealing with obese clients whether or not I use a formal movement assessment depends on their ability to actually move in the first place.  If they’re relatively young and otherwise healthy (Stage o or Stage 1 obesity) I’ll do a movement assessment as usual.  If their movement is greatly impaired or their obesity is really impacting their ability to move (due to pain, being deconditioned, etc) I skip it.  Of course, I could modify my assessment, but generally I don’t.  Someone in this position has bigger issues than whether they can dorsiflex their foot to X number of degrees or any other measure when it comes to movement.  Some may disagree and choose to assess anyway…and that is up to them.  Personally, I don’t always do it as I figure I can do it later when they’ve established themselves in some good nutritional and exercise patterns that will address their bigger issues.

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However, with clients that are in this category of obesity I think it is important to make sure to have their physician involved with doing some baseline and follow up assessments as well.  Measuring fasting glucose, lipid profiles, and various other health markers is wise to ensure that what you’re doing is actually making them healthier AND it serves as yet another marker of progress for the client.  And from a business perspective, their physician might notice what you’re doing and refer you more people…just sayin’.

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More to the point though, the doctor can also assess for sleep apnea (which can be related to depression and lack of weight loss) and other obesity related issues.  Free bonus tip:  If your client has sleep apnea make sure they get the mask refitted as they lose weight as it can become ineffective.

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Foam Rolling

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As a general rule, if a client can do this, we’ll do it.  If they can’t get down to the floor and up again without a big struggle, we skip it.  I do believe it is important, but not important enough to humiliate a client.  As they’re able, we’ll add it in.  The Stick may be an option for those who can’t get down to the floor if it is absolutely necessary.

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For those who can get down to the roller, remember that they’ll be putting a lot more weight onto a focused spot on their body and it can hurt.  If this is their first encounter with fitness that might be discouraging.  For this reason, we have 3 different foam rollers of increasing density with one being quite soft, and a little harder, and being the normal foam roller most would use.  I’ve found this helps.  My buddy Nick Tumminello also once mentioned putting a couple rollers under the area being rolled to increase the surface area and decrease pressure to get the same effect.  Nick is smart!

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Mobility Work

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For those clients I’ve done a formal movement assessment on, I will normally design the mobility program based on that.  For those I haven’t assessed, I make an assumption based on educated guesses as to what is typically tight/weak/etc.  This may be a crappy approach, but in the end, I’m getting people moving.  For many, breaks will be needed between drills and for some the drills alone can actually be the exercise session.

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Early in my career I used to try to make sure the client achieved their “planned workout”, but these days I think it is more important to just “roll with the punches” and work within the limits the client has.  Push a little.  Gain a little progress.  Show them small successes.  Then STOP!  Don’t force it.  Just encourage them and keep them coming back for more.  This will do infinitely more for anyone than breaking them down with hard workouts that make them overly sore and sick.

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Resistance Training

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Here’s the thing – with obese clients in these categories muscle will be lost with weight loss.  You can work to prevent it, but ultimately, it is going to go down.

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Here’s the other thing – many of these clients will have never worked out in their lives.  For most, it has at least been a long time.  Which ultimately means, it doesn’t really matter what you do (unless you do something completely idiotic) because they are going to get results (i.e., some muscle retention, strength, etc).

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I generally start these clients with 1-3 sets of 10-15 repetitions on 5-6 exercises in a whole body workout 2-3 times per week.  So on their first day (and for each workout for a few weeks) I might do 1 set of 10-15 on each of 6 exercises.  Over time I’ll bump it up to two sets.  And finally up to 3 sets.  Then I’ll probably move towards pairing antagonist exercises (like a row and a bench press), but keeping the same set/rep scheme.  Over time I may substitute in new exercises, but keep everything else the same.  In short, I keep it wicked simple.  My goal is to create CONSISTENCY as I think this is the most important factor for these folks.

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With increasing length of training time, strength, mobility, and weight loss their programs will start to look increasingly like my “normal” training programs, but at the start (and by start I mean first 3, 6, or even 9 months) their programs are pretty basic.

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Cardio

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While interval training may be faster and debatably “better” than steady state cardio (although I’m hard pressed to believe the second statement), I think it is probably the worst choice for a novice obese client.  I’ll often have them do as little as 10 minutes of moderate intensity cardio after a session and aim for a couple of extra walks (5-30 minutes depending on mobility, etc) during the week.  Ultimately, I tend to see walking as the gateway drug of fitness and while it isn’t necessarily the best exercise for weight loss, there are some remarkable health outcomes that can be brought about by walking alone.

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Over time I’ll increase the time (for the person who can only walk short distances) and intensity of cardiovascular activity for these clients.  Eventually I might include some more interval type protocols in the interest of time, but this would be far down the line and subject to client tolerance and interest in this type of training.  But the big thing you’ll notice in these programs is that resistance training is only typically 2 days per week (3 days max) and that my goal is to build up to 150-200 minutes of weekly physical activity by adding increasing amounts of cardiovascular activity (which can be as simple as walking).  Keep in mind that going from zero minutes of physical activity to 200 can take a LONG time…so patience is key and it is important to focus on the aforementioned small weekly steps forward.  Encouragement is paramount!

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Summary

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And that’s about it.  Pretty simple really.  I’m sure I’ve overgeneralized here as there are definitely cases where obese clients have done much less than this (only walking) and others have done much more.  Looking back, I’m not really happy with the article as I feel there are many more qualifiers and exceptions I should have included, but this would easily end up being a novel.

