Here's some interesting information.

Managing Weight Loss Expectations
          by Dr. Arya Sharma, M.D. Dr. Sharma's Obesity Notes

While there are almost no limits to short-term weight loss goals (anyone can starve themselves thin) – the reality of long-term weight loss is rather sobering.

While diet and exercise generally provide an average long-term (3-5 years) sustainable weight loss of about 3-5% of initial weight, even bariatric surgery patients tend on average to sustain a weight loss of only 20-30% of their initial weight.

Surgery, although much safer than generally thought, still bears a risk of complications and the question is how much risk patients are willing to assume if they really knew and understood how much weight they are likely to lose with surgery.

This was the subject of a study by Christina Wee and colleagues, published in JAMA Surgery, in which they examined weight loss expectations and willingness to accept risk among patients seeking bariatric surgery.

The researchers interviewed 650 patients interested in bariatric surgery at two bariatric centres in Boston.

On average, patients expected to lose as much as 38% of their weight after surgery and expressed disappointment if they did not lose at least 26%.

In fact, 40% of patients were unwilling to undergo a treatment that would result in only 20% weight loss.

Most patients (85%) accepted some risk of dying to undergo surgery, but the median acceptable risk was only 0.1%.

On the other hand, some patients (20%) appeared more desperate, willing to accept a risk of 10% or greater.

As one may expect, there were important gender differences in these findings: while women were more likely than men to be disappointed with a 20% weight loss, they were also less likely to accept a greater mortality risk.

An important finding for clinicians was that patients with lower quality-of-life scores and those who perceived needing to lose more than 10% and 20% of weight to achieve “any” health benefits were more likely to have unrealistic weight loss expectations.

This study not only shows that most patients seeking bariatric surgery have rather unrealistic weight loss expectations but also that a substantial number may well be be disappointed with their weight loss after surgery.

It is also evident that many patients believe that they need to lose a rather substantial amount of weight to derive “ANY” health benefits, when in reality even rather modest (and certainly the average 20-30% weight loss seen with surgery) carries substantial health benefits for patients. (Many patients would in fact benefit substantially if they simply stopped gaining weight).

I certainly wonder what educational efforts may be necessary to align expectations with the clinical reality of bariatric surgery and whether better managing expectations is likely to alter current practice?

None of this information is surprising to me.  I've both read it and witnessed it again and again.

Permanent weight-loss is so incredibly difficult.  Right now, even short-term weight loss feels impossible.  At present, I'd feel grateful to see any kind of weight-loss take me back down nearer to my goal weight. Weight-loss somehow has to occur in the first place, BEFORE it can become permanent.  After all, every weight-loss is short-term until it becomes permanent.

Most people will find this entire article discouraging, 
 However, to show where MY head is at ... right now, the following statement at the beginning of this article actually made me feel unexpectedly HOPEFUL.

"...there are almost no limits to short-term weight loss goals 
    (anyone can starve themselves thin)... "

22 years ago at age 47, weighing 271 lbs. at a height of 5'0",  I had an RNY gastric bypass, open surgery, with NO removal of any intestine, which means that every calorie I eat is still digested, and still counts. 

The doctor's recommendation for post-surgery eating was simple. "Eat three meals a day of whatever food you want, but make half of each meal protein; avoid fried foods and sweets; and have no carbonated beverages."

My surgery was done when the procedure was still considered experimental.  At the time, it was performed here in California by only a few doctors. To get surgery, people had to travel to San Diego, stay in the hospital 2 or 3 days, then stay at a local hotel for an additional 10 post-surgery days before being released to return back home.  Follow-up care was received once a month during the surgeon's visit to one of the nearby temporary clinics located in various cities throughout California.  About five years later,  surgeons all over California began setting up specialized practices for weight-loss surgery, and coordinated with nutritionists who made specific post-surgery diet recommendations like protein shakes etc. That happened several years before laser surgery became common.

The first year after surgery my body would tolerate very little food.  Eating more than one-quarter to one-half cup of food at a time made me feel uncomfortably stuffed like after Thanksgiving dinner.  

I frequently experienced Dumping syndrome, which is caused by food passing too quickly into the small intestine. This caused immediate symptoms of flushing, weakness, fatigue, dizziness, and an intense desire to lie down. Severe episodes include feelings of nausea, and even stomach cramps.

