Core Weight Management Guidelines: A Summary of the Academy of Nutrition and Dietetics’ 2014 Evidence Based Guidelines – Strong, Imperative Strategies

By Robert Lee, ND, MS, MA

If you have weight loss resistance, it is vital that you have and are utilizing the most proven weight management recommendations that are available. Not sure what is available? Take a look at the most proven (a.k.a. evidence-based guidelines) for weight loss and maintenance, and incorporate these strategies into your lifestyle if you are not already doing so. As everyone has different health issues, please see your primary care physician and other healthcare provider to determine whether the following strategies are appropriate for you and also to refer you for nutritional, behavioral, psychological and exercise professionals, as indicated.

This article is part of a series on evidence-based guidelines on weight management. It will focus on the strong, imperative strategies for weight loss and management, which are the most proven and globally applicable strategies available. Subsequent parts will focus on additional globally applicable strategies for weight management (such as one emphasizing exercise/activity levels, additional counseling and micronutrient specific strategies). However, the strategies summarized in future reports have not been substantiated by research sciences to the extent to which the strategies summarized in this segment have been. All the strategies being presented may complement what you are currently doing.

I. Medical Nutrition Therapy with a Registered Dietician Nutritionist (RDN) or other healthcare professional for overweight and obese individuals. If you are not sure if you are overweight or obese, you may use the Body-Mass Index (BMI) calculator on the following link: BMI Calculator. To achieve most effective weight loss, medical nutrition therapy should consist of at least 14-visits with a qualified healthcare professional over a period of at least 6-months.. Following weight loss, weight maintenance through medical nutrition therapy should be utilized and consist of monthly visits for 1-year with a qualified healthcare professional. These interventions result in both weight loss and weight maintenance, respectively, as well as reduced risk for diabetes, disorders of lipid metabolism and hypertension.

II. Comprehensive Weight Management Program involving the following threecomponents:

  1. A reduced calorie diet
  2. Increasing physical activity, and
  3. Use of behavioral therapies.

This combination approach is more successful than using any one intervention alone andcan lead to weight loss as well as improved glucose tolerance and other physiological factors for the reduction of cardiovascular disease.

III. Utilize Multiple Behavioral Therapies within the Comprehensive Weight Management Program. These behavioral therapies should include:

  • Self-monitoring: Adults who need or desire to lose or maintain weight benefit from using self-monitoring of food intake (such as food diaries, online or smart phone based food entry and calculator programs). These self-monitoring programs improve nutrition-related outcomes related to weight loss and maintenance.
  • Motivational support significantly enhances weight loss, as well as, adherence to programs and improvement in glycemic control, percentage of energy intake from fat, fruit and vegetable intake. Motivational support should come from the healthcare practitioner working with you, yourself personally, as well as from family members, friends, co-workers and the rest of the environment surrounding you (nutrition and exercise classes, nature, the gym, etc.).
  • Portion control, structured meal plans and meal replacements. Strong evidence suggests a positive relationship between portion size and bodyweight, and various types of meal replacements products and structured meal plans are helpful in achieving health and food behavior change.
  • Goal-setting: Your active participation in selecting and setting goals helps to target important and personally appropriate goals.
  • Problem-solving strategies can result in improvements in key outcome measures including weight loss management in people with diabetes and improvements in fat consumption, self-efficacy and physical activity. For example, substituting fruits for pastries, consuming green tea instead of soda, preparing healthy meals with friends on the weekend and/or walking daily in the morning and/or right after dinner can be helpful strategies that encourage you to overcome problems at hand.

IV. Setting Realistic Weight Loss Goals. Such as ONE of the following:

  • Up to two pounds per week
  • Up to 10% of baseline body weight
  • A total of 3-5% of baseline body weight, if you have hypertension, hyperlipidemia or hyperglycemia

These strategies report successful weight loss of one to two pounds per week and up to 10% of body weight over one year. Sustained weight loss of 3-5% of baseline body weight also result in clinically meaningful reductions in triglycerides, blood glucose, glycosylated hemoglobin (HbA1C), and the risk of developing type 2 diabetes. Greater amounts of weight loss also reduce blood pressure, improve LDL (“bad”) and HDL (“good”) cholesterol, and reduce the need for medications.

V. Utilize Community Resources such as local food sources, food assistance programs, support systems and recreational facilities. A moderate strong link exists between food environment and dietary intake. Ask qualified healthcare professionals to direct you to community resources and also search for these resources online, at local hospitals, through town/city and county resources, community centers, and ask friends, family and co-workers of any resources they can provide you.

VI. Assess Energy Intake and Nutrient Content of the Diet
Qualified healthcare professionals can assess your energy intake and diet. You can also estimate the energy and nutrient intake of the diet using free, online and smart phone based programs. The two resources most frequently used for these purposes are MyFitnessPal and NutritionData, although suitable alternative to these may be available.

