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Effect of Weight Loss on Obstructive Sleep Apnea: The Importance of Tongue Fat (atsjournals.org)
81 points by bookofjoe 12 days ago | hide | past | web | favorite | 127 comments





I'm a dentist who regularly treats OSA with dental appliances; they work by posturing the mandible forward with a maxillary and mandibular (two-arch) device as a way to increase the cross sectional area of the posterior airway, reducing apneic events -- but it is important to know that the gold standard remains the positive airway pressure (CPAP) device.

I would also like to point out that I see an incredible amount of fat-shaming that is rooted in a drumbeat of research that (correctly) shows lower health risks in many areas when BMI is lowered. In reaction to that, it is important to understand that for many people weight loss is neither practical nor maintainable and for that reason it is critical that we continue to advance our treatment of things like sleep apnea.


I'd just like to chime in as someone who has lost and kept off about half his bodyweight, that yeah, losing significant amounts of weight is a very demanding undertaking. It requires a significant lifestyle change, large investments of time, is emotionally and cognitively draining, and to top it all off does not positively impact your quality of life nearly as much as is touted. To be successful at it requires a level of obsession that qualifies as an eating disorder in its own. I track every calorie I eat, and weigh myself everyday. I have to hate seeing those numbers go up. I have to feel shame at overeating and not allow myself to make excuses for it, lest I become complacent. I can't keep food in my house. I avoid social gatherings because there's almost always food involved. You might think you can just not partake but it doesn't work like that, your brain thinks you're starving and has all sorts of ways to wear down your will and convince you it is ok to eat. It's kind of a living hell.

Based on personal experience, I am quite confident that physicians have absolutely no idea how to give actionable advice in this area, and nutritional specialists are only slightly better. None of them care about your suffering, because that isn't something they measure.

I guess what I'm saying is that yeah, it is possible for anyone to lose and keep off significant amounts of weight, but basically none of you have any idea what it really takes.


This is the most accurate description of a "weight loss journey" I've ever read. I was obese (40%+ body fat). Now I'm fit and healthy. Like you, it took me a decade to get there. Anyone who thinks it's easy or simple to make the lifestyle changes that requires, hasn't done it themselves.

It's not about the diet - most diets actually work, if you can stick with them for the rest of your life, but that's a huge if. CICO or keto or IF or carnivore or whatever, doesn't matter. Permanent weight loss requires the much harder task of fundamentally changing your brain's relationship to food. The only way that happens is through practice and painful failure.

You do have control over your weight. But losing fat and maintaining a lean body will be one of the hardest things you ever do.


> requires the much harder task of fundamentally changing your brain's relationship to food. The only way that happens is through practice and painful failure.

I've been on this journey for over ten years now -- basically on the practice and pain path you describe. But it wasn't until I read Allen Carr's "Good Sugar Bad Sugar" book that I began to mentally relate to sugar and carbs like any other significant addictive drug like nicotine or heroin. The sugar and carbs are not just passive calories that you ingest -- they actively affect how your brain and body relate to food.

Once you make that mental switch, then it's much easier to drop and stay off them. I mean who would say it's okay to have heroin cheat days?


It doesn't help if almost all external nudges in the domain that matter most (affordable, easily accessible food) are terrible. The few times I visited the US I was constantly shocked at how the food environment felt like it was trying to make me obese at all costs.

"The only way that happens is through practice and painful failure."

There are other ways to do this, but they require you to leave your world behind. For many, their environment is what built and maintains their unhealthy relationship to food.

For me, the day I left Texas was the day I started dropping pounds. Then, the day I left Utah for London was the day I dropped even more pounds. Then, the day I started running was the day I began approaching my lower limit (likely bordering into unhealthy body fat % on marathon race day).

The biggest challenge of you and the commenter above you was that you were swimming up stream. Hopping into a stream that leads away from fat behavior, instead of toward it can do much of the work for you.

I fully appreciate that's a luxury, but it's something people who have a choice should consider.


I couldn't agree with this more. It is possible for me to lose and keep off weight if I literally devote all my energy towards it. It's important to remember that everyone is different. Some people would struggle to gain 100 pounds, others could do it easily, and most people understand that. But for some reason when it comes to losing weight instead of gaining, understanding goes out the window.

I appreciate people commenting and trying to offer advice, but I think you missed the point of my post. Imagine this: Someone offers a group of 100 people a huge prize (that they all desperately want) to gain 100 pounds as quickly as possible. If we checked back in on these people in 3 months, I guarantee that some of them would have added 100 pounds, but some of them wouldn't be even close. What would you say to the people who weren't able to gain weight? Would you tell them about how it is just simple thermodynamics and lecture them on physics? I'm guessing you wouldn't. We all understand that it will be harder and easier for different people. Losing weight is the exact same.

Losing weight is hard (speaking from experience), but ultimately it's still just a question of physics. Eat less, eat food which will fill you for longer (breakfast: porridge, lunch: fruit, nuts, etc.), and eat a reasonably healthy meal you've cooked each night. Meanwhile, eat smaller portions and do some exercise. Your body can't defy the laws of physics, so you will lose weight. It is that simple.

Overthinking it and coming up with horse shit reasons why it's totally fine to eat the amount you're eating and blaming some external factor (e.g. one's body) is the problem.


This is the same dismissive, ignorant, platitudinal advice that the parent commentator was directly referring to.

I find it supremely hilarious that you refer to the person's own body as an external factor.


The truth is, it's none of those things. I am just unwilling to indulge people's fantasies on this issue, because I've lived through it having been clinically obese myself in the past.

>I find it supremely hilarious that you refer to the person's own body as an external factor.

It's external in the sense that we have no control over our DNA, which is implicitly being blamed when one speaks of one's own predisposition towards weight gain. It's not that funny.


Thermodynamics doesn't lie.

Operate at an energy deficit and I guarantee you'll lose weight.

Is it going to feel horrible? Hell yes.


Thermodynamic doesn't lie... but it isn't even close to being the most important factor at work.

A Pound is 3,600 calories. I can easily eat 1,800 calories over my maintenance requirement.

Do you think in one year I am going to gain 180 pounds or .5 pounds per day?