I experienced severe dumping symptoms after just a swallow or two of fruit juice; or one or two bites of fried-or-greasy food; or a bite or two of any sweet like cookies, cake, pie, candy. I also became lactose intolerant. Milk made me feel ill, and even the tiniest bit of ice cream, with it's combination of milk and sugar, immediately made me lie-down-with-dry-heaves-ill.

Therefore, due to my weight-loss surgery, that entire first year my food intake was somewhere between 200 to 600 calories a day, which caused my weight to drop from 271 down to 161 lbs .... without dieting. This happened while I ate however much I could, of whatever food my body would tolerate.  The reason I did not binge, cheat, or quit, even when my weight-loss was slower than I believed I deserved, was because it was physically impossible for me to do so. 

Most people think that weight loss after WLS always happens rapidly.  That immense amounts of weight fall off everyone's body every week, 5-10-15 pounds, week-after-week, like on the Biggest Loser tv show.. only maybe even faster. 

However, Real Life AFTER a Gastric Bypass Surgery, works just like Real Life BEFORE a Gastric Bypass Surgery.  Even though after a RNY surgery Everyone has a smaller stomach, and Everyone eats just a small amount, the rate of weight-loss continues to be an individual matter.  Some people's bodies simply drop weight faster than other people's bodies, and surgery doesn't change that fact. 

Below is a graph of my own individual weight-loss results. This is what happened to MY body during the 64 weeks after a RNY gastric bypass surgery.  I did not diet during that time, but the surgery severely restricted what I ate, and the amounts I ate. I was physically unable to cheat, and I was physically unable to quit.  Plus, of course, I was strongly motivated to lose weight.  Remember, I was a 48 year old, sedentary female who was only 5 ft 0 in tall.

For the next 2 to 3 years I maintained in the 160s while eating as much food as my body would tolerate, however, my stomach begin stretching, and my body began to tolerate more food, and again, I had to begin dieting to keep my weight down.

For the next 10 years, I worked at dieting to keep my weight down, but my weight kept creeping up. I felt I simply could not bear weighing over 200 lbs again, after all my effort, pain, and expense. My struggle to avoid gaining more weight allowed me to maintain in the 190s for several years.  In September 2004 I began logging my food into DietPower, which is a computer software food journal that I discovered online.

At that point, I begun losing weight, and about 16 months later, after working to eat a daily average of approx 1230 daily calories, I reached my goal weight of 115 lbs.

During all of the 8+ years since that time I've been working to maintain at or near that goal weight.

SO ....to summarize the NEXT SEVERAL YEARS: 

Without Dieting

Maintained in the 160's the following 2 ½ years until weight crept into the 170s.  

Started Dieting again, with following Results.

Back to the 160's for 4 months, then weight crept back up into the 170s.

Maintained in the 170's for 2 years, then weight crept on up into 180's. 

Maintained in the 180's for 2 years, then weight crept on up into the 190's

Maintained in the 190s for 2 years,  

          Next

Started Dieting Successfully - began tracking food daily using computer software.

September 20, 2004 - weight 190

January 27, 2006 - weight 115

8+ years later, now in 9th year of dieting to maintain weight-loss.  

Total Summary: 

            Weight                        Weight                  

Pre Surgery …...     241            Reached.... ...... 161  =   110 pound Loss

Post surgery …..     161      Regain….....… 190   =     29 pound Gain

Food Tracking...     190           Goal reached….115  =      75 pound Loss

For further information see the section ABOUT ME here at DietHobby.

 
Much of the weight-loss and maintenance information available to us is both inaccurate and unhelpful. Like Dorothy of Oz and Alice of Wonderland, during my lifetime of research on those issues, I've seen some "weird shit".

Here in my DietHobby online scrapbook I work to sort out and save reasonably accurate information that might prove helpful to me and perhaps to others.

The article below deals with the issue of Energy In and Energy Out, which is not as simple as most people believe.

People have different body weights because each of them has an individual physiology and psychology which ultimately determines their own individual levels of "energy in" and "energy out" AND which also determines how their own individual bodies respond to it. 

