Category Archives: Advice on how to Lose Weight

What’s the Best Way to Help People Lose Weight?

If weight-loss programs advertised on television were to be believed, then it is obvious that the best way to get people to lose weight and keep it off is to eat commercially available, calorie-controlled packaged meals and snacks. In just [insert number of days] you, the consumer, will drop at least 10 to 20 pounds, lose your hunger completely, and never have another food craving, according to the promises in the ads. Two runners-up would include an FDA-approved weight-loss drug that takes away appetite and replaces the pleasure you get from eating with something not defined, and/or an exercise device that melts off pounds and replaces them with a “ripped” body that looks good in a minuscule bikini or swim trunks.

Despite the allure of such advertisements, and the wish to look like the models proclaiming the efficacy of such weight-loss interventions, extensive research indicates that they are not the best way to lose weight and keep it off. No surprise.

A few days ago, the Journal of the American Medical Association (JAMA) published a paper that summarized several years of analyzing current interventions on weight loss and maintaining weight loss. The report did not include results from surgical interventions that reduce the size of the stomach, such as putting a balloon in the stomach or removing food from the stomach through a tube that empties into a receptacle. The criterion for review of the weight-loss interventions was whether or not they could be “provided in or referred from a primary care setting.”

The report stressed the importance of identifying the most effective means of bringing about weight loss because of the alarming prevalence of obesity in the states. The commonly accepted definition of obesity is a body mass index (BMI) of 30 or higher. (This is weight in kilograms divided by height in meters squared; there are websites that help with this calculation for the arithmetic-challenged reader.) More than 40 percent of women and 35 percent of men in the United States today meet the criterion for obesity.

Intensive, multifaceted weight-loss interventions were found to be the most successful based on the authors’ review of published studies. Such interventions lasted one to two years, with monthly or more frequent meetings. Although food plans that would support weight loss were part of the intervention, the report did not single out any particular type of diet, other than inferring it would have to be a food plan that could be followed for many months. People were encouraged to monitor their weight and exercise levels, to use food scales to weigh their food, and behavioral support was consistently offered. The settings ranged from face-to-face meetings with individuals or a group to remote interactions via Skype or other computer-assisted interactions.

Even though the review looked at programs that could be carried out in a primary care setting, as opposed to surgical interventions, primary care physicians were rarely involved in the programs. A “village” of behavioral therapists, dieticians, exercise physiologists, and life coaches offered a variety of services designed to enhance not only the weight loss but also its subsequent maintenance.

The study rejected the use of weight-loss drugs because the authors wanted to find interventions that caused the least harm. Such drugs come with a long list of side effects: anxiety, gastrointestinal symptoms, headache, elevated heart rate, and mood disorders, to name a few. The side effects from behavioral interventions might be aching muscles from a new exercise or a longing for highly caloric foods. The authors did note that when pharmacological interventions were combined with behavioral ones, the results were better than with either intervention alone. But there was a high rate of attrition, i.e. withdrawal from the studies among those taking weight-loss drugs, perhaps due to the side effects.

The takeaway message from this comprehensive report is that the thousands of people in need of weight loss should locate a primary care physician who will then direct them to an intensive and comprehensive behavioral weight-loss program meeting at least once a month for 18 months or longer. The program should help them buy and prepare the foods they should be eating, make sure that they have the time and money to participate in frequent exercise, identify or solve problems causing emotional overeating, and make sure that weight-loss successes are supported by family and friends and not sabotaged. The report did not mention cost; the studies the authors reviewed were free to the participants.

“When pigs fly!” might be the somewhat cynical response to this paper. Yes, of course, all these interventions will presumably work, except perhaps for those patients whose weight gain was a side effect of their medications. It is very hard to lose weight when drugs such as antidepressants and mood stabilizers cause hunger that does not go away.

But how many primary care practices have the money and time to formulate and carry out the intensive programs recommended? How many hospital-based weight-loss clinics have exercise physiologists, life coaches, therapists, and dieticians to pay personal attention to the participants? Where does one go to find such programs?

And yet, what are the alternatives? The list of medical problems associated with obesity, ranging from orthopedic disabilities to cancer, is not getting smaller. Might technology be the answer? Smartphones allow us to monitor many aspects of our daily lives, from how we sleep to whether we feel stressed. Might robots or some other form of artificial intelligence prevent us from eating portions that are too large or moving too little (some do already), or ask us what is really wrong when we open the freezer to look for the ice cream? Can a robot remind us to do our exercise routine, or meditate, or stop working and give ourselves some private time…or turn off the computer or television and go to sleep? And would we be less likely to deny that we have just eaten a bag of cookies to a robot?

Human interventions have not worked all that well; perhaps it is time to turn to the other.

References

“Behavioral Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults,” US Preventive Services Task Force Recommendation Statement US Preventive Services Task Force JAMA, 2018; 320(11): 1163-117.

Is the Gym the Place for Psychotherapy?

I was on the treadmill when the battery for my noise-canceling headphones died. As I took them off and hung them on the railing of the machine, I heard a personal trainer talking with some urgency to the woman walking on the machine next to me. She was in her late forties, more or less, and about forty pounds overweight. He questioned whether she had planned to cancel the training session because she had not lost any weight, and when she nodded in the affirmative, he went on for some minutes, describing her emotional problems and what she should do about them. The noise of the treadmills was not loud enough to block his voice. The trainee, a woman, was a little out of breath which may be why she did not respond to his lecture.