VII. Achieve Nutrient Adequacy During Weight Loss
During weight loss, a qualified healthcare professional should prescribe for you an individualized diet, including your preference and health status, to achieve and maintain adequate nutrient adequacy and reduce caloric intake based on one of the following strategies:

  • 1,200 Cal to 1,500 Calories per day for women and 1,500 to 1,800 Calories per day for men.
  • Energy deficit of approximately 500 to 750 Calories per day
  • A diet emphasizing high consumption of fruits and vegetables as well as restriction in high-carbohydrate, low-fiber, high-fat and fast foods, which are all proven to promote weight loss. Examples of these diets include Harvard’s Healthy Eating Plate, the Mediterranean Diet, the Anti-inflammatory Diet, as well as condition specific diets including DASH Diet for blood pressure reduction, TLC Diet for cholesterol reduction, and MIND Diet for Alzheimer’s disease prevention and cognitive health. Note: Dietary patterns emphasizing glycemic index and glycemic load of the diet have not been shown to specifically affect weight loss although they may be helpful for diabetes related health outcomes.

VIII. Maintain Nutrient Adequacy during Weight Maintenance
Following weight loss, calories of food consumed should generally match (and not be greater than 500 calories below) the amount of calories burned per day. A qualified healthcare professional should assess this. You can also estimate the amount of calories burned per day by adding the calories burned by the body’s resting (or basal) metabolic rate and the calories burned by activities (including exercise and routine movement like walking, shopping and cleaning). See these links to calculate your resting (basal) metabolic rate and calories burned from typical activities.

IX. Assess, Monitor and Evaluate Data of the Comprehensive Weight Management Program.

The following data should be assessed by a qualified healthcare professional to individualize and improve effectiveness of the Comprehensive Weight Management Program:

  • Food and nutrition related history including but not limited to beliefs and attitudes including food preference and motivation, food environment including access to fruits and vegetables, dietary behaviors such as eating out and screen time (TV, computer, etc.), dietary experiences including food allergies and past dieting history, medication and supplements, as well as, physical activity.
  • Physical measurements including height, weight, BMI, waist circumference, weight history, and body composition (if available).
  • Biochemical data and medical tests including but not limited to glucose and endocrine profile and lipid panel.
  • Nutrition-focused physical findings including ability to communicate, emotional patterns, amputations, appetite, blood pressure, body language and heart rate.
  • Past medical history and/or related family and social history such as: appropriateness of weight management in certain populations (such as eating disorders, pregnancy, receiving chemotherapy), living and housing situation and socio-economic status.

Potential Benefits Of These Strategies

  • Improving a person’s ability to achieve optimal nutrition through healthful food choices and a physically active lifestyle.
  • Although costs of medical nutrition therapy (MNT) sessions and reimbursement vary, MNT is essential for improved outcomes.
  • MNT education can be considered cost-effective when considering the benefits of nutrition interventions on the onset and progression of comorbidities versus the cost of the intervention.

Potential Harms

Overall Risk/Harm Considerations
When using these recommendations, have your physician and other healthcare provider consider the following general risks and harms:

  • Your age, socio-economic status, cultural issues, psychosocial and mental health status, health history and other health conditions.

Assess how these recommendations may work with or against any other therapies you are currently receiving and/or the conditions that you currently have.

Reference:

  • Academy of Nutrition and Dietetics. Adult weight management evidence-based nutrition practice guideline. Chicago (IL): Academy of Nutrition and Dietetics; 2014. Available at http://www.guideline.gov/content.aspx?f=rss&id=48761&osrc=12 (accessed Mar 24, 2015).

About Robert E. Lee, MA, ND, MS

Dr. Lee is an intern at Yale-Griffin Prevention Research Center as well the owner and a primary care general practitioner at The Awakening Center in Connecticut. He is a board-certified and state licensed naturopathic physician that graduated with top of class marks in clinical rotations from the oldest accredited naturopathic medical school, National College of Natural Medicine in Portland, OR. Dr. Lee also holds two masters degrees focused on both the research sciences and arts of integrative medicine, and has worked in research since 2006 at various departments of Yale University’s School of Medicine and its affiliates, as well as Helfgott Research Institute, with support from National Institutes of Health grants and a number of additional funding sources.

Dr. Lee’s career focuses on helping people and the world through implementation, investigation and validation of integrative and naturopathic medicines, particularly mind-body medicines, spirituality, nutrition, exercise, manual therapies, herbal medicine and other lifestyle approaches. In addition to his training in naturopathic and integrative medicines, Dr. Lee has been practicing meditation since childhood, studying nutrition and exercise since adolescence, is a student and teacher of advanced forgiveness, mindfulness and spirituality based on A Course In Miracles and other traditions, and is also trained in cognitive behavioral therapy, transcendental meditation, kriya yoga and vipassana. Furthermore, Dr. Lee was a collegiate ice hockey player and is currently a Crossfit athlete.

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Why not focus on easier-to-adopt habits ?

Click here for the article and video

By focusing on weight, we may be missing the broader picture of what it means to be healthy.

Brian Mattson is not the picture of health. Few would look at him and say: “There’s a healthy fellow.” But that’s a shame, because Mattson is a pretty healthy guy. In fact, by a number of measures, he’s healthier than most Americans.

Mattson walks every day, on average exceeding the CDC recommendations for daily aerobic physical activity. Less than half (48%) of Americans meet this benchmark. Mattson also eats about three servings of fruits and vegetables every day. Estimates of the average American fruit and vegetable consumption range from one and a half, to three servings a day. The target should be 5 to 13 servings, or at least “half your plate” according to latest USDA dietary guidelines.

Sure, Mattson is the first to admit it’s not perfect, but compared to his situation five years ago, he’s doing quite well, and the changes he’s made in his life have become habits that he’s been able to maintain over years.