A snapshot of the unaveraged data contained in scientific research of Individual BMR or RMR (metabolism rates) bears a strong resemblance to a blood spatter pattern at a violent crime scene. Metabolism rates are all over the place, but these widely varying numbers are then averaged out to create the calculations we see formulas like Harris-Benedict, Mifflin, etc.  An Average is a Statistical number for mathematical convenience. It is not an accurate number for Everyone, and sometimes is not even accurate for Anyone ... similar to the following joke: 

A biologist, a chemist, and a statistician are out hunting.  The biologist shoots at a deer and misses fifteen feet to the left, the chemist takes a shot and misses fifteen feet to the right, and the statistician yells "We got 'em!"

People the same sex, age, and size can take in the same amount of "energy" and do their best to engage in the same amount of activity, but wind up with very different weight results. 

In tightly controlled feeding studies, the same absolute amount of extra calories can result in very different amounts of weight gain. Also, the exact same amount of caloric deficit will result in widely different amounts of weight loss. 

In general, this basic fact of human nature is overlooked, or ignored. 

Here is a recent article by obesity specialist, Dr. Sharma addressing this problem. 

Why The Energy Balance Equation Results In Flawed Approaches To Obesity Prevention And Management

    by Dr. Arya Sharma, MD 
         @ Dr Sharma's Obesity Notes 

Allow me to start not with the first law of thermodynamics (energy cannot be created or destroyed) but rather, the second law of thermodynamics, according to which entropy (best thought off as a measure of disorder), in any closed system, increases till it ultimately reaches thermodynamic equilibrium (or a state of complete disorder).

As some of us may recall from basic biology, the very definition of “life”, which tends to move from a state of lesser organization to a state of higher organization, is that it appears to defy the second law of thermodynamics (this is often referred to as “Schroedinger’s Paradox”).

In actual fact, we can easily argue that the second law does not apply to living organisms at all because living organisms are not closed systems and life’s complex processes continuously feed on its interactions with the environment.

Yet, when we consider the first law of thermodynamics and how it applies to obesity, we seem to forget the fact that we are again dealing with a complex living organism.

Thus, in what has been referred to as the “Folk Theory of Obesity”, we simply consider weight to be a variable that is entirely dependent on the difference between energy input and energy output (or “calories in” and “calories out”). And in our arithmetical thinking, we consider “energy in” and “energy out” as simple “modifiable” or “independent” variables, which if we can change, will result in any desired body weight.

In fact, our entire “eat-less-move-more” approach to obesity is based on this concept – the central idea being, that if I can effectively move “energy in” and “energy out” in the desired directions, I can achieve whatever weight I want.

This notion is fundamentally flawed, for one simple reason: it assumes that weight is the “dependent” variable in this equation.

However, as pointed out in a delightful essay by Shamil Chandaria in my new book "Controversies in Obesity", there is absolutely no reason to assume that weight is indeed the “dependent” or “passive” player in this equation.

Indeed, everything we know about human physiology points to the fact that it is as much (if not more) body weight itself that determines energy intake and output as vice versa.

Generally speaking, heavier people tend to eat more because they have a stronger drive to eat and/or need more calories to function – in other words, body weight itself may very much determine energy intake and output (and not just the other way around).

Similarly, losing weight tends to increase hunger and reduce energy expenditure – or in other words, changes in body weight can very much determine changes in energy intake and expenditure (and not just the other way around).

Thus, the idea that we can control our body weight by simply controlling our energy intake and output, flies in the face of the ample evidence that it is ultimately our physiology (in turn largely dependent on our body weight) that controls our energy intake and output.

Thus, to paraphrase Chandaria’s key argument, it is not so much about what “energy in” and “energy out” does to our body weight – it is more about what our body weight does to “energy in” and “energy out”.

Once we at least accept that this equation is a two-way street, rather strongly biased towards body weight (or rather “preservation of body weight”) as the key determinant of “energy in” and “energy out”, we need to ask a whole different set of questions to find solutions to the problem.

No longer do we restrict our focus to the exogenous factors that determine “calories in” or “calories out” (e.g. our food or build environments) or see these as the primary targets for decreasing caloric intake or increasing caloric output.

Rather we shift our focus to the physiological (and psychological) factors (often dependent on our body weights) that ultimately dictate how much we “choose” to eat or expend in physical activity.

Chandaria’s essay goes on to discuss the many “derangements” of physiology that we know exist in obese individuals (and probably already exist in those at risk for obesity), including leptin resistance, impaired secretion of incretins like GLP-1, insulin resistance, alterations in the hypothalamic-pituitary-adrenal (HPA axis), and sympathetic activity. (Any keen student of human physiology or psychology should have no problem further extending this list.)