What to do?  “I really should not be hearing this,” I told myself.  As someone who has done weight counseling and clinical research, I know how important it is to protect the privacy of everyone with whom I have contact.  Having a therapeutic conversation with a client would be done in an office, and the information in my notes was protected against an invasion of privacy. And yet, this trainer was conversing in a sufficiently loud voice so that I, and perhaps someone on a nearby machine, could hear what he was saying. Should I have been hearing about her problems with her mother? Did I want to know what she eats when she is upset? I suppose we all would benefit from his advice to take better care of ourselves, but it was not necessary for me to hear that as a bystander.

Combining exercise and talk therapy is certainly a good idea, as it may amplify the benefits of both. Presumably both therapist and client are better off engaging in physical activity; we all sit more than we should.  And as a friend told me, you, the patient, know that your therapist isn’t sleeping while you are talking if you are walking together. Sometimes simply walking side by side with someone who is an empathetic listener makes it easier to talk about problems than sitting face to face. How many of us have taken a walk with a friend or family member to discuss a problem?

But the personal trainer is neither a friend nor a family member, much less a licensed therapist. Yet because his advice was being given in a professional capacity as a paid trainer, it is reasonable to assume it would be taken more seriously than if the advice came from a friend or another gym member on an adjacent treadmill.

It is very tempting to give advice even when it is outside the area of one’s expertise. I go to the gym; shouldn’t I be able to help a weight loss client plan a program of physical activity?  For example, when I see a client for a weight-loss consultation, I ask about the level of physical activity and usually suggest exercise as part of a weight-loss plan. Certainly I should be able to suggest even more: how much weight lifting should be done along with cardiovascular activity.  But I am not a certified personnel trainer and I would never give advice as to the kind of exercise that should be followed, beyond the obvious recommendation to walk. Instead, I recommend a consultation with a personal trainer or physical therapist to make sure that the physical activity is compatible with the client’s health, stamina and age.  Would I take the client to a gym to show her how to use the machines? Of course not.  I do spend time with clients helping them figure out when their schedules will permit them to exercise.  And once I discussed with a client what she could wear in the gym that would flatter her shape. (It is hard to find workout clothes in large sizes.)

However, I have overheard many trainers who have relatively little nutritional expertise giving advice about diets or nutritional supplements; sometimes their information is erroneous or based on little evidence that a particular supplement, for example, is safe and effective.  Too many times, I have been told that a friend is following the latest diet fad because his or her trainer recommended it.

Would we be taking financial advice from our trainer or listening to her about how to decorate our living room, buy a car, or deal with a troublesome teenager? Unlikely.  Would we take marital advice or suggestions on how to deal with an aging parent from the person who helps prepare our income tax?  Probably not. But as I kept glancing at the woman on the treadmill beside me, I wondered why she was allowing her trainer (and not a therapist) tell her how to handle the demands of her mother, or problems with her marriage. (I obviously heard too much.) Was it because she was a captive on the treadmill? Or maybe she believed that someone who is overseeing how your muscles are working is competent to advise her on her emotional state.

The trainer’s advice to exercise faithfully, eat frugally, and give her some time for herself are within the bounds of common sense; they are suggestions that any of us could give and receive.  But if he plans on continuing his gym psychotherapy, let him go through professional training and receive the credentials to do so. And then he should he want provide therapeutic consultations in the gym, go to a place where only the client is listening.

Working Toward Weight Gain

A few days ago, I was in the office of my ophthalmologist for my annual eye exam. The practice is huge, and the volume of patients is processed–so to speak–by a row of administrative personnel, each sitting in a cubicle. I checked in at one such space and later checked out with the same clerk. As I watched her scan the computer to then print out the appropriate paperwork, it occurred to me that her job was almost totally sedentary. She did not have to move more than a few inches to access her computer, and the printer was under her desk so she did not have to walk over to another area to retrieve a printout. She was not chained to her chair, yet I doubt she was able to leave it until lunch and then again when the office closed. Unless she had far to go for lunch, or exercised during that noon break, she was completely sedentary for hours.

Until robots take over many of the routine jobs now performed by humans, more and more employees will be working in occupations characterized by an absence of physical activity. About seven years ago, a report was published on changes in physical activity related to occupation over the past fifty years in the United States. The authors used data from the United States Bureau of Labor Statistics that analyzed the amount of energy expended for jobs in private industry from l960 on. When the data were first collected in the early l960s, almost half of non-government jobs required moderate to strenuous physical activity. 50 years later, this number dropped to 20 percent. The authors translated these figures into changes in the number of calories that are expended in work and stated, “We estimated a reduction of more than 100 calories per day in occupation-related energy expenditure over the last 50 years.”

50 years ago, the woman processing my eye doctor’s records would have been using a typewriter and thus expending more energy than tapping on a computer keyboard. She probably would have to get up from her chair and walk to the office copy machine to make a copy of my record rather than pushing a button on her computer and reaching under her desk to retrieve the paper from the printer. Multiply this by every patient, every five minutes or so, and her calorie output would have been considerably more than it is today.

The authors of this report discussed the implications of the decrease in work-related physical activity as a risk factor for obesity. They suggested that as we increase the use of labor-saving, we are promoting the increase in weight of the population in general.

They recommend physical activity to compensate for the sedentary nature of many occupations. According to them, if the woman processing my paperwork engages in 150 minutes of moderate activity a week, she will compensate for her lack of activity during her work hours. But, as they point out, only one in four Americans meets this goal. Given the long commuting time many workers face, as well as the unending tasks to be done at home, it is unlikely that the three out of four Americans who are not exercising will suddenly find the time to do so during their limited after work hours. And even if some physical activity occurs on weekends, unless it is prolonged it probably will not compensate for the inert workweek.