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In my next post I’ll discuss the differences between training those in these categories of obesity and class 1 obesity, and the following post will cover a discussion of nutrition for both groups.

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In the meantime, if you have a specific question related to this post, please ask in the comments section below and I’ll be happy to address it.

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Check out Part IV of this series HERE.

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If this article has helped you or you think it might help others please share it via Facebook, Twitter, or whatever social media you like or simply hit the “like” button below.

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In my previous post I wrote a little bit about the categorization of obesity in terms of classes (weight) and the staging of obesity (health measures) that I use to help me training clients with excess weight.

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Today I had planned to get started on describing the methods I use to train those with varying degrees of obesity when it struck me that a lot of fitness professionals don’t truly understand obesity and, as a result, are misguided in their attempts to help people lose weight.  Most certainly, people are eating more and moving less, but unless we understand WHY people are consuming more and failing to move it will be darn near impossible to address these issues.  Today, my goal is to share with you some of my thoughts and provide you with some resources so that you can begin to understand the root causes of obesity.  By understanding these you can put in place practices to address them and have incredible results with these clients.

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If you’re going to train people with obesity, you should understand it.

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As I mentioned above, by understanding the determinants of obesity you can work towards addressing them and by doing this your results with this population (remember that many people who think they need to “lose a few pounds” are clinically obese).  In fact, I’ve mentioned before that addressing these issues need not even be a burden for a fitness professional, but an opportunity to make more revenue and differentiate themselves in a very competitive market.

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Here I am going to provide a few great resources on obesity.  Many who read this won’t take the time to check them out, but those who do will be rewarded with an incredible amount of understanding of this complex problem and I can guarantee it will be eye opening.  When I first started formally working with this population I thought I had all the answers…and I certainly didn’t.  So trust me when I say that the time you take to do this will be worth your while.

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Here is what I would do:

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Go to the blogs of Dr. Arya Sharma and Dr. Yoni Freedhoff and sign up for updates via email, RSS, Facebook, Twitter, or whatever.  Read them as they come.  Get smart.  And, perhaps more importantly, you can go to the Canadian Obesity Network website and download their book Best Weight for FREE.  All you have to do is sign up for a membership (which is also free) and you can get your mitts on a copy.  Although it is more geared towards physicians treating obesity, it will definitely provide insight on how to manage those with obesity and barriers to weight loss including medications, sleep apnea, and tons of stuff you probably hadn’t even thought about.

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I would also suggest taking the time to watch the video HERE by Dr. Robert Ross on the Cardiac and Metabolic Benefits of Exercise.  Dr. Ross is a great speaker and he makes some great points in this presentation.

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Recognize that obesity is a chronic condition

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Obesity, much like hypertension (high blood pressure) is a life sentence.  In other words, once you have it, you’ve got it for life.  But also like hypertension, when it is managed appropriately through activity, diet, and lifestyle changes it can essentially be controlled to a point where the person no longer meets the criteria to be defined as obese.  However, just as with any chronic condition, if you stop the treatment (i.e., stop exercising and increase intake) the condition returns full force.

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So even if a person loses weight, eats well, exercises regularly, and has a seemingly stable new lifestyle pattern, it IS still a chronic condition and remission is possible (and actually likely).  In fact, MOST people who lose weight will gain it back (some suggest the number is as high as 95%) which is why my focus weight clients is NOT on weight loss per se, but on the behaviors and habits associated with those results.

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Frankly, I’m not impressed if someone reports that they’ve lost 50 pounds in 12 weeks with program X as I’m almost positive that most programs have failed to address the reasons why the person became overweight in the first place and the results will be temporary.  This is why I think it is important to a) make clients aware of the chronic nature of weight management, b) don’t offer or promote programs that deliberately contradict this statement, and c) don’t let clients bully me into helping them lose weight quickly on the promise of transitioning to a more sustainable program later.

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Appreciate that PERMANENT weight loss is a slower and more behavior oriented practice.  And that practice must be forever as the condition most certainly is as well.

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Eliminate Your Bias

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Imagine going to get professional help with something and the person who was supposed to help you (i.e., the person who SHOULD be in the best position to help you) had an inappropriate preconceived notion that you were unintelligent just because you worked in a gym?  And what if their help towards you was based on this assumption?  What if they treated you like you were unintelligent?  How much help would they be to you?

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Taking this back to obesity, what if you (the person who SHOULD be in a position to help) were uneducated about obesity and had assumptions and biases that were actually AGAINST the person you were supposed to help?  How much help would YOU be?

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As a whole, I think that the fitness profession (who should be the ones equipped to make a difference with weight management) are probably the worst off when it comes to biases and stereotypes against obese folks.  In fact, we are so busy reading about the latest and greatest fat loss workouts or diets that we fail to educate ourselves on the ACTUAL causes of obesity (note: it has nothing to do with the fact that they didn’t properly time their post-workout shake with 20 grams of whey, 6 grams of BCAAs, creatine, and waxy maise).  So, if we want to be a force for ending this epidemic, we need to understand it…and rid ourselves of our biases.

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The first step to this is to identify your biases and then you can proceed to address them.  I wrote a post about a tool you can use to do this HERE.

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So that’s it for today.  Bookmark this if you need to, but make sure to take advantage of those resources because they are the foundation upon which my methods for training obese people are built.  Next time I’ll get into the actual practices of training obese clients.