 

Brian took his first steps towards healthier living in 2009, when the wellness organization Blue Zones initiated a pilot project in his home town of Albert Lea, Minnesota. As part of the program he took a life expectancy assessment, the results of which had him on the road to dying young–in his 50s. This wake up call got him walking every day and eating more vegetables. The walking group he joined also got him out into the community, interacting with people, and even resuming his involvement in the local theater. These simple things extended his estimated life expectancy by 20 years. He didn’t start a restrictive diet. He didn’t join his local gym’s extreme weight loss challenge. And that’s probably a good thing, because the weight-loss industry has yielded poor results.

Mattson told me on the phone that since we met last year, he’s lost 20 pounds, averaging a pound of weight loss per month. Not because he was trying to lose weight, but merely as a side effect of the healthy habits he developed. The habits were encouraged by changes instituted in Albert Lea as part of Blue Zones’ efforts to emulate the healthiest and happiest communities in the world. The book The Blue Zones, points out that dieting and exercise are not common in these long-living communities. I asked author and Blue Zones CEO Dan Buettner why weight loss was not a primary focus of his organization’s efforts:

“To see your weight go down isn’t an answer for a happy life. People we’ve seen in the Blue Zones not only live a long time, but they’re also in the top quintile of the happiest places in the world. It turns out most of what makes us feel truly genuinely happy is also good for our health. I’d just as soon lead with quality of life and leave the weight-loss as a happy byproduct.

Sure, Albert Lea collectively shaved about two tons [of body weight] among the [participants], but that’s not what we set out to do. We set out to get them more connected socially, to change their environment to make walking easier, and to make fruits and vegetables more available, and eating them more socially acceptable and a common part of daily life.”

I asked Brian Mattson how he thinks things would have turned out if he had started with a weight loss goal, rather than his modest eating and walking goals.

“I don’t think I would have done it.” He said. “It’s the same as the 10 or 12 other times in my life I’d tried to lose weight. I’d last about a week and a half and then give up and gain it all back. Now I’m taking small things each time, and I’m not killing myself doing it. A pound a month doesn’t seem like much, but it’s a consistent pound a month.”

A meta-analysis published late last year suggested that obesity in and of itself is a risk factor for heart attacks and early death. The ensuing media coverage shouted “you can’t be fit and fat!” Another study published this January seemed to respond: “yes you can!”

In light of this, a brief thought experiment:

Assuming the you-can’t-be-fat-and-fit study is accurate (it didn’t actually take into account fitness among other issues), the risk for cardiovascular events and/or death was 24% higher in metabolically healthy overweight folks compared to metabolically healthy normal weight folks.

Compare that with a 2003 Danish cohort study that found a 29% reduction in risk of death from adopting regular moderate physical activity, and another more recent cohort study describing a 53% higher mortality rate among non-fruit and vegetable eaters, versus those getting their 5-a-day.

Why do we obsessively focus on a very-hard-to-affect risk factor (body weight) that yields no better results than easier-to-adopt habits, that provide clear health benefits? If you were an inactive person who eats a poor diet and suffers from obesity and were presented with these numbers, knowing that dieting and sustained weight-loss are very difficult and usually unsuccessful, what would you do?

Everywhere we go, from the mouths of our peers, on every magazine rack, Internet ad, and weight-loss reality show, we get the message: you need to lose weight. You are too fat. Maybe it’s time to retire this line of thinking. Maybe it’s time to go for a walk, or eat some asparagus, just because those are good, pleasurable things to do, and will make our lives better, whatever our weight.

Brian Mattson’s story should help us rethink what health looks like. If we decide that health looks like chiseled abs, toned arms and yoga pants, we’re leaving a lot of people behind. When our health ideal comes in the form of a cover model on Shape, no one will ever be healthy, and if we can’t be healthy, what’s the point? It’s a recipe for defeat.

I’ve heard it rightly argued that we should refrain from judging someone’s health based on appearance. For all we know, that overweight woman we see on the street might be exercising every day, eating better and may have already lost a lot of weight, and just “isn’t there yet.” I would take it further and argue that if those habits are now a part of her life, she’s already made it.

If we were to shift the conversation towards a culture of health–one that values healthy eating and regular physical activity as ends unto themselves, we may be happily surprised to find that not only are we living longer, happier lives, with less disease and fewer health costs, but also, we may need to drop a collective pant size or two. Or not. Either way, we’re better off.

Post Script:

This reads as if health outcomes were entirely dependent upon what individuals consciously choose or choose not to do. Most of the literature indicates that a vast number of complex environmental factors have far more to do with our health outcomes than our personal choices. However, the choices we make certainly come into play, and this post explores a new way to approach those choices and how we talk about them.

Photos courtesy of the Rudd Center for Food Policy & Obesity.

 

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The Well-Chewed Calorie: Rumination or Ruin?

Dr. Katz’s reply to the article entitled: “Always Hungry? Here’s Why” by Dr. David Ludwig and Dr. Mark Friedman.

Click here for the article:

http://www.linkedin.com/today/post/article/20140518150913-23027997-the-well-chewed-calorie-rumination-or-ruin?trk=mp-reader-card

Many of you have doubtless already seen the commentary in today’s New York Times by my friend and colleague, Dr. David Ludwig (with Mark Friedman, whom I don’t know), entitled: “Always Hungry? Here’s Why.” If you have not read the piece, I commend it to you.