Chairs perched on bicycle pedals and mini treadmills, are now being used by many who otherwise might be stuck unmoving an office chair. Those who fear the consequences of prolonged inactivity welcome the opportunity to move the bottom half of the body while the head and hands are occupied in writing reports or code. The use of these devices could be expanded to a much larger population such as medical office workers or anyone else forced to spend most of the workday seated. However, this is unlikely to occur; in addition to the obvious cost of such devices, it might seem strange to check into a medical office for an appointment and find the medical secretary bouncing up and down on her under-desk pedals.

Another option is to schedule walking breaks for workers who otherwise have little opportunity to stand up, let alone walk. This requires time and attention to the employee’s schedule; five-minute walking breaks when patients are waiting in line to be checked in or out means having someone available to cover while the break occurs. This may be too much trouble logistically and too costly financially. Ironically, employees who still smoke and must leave the workplace to do so have a built-in opportunity to move. If they can take a break to smoke, why shouldn’t others be allowed to take a break to move?

Another solution is to rotate the sitting employee into positions that require walking so that for some of the work day he or she is released from the chair. In the office I have referenced, another employee takes the patient to the area where the doctor’s office is located. (The practice is so large one almost needs a GPS system to find the appropriate office by oneself.) If the person checking people in and out were to be a patient escort for part of the day, or some other job that required walking, then the sedentary routine would be broken.

But these are rather weak solutions to a major problem confronting most occupations: How do all of us whose work is associated with being relatively inert get enough physical activity without sacrificing sleep, family, social obligations, and financial goals? Perhaps the answer is for workplaces to offer brief opportunities to stretch and to move, even if it is only for 15 to 20 minutes a day.

It may not be enough to compensate for all those hours of sitting, but it is a start.

The Unfortunate Association Between Pain and Obesity

Anyone who suffers from chronic joint and/or muscular pain and is also struggling with obesity realizes how much each impacts the other.  The pain makes it hard to move to exercise without discomfort. The pain of fibromyalgia also makes it hard to deny oneself food that is pleasurable (and possibly fattening) because such eating is a source of pleasure. Pain makes it hard to be in a good mood, and not surprisingly, may potentiate depression. That, in turn, affects eating, sometimes causing weight gain, as do most antidepressants.

Thus more pain is experienced.

Another concern is that insomnia can result from pain; few people can sleep through the night because of the unrelenting disturbance. The fatigue from lack of sleep often leads to overeating, weight gain, and more pain.  And, just to make things worse, two of the drugs prescribed to help pain, especially that of fibromyalgia, can cause weight gain (Neurontin and Lyrica). And so more pain occurs.

Pain comes in many varieties: headaches, abdominal pain, joint and muscle pain, and fibromyalgia.  A review by Okifuji and Hare in the Journal of Pain Research details the ways pain and obesity interact; their review makes the reader feel grateful for every minute that is pain free. (“The association between chronic pain and obesity,” Okifuji, A., and Hare, B., J Pain Res. 2015; 8:399) When obese individuals claim that it “hurts to walk, to climb steps, to get up from a chair, to lift anything,” they are describing the way their weight affects their inability to move without pain.

According to Okifuji and Hare’s review, as BMI (a measurement of weight relative to height) increases, so too does chronic pain.  In one study, fewer than 3% of people with normal BMI reported low back pain, but almost 12% of morbidly obese individuals did so. Anyone who has watched the television series “My 600-lb Life” has seen the pain on the faces of these extremely obese people when they have had to stand or walk. It seems unbearable, yet even at a considerably lower weight, the body may respond to carrying around extra pounds with chronic pain.  The Arthritis Foundation has some compelling information about the relationship of excess weight and pressure on the knees: every extra pound carried puts 4 pounds of extra pressure on our knees. So if one is only ten pounds overweight, forty pounds of extra pressure is placed on those joints. This means that weight gain associated with a painful disease like fibromyalgia, typically more than twenty pounds, may put enough pressure on the knees to cause another source of pain.

If obesity is exacerbating chronic pain, such as that associated with arthritis or fibromyalagia, the solution is simple but not easy to achieve: lose weight.  Many studies that have shown relief of pain with weight loss.  In a typical study, when adults suffering from joint pain are put on a diet with or without the kind of exercise that their bodies can tolerate, they lose weight and their pain is diminished.  (“Diet and Exercise for Obese Adults with Knee Osteoarthritis,” Messier, S., Clin Geriatr Med, 2010;26:461; Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomized clinical trial,” Messier, S., Mihalko, S., Legault, C., Miller, G., JAMA, 2013 Sep 25; 310(12): 1263-73)

But anyone who has experienced even transient pain from, for example, an overly ambitious workout, the first long bike ride of the season, too much weeding and hauling a wheelbarrow, or some unexplained back pain that thankfully disappears a week or so after it mysteriously arrived… knows how hard it is to move without pain. Unfortunately, our appetite rarely disappears when the pain arrives.  A friend who is extremely active was transported through an airport in a wheelchair after a virus-like infection caused severe back pain. His agony prevented him from walking more than a few steps at a time. After he recovered, he told me how reluctant he was to move when he was in such pain.

“Unfortunately, I didn’t lose my appetite so I was eating as much as before,” he said.