Thermodynamics is only involved at the simplest levels. Hunger and satiation are regulated primarily with leptin, not thermodynamics. Fat storage is controlled primarily with insulin which is itself regulated by various endocrine system components. Thermodynamics is only involved at a level far below complex systems control dynamics.

I think overthinking and coming up with bad excuses is just a symptom, not a cause. First the human does something their rational mind didn't want to, because the rest of the brain outvoted it, and then the mind comes up with an explanation to feel more in control.

I'd actually be surprised if there's much correlation between understanding physics and having one's weight under control.


Zero correlation. And everyone can learn calculus, but some people will have to put in a LOT more effort than others.

Not sure why downvoted, maybe a bit harsh...but this is the absolute truth. I'd argue that exercise itself doesn't even play a huge role, though it does help. Eat less calories until you start losing weight. I understand there are mental hurdles to this simple mantra, but its truth is unchanged.

And this doesn’t help when one’s body switches into “starvation mode” lowering one’s BMR making it even _harder_ to lose weight. One’s microbiome can also substantially affect one’s BMR.

Neither your comment nor your parent comment add anything except noise to this discussion.

Weight, health, and fitness are all _correlated_, but sometimes in ways that aren’t intuitive and that western society’s fat-shaming (of which the “just eat less” mantra is a prime example) completely misses the point.


I don't mean to fat shame, apologies if it comes off as such. My own weight fluctuates a lot, as I go through periods of something akin to depression. When I'm overweight, I know what needs to be done, yet for whatever reason, don't do it.

That said, we are not adding noise. We are giving the physics level truth. It's like being told an answer, and being told to show the proof, in my opinion. The answer is to eat less calories, but working the problem isn't so simple. There are a ton of variables into how or why someone can't follow this regime, some valid, some probably not.

Starvation mode is vastly overstated.

I wonder why people in starving nations don't have this magical starvation mode, or glandular problems, or microbiomes that make them fat. Are we exceptional?


Is the main inhibitor just the sensation of hunger being miscalibrated with your calorie goals? Instead of using mind over matter, what techniques exist for eliminating the sense of hunger?

Coffee suppresses my appetite pretty well. When I do intermittent fasting, I allow myself to drink as much coffee as I want and I have no trouble making it to dinner before hunger becomes distracting.

You might have to drink a _lot_ of coffee though because there's a lot of hours between morning and dinner. I have a coffee maker that brews right into an vacuum carafe (which keeps it hot up until dinner time) and I also have a yeti mug that keeps a single cup of coffee warm for ~1-2 hours, which helps me nurse fewer cups throughout the day.


Celebrities are known for using (illegal) stimulant drugs for this purpose. Of course I highly don't recommend doing this, those drugs will give you a heart attack long before your fat would have.

As another poster said: stimulants. Ephedrine is one of the easiest to acquire that has reasonable potency, but I caution that a) there are negative consequences to stimulant abuse and b) you do become resistant (and eventually dependent). I have tried it for protracted periods of time but it was ultimately unsuccessful at lowering the difficulty.

It is a bit fascinating that using coffee or other stimulants seems to be a 'hack'. I guess there's the "diet pills" market, but I am uninformed about how effective these things are, having never had to try to lose weight. It does seem like such a drug that actually worked would be transformative though.

For me personally, I'm always hungry, and my body is apparently really good at storing excess food as fat. The only truly successful method for reducing hunger that I've ever discovered is fasting. After fasting for a few days, I'm no longer hungry. Unfortunately, it's not the most convenient thing to do.

There’s also sometimes a lack of a particular chemical pathway that signals satiation (e.g., “I’m full, stop eating“). If this is what happens in one’s particular situation, one has to develop _other_ mechanisms to replace the signal.

Some bits of personal advice:

1. Try eating more vegetables (tomatoes, cucumbers, coleslaw, but watch for the sauces). They do a wonderful job a filling the stomach, but they would give you like 20x less calories than bacon or fries.

2. The weight you see on the scale is a combination of your fat, liquids retained by the body, food in your pipeline, etc. Based on my personal experience, the non-fat part (that goes away in the 1st week of dieting and easily gets back) can be up to 10-12 lbs. You need some model to account for it when watching your weight, otherwise it gets pretty depressive.

3. It's tough to keep high-calorie foods off every single day and it's tough to diet for weeks in a row. Having a moderate diet for 1 week every month, while eating a bit over for the rest 3 weeks is much more tolerable than the extremes.

4. Do portion control. The subjective pleasure we get from the food scales logarithmically with the amount, the calories scale linearly.


REALLY? You would like to introduce the poster to the concept of "portion control" and "vegetables"? Did you skip reading his comment? You might as well respond to a comment about how long it takes to develop a new feature with a recommendation to learn keyboard shortcuts. How absurdly condescending can you get?

The grandparent comment didn't mention vegetables or portion control, which I'm sure the grandparent knew but it's fine to emphasize it. I think the parent comment to yours is fine, just re-emphasizing key points that the parent didn't explicitly state.

Yes, and the doctors and nutritionists he talks about probably didn't know about these incredibly basic concepts either? You might not know this but nutritionists are professionals who give people advice about healthy diets.

I am advising the poster to avoid extremes and find a trade-off between torturing themselves and having an unhealthy weight. The devil is in the details.

The devil is in the amazingly unlikely assumption that you have literally anything to offer him on this topic.

I know what it takes. I haven't done it, but a couple of my friends have, and they've described the herculean effort required. The things people usually expend their effort on

* Maintaining relationships with friends, family, and loved ones

* Excelling at their job

* Reducing bad habits(like drinking, tv watching, smoking, etc)

* Pursuing hobbies

* Raising children

And all of them have had to make significant sacrifices across the board to maintain their weight.


Thanks for your comment, how long have you been at it?

Edit: Saw your note below > "150+ lbs, the past decade"


> ... your brain thinks you're starving and has all sorts of ways to wear down your will ...

I thought losing weight was about willpower and starving as well. But you can only keep that up for so long until your willpower breaks. Then I read this book, Allen Carr's "Good Sugar, Bad Sugar: Eat yourself free of sugar & carb addiction". It changed how I view things and now I no longer worry about how much I eat.