Regarding Dr. Ludwig, he is indeed both colleague and friend- and I am proud to call him both. He is a prolific, insightful, and accomplished researcher- and one of those rare individuals whose intellect sends out sparks to ignite better thinking by those around him. For whatever my opinion is worth, I consider Dr. Ludwig one of the best in the business of both learning what we need to know about diet and health, and putting it to good use.

Regarding the New York Times piece, and the more scholarly commentary in JAMA on which it is based, I have a number of favorable impressions. The commentary essentially posits that we are not fat because we overeat, but overeat because we are fat- exploring the inner life of the adipocyte and its interactions with an array of hormones, insulin salient among them- to make that case. The commentary is thoughtful, well reasoned, and provocative. Dr. Ludwig’s excellent research, focused on glycemic index and load in particular, is cited for support.

But I am worried that even commentary of this caliber is subject to the law of unintended consequences, which has been the bane of public health nutrition for far too long already. In particular, I searched the text of both the pop culture and scholarly versions of this essay, and in neither case found any of these four words: survival, culture, satiety, or synthesis. I think these are crucial considerations, and potentially grave omissions.

On Survival: Drs. Ludwig and Friedman posit that we overeat because we get fat, but that merely begs the question: why did we get fat in the first place? They address this to some extent, but fail to emphasize what I think is the essential, and obvious answer: survival. Throughout most of human history, calories were relatively scarce and hard to get, and physical activity was unavoidable. We are adapted to that world. But we have devised a modern world in which physical activity is scarce and hard to get, and calories are unavoidable. Houston, we have a problem.

In a world of relative caloric scarcity and fairly constant demands for physical exertion, appetite for salt, sugar, fat, calories, variety- all fosters survival. In Nature, you eat what you can when you can, and you don’t get fat not because you are trying to avoid it, but because survival is challenging and conspires against it. In an unnatural world of constant abundance of tasty calories and labor-saving technology, you behave as you always have- but wind up with very different results.

You get fat. And then, sure, being fat may propagate the problem in a number of ways- but the bedrock explanation for overeating is not being fat; that is an obvious chicken-and-egg conundrum. The bedrock explanation for getting fat is: we have made it fun (e.g., tasty food; sedentary recreation) and easy to get fat, and hard (e.g., a need for constant restraint; hectic schedules; etc.) to avoid it.

On Culture: Culture is bigger than any one of us. Cultural variation in behavior and health outcomes tells us rather indelibly, whether we like the message or not, that the basic care and feeding of the human body is highly dependent on actions of the body politic.

The Blue Zones have longer lives, better health, and more happiness than the rest of us not because of a preferential focus on calories, or refined carbohydrates- but rather on living well. When pleasure is derived from strong social connections, there is less need to get it from toaster pastries. When culture normalizes good use of feet, forks, and fingers; and encourages attention to sleep, stress mitigation, and love- health and long life result, all around the world.

Our inclination to keep chewing calories into ever smaller bits of academic grist may be the very opposite of what we really need: the big picture. Our culture markets multi-colored marshmallows to our kids, and tells them they are “part of a complete breakfast!” Highly paid advertising executives engineer the angle of gaze on cereal boxes by iconic cartoon characters to influence, maximally and subliminally, the responses of children and adults alike. And we need to ask why are we fat? Come on! Maybe “hypocrisy” should be on my list of missing key words, too. Our culture seems to have no shame of it.

On Satiety: Satiety refers to a feeling of fullness, and implies something about its duration as well. We have long recognized, all but intuitively, that the satiety attached to diverse foods is highly variable. For instance, we have referred in the vernacular to some foods as “stick to the ribs,” meaning they make- and keep us- full.

But now, again, welcome our cultural hypocrisy. We invite the likes of Dr. Ludwig to debate the origins of obesity, even as teams of PhDs work for Big Food companies to engineer foods that maximize the calories it takes to feel full. Michael Moss is only the most recent to tell us this tale; others have before. In a world where functional MRI scans and teams of scientists design foods so that bets that we “can’t eat just one” are entirely safe, the relevant question is not why so many of us are fat- but how on earth ANY of us manage not to be!

The key issue here is that inattention to satiety invites us to debate the relevance of calories, and carry on as if there is a choice to make between the laws of thermodynamics and the machinations of appetite. Why choose? The quantity of calories figures relevantly into energy balance and the hegemony of thermodynamics, while the quality and character of those calories determine how many it takes to feel full. The prevailing tendency in our culture is to maximize the calories it takes to feel full- making epidemic obesity little less than a fait accompli. We can reverse engineer this process to astonishingly good effect- but few in our society have the relevant skills.

On Synthesis: And finally, the dualistic view advanced here- calories must be about quantity, or quality; obesity must be cause, or effect- may obscure a truth that is both more holistic, and more actionable. In other words, what we get in the commentary is another hypothesis, while in my opinion, what we most need is synthesis.

Consider, for instance, the work of another friend and colleague, and another exemplar of the academic method, Dr. Brian Wansink. Dr. Wansink’s research has shown that substantial variations in both the quantity and quality of foods consumed can be achieved by influencing such factors as lighting, placement, and packaging- before ever even addressing the composition of the food itself. Instead of a seemingly endless parade of competing hypotheses about what TRULY matters, why not consider the possibility of a truth that is greater than the sum of its parts: just about every aspect of modern culture that makes it modern is obesigenic, and if we want to fix the problem, we have to fix it comprehensively.

