Slimming Books

[Dorthea Seate]

OnChristmas morning, my sister-in-law watched me open her gift, her face frozen in anticipatory excitement. It was a dingy paperback copy of a book called Slimming Down, authored by longtime Johnny Carson sidekick Ed McMahon. It was a product of its time: red and orange text on a canary yellow cover,

In the coming days, I devoured the book, eagerly reading out excerpts to my family, who met them with delight. We visited a used bookstore, and I found myself bringing home copies of I Prayed Myself Slim and What Would Jesus Eat?

Nearly all of the diet books in my collection have a sinister side, a willingness to profit off the deeply human desire for love, connection, and longevity. I spend my days writing about the social realities of being a fat person, and critiquing a culture that insists upon thinness at nearly every cost. It is a strange pairing, me and this collection.

But taken together, I find this collection of diet books to be extraordinarily liberating. They shed so much light on some of the most insidious, dangerous parts of diet culture. Many champion disordered eating. Most posit that changing our bodies is the one true way to tackle our own insecurities, making our nebulous anxieties into a clear task, albeit a Sisyphean one. And all serve as a timely and welcome reminder that no diet is a panacea, and no changes to our bodies will deliver us from the glorious, messy work of being human.

Institute of Medicine (US) Subcommittee on Military Weight Management. Weight Management: State of the Science and Opportunities for Military Programs. Washington (DC): National Academies Press (US); 2004.

The most important component of an effective weight-management program must be the prevention of unwanted weight gain from excess body fat. The military is in a unique position to address prevention from the first day of an individual's military career. Because the military population is selected from a pool of individuals who meet specific criteria for body mass index (BMI) and percent body fat, the primary goal should be to foster an environment that promotes maintenance of a healthy body weight and body composition throughout an individual's military career. There is significant evidence that losing excess body fat is difficult for most individuals and the risk of regaining lost weight is high. From the first day of initial entry training, an understanding of the fundamental causes of excess weight gain must be communicated to each individual, along with a strategy for maintaining a healthy body weight as a way of life.

The principle of weight gain is simple: energy intake exceeds energy expenditure. However, as discussed in Chapter 3, overweight and obesity are clearly the result of a complex set of interactions among genetic, behavioral, and environmental factors. While hundreds, if not thousands, of weight-loss strategies, diets, potions, and devices have been offered to the overweight public, the multi-factorial etiology of overweight challenges practitioners, researchers, and the overweight themselves to identify permanent, effective strategies for weight loss and maintenance. The percentage of individuals who lose weight and successfully maintain the loss has been estimated to be as small as 1 to 3 percent (Andersen et al., 1988; Wadden et al., 1989).

Evidence shows that genetics plays a role in the etiology of overweight and obesity. However, genetics cannot account for the increase in overweight observed in the U.S. population over the past two decades. Rather, the behavioral and environmental factors that conspire to induce individuals to engage in too little physical activity and eat too much relative to their energy expenditure must take most of the blame. It is these factors that are the target of weight-management strategies. This chapter reviews the efficacy and safety of strategies for weight loss, as well as the combinations of strategies that appear to be associated with successful loss. In addition, the elements of successful weight maintenance also will be reviewed since the difficulty in maintaining weight loss may contribute to the overweight problem. A brief discussion of public policy measures that may help prevent overweight and assist those who are trying to lose weight or maintain weight loss is also included.

Increased physical activity is an essential component of a comprehensive weight-reduction strategy for overweight adults who are otherwise healthy. One of the best predictors of success in the long-term management of overweight and obesity is the ability to develop and sustain an exercise program (Jakicic et al., 1995, 1999; Klem et al., 1997; McGuire et al., 1998, 1999; Schoeller et al., 1997). The availability of exercise facilities at military bases can reinforce exercise and fitness programs that are necessary to meet the services' physical readiness needs generally, and for weight management specifically. For a given individual, the intensity, duration, frequency, and type of physical activity will depend on existing medical conditions, degree of previous activity, physical limitations, and individual preferences. Referral for additional professional evaluation may be appropriate, especially for individuals with more than one of the above extenuating factors. The benefits of physical activity (see Table 4-1) are significant and occur even in the absence of weight loss (Blair, 1993; Kesaniemi et al., 2001). It has been shown that one of the benefits, an increase in high-density lipoproteins, can be achieved with a threshold level of aerobic exercise of 10 to 11 hours per month.

