Efficacy vs. Effectiveness for Diet and Exercise.
There was recently a big hubbub about flossing. It turns out that flossing is efficacious (i.e., it can work) but not effective (i.e., it doesn’t benefit people as it is ordinarily practiced). That is, there is evidence that when a person flosses as directed for a long period of time, that person will usually have healthier teeth than a person who doesn’t. But at the population level, flossing isn’t effective because almost no one actually does it like that. And so there’s no evidence, when you compare two groups, one of which says they floss, and another that doesn’t, that the flossing group has healthier teeth on average.
I suspect diet and exercise for weightloss is similar. We have all these studies that show the various metabolic and physical responses to various interventions. Some say diet is better. Some say exercise is. But what almost everyone agrees on is that over time people gain weight back and most people don’t achieve lifelong weightloss. Once a person is obese, they may be able to make short term impacts, but long term BMI reduction is very rare. This has led many people to conclude that there’s no hope for weightloss, and we should focus on other aspects of metabolic health.
Now, it is certainly true that people’s metabolisms slow as they age, and getting the same bang for one’s buck, diet and exercise-wise, gets more difficult as we get older. Also, as time goes by, people are at risk of injury and disease which may impact their ability to maintain a diet and exercise regimen. But those strike me as rarer than the most common issue people face. Dieting is hard, and sucks. Exercise is hard, and sucks. So we quit.
We often create diet and exercise goals, like losing a specific number of pounds, or accomplishing an exercise challenge like a race. Then, when we’ve achieved it, we stop doing the things that got us there. We reward ourselves with treats and rest, which disrupt our routine, and eventually end our investments. We treat these goals as if, once achieved, our bodies never change again, so we can stop doing the things it took to get us there.
We know that diet and exercise are efficacious. The laws of thermodynamics require them to be. If you limit the input of energy, and increase the expenditure of energy, eventually, your body will be forced to decrease mass to compensate for the flux. There will be issues, like metabolic changes that conserve energy, etc., but there is only so much conservation one’s body can do.
But diet and exercise are not, by and large, effective. Because people don’t do them well, or sufficiently, or for a long enough time. The caloric deficit one has to maintain for a weightloss of 50 pounds, like I did, is enormous and challenging. I have spent time and effort for years, and it’s been difficult and painful. I’ve had injuries, I’ve had setbacks, I’ve had to commit to an entirely different way of life from the one I used to have, and it’s had to be permanent.
Diet and exercise are at least somewhat similar to abstinence as a treatment for addiction. We know good and well that if you don’t drink, if you don’t take drugs, you don’t get drunk and you don’t get high. But telling an alcoholic, “just don’t drink,” or an addict, “just don’t use,” is not an effective treatment, no matter how efficacious it would be if they followed the advice. Most addicts will never stop using. Most addicts will die in active addiction. We don’t know how to make efficacious treatments more effective, mostly.
The same is true, I think, for diet and exercise. Changing lifestyle is hard. It’s not a matter of will, I know that from my own experience being sober now for more than 8 years. It takes a sea-change of behavior that I’m not certain how to describe. It takes seeing one’s self and one’s life in a new way. It takes effort and determination, yes, but it takes something else as well. Not something more, maybe not internal at all. Certainly, I could not stop drinking alone.
I don’t know why I’ve been able to make life changes and other people who want to just as badly can’t. I know it’s not about money or time, because I know people with less of both who’ve succeeded better than I have – though I admit money and time have made my path easier. It’s not will. It’s not intelligence.
Maybe it’s just luck. Maybe I’m just lucky that making wholesale lifestyle changes agrees with me. That I am enriched and satisfied, internally, by the kinds of things I have to do to achieve these things. I don’t know. I don’t know how to pass it on. I wish I did. Because the things I have accomplished in sobriety and in fitness have brought me joy and pride and capability. I wish I knew better how to share them.