Increasing mobility as a way of preventing weight gain and supporting weight loss is advised for almost all situations in which there is chronic pain, as long as there is no possibility of damage to joints or muscles. The best way to go about this is with guidance from a physical therapist who can advise on movements that either will not hurt, or cause too much discomfort. Swimming and/or aerobic exercises in warm water is less likely to cause pain than activities involving some impact on joints. Gentle yoga is also recommended with instructors who know how to protect the participants from movements that will hurt. Recumbent bikes tend to be more protective of joints and muscles than other pieces of equipment in a gym, but even this piece of equipment should only be used with the advice of a physical therapist. Walking, if not too painful, should be done where there are places to sit and rest, should the pain becomes too intense to continue.

Dieting is equally difficult. When pain restricts most physical activity, it is hard not to gain weight since the individual requires many fewer calories than when normal activity is taking place. Muscle weight may be lost due to the inactivity, but excess calories will continue to be turned into fat. A dietician can figure out how many calories should be consumed in relation to the degree of inactivity caused by the pain. And just as important, the dietician can develop a food plan to make sure that all essential nutrients are being consumed within the calorie limits. Pain and attempts to lose weight should not lead to a nutritionally inadequate diet.

Even small amounts of weight loss are beneficial. If every pound gained may make the pain worse, every pound lost should bring some relief.

Accidental Weight Loss: A Gift for the Dieter

Three of my friends are suddenly thinner, and they are delighted because none of them was dieting.  One lost weight because work required her to travel across several time zones, and she found that she was sleepy, but not hungry, at mealtimes in the new time zone. Another had unexplained abdominal pain, was put in the hospital for tests, and did not eat for several days because of the tests and the pain.  When she returned home, she found that she had lost several pounds. The pain went away unexplained, but the weight loss remained. A third moved and was so busy unpacking, she ate when she remembered to eat, and that consumed were protein bars unearthed in one of the boxes. Because she couldn’t remember where anything she had unpacked was, she walked miles in her home trying to locate the stuff she needed, such as her cell phone.

None of these women was obese, but each wanted to lose between 15 and twenty pounds, but had not gotten around to doing so (one for several years). However now, after noticing their unexpected weight loss, they put themselves on a diet because as one of them told me, “My weight loss was a gift and I didn’t want to throw it away.”

Who knows what motivates someone to go on a diet at a particular moment? Sometimes it is done during a traditional dieting time, such as the first week in January. Diets are started because a special occasion is occurring several weeks or months hence and right now the article of clothing to be worn is tight. Or the occasion itself calls for appearing slimmer; weddings and reunions are noteworthy for being diet motivators. Medical reasons are often motivators for weight loss, too, but sadly are usually accompanied by the development of a medical problem like diabetes or painful orthopedic issues. Occasionally a picture of oneself from an unflattering angle strips away the ability to deny the excess pounds, or the inability to fit into the new season’s clothes that fit a year ago demand that either weight be lost, or a new wardrobe be purchased. But these reasons for starting a diet involve a conscious ‘before’ when the individual was not on a diet, and a conscious ‘now’, when the diet has been started. Accidental weight loss is just that; no conscious decision is involved, it just happens.

Perhaps the most positive aspect of accidental weight loss (in addition to the lost weight itself) is realizing that it is possible to drop pounds without even trying. Many who struggle to lose weight believe that they won’t be able to. The pounds appear to be stuck with permanent glue to various parts of the body. Diets are started and weight may be lost, but to do so requires a great deal of effort: meal planning, and preparation, and time for exercise. Of course this healthy way of life should be followed regardless of weight change, but we are human and unless weight loss is substantial, we may feel that losing weight is not worth the effort we are putting into doing so.

Accidental weight loss seems to produce a looser skirt or pants, a zipper that goes up easily, a shirt whose buttons close without any obvious effort.  “My unplanned weight loss proved to me that when I eat less and move more, the pounds came off, “said my friend, “and I didn’t have to follow any peculiar diet, or any specific kind of exercise.“

Accidental weight loss challenges the claims that the dieter must eat, or avoid eating, foods from specific food groups, must overcook the food, or eat it raw, must allow it to ferment to produce specific bacteria, must subject the body to fasting, cleanses, supplements made from herbs and twigs, injections of fat burning hormones, hypnosis, packaged foods made in an industrial plant, or the latest tabloid ‘miracle’ diet, in order to lose weight. When weight is lost accidentally, it seems that the body wasn’t paying attention to all these diet remedies. It just responded to less food coming in, and in some cases more energy was being used up by your body, and that simply equates to that your physiology used up some of its fat stores, for energy.

The realization that the body is capable of losing weight without formal dieting should be transformed into a strategy for continuing to lose weight. The first step should be reviewing in a non-judgmental way, the eating and physical activity habits that caused the weight gain, and next figuring out what acceptable changes can be made to sustain the weight that has already been lost. With a suddenly slightly lighter body, eating smaller portions, or going for walk rather than sitting on the sofa, may become easier. Throwing away high fat, high sugar, and high sodium snacks that have been an obstacle to weight loss, might seem sensible rather than a culinary sacrifice and exploring alternate methods of decreasing stress other than eating.

After accidental weight loss, you are unlikely to continue to lose weight without consciously making an attempt to do so, but you will be able to. Your body has shown you that it is able to remove a few of those pounds you once felt would never be lost. Now your body is just waiting for you to continue to lose more.

