Weight Loss

Americans are getting fatter and fatter. Sorry to be blunt, but this is not a minor problem, and we aren't just putting on a few pounds as we age. If you think you can stand the shock, go to http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/. The most informative/frightening visual is slide four of the Powerpoint presentation (posted on the wall in my office and on my website). The latest data are from 2002. In just 11 years we have gone from having 4 states with an obesity rate of 15-19% of the adult population to a point where now every US state has that level of obesity or more. In fact, by 2002, 28 states had obesity levels of 20-24% and in 3 states 25% or more of the adult population was obese. Fully 65% of American adults are overweight or obese. The consequences of this are big time for our health - increased risk of diabetes, heart disease, cancer, kidney disease, arthritis, etc., etc. It is hard to come up with many diseases for which a higher weight lowers our risk.

How did we get this way? While no one has been rushing to claim responsibility, it is pretty easy to point fingers. A number of factors are to blame, most of which are in our power to change.

The US government campaign to educate us about fat led to a dietary cultural perversion - Fat is bad, anything else is fine. Low fat this. Low fat that. Less fat in our food, but lots more fat inside our clothes. The food manufacturers make a profit by creating quick easy, tasty morsels to pop in our mouths all day long. They do a great job. Leaving fat out, they pumped up the carbohydrates (read SUGARs) to make their products taste good. The American consumer thought "No Fat. Great! I'll eat two!" The processing dropped out important nutrients (especially B vitamins, which would have balanced things out a bit), and left us hungry for something we didn’t know.

This bad dream wouldn't have been so nightmarish had we not been simultaneously mutating into a nation of couch potatoes. Exercise not only burns calories, but after exercise your body continues to burn calories at an elevated rate. Exercise makes muscle. The higher your percentage of muscle mass, the more calories you burn while sitting in a chair or sleeping. Exercise makes your body more sensitive to insulin, so it drives the sugars into cells that you can use for energy, instead of storing it as fat.

The American equation has been:

More calories in + fewer calories out = WEIGHT GAIN

How can we change this? The first step is to understand this simple formula:

Energy in - Energy out = Weight change

If you eat more calories than you burn, you gain weight. If you eat less or burn more, you lose weight.

The first step is to work on creating the best numbers you can for this equation.

EXERCISE
Build your activity. Wear a pedometer to gauge and then increase your activity. Walk more. Take stairs instead of the elevator. Park your car further from the door of the mall. Little steps add up. Make it more enjoyable by building an exercise program around activities you enjoy. If you are social, join or start a walking club. Dig out your tennis racket. Train for your first marathon (or first mile!).

Although aerobic exercise is more important because of its many health benefits, lifting weights will improve your body composition by turning that energy storing fat into energy burning muscle. Body composition is also influenced by diet and hormonal factors.

EAT GOOD FOOD
Similarly, little food choices can add up to big positive effects. Eat a little bit less. Allow yourself some ice cream, but not a big bowl. Choose whole grain foods ALMOST always. Eat only when you are hungry Eat slowly. If you eat too fast you will start feeling full after you have already eaten too much. Eat while you eat. Pay attention to your food. Don't watch the television or read. Enjoy your food.

There are many more subtle changes you can make that are likely to have positive effects.

NUTRIENT TIMING
It turns out that merely matching the number of calories you consume in a day with the total caloric output for the day is sometimes not enough. Pretend you eat little throughout the day, and then eat most of your calories at night. Bodies tend to respond to that scenario by turning down the metabolic rate because of the daytime fasting, and then turning the evening calories into fat, storing them up for the next day's fast.

So, it is not a good idea to eat a big meal and then go to sleep. This can be an important factor when someone is really truly restricting calories, but not losing weight.

WATER
Here I go again. Water is essential to life. Very few of you drink enough water. Lagging behind in fluids prevents optimal physiologic function. I find that inadequate fluid consumption leads to unhealthy food cravings. Just try it, okay?

STRESS
Stress hormones alter the body's response in many ways, including to carbohydrates. Rushing around and feeling pressured not only leads to poor eating habits, but unless you're so stressed that you stop eating, your body also will tend to put on pounds. Along the same line, we have evidence that irregular sleep patterns and sleeping too little leads to weight gain.

SUPPLEMENTS
There are a tremendous number of supplements marketed for weight loss or body composition change. Most of them are ineffective. Some, like ephedra, are effective but dangerous. Some, like citrus aurantium, may be both effective and dangerous. Frustratingly, some appear even amazingly effective in research, but almost worthless in practice. Of course, a great deal of uncertainty arises from applying research techniques to such a complicated lifestyle issue. I believe that understanding individual differences is the key to making sense of this confusion. Each person's metabolism differs. Some need very little of one nutrient, while others need more than the government recommended "normals". Most people are not consuming optimal levels of each essential nutrient. Grabbing the wrong foods to satisfy a craving resulting from a biological need can lead to obesity, as the person eats and eats without getting the nutrient the body needs. The food industry cranks out all of those fast and easy convenience foods because we buy them, not because they are good for us. Have you ever thought about how strange it is that we have "food" and also "health food"?