The key is in understanding that your hunger is driven by an addiction to sugar and carbs -- they're not what your body considers food so it always feels hungry. Change your diet and you no longer constantly feel hungry while still losing weight.


Yeah, I hear this and other fad internet diet stuff all the time. You think in 10 years I never tried this stuff? It did not make a significant difference.

> I hear this and other fad internet diet stuff all the time

I've been eating a lower carb diet with portion control for more than 10 years now with little to no exercise. I recently changed into a low carb diet. Over this 10 year period I lost 30% of my body weight.

The only fad I've seen so far is the notion that practicing willpower and portion control while still eating sugar and carbs is a maintainable position.

Best of luck to you. But as others have noted, the rampant obesity in today's society is a recent problem - not something that happened in previous generations. What's different?


The vast majority of people no longer do manual labor for a living. And food used to cost a lot more. It's also possible that anti-smoking campaigns have had an effect since nicotine is a stimulant (which can suppress appetite) and reduces your sense of taste (making food less appealing), but that's probably a stretch.

There seems to be something else going on in addition to what you've mentioned.

https://www.sciencedirect.com/science/article/pii/S1871403X1...


I agree with all of your points. But there is more going on here.

Take a look at the top 5 strongest men in the world. They spend their days working out and probably burn more calories in a day than I do in a week. They have big, strong muscles that are covered over by a layer of fat. Same is true of many manual laborers today - landscapers, roofers, builders.

http://theworldsstrongestman.com/athletes/

Compare that to body builders (work out, eat lower carb/sugar) or concentration camp prisoners who are underfed (whether they do labor or are almost entirely sedentary).

https://www.google.com/search?as_st=y&tbm=isch&as_q=concentr...

https://www.google.com/search?as_st=y&tbm=isch&as_q=body+bui...

Comparing the groups (and my own experience) convinced me that eating (rather than exercise) is >80% of how much fat you will carry.

I'd say one of the biggest differences today is that sugar and carbs have become well accepted highly addictive drugs in our society. Feeling down? Go treat yourself to some ice cream! Is it any different with nicotine or heroin addicts?

I look at obese people in the same way that I look at nicotine or heroin addicts. It's not their fault, they're just normal people who are unfortunately caught in the tractor beam of addictive substances and they may not even know it. I didn't know it when I was a carbaholic. I thought I was fine -- didn't really connect my hangry episodes with withdrawal symptoms.


Keto style diets made a huge impact on my life. I will say this though: it's very difficult to eat low-carb in America. While I was overseas in the South Pacific, there were a lot more low carb options and produce was of higher quality. Here in American, everything is loaded with sugar and I've had to cook a lot more of my own food if I want to stay healthy. But I agree, cutting out sugars/starches greatly changed things for me. Have a Steak and Salad instead of a Steak and Fries. For breakfast, just have the bacon and eggs and skip the toast. It makes a massive difference.

I have had a lot of success with the Weight Watchers method. I want to lose around 18 kg and I lost already 12 since middle of October.

My job did Weight watchers and I lost 25 lbs and am now not overweight. I am now a WW lifetime member. There really isn't a gimmick to what they do. They provide accountability, emotional support, and decent diet advice by emphasizing healthier choices. Most of the people in our program still failed though. I still go weigh in once a month for free as a lifetime member not to give up my commitment to healthy weight. I feel great, and everyone should give losing weight a try at least.

I think most people fail because they expect immediate results and can't stay consistent because they go too hard for immediate results. On WW when presented with an unhealthy meal option I would consider if it was really worth it giving how well I was doing, and I wanted to crush it on the scale every week. I think for me that was the most important driving force to not making bad decisions like eating a pile of cookies. People think they have to sit there depriving themselves with a pile of lettuce but that is exactly what WW discourages. You can eat whatever but it has a cost. For me I was happy eating lean good food like a small sirloin steak with some broccoli.


I will say Weight watchers is pretty effective

What percentage of people lose the weight they want and actually keep it off? Without that data we have no way to know how effective it is.

Have you heard of research tying childhood trauma to obesity?

> I track every calorie I eat

Why??

> and weigh myself everyday

Why???? Every week AT MOST. And even then, TRACK THE LONG TERM TREND.

> I can't keep food in my house

Why??????????????????

YOU NEED FOOD TO SURVIVE. You need food in your house to PREPARE MEALS that YOU PLAN. A caloric deficit WILL lower your ENERGY LEVELS ... BUT you are NOT REQUIRED to be HUNGRY because of it.

----

Don't listen to me. I'm not your doctor. I'm not your nutritionist.

When I wake up in the morning, I know I can eat one of a couple different meals. I can have oatmeal, or french toast, or pancakes, or greek yogurt. All of these meals are pre-planned so that I know how many calories I will consume. For a snack I can have almonds or a 100 cal ice cream bar or any one of my other foods. For lunch I'll eat a big salad or greek yogurt or maybe some canned salmon/tuna with blah blah blah.

The point is. I don't track my calories because I have a meal PLAN. I don't just jaunt off to a restaurant, """track""" 1500 calories, and say to myself "Welp guess I'm going hungry for the next 12 hours". That's STUPID.

I have anywhere from 400-600 calories for breakfast. 300-400 for lunch. 400-600 for dinner. 400ish dedicated to snacks. That puts me at about 2000 calories for the day. That's maintenance level (basically, it will vary from person to person). To gain weight I ADD another 150-300 calories meal. To lose, I ease up on snacks or go for the low end numbers on my 3 major meals (400+300+400 == 1200 + 400 snacks == 1600 == caloric deficit).

I'm NEVER hungry. The worst part of a diet is the lower energy levels (drink some coffee). NOT THE HUNGER because there is NONE. Eat a pound a spinach. You will not be hungry!


This is spoken like a person who has never struggled with their weight.

The times I have successfully managed my weight were when I was able to control what I brought through the door of my apartment. I would always eat before going to the grocery store to reduce impulse buying. With the exceptions of fruit and veggies I aspired to never bring anything through the door that I could eat without having to cook in some way.