In Chandaria’s view, it is these physiological (and psychological) processes that ultimately determine whether or not someone is prone to weight gain or ultimately gains weight.

In fact, the only factor that determines why two individuals living in the same (obesogenic) environment will differ in body weights (even when every known social determinant of health is exactly equal), is because of their individual physiologies (and psychologies) which ultimately determine their very own individual levels of “energy in” and “energy out” (and how their bodies respond to it).

Readers may be well aware that in tightly controlled feeding studies, the same absolute amount of extra calories can result in very different amounts of weight gain.

Similarly, the exact same amount of caloric deficit will result in widely different amounts of weight loss.

Ignoring this basic fact of human nature distracts or, at the very least, severely limits us from finding effective solutions to the problem.

This “physiological” view of the first law of thermodynamics should lead us away from simply focusing on the supposedly “exogenous” variables (“energy-in” and “energy-out”) but rather draw our attention to better understanding and addressing the biological (and psychological) factors that promote weight gain.

This would substantially change the aims and goals of our recommendations.

Thus, for e.g., rather than aiming exercise recommendations primarily at burning more calories, these should perhaps be better aimed at improving insulin sensitivity and combating stress. Thus, rather than counting how many calories were burnt on the treadmill, the focus should be on what that dose of exercise actually did to lower my insulin or stress levels.

Indeed, we may discover that there is a rather poor relationship between the amount of calories burnt with exercise and the physiological or psychological goal we are trying to achieve. While more exercise may well help burn more calories (which I can eat back in a bite or two), it may do little to further improve insulin resistance or combat stress thus leaving my weight exactly where it is.

Similarly, rather than trying to restrict caloric intake, dietary recommendations would be based on how they affect human physiology (e.g. gut hormones, reward circuitry or even gut bugs) or mood (e.g. dopamine or serotonin levels).

In other words, fix the physiology (or psychology) and “calories in” and “calories out” will hopefully fix themselves.

Given that our past efforts primarily focusing on the “energy in” and “energy out” part of the equation have led nowhere, it is perhaps time to focus our attention and efforts elsewhere.

Or, as I often say in my talks, “We’re not talking physics here – we're talking physiology – that’s biology messing with physics”.

We cannot mess with the physics but we sure can mess with the biology.

Shamil A. Chandaria: The Emerging Paradigm Shift in Understanding the Causes of Obesity. In Controversies in Obesity.  Eds: Haslam DW, Sharma AM, Le Roux CW. Springer 201

My observation is that the fat people who become "normal" size and maintain that size for more than just a few years, manage to do this through doing the hard work it takes to continually and consistently oppose the natural physiological desires of their "reduced obese" bodies.

Rather than allow their bodies to tell them how to eat, they use their minds to overrule those bodies and consciously choose to eat food containing far less calories than their individual body desires.  Forever … one-day-at-a-time. 
It is possible, but it isn't easy.  
See Running Down the Up Escalator.

First, let me clarify that my definition of a "fat" or "obese" or "reduced obese" person is not someone who merely hangs somewhere around their BMI Obesity border. Meeting that criteria requires a person to put in more than two or three years at a weight of … at least …. 20 to 50 pounds above their BMI Obesity border. To me, those who fail to meet that requirement are merely "overweight", a condition that is often temporary for them. Although many of these people term themselves as "fat" or previously obese, in general, they appear to have a very limited understanding of true obesity or the fat condition.

An overweight person tends to think that because they went on their first diet and easily lost and kept off 10 or 20 lbs, then an obese person, on their 50th diet can do the same thing for a longer time and lose and keep off 100+ lbs. This attitude is easily seen within the numerous online diet forums that are full of overweight or formerly overweight people who are eager to offer copious advice and personal judgments along these lines to people who are obese or reduced obese.
This unequal comparison … apples to oranges … often confuses people who are truly obese or "reduced" obese and frequently results in negative self-judgments which are just wrong.

So, applying this clarification, There are psychological desires (of the mind), and physiological desires (of the body). What does it take to continually and consistently use one's mind to oppose the natural physiological desires of one's body? Is the ongoing difficulty of opposing those desires worth the effort that it takes to be "normal" weight?