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Check out Part III of the series HERE.

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Drop me a comment below and let me know what you think!  If you’re in the fitness industry and think your colleagues could benefit from reading this please don’t hesistate to share it.

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Notice I selected a picture of an obese person that didn't involve inaccurate stereotypes of them eating crappy food or being lazy.

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Over the past year or so a few fitness professionals (many of whom I respect) have written blog posts on how to train people with obesity.  As someone who is very familiar with this area, I figured I’d chime in with my own thoughts to add to the discussion and information about training this specific population for those who are interested in my take on the subject.

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As some of my readers know, I do some work for one of the very few government funded bariatric medical programs in my province providing evidence based (i.e., research backed) treatment for patients with obesity.  In our clinic we see hundreds of patients per year with weights ranging from 250 to 700 pounds.  My main role is to oversee the design and implementation of the exercise component of the program to get everyone exercising regardless of their physical, emotional, psychological, and economic limitations.  Combining that with my ongoing experience in the private sector in training people for fat loss (both online and in person), I feel that I’m in a good place to share my views on the topic.

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Definitions, Categorization, Etc.

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Before we can really talk about obesity though, we’ll need to clear up some definitions and lay down a foundation of understanding about how it is categorized.

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In short, obesity is defined and categorized primarily based on something called the Body Mass Index (BMI) which is essentially a height-weight scale.  In a publication in the early 1970′s it  scale was created as a proxy to determine body fatness in relation to height and weight, but more recent evidence suggests that this isn’t exactly true.  I’ll get into that in a bit, but for now you should know that BMI is the most widely used tool for the categorization of obesity in a medical setting.

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If you want to determine your BMI you can go HERE and use the calculator to let you know where you’re at.

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Categorization Based on BMI

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Under 18.5  -  Underweight

18.5 – 25  – Normal Weight

25 – 30  -  Overweight

30 – 35  -  Class I Obesity

35 – 40  -  Class II Obesity

Over 40  -  Class III Obesity

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Although this is the accepted World Health Organization categorization for obesity, it is pretty arbitrary and the divisions between most of the categories have no scientific explanation.  And since their are regional differences in “normal” body weights,  some places have different categorizations for obesity.  For example, the Japanese categorize anyone with a BMI of 23 as overweight and anyone with a BMI of 25 as obese.

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Of course, any astute fitness minded person will also note that BMI is limited in that it is not able to determine actual muscle and fat weight so someone who works out regularly and has a higher muscle mass might be categorized as obese while actually being quite lean.  In fact, the reverse can actually true as well which means that people with a “normal” body weight might actually carry an excess amount of body fat.  These are the people that we might call ”skinny-fat”, but are clinically defined as having normal weight obesity.

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Although I’m not sure this is universally agreed upon, having a body fat above 20% for males and 30% for females would make you obese regardless of your BMI.  And all of this leaves out the fact that where that fat is distributed may have an effect on cardiac health (i.e., fat around the waist = bad, fat around the hips = good) so you may be in danger regardless of whether or not you actually have a lot of fat.

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The Staging System

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So thus far we’ve talked about categorization of obesity based on weight and to some degree we’ve talked about body fat percentage without mentioning the methods used to measure body fat which is a different post entirely (Short version: Your home bathroom scale that measures body fat probably sucks).  However, to train people with obesity it is important not to just know how much they weigh, but the degree to which obesity is actually impacting their health, movement, etc.  To determine this it is helpful to determine the “stage” of obesity using something called the Edmonton Obesity Staging System (EOSS).  While I could type it all out for you, I’ll just swipe it from the site of Dr. Arya Sharma who is one of the creators of the system.

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STAGE 0: Patient has no apparent obesity-related risk factors (e.g., blood pressure, serum lipids, fasting glucose, etc. within normal range), no physical symptoms, no psychopathology, no functional limitations and/or impairment of well being.

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STAGE 1: Patient has obesity-related subclinical risk factor(s) (e.g., borderline hypertension, impaired fasting glucose, elevated liver enzymes, etc.), mild physical symptoms (e.g., dyspnea on moderate exertion, occasional aches and pains, fatigue, etc.), mild psychopathology, mild functional limitations and/or mild impairment of well being.

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STAGE 2: Patient has established obesity-related chronic disease(s) (e.g., hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, anxiety disorder, etc.), moderate limitations in activities of daily living and/or well being.

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STAGE 3: Patient has established end-organ damage such as myocardial infarction, heart failure, diabetic complications, incapacitating osteoarthritis, significant psychopathology, significant functional limitation(s) and/or impairment of well being.

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STAGE 4: Patient has severe (potentially end-stage) disability/ies from obesity-related chronic diseases, severe disabling psychopathology, severe functional limitation(s) and/or severe impairment of well being.

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Looking at the list above, you might discover that as a client you have a person who is actually has Class III obesity, but is a stage zero and has no related health or mobility problems.  This could be a guy who was a lineman on his college football team, maybe he’s actually still fairly active, and he’s not sick.  This guy might thrive with hard training and a slowly integrated nutritional program.

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Training this guy might be different than working with someone with class I obesity that is a stage 3 and has disabling arthritis making it difficult to move let alone hit up some heavy squats.  This person would obviously require a drastically different program which is why I get worried when I see generalized recommendations for training obese folks.

