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Perm J. 2010 Fall; 14(3): 92.
Published online Fall 2010.
PMCID: PMC2937862

Dear Editor,

We are pleased to respond to Keith Bachman, MD's comments on our recent description of our extensive experience with treating obesity in the Southern California Permanente Medical Group San Diego area. Dr Bachman's comments represent the usual views about treating obesity, a serious problem that is generally not handled easily or well.

  1. There is no question that unsupervised Very Low Calorie Diets (VLCDs) are dangerous, which is the point we made with our example of the Irish Hunger Strikers. Indeed, Optifast is not even available by prescription, but only in physician-supervised programs. Because we actively supplement with potassium, and monitor weekly, our impression is that our patients on an absolute fast supplemented with Optifast have fewer electrolyte problems than patients taking prescription diuretics.
    As separate and minor issues, distinctly fewer bowel movements are the natural consequence of not eating. Cold intolerance and fatigue will be experienced by a few as commonplace stress responses to not being able to destress by eating, but most patients report increased energy levels and reduced asthma attacks and other allergic processes. The psychophysiology of this improvement has not yet been described.
    Our San Diego Positive Choice Program, developed as the result of many years experience, differs markedly from the program supplied by the manufacturer of Optifast. That program, although safe and well intentioned in our opinion, does not adequately pursue the psychological underpinnings of obesity, thus needlessly limiting the effectiveness of their product. Dr Bachman accurately notes this limitation in his Point 3.
  2. Considering the approach usually given to treating obesity, the National Institutes of Health caution is appropriate to most of these circumstances. However, with capable medical supervision of electrolyte balance and related biomedical matters, risk is not an issue, as we have illustrated in our 30,000 cases. Our experience with treating these patients over 25 years demonstrated that maintaining weight loss has nothing to do with calorie intake in the weight-loss phase. Maintenance is totally a function of what is accomplished or not accomplished in the accompanying program, which needs to be psychodynamically (not nutritionally) oriented. This point has further been demonstrated by those patients who have been able to eat their way out of bariatric surgery, as we illustrated by the quote in our article, “The antidote [sic] to bariatric surgery is Karo Syrup.”1
  3. The whole point of our article centers on our having outcomes better than usual. That said, weight loss in any program is a function of patient compliance, which is a function of the support provided by the program. This, in turn, will be a function of how well the issues underlying any given patient's obesity are understood, by the program and the patient. This is not an easy concept to grasp if one persists in misunderstanding the caloric origins of excess poundage as the crux of the problem. That misconception mistakes mechanism for cause, a common error. We believe that our better-than-normal outcomes are the result of the support from our program, in conjunction with the VLCD.
  4. Indeed, rapid regain sometimes occurs, and is a blight in some programs, just as it sometimes occurs after bariatric surgery. The question is why does it occur in these instances? How do these individuals differ from those who do not regain? The answer to this question has absolutely nothing to do with calorie intake in the weight-loss phase, a point made clear in our article. It is the program that is the key determinant of long-term outcomes. Our program has been slow in development because we repeatedly tripped over counterintuitive aspects of obesity, such as the hidden benefits of obesity and the consequent threat of major weight loss to many individuals.
  5. This statement does not incorporate the cost savings to our patients in not buying any food or caloric beverages for 5 months. Thus, while our cost-neutral charge to the patient is approximately $2500 for the Program, including Optifast for 5 months and the Maintenance Program for the next 12 months, when corrected for food not purchased and dinners not eaten out, the actual net cost for most people will be only a few hundred dollars for a 17-month Program. On the other hand, to the degree that a person on a VLCD is also eating on the side, the economic costs of failure will indeed be high. The major reduction in office visits that we documented during and in the year subsequent to the Program are an additional benefit, either to the patient or to the health care system. Beyond this, the details of insurance programs other than Kaiser Foundation Health Plan were not examined.

Although we believe we made these points clearly, we also understand that they lie sufficiently outside conventional thinking about obesity that they perhaps need restatement in different ways. To that end, one of us (AR) has extended an offer to Dr Bachman to again visit the San Diego Positive Choice Program to see in action what we are describing.

Any major revision of commonly held ideas is difficult, uncomfortable, and sometimes threatening. The philosopher, Eric Hoffer, explored this problem well in his small monograph, The Ordeal of Change.2 In that regard, The Permanente Journal offers us all in Kaiser Permanente an important sounding board for the introduction of new thinking into an old problem that is obviously getting worse in the face of usual approaches, even though those approaches are supported by august governmental agencies.


  • Felitti VJ, Jakstis K, Pepper V, Ray A. Obesity: problem, solution, or both? Perm J. 2010 Spring;14(1):24–30. [PMC free article] [PubMed]
  • Hoffer E. The ordeal of change. New York: Harper and Co; 1952.

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