For previously sedentary individuals, a slow progression in physical activity has been recommended so that 30 minutes of exercise daily is achieved after several weeks of gradual build-up. This may also apply to some military personnel, especially new recruits or reservists recalled to active duty who may be entering service from previously very sedentary lifestyles. The activity goal has been expressed as an increase in energy expenditure of 1,000 kcal/wk (Jakicic et al., 1999; Pate et al., 1995), although this quantity may be insufficient to prevent weight regain. For that purpose, a weekly goal of 2,000 to 3,000 kcal of added activity may be necessary (Klem et al., 1997; Schoeller et al., 1997). Thus, mental preparation for the amount of activity necessary to maintain weight loss must begin while losing weight (Brownell, 1999).

When strength training or resistance exercise is combined with aerobic activity, long-term results may be better than those with aerobics alone (Poirier and Despres, 2001; Sothern et al., 1999). Because strength training tends to build muscle, loss of lean body mass may be minimized and the relative loss of body fat may be increased. An added benefit is the attenuation of the decrease in resting metabolic rate associated with weight loss, possibly as a consequence of preserving or enhancing lean body mass.

As valuable as exercise is, the existing research literature on overweight individuals indicates that exercise programs alone do not produce significant weight loss in the populations studied. It should be emphasized, however, that a large number of such studies have been conducted with middle-aged Caucasian women leading sedentary lifestyles. The failure of exercise alone to produce significant weight loss may be because the neurochemical mechanisms that regulate eating behavior cause individuals to compensate for the calories expended in exercise by increasing food (calorie) intake. While exercise programs can result in an average weight loss of 2 to 3 kg in the short-term (Blair, 1993; Pavlou et al., 1989a; Skender et al., 1996; Wadden and Sarwer, 1999), outcome improves significantly when physical activity is combined with dietary intervention. For example, when physical activity was combined with a reduced-calorie diet and lifestyle change, a weight loss of 7.2 kg was achieved after 6 months to 3 years of follow-up (Blair, 1993). Physical activity plus diet produces better results than either diet or physical activity alone (Blair, 1993; Dyer, 1994; Pavlou et al., 1989a, 1989b; Perri et al., 1993). In addition, weight regain is significantly less likely when physical activity is combined with any other weight-reduction regimen (Blair, 1993; Klem et al., 1997). Continued follow-up after weight loss is associated with improved outcome if the activity plan is monitored and modified as part of this follow-up (Kayman et al., 1990).

While studies have shown that military recruits were able to lose significant amounts of weight during initial entry training through exercise alone, the restricted time available to consume meals during training probably contributed to this weight loss (Lee et al., 1994).

The use of behavior and lifestyle modification in weight management is based on a body of evidence that people become or remain overweight as the result of modifiable habits or behaviors (see Chapter 3), and that by changing those behaviors, weight can be lost and the loss can be maintained. The primary goals of behavioral strategies for weight control are to increase physical activity and to reduce caloric intake by altering eating habits (Brownell and Kramer, 1994; Wilson, 1995). A subcategory of behavior modification, environmental management, is discussed in the next section. Behavioral treatment, which was introduced in the 1960s, may be provided to a single individual or to groups of clients. Typically, individuals participate in 12 to 20 weekly sessions that last from 1 to 2 hours each (Brownell and Kramer, 1994), with a goal of weight loss in the range of 1 to 2 lb/wk (Brownell and Kramer, 1994). In the past, behavioral approaches were applied as stand-alone treatments to simply modify eating habits and reduce caloric intake. However, more recently, these treatments have been used in combination with low-calorie diets, medical nutrition therapy, nutrition education, exercise programs, monitoring, pharmacological agents, and social support to promote weight loss, and as a component of maintenance programs.

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