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And if YOU are an “offseason” bodybuilder or you just train regularly and don’t have a solid nutrition program you might have gotten off easy before with the old mantra that “BMI doesn’t take into account my muscle mass so I’m not really obese”, but now you know that if your body fat is breaking 20% (or 30% for women) you ARE obese.  And you might actually be a class 1 or 2 on the staging system too.  You know that heartburn you’ve been getting and the slightly elevated blood pressure that you’re not paying attention to?  Those are potentially obesity related issues.

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So if you wonder why I spend so much time talking about obesity on my blog it isn’t because I’m talking about someone who is vastly overweight.  In my experience, most people who see themselves as having “only a few extra pounds” are actually clinically obese…and this includes those who exercise regularly and even fitness professionals themselves (we are not immune).

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Now that we’ve covered the basics and some definitions, in my next couple posts I’ll come back and drop some information about how I would go about training someone with different classes and stages of obesity.

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Check out Part II of the series HERE.

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PS:  If this post helped you or you think it would benefit others please share it.

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PPS:  Please feel free to join me on Facebook and Twitter.

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A while back I was very fortunate to connect with a very bright guy named Chi Chiu and recently began having a discussion with him about Gary Taubes new book Why We Get Fat.  I meant to get around to purchasing and reviewing the book myself, but given Chi’s passion for the topic (and the fact that he’s an evidence based uber genius) I asked him to do a guest blog about it.  I have to say…he certainly didn’t disappoint.  If you’re thinking about purchasing or have already read Why We Get Fat, you need to read this!

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Take it away Chi!

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This is not your typical review, because at the time of writing it, I do not own the book nor have I read it. It would have been easy for me to simply buy the book, read it, and write you a review, but I chose not to. Instead I’ll let Gary Taubes himself, try to convince me, to buy his book.

Gary Who?

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Gary Taubes is a science writer who has a Masters in applied physics and one in journalism. He has written numerous articles, but became an overnight sensation with the most controversial article of 2002 in the New York Times, ‘What If It’s All a Big Fat Lie” in which the role of (saturated) fat as a cause of cardiovascular disease was questioned. A bestseller “Good Calories, Bad Calories” followed. Taubes has won several awards during his career and recently he published “Why We Get Fat and What to Do About It.”

Where to start?

Most coaches get annoyed when they get advice from people who have no real world experience. I don’t care that Gary Taubes is a writer-only, and is not in the trenches with us. I’ll judge him solely on the information he provides.  He recently started a new blog to promote his book and there are numerous podcasts and YouTube interviews available, so you can get a general sense of what the major concepts in his book are and whether it is worth spending your hard-earned money on.

My first impression of Taubes is that of a reasonable man, posing reasonable questions.  He does not defy the energy balance and he seems to be genuinely annoyed by the failure of the widely promoted low-fat dogma combined with exercise approach to combat obesity. So let’s see what else he’s got to say.
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The Significant 20 kcal

His first post on his blog is about the significant 20 kcal per day. It’s a thought experiment on how eating one or two bites (20 kcal) too many can lead to 2 pounds of excess fat a year and 40 pounds in a period of 20 years (365 x 20 kcal x 20 years / 3500). So when you overshoot only 1 energy percent of your energy requirement, obesity will be inevitable.

With only such a small margin, it would be impossible to maintain a stable weight for longer periods. He argues that the body does not have such an accurate bookkeeping system and that therefore the laws of thermodynamics, while true, cannot explain why we do or do not get fat.

The 20 kcal per day thought experiment is actually a classic one, with many variations found in textbooks. He uses it to ridicule the counting calories approach as a means to maintain or lose weight. In a podcast Taubes jokes that the laws of physics only make sense, when you apply math skills of an eighth grader. And although it’s amusing, that doesn’t necessarily make it true.

Whether the body has an accurate enough bookkeeping system or not, is actually irrelevant. Thermodynamics controls this process all by itself, because weight change is self-limiting. Those extra two bites lead to more mass, which needs to be maintained and carried around. This comes at an energy expense and quickly leads to energy equilibrium. The other way around is that losing weight will lead to less mass and lower resting metabolism. These natural restrictions create a bandwidth and explain perfectly why a set point can be reached without high precision bookkeeping (Katan MB 2010).

This is a well-known fact and physiologists have developed mathematical models that accurately predict the required energy surplus to gain a certain amount of mass during a specific period. According to one of those models, a woman in her twenties with a BMI of 23 needs an excess of 370 kcal per day to get to a BMI of 29 in a period of 30 years (Katan MB 2010), a far cry from the 20 kcal Taubes suggests. 

In the same post he devotes at least a dozen paragraphs on why thermodynamics does not explain why we get fat, while ridiculing experts in the process. He uses a restaurant analogy to show that the laws of physics will only tell you that a restaurant is crowded because more people went in then there went out.

Well, the restaurant analogy therefore tells you quite accurately why people get fat and even what to do. Hire a door bitch!

[Note from Mark : A door bitch is a person who stands outside of a bar or club alongside the bouncers and chooses which people beautiful people to let in and which to keep out.  Don’t worry…I had to look it up too]

Of course it doesn’t tell you why people want to get into the restaurant in the first place and he ridicules the experts for not knowing the answer. In my experience, authorities that tell you that they do not know the answer are usually the real experts. Unlike the dime a dozen wannabe gurus whom seem to have all the answers. Taubes also claims to have the answer which I will cover in the next section.