This is a Judgment call that depends   
on the severity of the individual's mental pain which is caused by the culture's fat-bias, and the severity of the individual's physical pain which is caused by denying to one's own obese, or reduced obese body, the food substances which that body believes it needs for survival. 

We must each decide this for ourselves. Thus far, for me personally, the balance tilts toward accepting the physical pain to avoid the mental pain. However, my personal dieting history, including the past 8+ years of experiencing the difficulty of maintenance …. even though I've consistently continued my positive dieting behaviors …. have changed my perspectives on the feasibility of dieting and maintenance, especially for the "morbidly" obese.

Here's an excellent article by a healthy, "morbidly" obese person who discusses her own relationship with her physical body.

Me, My Body, and Relationship Counseling
           by Ragen Chastain www. danceswithfat

My body and I used to have a seriously bad relationship, and looking back it’s not that surprising. I grew up the daughter of a Marine and a multi-sport athlete. If I fell and ran to my father, I could expect to hear “Are you hurt or are you injured?” Hurt meant that it was time to suck it up; injured meant you were going to the doctor. He, along with coaches and dance teachers told me to “walk it off”, “play through the pain” and that “pain is fear leaving the body.”

I was told over and over again that my body was just a limitation to be overcome through mental toughness  – blocking out or working through the pain. It didn’t come naturally at first – I seemed to have an innate sense that my body deserved better than that, but at some point I turned a corner and got really good at thinking of my body as something separate, and something to be ignored.

I worked through stress fractures, and an IT band so tight it felt like it was going to rip in half, pulled muscles, sprains, strains, jammed fingers, knee injuries and a host of other issues. I ignored my body when it asked for food and hydration, and I scoffed at it when it asked for rest.

I became a compulsive exerciser and I started to look down on my body even more. I refused to give it what it needed and pushed it beyond reasonable, and then unreasonable, limits.  When my body would finally bend or break under the strain, I treated it with utter contempt. I believed that my body was just a “meat sack,”  a collection of muscles and bones that were trying to limit what I could do. I believed that my mind had to be stronger than my body and I felt triumphant when I ignored my body’s signals and “pushed through.”

If I ever had an acquaintance who treated me the way that I treated my body for all those years, I would never speak to them again. In fact, I would never have let it go on that long. But through all of this my body stuck with me (even though I wasn’t giving it the food, hydration, or rest it needed), my body continued to support me. It never gave up on me. If my body could talk, all it would have said for years would have probably be something like “&$*#(*@ *$*&*#(*$  and for the love of pete can we please take a nap?!” but I wouldn’t have listened.

We live in a culture that preaches that our bodies are limitations. I still think of my body as something separate (and I know and honor those for whom that doesn’t work.)  But it’s different now -  I consider my body as a cherished friend.  Think of everything your body does for you without you even asking: breathing, blinking, heart beating… every cell in your body is getting blood right now and you’re not even thinking about it.

I don’t know about you, but there are days when I am too distracted to focus on a game of solitaire. I’m pretty sure that  if I was consciously in charge of breathing and blinking and heart beat I would have been dead in middle school when I got my first Walkman and regularly walked into stuff because I was so into the soundtrack of A Chorus Line.

I’m not saying that pushing your body is always wrong, you have to decide what works for you. I know I’ve danced through plenty of injuries. What I’m suggesting is that you consider treating your body like you would treat a friend.  I can’t even count the things that my best friend has done for me, even though he might rather have been doing something else (hello marathon!) because he’s my best friend and he loves me and I asked. It’s the same with my body.

I’m privileged to be temporarily able-bodied and I learned more about that when I had a neck injury last year and lost the use of my right arm for almost three months.  I learned that even if my body has limitations, that doesn’t make my body a limitation and that I worked best when it was me and my body against a problem, and not me against my body. I don’t know what is in the future for me and my body and like any relationship, my body and I have to keep up the communication and we have breakdowns, but we’ve come a long way since our days of giving each other the silent treatment, and I’m feel like our relationship is healthier than it’s ever been.

My online Scrapbook, which I call DietHobby, contains articles about the diet subjects on my mind, which are organized in its ARCHIVES to provide me with future reference. Recently I've been reading, and referring to, books and articles about Fat Acceptance. The article above is one of those which I find valuable enough to scrapbook here.  

Looking for Progress,
because there's NO Perfection