My weight has grown since I got married to a woman with a metabolism that allows her to snack seemingly with impunity and who can be in the same apartment with snack food and not feel drawn to it.

If I am aware of delicious food in the house it can be a constant mental battle to not go eat it. In the morning when I'm full of energy it's easy to resist but late in the day when I'm stressed by work or whatever else my reserve of restraint is much less and I often give in.

I've been following microbiome research with interest. I understand that certain gut bacteria have the ability to stimulate the vagus nerve basically to get the kind of food they like. I am battling an enemy that has a direct line to my lizard brain.

The only solution is to not bring that food in the house.


The person you're replying to has successfully lost a lot of weight and apparently kept it off. Whatever they do works for them.

You can be successful and miserable.

>> I track every calorie I eat > Why??

To keep myself honest. I've tried not tracking it and it was too easy to slip into bad habits over time.

>> and weigh myself everyday

> Why???? Every week AT MOST. And even then, TRACK THE LONG TERM TREND.

To keep myself honest. Only weighing myself once a week it was two easy to slip into bad habits because I couldn't see the consequences of my choices for a whole week. Even then, it was too easy to pass off gains as water weight, which can fluctuate 5lbs quite easily over the course of a day. By weighing every day I get more data to work with which allows me to more easily plot the trend over time and be mindful of the effect of fluid retention or loss.

>> I can't keep food in my house

> Why??????????????????

Ugh. Look, I'm sure for you it's real easy to keep yourself from just walking in to the kitchen and making food when you're bored, but like many people who got fat I am a food addict, so it isn't easy for me. If there is food in my house, I will eat it. Mindlessly. Casually. It's too much temptation that I have to expend mental effort to fight. By making sure I only have just enough food to get through the weekend I ensure that the barrier to eating is much higher and it's easier to fight temptation.

I also keep just enough food at work to get through the work week. Work is harder regardless, because people bring in free food all the time and there are convenient vending machines.

> YOU NEED FOOD TO SURVIVE. You need food in your house to PREPARE MEALS that YOU PLAN.

No shit Sherlock. I keep just enough food to meet my plan and no more. Moreover, my plan is the same every single week so I spend as little time thinking about food as possible. I even prepare meals at work thanks to my microwave steamer, the single best decision I ever made for eating better.

> A caloric deficit WILL lower your ENERGY LEVELS

Yes, which has a corresponding effect on one's ability to exercise their willpower. This is well documented.

> ... BUT you are NOT REQUIRED to be HUNGRY because of it.

First of all, I disagree, because in order to lose weight your body literally needs to eat itself. Secondly, I'll repeat that I am a food addict. Hunger is not a requirement of being tempted to eat.

> Don't listen to me. I'm not your doctor. I'm not your nutritionist.

Physicians and nutritionists, in my considered opinion, give only slightly better advice than randos on the internet. I am not in danger of accidentally listening to you, I assure you.

> The point is. I don't track my calories because I have a meal PLAN. I don't just jaunt off to a restaurant, """track""" 1500 calories, and say to myself "Welp guess I'm going hungry for the next 12 hours". That's STUPID.

What happens is I eat my planned meal, for which I track the calories, and then I go hungry anyway. That's just how it is and telling people that they don't have to be hungry to lose weight is one of the reasons people fail at weight loss.

> I'm NEVER hungry.

That must be nice.


This is someone who gets it.

> In reaction to that, it is important to understand that for many people weight loss is neither practical nor maintainable and for that reason it is critical that we continue to advance our treatment of things like sleep apnea.

Thank you for this comment! I'd like to emphasize this point in particular. It took me a long time to come to this realization on my own, and I regret putting my brother under so much pressure to lose weight out of my own concern for his health. I likely did more harm than good with my efforts, only worsening his mental and physical health.

While losing weight solves a lot of problems, the decision to do so is one's own, and for some, it's an unreasonably difficult task. Not everyone is like you, and not every body is like yours. The best you can do to help someone suffering the consequences of excess weight is to be compassionate and supportive. Feel free to offer solutions and perspectives, but leave your emotions out of it. Respect the dignity and autonomy of others.


Weight affects so much more though. It's not just sleep apnea, but heart disease and diabetes as well. Any type of surgery risk is greatly increased by obesity.

Look at history. Even for people working desk jobs, Americans were much less obese than they are today. It's a systemic problem. Go into any gas station and try to grab a snack without sugar. It's difficult to impossible. We have more sugar and starch in our food today. I agree it's not necessarily a personal problem. It's a problem with the entire food industry and access to cheap sugar.

It's starting to affect people in other western countries too and we are missing a lot of education about the dangers of starch and sugar.


>In reaction to that, it is important to understand that for many people weight loss is neither practical nor maintainable and for that reason it is critical that we continue to advance our treatment of things like sleep apnea.

Sorry, but I have to call BS on that. Having lost ~50 lbs last year (after my blood pressure started getting scary), I can tell you it's all about planning and self-discipline. You plan a diet that fills your stomach and provides the major types of nutrients, yet gives less calories that your body burns every day, and you stick to it for a couple of months. No bullshit, no cheat days, no "let me just have that 500cal chocolate bar as an exception". And it works like clockwork, solving a bunch of health problems on the way.

As a matter of fact, I would call it very unethical to comfort people into an unhealthy lifestyle associated with major health risks and shorter life expectancy just to get an extra buck from treating numerous symptoms, instead of giving them a strong motivation to resolve the underlying cause.


Sorry, but I think the approach of treating the apnea with or without weight loss is an obvious win. Trying to summon any type of willpower when you're constantly sleep-deprived is almost impossible, much less the amount of discipline that chronically obese people need to break that cycle.

Is it possible that the amount of planning and self-discipline required is maybe what is sometimes neither practical nor maintainable, depending on the individual?

Having lost and gained weight multiple times, it can be a psychological hell when it seems both the body and the mind are doing everything they can to fight against your discipline and planning and keep you where you are instead.


Yeah, it's gotta seem like a very weird thing to say if you haven't been through it, but your mind isn't the single entity you think it is. There are different components each with different motivations, purposes, responsibilities, etc. And a few of them really don't like what you're doing. They have access to the same reasoning engine as the parts that want to lose weight so they can make convincing arguments. Fighting them off wears down your will until they eventually win if you aren't careful.