Although the laws of thermodynamics don’t tell you the complete story, they give you the boundaries. You cannot create something (mass) from nothing and the calories in / calories out concept is therefore not useless. After reading this post I was wondering whether this was representative for his book. The fact that he mentions that there is a whole chapter on the significant 20 kcal per day, suggests that the book must be filled with incorrect assumptions and useless over bloated analogies.

Why Diets Work, When They Do

While I found the first post somewhat amusing, the second blog post made me wonder whether I was actually wasting my time. The main concept of his post boils down to the following assumptions. 

1. Carbs are bad and make you fat

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2. Restricting calories is restricting carbs

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3. Weight loss through calorie restriction is carb restriction and any weight loss success may therefore be solely attributed to carb restriction. 

He covers a couple diet intervention studies and accuses the authors for not controlling the relevant variables, because they only control calories instead of carbs. The authors of the study actually only set out to control one single variable and that’s (the adherence to) the diet. Nothing wrong with that and for the most part they succeeded nicely. Adherence to the diet is the deciding factor, because it simply makes you eat less.

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Taubes then goes on that the hypothesis of carb restriction as a causal factor for weight loss, has never been tested and that therefore all results of the covered studies are unreliable. He needs more than 3800 words for this rant and fails to mention one of dozens metabolic ward studies (Grey N 1971, Kinsell LW 1964, Krehl WA 1976) that already refuted his unfounded assumption. No significant difference in weight loss has ever been established in studies designed to compare a low-carb with isocaloric high carb diet. The authors of the covered studies did not control the carb variable, because they already knew that particular answer. It would have been as useful as testing whether hot water is indeed warmer than cold water.

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Taubes articles and the increasingly popular paleo diet have fuelled the low-carb interest. They seem to inspire each other and Taubes does mention hunter-gatherer tribes more than once in his interviews. The general idea seems to be that hunter-gatherers eat low-carb.

Taubes mentions in a PODcast that Eskimo’s don’t eat carbs at all, while demonstrating great athleticism. This is a common misconception. I actually own a ‘carbs gone wild’ edition of an Inuit cookbook with no less than 240 pages exclusively with plant based recipes. That’s a whole lot of pages for a non-carb population. It comes as no surprise, that a study found that the Inuit actually have a daily carb intake of 127 grams  (Bang HO 1980). Taubes was of 20 times with the calories in/calories out calculation, but with the Eskimo’s he manages to miss the mark by 127 times. The 127 gram carbs may still be considered low-carb, but the Inuit are not living fossils nor are they representative for all hunter-gatherer tribes. The dietary pattern of the Kitava Indians for example, consists of around 70% carbs and yet obesity, diabetes, heart-disease and exercise for that matter, are non-existent in that tribe (Lindeberg S 1994). Paleo is not low-carb per se and carbs are not the causal factor for all western diseases.

It’s All Insulin, Bro!

In his third blog Taubes cites a couple of biochemistry books. The basic premise boils down to the following.

1. Insulin stimulates fat cells to accumulate fat while inhibiting fat mobilization

2. Chronic high insulin levels lead to insulin resistance and less uptake by the muscles and more uptake by the fat cells

3. Carbs lead to a high insulin response, which leads to B, which leads to A, which leads to why we get fat

He then goes to say that this insulin resistance is the underlying defect of obesity, diabetes and heart disease. Notice that he states ‘the’, not one of them or a risk factor, but the defect. He also states ‘underlying’, not contributing, not shared, not correlated, but he suggests it’s the causal factor. We get fat because we become insulin resistant, seems to be his main message.

This does not explain why more than 25 percent of obese persons are not insulin resistant (Stefan N 2008, Wildman RP 2008). The statement that it is the underlying defect, is at least an exaggeration, but that does not mean that insulin resistance may not be one of the causal factors.

Taubes mentions a lot of rodent studies, because human studies on the subject do not exist, for good reasons. To study it, you need to shut down the insulin receptors, but then you’ll die within days, which is an inconvenience. The fact that there is not enough time to get you obese, is of course the major obstacle. The next best thing is to shut down the liver insulin receptors and that’s what researchers have done with the so-called “knock-out mice”.

Having no receptors will of course lead to 100% local insulin resistance, which progressed into systemic insulin resistance with these mice. This was an interesting finding, but even more interesting was the fact that the mice did not get obese (Cohen SE 2007, Michaels MD 2000). So the little evidence that actually exists on the topic, suggests that insulin resistance is not the causal factor of obesity. 

If the insulin hypothesis is the heart of his book, it’s flawed. Not to mention all the nitpicking I can do on the claims he makes on insulin physiology, but it would take multiple posts to debunk all of them, like carbs being the sole driver of insulin response or his rather incomplete picture on how fats get stored and oxidized, etc. I can only add that I find it shocking, how many of his ideas seem to be based on conflicted or even refuted theories.

Saturated Fat, Can You Handle Me Baby?

The last part of his third blog post and the main topic on his fourth is the diet-heart hypothesis. He refutes the idea that saturated fat (SFA) causes heart disease and I have to agree with him. A recent review (Mozaffarian D 2010) containing intervention studies, suggests that saturated fat increases coronary events, but they were mostly JADAD level 2 studies. In other words they were poorly controlled. If you have no idea what that means, may I suggest purchasing Mark’s product How to Read Fitness Research.