Why Weight Loss Is Rarely Permanent

Many years ago at a meeting that addressed the usefulness of prescribing appetite suppressants for weight loss, one of the speakers (whose name will not be mentioned in case my memory is incorrect) said,

Obesity is a chronic disease.  Don’t think that allowing a patient to use weight-loss drugs will produce a permanent weight loss, or that other weight-loss intervention will also stop future weight gain. Obesity, like depression, alcoholism or autoimmune diseases, is chronic, and chronic diseases may go into remission because of medication and/or effective behavioral changes….So while sometimes one treatment is sufficient, the depression or skin rash never reappears after the initial intervention. The alcoholic stays abstinent.  Rarely is it that the diet plan or diet drug or surgery produces a permanent, positive change and weight stays normal. More commonly? The disorder reappears, more than once, and requires repeated behavioral, and/or medical interventions. Indeed, chronic treatment may be the only way to prevent flare-ups, a return of drinking, or depression.”

He went on to say that there is a bias toward people who gain weight again and again. We all know this…From the cruel remarks we make when someone is on a diet (Another one? Not again!) or gaining back the weight lost from the previous one (See, I knew she would never keep the weight off! ) to the hopeless attitude of physicians who give up helping a patient deal with constant diet failures (There’s no point wasting time talking about losing weight; he/she never listens.)

Weight-loss advice ranges from suggesting the most ridiculous or severe diets, to the simplistic mantra of portion control and exercise. Or else we keep quiet and shake our heads. “See,” we say to each other, “she has gained back all the weight she lost last year.“ And then we judge the currently popular diet with the comment, “Too bad this didn’t work, either.”

Yet so many of us have friends, colleagues, relatives, and acquaintances who have been abstinent and suddenly are found drinking again, perhaps after years of not doing so. When they are able to resume their AA meetings or come out of rehab, we don’t berate them with, “You failed. What is the point of helping when you will fail again? “ Rather, we support their effects to succeed.

If we treat obesity as a disease with a high probability of reoccurrence, as is the case with depression or alcoholism, then our entire approach to treatment can differ. All interventions will be presented honestly as a means of bringing the patient into remission, which may last weeks, months, or years. Still, the interventions will not be presented as a permanent cure. Taking out a diseased appendix is a permanent cure for a diseased appendix. Staying abstinent, if not a cure for alcoholism, is remission one day at a time.  Losing weight is not a permanent cure for obesity. Rather, it is remission from overeating and underexercising, one day at a time.

Treating obesity as a chronic disease allows a variety of interventions to be tried without blaming the patient if he or she fails to succeed at one or the other. Depressed patients are often switched from drug to drug, and the patient is not blamed when the depression doesn’t respond to a particular medication. Just as talk therapy is considered as important as drug treatment for depression and related mental illness, so too talk therapy should be part of the obesity treatment. Recognising what might erode control over eating is essential for success on a current diet, but also in delaying the onset of another weight gain flare-up. Semi-annual check-ups of weight status must be mandatory so the patient and care provider can identify emotional, situational, or even hormonal changes that might start the weight gain process. Such check-ups should remove the inevitability of weight gain in the minds of the patients.

For example, people who suffer from winter depression resign themselves to gaining weight over the dark months of late fall and winter, since weight gain is one of the symptoms of this particular type of depression. People also assume and anticipate gaining weight over the holidays. But why should this be? Would we assume that a friend, a recovering alcoholic, would start drinking over the winter, or that someone who is depressed every winter not be treated because the depression will come back the next year? If a patient had an intolerable flare-up of psoriasis, which can be maddeningly itchy, then every winter wouldn’t a dermatologist take steps to prevent it from occurring?

Because we don’t view obesity as a chronic disease, we simply do not treat it when we should. We don’t say to someone gaining weight, “You are experiencing a weight gain flare-up. It is important for you to be treated now before the situation becomes intolerable or hard to reverse.” A patient who has reoccurring depression should obviously be treated long before the symptoms become life-threatening. When the weight gain flare-ups occur, treatments also should be initiated. They include appetite suppressants, therapy, consultation with a physical therapist about exercise, use of calorie-controlled meals until control over eating is resumed, and participation in weight-loss support groups.

Of course, none of this will work if the weight-gaining patient refuses to acknowledge what is happening and/or resists treatment. Not all alcoholics who have failed to remain abstinent acknowledge what is happening or seek treatment; when they do, many are able to go back into remission. We must tell the obese individual to stop hoping for permanent weight loss. Keep the weight off today, and we will be there to help you if tomorrow is a problem.

If I Don’t Pay Attention to What I am Eating, Will the Food Contain Calories?

“What do you usually eat on a typical day when you are not dieting?”

I often ask this question when meeting a weight-loss client for the first time. Although I write down the information, I know that it is rarely complete. It is very hard for any of us to recall everything we have eaten yesterday or a few days ago, especially food that is not consumed as part of a meal. Did we munch on the potato chips that came with the lunchtime sandwich? Did we pop a few nuts in our mouths when we saw the bowl on the coffee table? Did we taste the food we are making for dinner and perhaps do more than just taste? Did we or didn’t we have a glass of wine with dinner, or was it two?

As hard as it is to remember what we ate it is even harder to remember how much. Few of us visually measure the size of the entrée put in front of us in a restaurant, or notice the quantity of food we eat at home. Was the chicken 4 ounces or 6? Was the rice a half a cup or two cups? How big was that piece of blueberry pie? And sometimes our best intentions to eat only a small part of what is put in front of us get lost when our attention is directed elsewhere while we are eating. I remember seeing a couple aghast at the size of their meals when it was put down in front of them in a restaurant known for their supersized portions. But they consumed everything on their plates because their attention was diverted to an intense discussion they began as they started to eat. The faster they talked, the faster they ate, and I suspect they never noticed how much they were eating until their plates were empty.