Calcium certainly helps with weight loss. Why it does is still mysterious. Americans seldom consume adequate amounts of calcium, especially teenaged girls and elderly women and men. Although there are many good nondairy sources of calcium (nuts and beans, for example) it appears that a hormone like chemical in milk products may increase calcium absorption and accentuate weight loss.

My experience is that the effectiveness of supplements (CLA, garcinia, chromium polynicotinate, and many others) varies dramatically from person to person.

CARBOHYDRATES VERSUS PROTEIN
The party line in medicine and nutritional science has always been that "a calorie is a calorie". In other words it makes no difference if the calories come from carbohydrates (CHO), protein or fat. This is now open to question. Breaking down and absorbing protein may consume more calories than CHO. Protein appears to be an important factor in satiety - feeling as if you have eaten enough. For that reason it is not surprising that the number of studies finding that patients lose more weight on low CHO/high protein diets is rapidly increasing. A review of these trials recently concluded there was no difference, despite an average weight loss of 18 pounds in the high protein diet studies compared to 2 pounds in the high carbohydrate studies. (There are lies, damned lies and statistics)

Regardless of the scientific understanding of how and why, success is the best outcome measure. My clinical experience is that patients find it easier to lose weight on a high protein diet. In the long term, however, such diets are likely to cause problems, especially because of the relative deficiency of certain nutrients.

FEEDBACK
Weighing yourself is one way to assess your progress. It is also another phobia for some people. I like to weigh myself daily. In the past I never did, and then it was a big shock and very dispiriting to discover how much my weight had changed when I was not paying attention. Your weight will fluctuate throughout the day and from one day to the next. If you can process the information with enough perspective to realize it is just one number at one moment in time and certain to be different soon, maybe daily weighing is a good idea for you. If not, maybe once a week would be right for you? It is your decision.

Muscle is denser than fat, so a simple weight gives a limited picture. At the same weight, if you have lost fat but gained muscle, your clothes will seem bigger, at least at your waist. People telling you that you look thinner is always a good sign. Either you have lost weight/improved body composition or they just really love you. Not bad either way.

It would be great to be able to reliably measure body composition and track improvements meaningfully. Unfortunately, the bioimpedence body composition scales out there ("body fat analyzers") are much too inaccurate to provide meaningful information. Variations in hydration make the readings highly unreliable. Fat calipers, even in the hands of an experienced professional, are not very good either. The only reliable way to measure body composition is by DEXA scan, which is high tech, expensive and requires radiation exposure.

Some people simply pay attention to how their clothing fits. In many ways this is a very good assessment, especially because shifting to a greater proportion of muscle than fat will make your waist much smaller than the scale would suggest.

EATING DISORDERS
Dysfunctional eating is too common a problem, and very serious for some. Over- attention to a child's weight on the part of a parent is one contributing factor. In many cases, disordered eating develops because food is the one element in that person's control. The stress, depression, anxiety or anger can be expressed in this unfortunate or even deadly way. The first patient I saw with an eating disorder was nearly 30 years ago in the University of Minnesota Medical Center. I have seen hundreds since then. It is very clear that each patient is different and the eating disorder is an expression of deeper problems.

TOXIC THOUGHTS
I should tell you about one factor which does not usually appear on lists explaining our expanding girth. Unfortunately, human beings have been creating large amounts of chemicals that were not a part of our environment in the past. Many of these linger in our bodies. A recent study found that these toxins impede weight loss by hormone-like effects blocking the body's heat generating processes. As you lose weight your body slows its metabolic rate. These toxins slow it more, and as you lose weight they hang around and have a more pronounced effect as they become a relatively larger percentage of your body mass. This is one more clear, although unanticipated reason to do what we can to clean up our environment.

CONCLUSION
Obesity is an important problem. Like any important problem it should be addressed and addressed thoughtfully. Each person is different. One person can respond to a supplement that does not help others with the same problem. Although ineffective for others, it can change that individual's life. One person might do better with a type of exercise that someone else hates. Find something you like, some exercise that fits into your life. Even if you don't lose a single pound or inch, exercising makes you healthier and reduces your risk of many diseases.

Often my job as a physician becomes that of a coach. I help patients sort out their strengths and weaknesses. Then we set reasonable goals together, leading them into better health. Doing the things you should do to better your health almost inevitably improves your body composition. The point is working to become stronger and healthier. I applaud ANY and ALL efforts. Make the effort and you will feel better. My task is to help you direct your efforts most effectively.

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