In the same year another publication (Ramsden CE 2010) showed no causal relation between SFA intake and coronary incidents. The authors were rigorous in obtaining missing data and shed new light on well-known studies. They also suggest that coronary incidents increase when you replace SFA with omega-6 oil. A practice that is actively promoted for deep frying and may get people killed.

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An invitation-only symposium last year in Denmark, lead to a recent consensus statement  (Astrup A 2011) shedding even more doubt on the contributing role of SFA in coronary disease. Even Dr. Daniel Steinberg, a world-renowned cholesterol specialist with over 400 published articles, states in his book that he does not support the diet-heart connection.

What to Do About It…according to Taubes

The subtitle of Taubes book is ‘What to do about it’ and that seems obvious. Stay off the carbs, don’t worry about the increase of dietary fat and the obesity epidemic will soon be over.

I counsel ‘how to lose the love handles’ clients, elite athletes, and bodybuilders (two of whom happen to be national champions) so I know a thing or two about weight loss. I have been involved in various nationwide multicenter lifestyle programs for obesity, diabetes, COPD, pregnancy, kids, low back pain, and RSI.

In most cases I co-developed the programs with experts, trained the practitioners and collected the data. In a 2-year multicenter (n=80) obesity program I’ve seen the results of thousands of obesity clients. I’ve seen the effect on weight, on physical, emotional and social functioning. I’ve seen the joy, the pain, the envy, the relapses and the recoveries. I’ve collected data through SF-12 surveys, the MHI-5, diaries, HRV measurements, weight scales and other health related tools. So, I know a thing or two about obesity.

I was shocked by the McKinsey report (2011) on the ‘real’ cost of obesity, which estimates a stellar sum of 450 billion dollar annually in the US alone. I find that hard to believe, because I found the report very limited. We have no idea what causes the obesity epidemic or whether it’s even bad for your health. There is no mention of the obesity paradox, a phenomenon where obese people are healthier and live longer than their slimmer counterparts.

So what about the unnecessary costs of overtreatment of obesity? No mention of confounding variables either. Most studies are from the United States, where the income gaps are huge. We know that low income is correlated with obesity, but most studies have not corrected the relationship of social economic status (SES) on disease endpoints. This is not a minor issue, knowing that in the US around 50 million (!) people lack health insurance (during any period of time).

So do poor obese people die from fat accumulation or from insufficient, but unrelated treatment? Or do poor obese people eat more cheap calorie dense food, deep fried in so-called heart-healthy omega-6 oil, which may get them fat and killed at the same time?

We also know stress kills and obese people have a lot to stress about like negative self-image issues, ridiculing, and even discrimination. On top of that, most of them weight cycle their whole lives, adding more to the stress, while increasing inflammation, which seems to be an integral part of weight cycling.

So what is it, that makes the obese sick? Is it fat accumulation, is it excess omega-6, is it lack of health-insurance, is it a negative self-image, an increase of inflammation, discrimination and therefore the McKinsey report itself? The interventions to heal the obese may actually contribute to the sickness, the increased mortality and therefore to the cost of obesity.

Obesity is not a simple problem that can be solved by buying a book, based on some serious flawed theories. If you think you are actually helping your obese clients with a low-carb diet and high intensity interval training, you may in fact have shortened their lives by a couple of years. Working with the obese requires specific knowledge and commitment, so if your program is an overweight XXL version of the program you have for your non-obese clients, please quit and give your clients a refund!

Not Your 23 Dollar Bill

From a hypothesis point of view, I’ve seen nothing novel in Taubes vision in Why We Get Fat. fat. Anyone who has some notion on alternative nutritional views will notice the familiar concepts. And of course some of it has merit, but some of it is out of context or even downright wrong.

If you already bought the book, or were sold on the concept, don’t feel bad about it. It’s like accepting counterfeit money. Nobody will blame you for it. It’s not like you accepted a 23 dollar bill and Taubes book is not as obvious as a 23 dollar bill. It looks like real money, it feels real money. it may even smell like real money, but that doesn’t make it real.

Then there is the ethical question. If it can pass for real, because people do tend to lose weight when following a low carb diet, what would be the harm in embracing the book? The same holds true for counterfeit money. If it looks real and you can pay with it, why should you stop using it?

There are actual several reasons. First of all is that someone gets hurt further down the line, because it will come out eventually. This will reflect badly upon you, which is of course your problem. But mind that it will reflect badly on our profession as well, which concerns us all.

The second reason is that we make progress, because we have rational in-depth theories that we turn into great experiments with outcomes we learn from.  Storytelling without conclusive evidence however, has kept us in the dark ages for centuries.

Do you really want to return to medieval ages where science had no place and babies died for what we now consider trivial reasons? I don’t think so!

Conclusion

Believing is accepting without proof, which is not a bad thing by itself, if you’re open to non-supporting evidence. Taubes selective citations and inappropriate examples suggest that he is more than just a believer, he seems to be a radicalist, ridiculing anyone opposing him. Judging Taubes own blog posts and interviews, I can only conclude that his book is unreliable. It’s not all bad, but if you cannot separate the good from the bad information, it will make you unreliable.

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The many flaws in his hypothesis make it impossible to answer the question of why we get fat. The subtitle ‘and what to do about it’ offers no real solution and does not take into account the complexity of (treating) obesity. This is the reason why I did not buy this book and will not recommend it to anyone else.