Reading emails on one’s smartphone, watching a video on a laptop device, or texting with the non-fork containing hand also interferes knowing how much is being eaten. When attention is elsewhere, the act of eating becomes automatic. The fork moves from plate to mouth to plate again, and the eater may not notice how much is being eaten until the plate is empty. If an hour later the eater was asked what and how much was eaten, he or she might be able to give only vague details. Indeed, sometimes the eater denies that much was eaten at all. “I just tasted the food and left most of it,” he will claim when the reality is that there was nothing left on the plate when he finished the meal.
Unless we must keep track of our food intake for health and weight-loss reasons (for example, a diabetic keeping track of grams of carbohydrate), we usually give only perfunctory attention to what we are eating. But even if we forgot what we put in our mouths, our metabolism does not. A calorie we do not notice eating still counts as a calorie we have eaten.

This absent-minded eating can make it very hard to lose weight. The heavily advertised weight-loss programs that restrict all food intakes to packaged drinks, snacks, and meals delivered to your door make paying attention unnecessary because the meal choices are programmed to enable weight loss. But if you are on a weight-loss program that gives you choice of what, and to some extent, how much you are eating, then often the only way to keep track of what you are eating is “to keep track.” There are apps for this, along with the traditional paper and pen food diary. Some people are able to keep track of everything they eat (they also balance their checkbooks), sometimes for months, and they are usually successful in losing weight and keeping it off. But for the rest of humanity for whom even keeping track of today’s date is difficult, recording everything that is eaten becomes very tedious very fast.

People who have maintained an appropriate weight for many years often follow an unchanging menu for breakfast and lunch. They don’t have to pay attention to what they are eating because their meal choices never vary. They often have rules about what they will eat for dinner as well: limited alcohol intake, salads with dressing on the side, eating only half the restaurant portion or sharing an entrée, avoiding fried foods and dishes with thick sauces or melted cheese, or avoiding all carbohydrates or all fats.

Weight-loss programs that do not make it necessary to pay attention to what and how much is eaten because all the foods are pre-measured rarely offer effective advice on how to pay attention to what is being eaten after the diet is over. The concept doesn’t sell very well in television advertisements for people who just want to lose the weight, but it is critically important to do so.

Making rules that limit food choices may be the most effective method, but may turn eating into more of a chore than delight. One thing that helps is spending 20 seconds to look at what is on the plate before eating. In those 20 seconds you can decide what you will eat in its entirety, what you will avoid and what you will eat sparingly. Taking a picture with a cell phone so the calories can be figured out later is also useful. It also may give you an idea of whether you have eaten anything healthy that day. Mindless snacking is a caloric hazard. Dipping one’s hand into a bowl or bag of snacks like nuts, cookies, or chocolate almost always causes excess calories to be eaten without any memory of doing so.

Not paying attention to what you are eating has a price: you may not know but, alas, your clothes and scale will eventually know only too well.

Will the Bacteria in Sauerkraut Make You Thin?

Most of us pay less attention to the many colonies of bacteria living in our intestinal tract than we do to the possibility that there may be colonies living on Mars. Recent research suggests it is time to do so. Our gut contains densely packed colonies of bacteria that affect not only digestion and diseases of the intestinal tract, but also our immune system and, according to some research, perhaps hunger, weight, mood, and athletic performance as well.

According to an article by Drs. Zhang and Yang, our intestinal tract contains more than 1000 or more bacterial species. These varieties of bacteria, of which we are usually unaware unless we have “tummy troubles,” function to assist in digestion,  particularly of high fiber fruits and vegetables. They break down the chemical composition of fiber, thus transforming the indigestible carbohydrate to substances, as well as short chain fatty acids, which are used for energy. Our bacteria are also gatekeepers, helping the intestinal immune system deal with foreign antigens or proteins when they enter our body. Intestinal bacteria contain enzymes that make vitamin K, a critical component in the formation of blood clots. Intestinal bacteria also synthesize other vitamins: biotin, vitamin B12, folic acid, and thiamine.

That the bacterial flora can change is well known to anyone who has taken antibiotics for several days, and then confronted with less than optimal intestinal functioning. The antibiotic wipes out so-called healthy bacteria, and sometimes it takes several days or longer to restore normal functioning.

Zhang and Yang’s report asserts that diet also causes significant changes in gut bacteria. Consumption of a high-fat, high-sugar diet causes unhealthy bacteria to flourish. Conversely, diets low in those nutrients, but high in fiber, bring back a better class of bacteria. For somewhat obvious reasons, most of these studies are done on laboratory animals, since they require samples of intestinal bacteria found in the feces, and it is hard to find human volunteers for these studies.

Is it possible that our bacteria can affect our mood? Some scientists suggest that we can reduce anxiety and depression if we have the good kind of bacteria. This is based on evidence that intestinal bacteria make neurotransmitters, the chemicals that transmit messages in the brain. But it seems unlikely that our gut will control our mood since neurotransmitters made in the gut never get into the brain. (But interestingly, we do talk about our gut having feelings, i.e., our language is full of expressions that suggest our gut has moods: a feeling in my gut, gut response, gut reaction, etc…)

Intestinal microbes may affect the amount of ghrelin, a hormone that tells the brain whether we are hungry. But if so, no one has figured out what species of intestinal bacteria may do this—or whether they will make us feel so full we will eat less. Now athletes are allowing their intestinal bacteria to be analyzed to see if they differ from those of sedentary folk. According to an article in a recent issue of Outside magazine, some super-fit athletes do have varieties of bacteria not found in non-athletes. However, since they tend to follow extremely healthy, low-fat diets, is it their diets or their incredible athletic feats that change the bacteria? (Or, do the bacteria contribute to their athletic success?)