Calories count, but counting calories is tedious business. And besides, few people are willing to spend their lives hungry when they have the option of fullness and satisfaction. So the answer is to reduce the calories it takes to feel full. That means eating better food, which in turn requires knowing what “better” food is (we do); being able to find, choose, and afford it (all possible- but how much better we could do!); combining better eating with routine physical activity; and shutting down the forces of cultural hypocrisy that invite us to wring our hands about epidemic obesity even while actively propagating it.

Drs. Ludwig and Friedman talk about the research we need. Maybe among it is a study of how a predilection for highlighting our doubts and debates as publicly as possible forestalls any meaningful action based on what we do know. Again, it would be as if: your foot catches fire, and you feel compelled to read competing theories about combustion point, flammability, flame retardants, the partial pressure of atmospheric gases, wound care, and skin grafting- before ever you fetch that pail of water. I say: go for it!

We must, of course, parse and debate, explore and question to advance our understanding- which is far from complete, and farther still from perfect. But then again- how perfect does our knowledge of combustion need to be to fetch a pail of water if our foot catches fire? There is a point at which debating the subtleties of what we don’t know while failing to act on what we do know may come dangerously close to fiddling while Rome burns.

In other words, as good and erudite as Dr. Ludwig’s insights are, maybe the calorie has been sufficiently well chewed already. And maybe endless rumination paves the road to procrastination and ruin.

 

-fin

Dr. David L. Katz has authored three editions of a nutrition textbook for health care professionals. He is editor-in-chief of the peer-reviewed journal, Childhood Obesity, and President of the American College of Lifestyle Medicine. He was commissioned by Annual Review in Public Health to write the review article, Can We Say What Diet is Best for Health? He is the author of Disease Proof, and most recently, of the epic novel, reVision.

www.davidkatzmd.com www.turnthetidefoundation.org

http://www.loreofthecorners.com/

http://www.facebook.com/pages/Dr-David-L-Katz/114690721876253 http://twitter.com/DrDavidKatz http://www.linkedin.com/pub/david-l-katz-md-mph/7/866/479/

Photo: Radu Bercan/Shutterstock.com

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Always Hungry? Here’s Why

A interesting article in the New York Time by Dr. David S. Ludwig & Dr. Mark I. Friedman

Click here for the link to the article: http://www.nytimes.com/2014/05/18/opinion/sunday/always-hungry-heres-why.html

Credit            Sarah Illenberger

 

FOR most of the last century, our understanding of the cause of obesity has been based on immutable physical law. Specifically, it’s the first law of thermodynamics, which dictates that energy can neither be created nor destroyed. When it comes to body weight, this means that calorie intake minus calorie expenditure equals calories stored. Surrounded by tempting foods, we overeat, consuming more calories than we can burn off, and the excess is deposited as fat. The simple solution is to exert willpower and eat less.

The problem is that this advice doesn’t work, at least not for most people over the long term. In other words, your New Year’s resolution to lose weight probably won’t last through the spring, let alone affect how you look in a swimsuit in July. More of us than ever are obese, despite an incessant focus on calorie balance by the government, nutrition organizations and the food industry.

But what if we’ve confused cause and effect? What if it’s not overeating that causes us to get fat, but the process of getting fatter that causes us to overeat?

The more calories we lock away in fat tissue, the fewer there are circulating in the bloodstream to satisfy the body’s requirements. If we look at it this way, it’s a distribution problem: We have an abundance of calories, but they’re in the wrong place. As a result, the body needs to increase its intake. We get hungrier because we’re getting fatter.

It’s like edema, a common medical condition in which fluid leaks from blood vessels into surrounding tissues. No matter how much water they drink, people with edema may experience unquenchable thirst because the fluid doesn’t stay in the blood, where it’s needed. Similarly, when fat cells suck up too much fuel, calories from food promote the growth of fat tissue instead of serving the energy needs of the body, provoking overeating in all but the most disciplined individuals.

We discuss this hypothesis in an article just published in JAMA, The Journal of the American Medical Association. According to this alternative view, factors in the environment have triggered fat cells in our bodies to take in and store excessive amounts of glucose and other calorie-rich compounds. Since fewer calories are available to fuel metabolism, the brain tells the body to increase calorie intake (we feel hungry) and save energy (our metabolism slows down). Eating more solves this problem temporarily but also accelerates weight gain. Cutting calories reverses the weight gain for a short while, making us think we have control over our body weight, but predictably increases hunger and slows metabolism even more.

Consider fever as another analogy. A cold bath will lower body temperature temporarily, but also set off biological responses — like shivering and constriction of blood vessels — that work to heat the body up again. In a sense, the conventional view of obesity as a problem of calorie balance is like conceptualizing fever as a problem of heat balance; technically not wrong, but not very helpful, because it ignores the apparent underlying biological driver of weight gain.