References

• Astrup A (2011), Dyerberg J, Elwood P, Hermansen K, Hu FB, Jakobsen MU, Kok FJ, Krauss RM, Lecerf JM, Legrand P, Nestel P, Risérus U, Sanders T, Sinclair A, Stender S, Tholstrup T, Willett WC. The role of reducing intakes of saturated fat in the prevention of cardiovascular disease: where does the evidence stand in 2010? Am J Clin Nutr. 2011 Apr;93(4):684-8. Epub 2011 Jan 26.
• Bang HO (1980), Dyerberg J, Sinclair HM. The composition of the Eskimo food in north western Greenland. Am J Clin Nutr. 1980 Dec;33(12):2657-61.
• Cohen SE (2007), Kokkotou E, Biddinger SB, Kondo T, Gebhardt R, Kratzsch J, Mantzoros CS, Kahn CR. High circulating leptin receptors with normal leptin sensitivity in liver-specific insulin receptor knock-out (LIRKO) mice. J Biol Chem. 2007 Aug 10;282(32):23672-8. Epub 2007 Jun 7.
• Grey N (1971), Kipnis DM. Effect of diet composition on the hyperinsulinemia of obesity. New England Journal of Medicine, Oct 7, 1971; 285 (15): 827-831.
• Katan MB (2010), Ludwig DS. Extra Calories Cause Weight Gain — But How Much? JAMA, January 6, 2010—Vol 303, No. 1
• Kinsell LW, et al. Calories do count. Metabolism, Mar, 1964; 13: 195-204.
• Krehl WA (1967), et al. Some Metabolic Changes Induced by Low Carbohydrate Diets. American Journal of Clinical Nutrition, Feb, 1967; 20: 139-148
• Lindeberg S (1994), Nilsson-Ehle P, Terént A, Vessby B, Scherstén B. Cardiovascular risk factors in a Melanesian population apparently free from stroke and ischaemic heart disease: the Kitava study. J Intern Med. 1994 Sep;236(3):331-40.
• McKinsey Quarterly (2011) The real cost of obesity, January 2011
• Michael MD (2000), Kulkarni RN, Postic C, Previs SF, Shulman GI, Magnuson MA, Kahn CR. Loss of insulin signaling in hepatocytes leads to severe insulin resistance and progressive hepatic dysfunction. Mol Cell. 2000 Jul;6(1):87-97.
• Mozaffarian D (2010), Micha R, Wallace S. Effects on coronary heart disease of increasing polyunsaturated fat in place of saturated fat: a systematic review and meta-analysis of randomized controlled trials. PLoS Med. 2010 Mar 23;7(3):e1000252.
• Ramsden CE (2010), Hibbelna JR, Majchrzaka SF, Davisa JM. N-6 Fatty acid-specific and mixed polyunsaturate dietary interventions have different effects on CHD risk: a meta-analysis of randomised controlled trials. British Journal of Nutrition (2010), 104: 1586-1600
• Taubes G Blog post 1 to 4 on www.garytaubes.com

Chi L. Chiu has a master’s degree in nutrition, one in health sciences and is currently a grad student psychology. He is the owner of Chivo personal training, Chivo physical therapy, Chivo sports performance and Chivo Continuous Professional Development center for lifestyle professionals. He is a member on various government en non-government funded advisory boards and works with clients on a daily basis.

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PS: Leave a comment below and let me know what you think.  Agree?  Disagree?

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PPS: No…he doesn’t have a blog.  I’m trying to push him into it…trust me.

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I figured I’d start out today with a quote from Dr. Arya Sharma’s because I think everyone trying to lose weight or help others lose weight should be reading his blog.

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“Public health discussion on preventing obesity that focus on eating less and moving more may do little more than perpetuate the already widespread stereotype that people, who are obese, carry that excess weight simply because they eat too much and don’t exercise enough.

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This is not a ‘healthy’ public discussion to have – as it calls on governments to intensify the ‘blame and shame’ game (adding a punitive touch when it comes to taxing and banning) rather than addressing the real underlying problems, which is that as a society we no longer have time to eat, have jobs that force us into sedentariness, make unhealthy food cheaper than healthy options, build cities that discourage active transportation, and create a latch-key generation of kids that cannot come home to a simple home-cooked meal eaten by the whole family seated at the table (with the television off).”

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I can’t even tell you how much I agree with that a statement.  If you are a fitness professional yourself, you need to think about how this statement relates to your practice and even your thoughts about weight management.

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And speaking about thoughts on weight management (see how I did that little seque there?) my question for all my readers who are fitness professionals is CAN WE HELP PEOPLE THAT WE ARE BIASED AGAINST?

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Despite trying to help people, many of us our equally as guilty of biases against people obesity as the general public (and even obese people themselves).  Today I thought it would be interesting to share a little resource I’ve discovered from the Yale Rudd Center to help you determine how weight bias is impacting YOUR beliefs. 

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You can check it out HERE.

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Simply fill out the ATOP (Attitudes Toward Obese Persons) and BAOP (Beliefs About Obese Persons) questionnaires and use the scoring sheets on the site to see how you did.  If you’ve got time, you can even do some of the other tests on the site.

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I think you might be surprised to find out what your real perceptions are.  I certainly was when I did these tests over two years ago and it changed my entire philosophy towards dealing with obese people for weight loss.  In short, I think helping people with weight loss first starts with the perceptions of those in a position to help.  If you think it is all their fault and are playing the blame game like everyone else, do you think they’re really going to listen?

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Take the tests and let me know how you make out in the comments below.