Much more research has to be carried out to show that intestinal bacteria are having a direct effect on hunger, athletic performance, or obesity before we can start manipulating our bacterial colonies to bring about certain desirable health effects.  To be sure, there are some studies now gaining interest, that have tested the effects of fecal transplants in which bacteria from healthy volunteers may be transplanted to the intestines of those suffering from an intestinal disease like irritable bowel syndrome. These studies are showing promise in helping people whose intestinal disorders do not respond to conventional therapies.

In the meantime, while we are waiting for more science to support some of the claims that our gut bacteria can alter our heath for better or for worse, we are told to load our intestinal tract with good bacteria. Supposedly, these good bacteria can be eaten if we consume fermented foods such as sauerkraut (fermented cabbage), miso and tempeh (fermented soybeans), kimchi (a Korean dish of fermented cabbage with hot spices), kombucha tea (a fermented drink made with tea, sugar, bacteria, and yeast). and kefir (a fermented yogurt drink). These foods contain probioticsor living bacteria, that when ingested populate our intestinal tract with good microbes. Pasteurization will kill the microbes, both good and bad, which is why many yogurts and canned sauerkraut are not on the list.

But there is a problem. Although scientists can identify many of the species of good intestinal bacteria, they are not listed on a package of tempeh or a bottle of kombucha. Moreover, how many bacteria are we actually eating? Probiotics may differ in their content of something called CFUs, or colony-forming units. CFUs describe the density of viable bacteria in a product. According to Dr. Shekhar K. Challa, a gastroenterologist who wrote Probiotics For Dummies, quantitating the CFUs of probiotics in most food products is almost impossible. CFUs are not listed under calories or any other place on the food label.

So will eating unpasteurized sauerkraut make enough good bacteria to make you thin (that is, if good bacteria will make you thin)? Probably not. But sauerkraut contains almost no calories, and chopping a cabbage, mixing it with salt and watching it turn into sauerkraut is something to do on a snowy afternoon. And after you eat it, its bacteria will have a happy home in you.

References

(“Effects of a high fat diet on intestinal microbiota and gastrointestinal diseases,” World Journal of Gastroenterology 2016, Oct 28; 22(40): 8905–8909) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5083795/

Don’t Avoid Exercise Because It Makes You Hungry

Among the many kinds of advice given to those who are trying to lose weight, exercise usually ranks just below diet. But just as weight-loss advice can be contradictory and confusing, so too are the recommendations for exercise. No one disputes the benefits of physical activity on everything from improved digestion to better cognition. The adverse effects of ignoring the prescription to move ones body are just as compelling: no exercise equates to bad sleep, bad bones, and bad mood, among other unpleasant symptoms.

But many dieters and weight maintainers are reluctant to exercise because they fear the effect on their hunger. Exercise seems like an ineffective, and indeed unworkable, way of losing weight when post-exercise appetite may lead to eating many more calories than those worked off. Anecdotal reports by dieters of feeling ravenous after a stint on the treadmill or weekly Zumba class supports the erroneous belief that exercise while dieting should be avoided to prevent overeating.

Curiously, highly-trained athletes (who, of course, don’t have to worry about their weight) are the least likely to want to eat after their highly intense exercise routines are completed. In a study published a few years ago on appetite among female athletes, the scientists found that intense exercise actually decreased subjective hunger. Moreover, ghrelin, the hormone in the gut and blood that regulates hunger, was decreased and another hormone that shuts off appetite, increased. (“No Effect of Exercise Intensity on Appetite in Highly-Trained Endurance Women,” Howe, S., Hand, T., Larson-Meyer, D., Austin, K. et al Nutrients, 2016; 8 ) The same effect had been found earlier in studies carried out with male endurance athletes.

Since most of us are not likely to devote a good portion of our lives to training for competitive athletic events, we cannot rely on this for suppressing appetite after exercise. However, it seems that even unfit obese men may also experience a decrease in hunger after intense exercise, at least for 30 minutes after the exercise session completed. Whether they overate several hours later was not reported. (“The Effects of Concurrent Resistance and Endurance Exercise on Hunger Feelings and PYY in Obese Men,” Asrami, A., Faraji, H., Jalali, S., International Journal of Sport Studies, 2014 4; 729-)

But one may ask: what is wrong with being hungry after physical activity? Isn’t hunger a natural and inevitable response of the body after calories are used up? A Food Network show featuring life on a ranch in some unnamed cattle-raising part of the country often features recipes for the “hungry” family and ranch hands after a day of especially hard work. It would be absurd for the workers to avoid physical labor just because they are very hungry when they return home to eat a substantial meal.

But most of us have traveled far from the natural progression of physical activity to hunger to eating to a return of energy, and thus being able to work again. The “I am so hungry that I could eat a horse” (or whatever animal comes to mind) statement after hours of manual labor or recreational physical activity seems to many like a prescription for weight gain, rather than the way nature intended us to feel.

But it is not. Hunger is natural. The hormones causing us to want to eat are there to make sure we do so in order to live. If hunger disappears, as is the case for some with late stage Alzheimer’s disease, the individual will not survive unless others make sure to feed the patient.
In short, we should stop being afraid of being hungry. Hunger means our bodies need food the way being thirsty means our bodies need water. How we satisfy our hunger is what we have to improve if we want to stop gaining weight and begin to lose it. Just as we could, but should not, satisfy our thirst by drinking gallons of champagne or sugary sodas; we should satisfy our hunger not by consuming junk food, but by eating foods that not only supply calories (to replace those used up in exercise) but also needed nutrients into our bodies.