This is why diets that rely on consciously reducing calories don’t usually work. Only one in six overweight and obese adults in a nationwide survey reports ever having maintained a 10 percent weight loss for at least a year. (Even this relatively modest accomplishment may be exaggerated, because people tend to overestimate their successes in self-reported surveys.) In studies by Dr. Rudolph L. Leibel of Columbia and colleagues, when lean and obese research subjects were underfed in order to make them lose 10 to 20 percent of their weight, their hunger increased and metabolism plummeted. Conversely, overfeeding sped up metabolism.

For both over- and under-eating, these responses tend to push weight back to where it started — prompting some obesity researchers to think in terms of a body weight “set point” that seems to be predetermined by our genes.

But if basic biological responses push back against changes in body weight, and our set points are predetermined, then why have obesity rates — which, for adults, are almost three times what they were in the 1960s — increased so much? Most important, what can we do about it?

As it turns out, many biological factors affect the storage of calories in fat cells, including genetics, levels of physical activity, sleep and stress. But one has an indisputably dominant role: the hormone insulin. We know that excess insulin treatment for diabetes causes weight gain, and insulin deficiency causes weight loss. And of everything we eat, highly refined and rapidly digestible carbohydrates produce the most insulin.

By this way of thinking, the increasing amount and processing of carbohydrates in the American diet has increased insulin levels, put fat cells into storage overdrive and elicited obesity-promoting biological responses in a large number of people. Like an infection that raises the body temperature set point, high consumption of refined carbohydrates — chips, crackers, cakes, soft drinks, sugary breakfast cereals and even white rice and bread — has increased body weights throughout the population.

One reason we consume so many refined carbohydrates today is because they have been added to processed foods in place of fats — which have been the main target of calorie reduction efforts since the 1970s. Fat has about twice the calories of carbohydrates, but low-fat diets are the least effective of comparable interventions, according to several analyses, including one presented at a meeting of the American Heart Association this year.

Credit            Sarah Illenberger       

 

 

A recent study by one of us, Dr. Ludwig, and his colleagues published in JAMA examined 21 overweight and obese young adults after they had lost 10 to 15 percent of their body weight, on diets ranging from low fat to low carbohydrate. Despite consuming the same number of calories on each diet, subjects burned about 325 more calories per day on the low carbohydrate than on the low fat diet — amounting to the energy expended in an hour of moderately intense physical activity.

Another study published by Dr. Ludwig and colleagues in The Lancet in 2004 suggested that a poor-quality diet could result in obesity even when it was low in calories. Rats fed a diet with rapidly digesting (called high “glycemic index”) carbohydrate gained 71 percent more fat than their counterparts, who ate more calories over all, though in the form of slowly digesting carbohydrate.

These ideas aren’t entirely new. The notion that we overeat because we’re getting fat has been around for at least a century, as described by Gary Taubes in his book “Good Calories, Bad Calories.” In 1908, for example, a German internist named Gustav von Bergmann dismissed the energy-balance view of obesity, and hypothesized that it was instead caused by a metabolic disorder that he called “lipophilia,” or “love of fat.”

But such theories have been generally ignored, perhaps because they challenge entrenched cultural attitudes. The popular emphasis on calorie balance reinforces the belief that we have conscious control over our weight, and that obesity represents a personal failure because of ignorance or inadequate willpower.

In addition, the food industry — which makes enormous profits from highly processed products derived from corn, wheat and rice — invokes calorie balance as its first line of defense. If all calories are the same, then there are no bad foods, and sugary beverages, junk foods and the like are fine in moderation. It’s simply a question of portion control. The fact that this rarely works is taken as evidence that obese people lack willpower, not that the idea itself might be wrong.

UNFORTUNATELY, existing research cannot provide a definitive test of our hypothesis. Several prominent clinical trials reported no difference in weight loss when comparing diets purportedly differing in protein, carbohydrate and fat. However, these trials had major limitations; at the end, subjects reported that they had not met the targets for complying with the prescribed diets. We wouldn’t discard a potentially lifesaving cancer treatment based on negative findings, if the research subjects didn’t take the drug as intended.

There are better ways to do this research. Studies should provide participants with at least some of their food, to make it easier for them to stick to the diets. Two studies that did this — one by the Direct Group in 2008 and the other by the Diogenes Project in 2010 — reported substantial benefits associated with the reduction of rapidly digestible carbohydrate compared with conventional diets. We need to invest much more in this research. With the annual economic burden of diabetes — just one obesity-related complication — predicted to approach half a trillion dollars by 2020, a few billion dollars for state-of-the-art nutrition research would make a good investment.

If this hypothesis turns out to be correct, it will have immediate implications for public health. It would mean that the decades-long focus on calorie restriction was destined to fail for most people. Information about calorie content would remain relevant, not as a strategy for weight loss, but rather to help people avoid eating too much highly processed food loaded with rapidly digesting carbohydrates. But obesity treatment would more appropriately focus on diet quality rather than calorie quantity.

People in the modern food environment seem to have greater control over what they eat than how much. With reduced consumption of refined grains, concentrated sugar and potato products and a few other sensible lifestyle choices, our internal body weight control system should be able to do the rest. Eventually, we could bring the body weight set point back to pre-epidemic levels. Addressing the underlying biological drive to overeat may make for a far more practical and effective solution to obesity than counting calories.

 

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Can We Be Fat and Fit?

A study published online this past week in the Journal of the American College of Cardiology, and generating widespread media attention, challenges the notion that it’s possible to be fat and fit. Or so it seems; as ever, there is some potential devilry in the details. Let the exorcism begin.