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Today I want to switch gears and share a reader question that I’ve received and a snippet of my answer.  But first, a little background.

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Within the body there are two main types of adipose (fat) tissue.  White adipose tissue is probably what you’re most familiar with as this is what you’ll be spending most of your time and effort trying to lose when you’re on a fat loss plan.  Brown adipose tissue (BAT) or brown fat, on the other hand, is actually metabolically active fat and can contribute to thermogenisis and calorie burning due to the large number of mitochondria within the cells.  Some have actually proposed that new weight loss drugs will be able to target brown adipose tissue to increase calorie output and increase weight loss as a result.

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Which leads me to our reader question…

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I think it’s great that we find out as much about our physiology as possible, but then using this just to give fat people drugs to raise their BAT content, so they can eat as before or even more is quite perverse.  What about dieting?! This is a great dilemma of our society today.  Always trying to find the easy way out (i.e. pharmaceuticals) instead of just trying hard enough by dieting (and exercising).  What do you think about this?

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And my answer…

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In terms of obesity management, there are still many unknowns, but one thing we do know is that diet and exercise typically only prove useful in the short term as many people (over 95%) will regain some or all of the weight lost in the long term.  So just saying “exercise more and eat less” is not an effective strategy for weight management in this group.  They don’t fail because they don’t understand WHAT to do.  It is more about application.  Further, this underscores the need for a greater focus on the cognitive and behavioural strategies for weight loss which is the focus of much research and practice right now.

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However, we also know that previous anti-obesity drugs can not only help morbidly obese patients lose 5-10% of their body weight (not a lot, but the amount required to improve health markers dramatically) and keep it off with greater success.  In the wake of drugs like Merida being pulled from the market (due largely to use on contraindicated patients) and other drugs like Contrave and Qnexa getting rejected by the FDA, there is only one anti-obesity drug on the market right now.  That drug (called Xenical) is a fat blocker and it is not really well tolerated as it can lead to loose stools and a bad sneeze could totally ruin your day.

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How is it that we have drugs for Diabetes, depression, hypertension, anxiety, and almost any other problem under the sun, but we can’t treat obesity???  Isn’t this THE single biggest epidemic causing many of the conditions above?  (Hint: Part of the reason is weight bias and discrimination where we think obesity it solely the fault of the afflicted.  This stereotype needs to change.)

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Now I am not saying that we should medicate INSTEAD of behavioural treatment, dietary counselling, and exercise, but I think that medication in conjunction would go a long way to making weight loss more sustainable and improve the health of these people.  To take it further, the previous classes of drugs for obesity that act like stimulants will probably never survive the FDA panels.  New classes like GLP1 Agonists are coming, but drugs for BAT might just save lives.

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And I don’t think these should be for the general population who want to lose a few pounds, but I have no problem treating people for obesity with these drugs.  After all, the very best drugs have only resulted in just over 5% weight loss anyway.  While this is great for obesity treatment and health, most people wouldn’t even bother.

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Which, of course, leads to the question…if we can’t create drugs that safely produce more than 5% weight loss, what makes people think there are supplements that can do more?

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So that’s my perspective.  What do you think?  Agree?  Disagree?  Let me have it in the comments section below.

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Yesterday I posted a link to an article that talked about many of the psychosocial elements that play into the success or failure of a weight loss program with obese clients. 

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In the comments below, another Canadian fitness professional named Kyle Grieve asked what I think is a very important question:

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“For people in the fitness industry, how will we ever be able to treat the physiological, psychological, or sociological issues they have?  It’s way out of my scope of practice.”

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To me, rather than being a limitation, perhaps this is an opportunity for those fitness professionals working with obese clients to add another approach to their paradigm.  Many private fitness studios have physiotherapists and massage therapists to with with things that are beyond the scope of most strength coaches and trainers.  Why not add a social worker to the team and offer counselling as well?

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The studios that do this would invariably set themselves miles apart from those that don’t and, as I said before, I think this is going to be the future of weight management.  Dealing with client nutrition and training is going to be futile in the long run unless you deal with their barriers in the first place.

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From a business standpoint (because you can’t run a business without making money) it is another service that can be billed for.   Since group classes often work well in this regard, the cost to clients could be low and the facility owner could make a tidy profit.  This is a win for the client and the owner of the facility. 

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The other point to be taken home is that those not trained to deal with the psychosocial elements in weight management should step back and leave it to those who are or refer out for such counselling to run parallel to their training/nutrition efforts.  If a client got injured you’d refer out right?  Why not here?

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And finally, I’ll state again that I think that addressing barriers to fat loss should not only be limited to morbidly obese clients, but to anyone who needs a lifestyle change whether pursuing fat loss or muscle gain.  If you think about it, do your clients struggle because they don’t know what to eat or how to train (they should if they’re paying you) or is it because they’re “just not getting it done” for some reason?  If this is the case (and it will be for most people) then this is where extra attention needs to be spent.

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More time hammering home the importance of good nutrition and not missing workouts alone isn’t going to do the trick.  After all, if that worked the number of overweight people in North America wouldn’t be nearly so high would it?

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PS: Don’t forget to leave me a comments on THIS POST to score your free copy of Nick Tumminello’s Strength Training for Fat Loss DVD which I’ll do a draw for tomorrow morning.  Go get it!

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PPS: If this post strikes a chord with you, please consider sharing it.  This is most certainly a topic that I’m very passionate about.