And that isn't counting the effects of other parts of your body like your gut microbiome.


>>Is it possible that the amount of planning and self-discipline required is maybe what is sometimes neither practical nor maintainable, depending on the individual?

In my personal endeavors I've found that the amount of self-discipline something requires is inversely proportional to how motivated I am to achieve the end result. If I'm being required or forced by an external circumstance, I end up needing enormous amounts of self-discipline. But if I really want it (as in, if I'm internally motivated) then all I need to do is resist the occasional temptation to veer off the path, so to speak.


I actually find it's the reverse of this for me. I'd almost rather be forced to lose weight at this point because then I think I'd have a better chance at accomplishing it.

Trust me when I say I want to lose weight but have started to succeed multiple times only to eventually fail in my internal battle of will


> Having lost ~50 lbs last year

Trust me, it's too soon to say what you're saying. Source: lost >150lbs and kept it off for the past decade.


Maybe. I've actually implemented a rather complex set of rules to maintain my weight and it has been working so far. I keep a rough estimate of the calorie intake every day and try to keep it within reasonable bounds. I do make exceptions (hey I still love eating 2 pounds of steak with 3 pints of beer), but those days are followed by heavy dieting days to bring the calorie balance back. I also have a high-watermark/low-watermark system for my weight, so in case it runs away (like during holidays or trips), I am still 1.5-2.5 weeks away from reaching my normal weight.

I'll level with you: the easiest part for me so far was the initial weight loss. I got down to 15lbs less than I am now and it was much easier than it has been since. It's like my body adjusted and got much more conservative but it took a year or two. Maybe that won't be true in your case, but give it time before you make an assessment about the difficulty.

how many hours did that "implemented a rather complex set of rules" take?

Perhaps your anecdote does not qualify as a suitable counter argument. Is yours a normative experience? It is easy to lose weight in the sense that the solution is easily stated. Just restrict calories enough and weight will be lost. I suggest this is one of those things that is easy to say and hard to do. Isn't it akin to telling lifelong smokers, "Just stop smoking."? After all, if one simply doesn't smoke cigarettes then one will no longer have a smoking problem.

Can you see that perhaps your level of commitment is not possible for some people? Some people simply lack the willpower to do this.


> Isn't it akin to telling lifelong smokers, "Just stop smoking."?

It absolutely is. And I say this as someone who, after 25 years smoking, I stopped one day. I wasn't even really wanting or trying to quit. I just... stopped.

I consider myself incredibly fortunate at the complex, unlikely, and non-transferable, set of conditions that made this happen to me. Despite my success, or precisely because of my success, I am the least valid person to help a smoker quit.


> Sorry, but I have to call BS on that. Having lost ~50 lbs last year (after my blood pressure started getting scary), I can tell you it's all about planning and self-discipline.

Ah, I see, you have the highest possible qualifications in the medical field!

> instead of giving them a strong motivation to resolve the underlying cause.

OK, so, please explain, then, how you treat, for example, various thyroid problems that are the underlying cause for increased body weight and that no real treatment is known for? Given that you are so highly qualified as to call bullshit on a medical professional, you sure will be able to offer more than telling everyone who has superficially similar symptoms to yours that they are too stupid to cure themselves because they don't do what you have done?


Don’t know why you’re being downvoted when the parent is saying there’s no valid medical reasons that make weight loss difficult. Quite a few people making absurd comments like that in this thread.

And yes thyroid problems make it amazingly difficult to manage your weight.


You have been probably been very busy over the last year maintaining a very healthy lifestyle(which is awesome).

So what the studies say of everyone who starts a diet some will successfully lose a significant amount of weight. And of those success stories every single study that's followed them for 5-10 years shows that almost everyone regains almost all the weight.

The most famous of these studies was "The Biggest Loser". But are others, but they all show the same effect.

I've tried finding a study that showed sustained long term weight loss through diet, and there aren't any.


Did you accomplish your weight loss while working manual labor 64hrs per week?

No one doing manual labor for 60+ hours a week is morbidly obese.

Rather significant leap to take given the average hours worked per week in the US are over 40 and the % of US adults classified as obese is something like 40% or more as well - lots of candidate individuals out there. You really going to claim it's impossible for someone to be doing manual labor 60+ hours a week to pay rent and also have weight problems? Exercise doesn't automatically make you lose weight, high calorie intake or metabolic issues etc could cancel it out no problem. If it was as simple as 'just exercise a lot' weight issues wouldn't be so widespread.

I don't know about morbidly but have definitely seen many manual laborers that would be considered obese.

If you want to be thin, spend >80% of your effort in the kitchen. If you want to be strong, join a gym.


And also did you have a working kitchen? Access to a decent grocery store? Were you free from constant stress about how you would pay rent?

People don’t have those things any more than they do now 50 years ago when people weighed less.

They also didn't have grocery stores full of elaborate corn subsidy byproducts.

Just adding another datapoint: With no particular dieting, I tend to hover around 95kg. I was able to get down to 80kg with smart dieting. But I was miserable at that weight.. I couldn't concentrate when programming, my brain kept interrupting me with hunger signals. I put the weight back on; I'd rather not live the rest of my life in hunger-misery. 20 years later and I'm still fine with that decision. I get plenty of exercise and eat lots of vegetables and take other steps to be healthy, but significant sustained weight loss with it's side effects is no longer desirable... until medicine comes up with a pill that removes the hunger itself w/o nasty side effects.

CPAP is 800CAD here (though only about 200 after insurance) and dental appliances are even more expensive and not covered by insurance. Anecdata: I know that going over a certain weight triggers apnea and snoring for me so I try to stay under it - less expensive, less intrusive, better for the health overall. Research like this is both interesting and important to me. It is not about fat-shaming, it is about knowing the options. I understand that there are people for whom weight loss mai not be attainable or maintainable but it certainly will help to a great number of people.

Got a CPAP about a year ago, changed my life. Weight issues aside I also have a big neck which means I'll probably have OSA even if I achieve a normal BMI.