First, the argument has long prevailed that it is possible to be both fat and fit, and that fitness trumps fatness. Perhaps the best known champion of this concept is my colleague, Dr. Steven Blair at the University of South Carolina. Fundamentally, I agree with Dr. Blair. Studies suggest that being heavier but fit is better in terms of overall health outcomes than being very thin, but unfit.

But on the other hand, in the real world fit and not-so-fat tend to go together, for the most obvious of reasons: the things we do to make ourselves genuinely fit are also the best strategies for lasting weight control. Up to a point, fitness is a product of exercise, which tends to be Dr. Blair’s primary focus. But true fitness also means good metabolic health, and that is highly dependent on diet as well. Food, after all, is the fuel for the physical work of the human body.

All of which suggests that genuine fitness derives from eating well and exercise. Those are the winning strategies for weight control, too. Eating well and being active are not, of course, a guarantee of any particular weight. Weight is not a choice, and is governed by some factors we don’t control- such as genetic variation, ethnic heritage, and even our intestinal flora. And, it’s also possible to eat well, but too much.

But other things being equal, healthful eating and routine physical activity work not only for weight loss, which can be achieved with any cockamamie diet, but for lasting weight control. There is evidence of this from many sources, among the best of which is the National Weight Control Registry. The Registry now has data on over 10,000 people who have lost a substantial amount of weight, and kept it off for year. Invariably, these people eat well and exercise. It works.

So, in the real world, most people who are truly fit tend to be at least relatively un-fat; and most people who are un-fat for the long term (in the absence of a health problem to account for it) tend to be fit. A Harvard study some years ago looked at a large population divided into fit, yes or no; and fat, yes or no. There were lots of people in the “fat, not fit” cell, unfortunately. There were fewer, but many, in the “fit, not fat” cell, and the “not fat, not fit” cell. The smallest of all was “fat, fit.” The combination does not seem to be common in the real world.

Which leads us back to the new study, which headlines suggest challenges even the possibility of the combination. The study was conducted among over 14,000 adults in Korea, both men and women, lean and overweight. They were all “metabolically health” as defined by normal levels of blood lipids, blood glucose, and inflammatory markers.

Coronary artery CT scanning was performed to look for calcification, a reliable indicator of atherosclerosis. The principal study finding was that as body mass index went up, so did coronary calcification. Despite having a “normal” metabolic profile, the overweight and obese members of this cohort had more plaque in their coronary arteries than their lean counterparts.

When the researchers adjusted for finer gradations in the laboratory measures, the association was much explained. In other words, while the overweight members of the group all had “normal” metabolic markers, they were a bit less normal than among the lean members. Lipids and inflammatory markers were high normal, and so on.

From my perspective, the study left out a lot of important information. Very little was said about exercise levels or cardiovascular “fitness.” Normal metabolic indicators is not the same as being genuinely fit. There was no detail about dietary intake either, and it is certainly possible that variations in diet quality might have had something to do with variation in coronary calcification. And finally, while body composition was assessed, the results were not presented based on body fat distribution. We have long known that in terms of metabolic health and heart disease risk, all obesity is not created equal; it’s fat accumulation around the middle that matters most.

Still, the study suggests that even with other metabolic factors accounted for, excess body fat is, by itself, a risk factor for coronary atherosclerosis. That is a potentially important message that argues back against the “ok at any size movement.” Size may be ok, but coronary disease is not. If we have to control our body fat to prevent calcified plaque in our coronary arteries, that is not a body image issue; it’s a matter of potentially life and death significance.

But while this study suggests that metabolic fitness and degree of fatness may both matter, it changes nothing about how best to address both. Eating well and being active remain the best medicine both for defending against fatness, and cultivating fitness.

 

-fin

Dr. David L. Katz is President of the American College of Lifestyle Medicine. He is the author of Disease Proof, and most recently, of the epic novel, reVision.

www.davidkatzmd.com www.turnthetidefoundation.org

http://www.loreofthecorners.com/

http://www.facebook.com/pages/Dr-David-L-Katz/114690721876253 http://twitter.com/DrDavidKatz http://www.linkedin.com/pub/david-l-katz-md-mph/7/866/479/

 

Photo: tmcphotos / shutterstock

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Weight-Loss Resistance and Choices

Here is the link to Dr.Katz’s recent posting on Huffington Post about weight-loss resistance.

Click here to read the Huffington Post Article

 

 

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Self-Care as a Strategy for the Holidays

For 11 months out of the year, it seems easier to be committed to weight loss than for the 1 month at the end of the year. The holidays change everything.  Though the holidays can be a meaningful time to be with family and friends, it can also raise anxieties about losing ground on your struggle to lose and keep off weight. At this time, it is easy for one’s focus to be drastically diverted from your health and wellbeing to just about everything and everybody else.  To get through the season, rather than concentrating on a few events and holidays, continue to focus on your own self-care throughout the season. Here are some ways to be good to your body, mind and spirit during this hectic time.

Visualize Success. Keep your goal at the top of your mind every day.  Each morning or evening, take ten minutes just for you. Create a relaxing environment with candles, calming music, essential oils, then quiet your mind and visualize yourself on January 2nd. The holidays are over and you have just gotten through the holiday season successfully. Imagine what your success will look like? How good will you feel and look? Do you notice that you don’t feel bloated, but you also don’t feel deprived either? Repeat this daily throughout the holidays. Not only will you keep your goal in mind, you will feel good carving out some “me” time each day.