Dieters are told to try to eat fewer calories than needed so the calories in their stored fat will be mobilized to make up the difference. But unless the dieter goes on a drastically low-calorie diet, or a diet that eliminates certain categories of foods, it is possible to eat less, satisfy hunger, and still lose weight. We often eat beyond feeling full, that is, beyond the cessation of hunger; this is why we eat dessert. If eating stops when hunger disappears—even if all the food has not—weight can be lost.
Should you eat before or after exercise? It depends on your body. Some cannot exercise after eating and will eat breakfast after, rather than before, working out in the morning. Others find that they don’t have the energy to play tennis or go hiking unless they have eaten. Therefore, they will eat enough to give their muscles fuel for their workout, but not so much that they feel too stuffed to move.

Sometimes during long bouts of exercise, such as a long bike ride or hike, the first sign that the body needs food is not hunger but fatigue. I remember once when I was cross-country skiing all day, I become too exhausted to move my skis up a hill to get back to the lodge. As I stepped outside the track to let a woman behind me pass, she handed me an energy bar. “You need food,” she said. “Eat this.“ She was right. Within a few minutes I felt my fatigue lift, and I was able to continue moving.

We are told to be in touch with our bodies. Exercising, being hungry, and eating healthfully are excellent ways of communicating with ourselves.

 

 

 

Is the US Becoming More Obese Because of Medication?

Despite a blizzard of weight-loss programs, touting novel fat-reducing foods, and innovative exercise devices, the country is getting fatter and fatter. The Centers for Disease Control and Prevention reports that nearly 4 in 10 U.S adults, according to their body mass index, can be classified as obese. Obesity is not evenly distributed among the states. The losers; i.e. the thinnest states, are Colorado, Hawaii, Massachusetts, and D.C. The gainer is West Virginia where almost 40% of adults are obese.

We have been becoming heavier for so many decades that we forget how thin we were as a country 80 or more years ago. It is only when viewing newsreels of the first half of the 20th century in which most adults look extremely thin that you realize what we now consider thin was considered normal weight back then.

The same old reasons are brought out yearly to explain why we, and indeed the rest of the world, is getting fatter: junk food, sugary drinks, dependence on motorized transport rather than our two feet, humongous restaurant portions, intestinal flora that make our bodies store fat, too much time on electronic devices, and too little time in the gym.

Might our growing obesity be related to the weight gain after smoking withdrawal? Weight gain is common among ex-smokers, and studies as reported by the National Bureau of Economic Research (Sharon Begley, “Gut Check”) suggest that it may be 11-12 pounds on average. But a close examination of who gains the most weight indicates that smokers with the lowest BMI are most likely to gain the most, and 11 or 12 pounds is not enough weight gain to make them obese.

Could medications used to treat mental disorders be another, mostly overlooked cause of national weight gain? That psychotropic drugs—the medications used to treat depression, anxiety, bipolar disorderschizophrenia and other mental diseases—cause weight gain is established. Sometimes the weight gain is only a few pounds, stops after a month or two, and is lost as soon as the treatment ends. But many drugs cause substantial weight gain because the patient experiences a relentless urge to eat. Moreover, to the chagrin, indeed horror of some patients, stopping the medications does not always cause weight loss even with dieting and exercise.

Data on the use of psychotropic drugs comes from a 2013 Medical Expenditure Panel Survey discussed in a Scientific American article by Sara Miller.  One in six Americans is taking a psychotropic drug, although not all are being prescribed for mental illness. There have also been many studies showing that depression itself is linked to future obesity. A common depression, Seasonal Affective Disorder, is diagnosed in part by the overeating and weight gain of patients during the increased darkness of winter. Often the depression of PMS and pre-menopause is accompanied by overeating and weight gain as well.

Yet in the list of causes for our increasing girth, reasons such as genes, inflammation, bad gut bacteria and bread are more likely to be found than the weight-gaining potential of depression and the drugs that treat it.

Where are the weight-loss programs specifically designed to help those whose overeating is caused by lack of sunlight, or hormones affecting appetite control centers in the brain, or drugs that hijack control over satiety? Where are the support services for those who are embarrassed to go to the gym because their medications have turned their formerly fit and slim body into a much heavier one?  Recently someone who has been struggling to lose the weight gained on her medication for obsessive-compulsive disorder told me that her dietician put her on a low- carbohydrate diet. “I was craving carbohydrates all the time,” she told me, “so the dietician figured the easiest way to take care of that problem was to remove them from my diet. She did not realize that my medication had caused the cravings even though I told her. And since I couldn’t stop my drugs, I just craved bread and pasta so much on her diet that I began to binge.”

 

This story is typical in that this patient was not seen as needing specialized weight-loss help because her weight gain was the result of a drug, and not related to emotional issuesor an inability to make healthy food choices. Moreover, the dietician’s advice to remove carbohydrates showed lack of knowledge on the effect of eating carbohydrates on serotonin synthesis. Serotonin levels drop when carbohydrates are not consumed and often lead to a worsening of the obsessive-compulsive disorder, depression, or other mental disorders.

How long is it going to be before weight-loss professionals acknowledge that many of the obese in the United States are that way because of their medications? How long will it be before thought, labor, and money are put into programs to address their special needs?

Will 2018 bring about needed innovations in weight-loss therapy for these individuals, or will we just become fatter?