Anyway, highly recommend a sleep study for anyone here who has symptoms like waking up feeling tired, dozing off in the afternoon, etc.


amen is all I have to say to that. Don't hesitate or worry what your significant other will think, just get one.

Best part: You can sleep with a cover over your face and still breathe fresh air.


Nobody who fat shames has shown me research about the efficacy of fat shaming on weight reduction. That's not necessarily because the research doesn't exist, it's because they just don't care.

Nobody wants to be fat and most are already pretty ashamed about it. The big over-eaters (like myself) are sort of like addicts, but its a drug we really can't quit. It's like trying to manage your alcoholism by drinking 2 drinks a day instead of 10.

It's easy to think "why doesn't the pig just eat less." I used to think that way until my diagnosed thyroid conditions (which made me skinny by default) was treated. Karma.

Though some fat acceptance groups go too far when they criticize doctors for telling them to lose weight.


As someone with OSA - and a busted TMJ, so no mandibular advancement for me -, let me tell you: CPAP sucks.

Sure, you die slower, you snore a hell of a lot less, and you feel more rested and energized. That's all (truly, no snark) great.

But it sucks. Spontaneous sleepovers become impossible. Travel becomes a chore. Sleeping with bedfellows now comes with a noisy attachment. You have to rent or buy a relatively expensive machine. You have to get annual checkups, and you have to give up a fair amount of privacy to prove you are complying with the therapy... Not that much fun.


Have you tried the alternative dental appliance? Lots of people don't seem to know about it, but I'm using one and it works:

https://news.ycombinator.com/item?id=22014204

I even heard on Joe Rogan that he has to use one. Not sure why more people don't know about it. I guess it depends on whether your doctor or dentist diagnoses it, but that shouldn't be the case. They should exchange more information!


Agreed, sadly. I have a CPAP and it's just deeply unpleasant to use. It isn't worth it.

Dismal compliance numbers say that many to most people who try CPAP feel similarly.


Have you looked into the portable CPAPs they are much smaller, Resmed has one. Still a pain but nice for travel. I’ve also seen online cpap companies that send you a at home test that qualifies for coverage.

On topic: losing weight has a positive effect for sleep apnea. This is interesting, but something I had intuited from the small sampling of those I know with sleep apnea and weight problems. There are other factors that seem causal, like smoking, that would be interesting to hear about. Off topic: losing weight is hard to do for many people.

> In reaction to that, it is important to understand that for many people weight loss is neither practical nor maintainable

So you're saying that even though the obesity epidemic is an entirely new thing, that there's no way that these people can lose weight and keep it off?

It might require a lifestyle change, but saying it's not possible because change is hard is bullshit.


Maybe most can, which doesn't mean there aren't many who can't. Fat people aren't a new thing.

The amount of them percentage wise is.

what if your current life situation doesn't allow you time to go to the gym or spend any time at all meal planning??

Change your life situation? I guess I've worked 77 hour weeks (11 hour days, 3 weeks on 3 days off). No kids at the time, but still had to make my lunches every day because otherwise you didn't eat (working in the field). Meal planning actually saves you time.

>it is important to understand that for many people weight loss is neither practical nor maintainable

People need to stop eating processed sugar. Losing and keeping off weight is easy. As soon as I stopped eating, candy, baked shit from coffee shops and crap, fast food, and stopped drinking pop, it became hard to gain weight. That shit's poison. It gives your body nothing. Cutting out nearly all processed sugary food is the easiest way to lose weight with basically no effort. I didn't change my lifestyle, I don't count calories or exercise to any regime. I sat for hours a day at my last job. I just stopped eating garbage and eating food that's actually food. I'm 5'8", I'd been over 200lbs for years and years. I can't get above 150lbs now and all I do is not eat sugar or processed crap. I eat tons of cheese and meat, I have at least one kind of grain and vegetable with each meal.

If the main ingredients of something are chemicals and sugar. It's not food. Don't eat it. Your body will be healthy, you'll lose weight. It's a pretty simple concept. These things give your body nothing. Your body needs certain things to make new cells and perform biological functions, eat those things and you'll be healthy. Eat garbage and poison and you won't be.

Eta: Sorry for the tone of my post. I've sat and watched a good friend of mine slipping in and out of a diabetic coma in a hospital brought on directly by the food he eats and to this day he still refuses to change his diet in anyway and I'm honestly worried it's going to kill him. This topic makes me a little more unreasonable than usual.


If you eat that "poison" then quitting it will drop your weight. But some people don't eat that "poison" and yet they still carry a lot of body fat. So it is good general advice but insufficient for people with a genetic predisposition to obesity. I for one eat mostly salad, never drink sodas and don't really like sweet things, usually skip breakfast, hunt rabbits most days on steep terrain (for exercise and dogfood)... and yet I sit at 220lbs.

You have a friend who will probably die before he changes what he eats and you still call it "easy"?

He's in his 50's and doesn't believe the food causes problems and just doesn't care. It's not a matter of a lack of willpower or trying, in his case it's a lack of giving any kind of fucks.

Proper and adequate sleep is also an important part of weight loss, so I find it naive to only attempt to fix the weight issue.

It's a vicious catch-22 to not be able to breathe enough to sleep well enough to lose weight so that one can breathe in the first place.


Hey, are you referring to the SUAD Device? I am thinking about getting one and curious if there is an alternative. I have heard mixed things about their quality. Thank you for sharing your knowledge with us.

Forgive my ignorance in this area -- these dental appliances, do they permanently reshape the jaw over time?

Wow great to see a dentist here! I've had a lot of experience with sleep apnea in the last couple years, and it seems to be under control now after about 5 remedies, the most of important of which is a dental appliance. The other ones were sleep position, weight loss, and breathing habits, as you might imagine.

What do you mean by "gold standard"? Is it because it's more effective for severe sleep apnea?

From my perspective, the dental appliance is easier to use, and is better for traveling. I also tried a CPAP but couldn't get the hang of it.

It's also super creepy that CPAPs all seem to have a cell modem that spies on you. (OK, that info also helps the doctor, but still.)

I know a couple other people who are having problems with CPAP, and the doctor has not even made them aware of the dental appliance. They're surprised when I tell them there's an alternative.

