I just read this very honest article by an Australian physician about her experiences with obesity, both as an attending doctor in a hospital and specifically as the doctor that does the pre-surgical evaluation of potential bariatric surgery patients (link shared by Crossfit HQ's Facebook).
Fat City - What can stop obesity?
It's a brilliant read. She covers the dilemma of having to point out that a patient's weight is negatively impacting their health while knowing the kind of shame she is inflicting on them (on average fat shaming is counter-productive and just plain wrong).
To me the most interesting parts is about the bariactric surgery. If I remember correctly gastric banding has a success rate ~50% and a gastric by-pass has a success rate ~75%. Death from complications is about 0.5%. From my friend, who's an anaesthesiologist and has worked on a number of these surgeries, this is pretty bad but the challenge is that any time you put the morbidly obese through any surgery you run a number of risks that are absent from "normal" surgery. So in addition to the high risk of bursting stitches there's also a risk associated with general anaesthesia. But if you decide not to do the surgery then you still get morbidly obese patients under the scalpel at some point.
I usually hate the whole IIFYM mentality (If It Fits Your Macros - a concept that you eat anything as long as the three macro-nutrients hit your target) but for someone like the 200 kg young man she describes, who literally doesn't have anything enjoyable in his life apart from junk food, I think it is actually a better option than Paleo. Phew, too long sentence. But when someone can't even leave their bed some days then asking them to cook all their meals and ignore all junk is probably a bridge too far. Someone like that needs to manage how many calories are going in and he needs to do it in the simplest way possible. If he gets that working then he might learn that he can eat more food if he goes for a healthier option. Let's do some math! I love numbers. He could probably stand to lose 120 kg. There's ~7.2 kcal/g in adipose tissue (that's probably not the most precise number btw). So he has 864,000 kcal to lose. If we guess that his metabolism turns over 3000 kcal per day (yes, the bigger people are, the higher their base metabolism is). That might be low. Let's say 4000 because that's definitely too much. Then he has stored enough energy for more than 216 days. Without any calories from outside of his body. So basically, this dude needs a diet that is sustainable for about 3 years. Not a "Lose 5 pounds in 7 days with this skinny bitch we hate"-Cosmo-cover-diet. I don't like to admit it but Brad Pilon's Eat Stop Eat or Martin Berkhan's methods would probably be the best for him (both are intermittent fasting approaches with calorie restriction). Of course any successful weight-loss diet is simply a set of ways of acting that allows a person to eat fewer calories than their body needs without experiencing hunger (and preferably without a down-regulation of thyroid function).
My only issue with that article is that she thinks you can't be hungry when your stomach is full. It's a terrible feeling but perfectly possible. It's true that the stomach being full sends one signal to decrease the sensation of hunger but if you are in calorie deficit then that's another signal to increase hunger. Protein deficiency increases hunger. High concentration of fats and monosaccharides override satiety. I'm sure there's a lot more. Now I'm hungry.