And one of these people is a doctor himself! I feel like sleep apnea is being treated very poorly given how common it is, probably for economic reasons.

I know everyone wants to say this about their pet cause -- but it does seem like an "epidemic". The "epidemic" of weight gain seems to be an obvious reason for this. FWIW my BMI is now normal (less than 25, 166-169 at 5'9"), and I still need the dental appliance and to sleep on my side. Either one alone doesn't cut it.

I've also been meaning to write a article about "Why AHI is wrong", which is basically because outliers determine outcomes and AHI doesn't measure outliers. It's a "count". It has a lot of the fallacies that Nassim Taleb talks about in his books.

The AVERAGE minute of sleep doesn't matter; the WORST minute of sleep matters. The worst minute can ruin your whole night's sleep (or at least a REM's cycle worth of sleep), or it can cause you to have a heart attack and die.

My AHI is 6 or 7, and most doctors have dismissed that as not important. However my sleep quality has improved greatly with all these remedies. Several minor health problems have cleared up all at once.

The thing that motivated me to get treated was that I crushed a tooth in my sleep, which many doctors don't realize is related to sleep apnea (but my dentist did thankfully). But I think of all the people who did NOT happen to crush a tooth and are undiagnosed. I guess it's one of those things that kills you over 20 years and used to be called "getting old". But really it was amazing to me how many problems can have the same fundamental cause.

FWIW I highly recommend this book about the "sleep breathing paradigm". It's written by an ENT who has observed a lot of these things in his practice. A key point is that he actually looks at your airway and sees if your tongue obstructs your airway when lying down. I went to 2 ENTs and neither of them did that. They don't understand the mechanism behind sleep apnea! It's geometry and gravity.

This book is not popular, which is a shame. Don't judge a book by its cover :) It's a bit dense but that will be fine for HN readers.

https://www.amazon.com/Sleep-Interrupted-physician-reveals-r...


I understand what you are saying but, economically, treating the symptom rather than the cause is expensive; somehow there needs to be some way to create a cost high enough to encourage people to attack the cause of the problem; and shame can be a useful way to increase the cost. So "fat shaming", although politically incorrect these days, should not be thrown out as a way to encourage behavior that benefits society as a whole and the person as whole. If there was a high enough cost to being fat then you would see it would become practical and maintainable.

If literally not being able to breathe isn’t enough, people being dickheads probably isn’t going to do it.

Please think harder.


Indeed. For some people it's easier to commit suicide than it is to lose weight. Shame is not an ethical treatment method.

Well you don't have to be "a dick" to shame somebody. Just tell them the truth and help them realize the toll they take on society and themselves when they choose certain actions over others. When they come to realize and understand the truth they will feel the shame they ought to feel...and thus pay a small part of the cost to others that they have incurred.

Do you believe that a smoker that has thrown a cigarette out the window and burned down a home should not have to feel shame because of their actions? If you do then the obese ought to as well. Their obesity exacts great cost to the medical system that we all have to bear, it takes from their productivity that they could offer to others (society and their own family) and benefit from themselves in a multitude of ways. Their actions are the same as the careless cigarette smoker...selfish. And selfish actions are shameful and that shame should be felt. We should not try to be so "noble" as to protect them from it. When we do the selfishness tends to proliferate.


It is likely that many people overweight are already ashamed and it helps absolutely nothing to attempt to further pile onto that negativity.

Sorry, but no amount of "truth telling" in this way will come off as anything but being an arse. I'm sure you have your own selfish actions and your own ways of "taking a toll on society". This post reeks of a special kind of arrogance, whether you intend it or not. Your flawed analogy makes it worse. Why not just equate it with smoking itself- instead of something like a house burning down?

It's far more complicated than "person does selfish thing and hurts society because of it". Your post speaks like someone that has never had to lose weight or break out of an addiction.

I don't say any of this to attack you but just how ridiculous and supremely unhelpful this line of thinking is. It's like telling someone to just snap out of depression, or "just stop smoking", or whatever. It's not as simple and devoid of nuance as you'd like to believe.

And trust me, as someone that has gained and lost weight both, the last thing that matters to me is something external and abstract like my effect-in-the-aggregate on society. I'm far more interested in feeling healthier, sleeping better, and gaining the personal benefits from it. The same goes for most people, I would think, and no amount of philosophizing about society will change that.


Fat people already know they’re fat. “Telling them the truth” isn’t useful, to you or to us.

Being fat isn’t selfish, it’s just self-destructive. Same as smoking (in private, where no other party is exposed to any smoke). Your “and burns a house down” example is an attempt to conflate the two.


> Their obesity exacts great cost to the medical system that we all have to bear, it takes from their productivity that they could offer to others (society and their own family) and benefit from themselves in a multitude of ways.

This complaint runs into a more fundamental dispute: freedom versus collectivism. In a purely libertarian world, everyone would be absolutely free to do whatever they want. In a completely socialist world, one is only free to do what they want insofar as it has no negative effect on others, or if it does, they should compensate others for the harm they cause.

There are problems with both extremes. Absolute freedom can lead to anarchy which will effectively prevent people from coordinating and building anything collectively. But forcing individuals to adhere to a strict cost/benefit analysis for every action stymies creativity and personal freedoms.

When considering a ban on a particular individual behavior (e.g., eating too much), it's perfectly reasonable to talk about the larger social harms (e.g., increased medical costs). But it's also important to consider the freedoms that are being taken away by such a policy (e.g., the freedom to eat what you want).

Western society has never solely been focused on maximizing overall social well-being, it has also balanced ideals of individual freedom with it. China, in contrast, has focused almost entirely on collective well-being over individual freedom. Many people (myself included), would prefer to live in a less successful but free country rather than a more successful authoritarian one.


> When considering a ban on a particular individual behavior (e.g., eating too much), it's perfectly reasonable to talk about the larger social harms (e.g., increased medical costs). But it's also important to consider the freedoms that are being taken away by such a policy (e.g., the freedom to eat what you want).

You get both individual freedom and remove the harm to others from obesity if you stop forcing service providers to work for free.

The only reason that people who choose to become obese are a drain on others is because there is currently a mechanism for them to force others to absorb the cost of their resulting health care.

Make it so that people have to pay for healthcare for themselves either out of pocket or via insurance instead of forcing hospitals to serve all comers (like any other service that is provided to people), and suddenly you get the best of both worlds: everyone gets to eat what they want, smoke what they want, inject what they want, and nobody else is forced to pay for the poor decisions of anyone else. Everybody wins.


> Make it so that people have to pay for healthcare for themselves either out of pocket or via insurance instead of forcing hospitals to serve all comers (like any other service that is provided to people), and suddenly you get the best of both worlds: everyone gets to eat what they want, smoke what they want, inject what they want, and nobody else is forced to pay for the poor decisions of anyone else. Everybody wins.

Unfortunately, your argument runs into an opposite extreme. Yes, freedom is important, but it's not the only thing that's important. There is different, but similarly strong argument that society should preserve life.

Freedom dictates that people should be allowed to do what they want, even if it causes self-harm. Life preservation dictates that we should do whatever it takes to preserve life. Both of these values are are pretty fundamental, baked into most religions and political philosophies. Sometimes however, as in the case you point out, these two values butt against each other.

The answer is not to choose one or the other, but to properly balance them.


Forcing people to pay for things at gunpoint that they do not wish to buy is pretty far down the list of acceptable trade-offs, in my book.

It’s absolutely not an extreme view. We already do this for food, for example, which is also required to support life. Being hungry does not entitle you to steal from a supermarket, under our system.

Forcing hospitals to treat anyone regardless of ability to pay is really just forcing an unfair tax onto everyone else who happens to use that hospital in the form of increased prices. That’s not a reasonable system.


Sources for those claims?

Do you need really need "sources" to know that shame acts as a deterrent not to do something, and/or as a motivating factor to do something, for a multitude of actions good or bad and has done so for thousands of years of human history? Simple observe...and you will have all the sources you need.

I need sources for your theory that it will be an effective way of motivating the desires behavioral change, yes. After all, if you simply look around then you can see it doesn't work.

> for many people weight loss is neither practical nor maintainable

Hard disagree.

As for practicality, weight loss is a function of thermodynamics. Caloric deficit == weight reduction. Doesn't matter your physiology.

As for maintainability, well that certainly depends on how a person is taught to diet. If you tell someone they need to eat less to lose weight (which is what almost every diet does) then, yes, it will be hard to maintain. If you tell someone to eat more (low calorie) food then weight loss is easy.

Most obese, untrained people will very readily drop tons of fat weight with little stimulus.

When I diet (whether the intention is gaining or losing weight) I'm probably eating 2x as much food as an obese person who is wondering to themselves "why is my metabolism so slow?". It's not. The foods I eat just contain less energy than the foods they're eating.


> Caloric deficit == weight reduction. Doesn't matter your physiology.

True. This is the one piece of weight loss advice that multiple scientific disciplines agree on. However, being true does not make it easy.


Did you miss the part where I describe how to make it easier? Did you miss the part where I criticize diet culture from preaching starvation as some sort of virtue.

> If you tell someone they need to eat less to lose weight (which is what almost every diet does) then, yes, it will be hard to maintain.


Yes. your advice is not significantly different than common advice on how to make it easy, and my personal experience with trying many, many things is that it is never actually easy.

I do it and have done it many times. You're not sacrificing anything by buying products with fewer calories in them. Just read the label.

Wait. So you are saying your method allows you to lose weight but you can't keep it off long term? There are tons of diets that do that.

Hah! A funny observation. No the weight loss and gain were not based on my ability to maintain that level. They were based on changing priorities. When I first started, I wanted to be a body builder (so I gained). Did it for a while, then wanted to be "athletic" (so I lost). Then I maintained for a while (focusing on career, lost a lot of weight from sedentary lifestyle). Then I wanted to be a powerlifter which required fluctuations in weight. Now I want to be a "strongman" (so I'm gaining). Btw I'm not a world class athelete. I never even compete. I just enjoy chasing the goals and seeing my body adapt. Its a fun hobby(-ies) that's all.

My change in weight reflects a change in priorities and habits. Not an inability to maintain.


So where is the study which shows your method works better than all the other diets out there? Lots of people have diets that work for them, that fails totally when other people try it. If your plan is truly that successful it should be taking the world by storm.

When I was in my 20s, I weighed around 165 and never snored. By the time I was in my early 40s, I weighed about 225 and snored like a bandsaw and was diagnosed with sleep apnea. I improved my diet and started exercising 5 days a week. By the time I dropped back down to about 175 my snoring and apnea were both totally gone. At least in my case, the snoring and apnea were definitely weight related.

I'm not surprised by this. When one gains weight, it is distributed pretty much everywhere. I gained 25 lbs from a sedentary lifestyle that many of us on this site have from our jobs. I lost it, and snoring/acid reflux went away completely.

If you go pick up a 25 lb ham hock or something like that you will notice the volume it takes up. Fat is even less dense so it takes up even more volume. Sure, it does deposit in some places more than others like the waist line, but even things like my ski boots fit me different. They were previously too tight for several seasons so it wasn't just that they broke in. So all that fat is being deposited all over, and some of that is in your tongue, and I'm sure in your soft palate.

I notice a lot of talk about fat shaming here and how telling people just to diet isn't going to solve the problem. This is all true, but is irrelevant really to the conclusion here. Losing weight is a good way to reverse things like sleep apnea and acid reflux along with many other problems. So if one can do it, it is the best way to do it. Not all people with sleep apnea will be cured by losing weight but it goes a long way for many.


Always profile before optimization.

Lived with a friend who is kinda fat, for months before getting my apt. Some times I thought he was going to die asphyxiated. Thing is serious.

The corollary, which I deal with a lot, is that allergies such as MCAS and other mast cell issues cause tongue edema with the same effect. Antihistamines (H1 and H2 blockers) can help in the short term but have severe drawbacks, such as interfering with melanin formation. Ginger and many antidepressants, such as elavil, are also extremely potent antihistamines.

Commenters with sleep apnea, what have you done to resolve it, and how has it worked?



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