Focus on People, Not Food. Look at each party and holiday meal as a time to socialize with friends, colleagues and family, rather than worrying about a minefield of bad eating choices. The opportunity to be with people you care about contributes a lot to your wellbeing and can create a sense of satisfaction. Since you can’t have a conversation with your mouth full of food, you can limit what you eat and drink by spending your time connecting with people .  Instead of worrying about the delicacies that are talking to you from the buffet table, look at the friendly faces and talk to them instead.  You will have a much richer conversation, I guarantee it!

Non-Party/Non-Holidays are just regular days. Keep your usual weight loss regimen and exercise schedule on the days in between the special days. The good news is that regular days throughout the season far outnumber party days and holidays. On these days, do what you did all year: exercise, eat right, hydrate and rest.

Don’t be a people pleaser. It’s so hard to say “no” to people when they are asking for your help or involvement or even asking you to take second helpings of a favorite, but fattening dish. Saying “yes” every time creates stress and takes time away from meeting your own needs. Think about what you are getting yourself into before you say “yes,” rather than just pleasing every person. If you need to say no, do it kindly. “I’m so sorry I can’t help you with decorations this time.” “The dessert was delicious, but I’m so full from the sumptuous dinner you made I couldn’t possibly have seconds.”

Plan Your Indulgence.  You want to have grandma’s stuffing or your auntie’s delicious cheese cake, and you will be miserable if you don’t. Depriving yourself of those special, once-a-year things isn’t helpful. Go ahead and have some, but plan it out. Decide before hand what dishes, desserts and beverages you will have.  Write it down on a piece of paper, sign it and stick to it! If you are a visual person, use this old trick: take a paper plate and write or draw on it exactly what you will eat. (I write the names of the food on my plate because I can’t draw.) When it comes time to the meal, eat what you planned, and only what fits on one plate. No second helpings. Be honest – if you are going to go way off the rails, plan it on your one plate.

Above all, don’t get down on yourself if you stray far from your eating and exercise routine. The number one rule of self-care is to do just that – care for yourself.  Chalk it up to experience, and get back on track the next day. And by all means, enjoy yourself!

HappyHolidays!

Lela Reynolds, Certified Holistic Health Coach

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Here is an interesting article from the New York Time. Researchers from Boston Children’s Hospital investigated how the effects of deleting a gene act in the brain to control weight. A group of sibling mice were eating the same amount of food and exercising normally. Yet, mice without the MRAP2 gene gained twice as much as their normal siblings. This research can help us re-think the way we think about obesity. Here is the link for the full article:

http://www.nytimes.com/2013/07/19/health/overweight-maybe-you-really-can-blame-your-metabolism.html?pagewanted=all

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Forget Holiday Stress and Weight Gain with Green Smoothies

It’s almost a year now that I and my colleagues have been writing here, and it’s hard to believe that the year has gone so quickly.  I love doing this, because it keeps me searching for ways to beat our bodies’ resistance to losing weight, and sharing my research and experience with you. A lot of things work, some don’t and progress is often slow, but at least we have each other.

This fall, I tried something that gave me the best results in a long time – not only did I clock a 6lb weight loss at my doctor’s office, which was the largest amount in forever, but I feel better, stronger, and even younger than ever.  Two words for the best solution yet: green smoothies! You may think that a better time to talk about them would be in the spring or summer, but I say there is no better time to start a smoothie kick than right now during the holiday season. The next month can bring as much stress and bad food possibilities as the previous 11 combined, and a smoothie a day is a great way to give your body the nutrition it really needs to withstand increased stress and reject junk food. Using organic fruits and vegetables and a few other ingredients blended together, you can produce delicious drinks/meals that will give you all the vitamins, minerals and fiber your body craves and needs.

The Nutrient – Stress Connection

It is well known that stress wears the body down and makes it susceptible to illness.  Stress depletes the vitamins and minerals necessary for physical and mental health, as well as a strong immune system. When the body is lacking in minerals like magnesium, calcium and iron, or vitamins like B3, B6, B12, and C, health problems such as depression, fatigue and anemia can occur. These vitamins and minerals can be replenished by eating certain foods regularly like greens that contain many minerals and vitamins, vegetables, milk, grains, nuts and fruits. A green smoothie a day can contain all of the ingredients that can make this happen.

Smoothies vs. Juices

Green smoothies are fruits and/or vegetables, including a leafy green veggie, blended with a liquid and other ingredients to produce a smooth drink. Because you put in the whole fruit or veggie (minus seeds, core, stem, and sometimes skin), all of the nutrition from the produce is in the drink.  Smoothies require a powerful blender that is either made for the job or has multiple blending levels including “liquefy”. Smoothies are more nutritious than juices, because the juicing process removes nutrients from the skin, pulp and fiber, leaving only the liquid from the produce, which is usually very high in sugar. Leaving in all or most of the produces’ components gives you the total nutritional benefit.

Always use Greens

Dark, leafy greens contain a repository of essential minerals and vitamins. Even when I am very careful about what I eat, I don’t get enough every day unless I use them in a smoothie. Try these greens as the central ingredient:

  • Kale – If you are not a fan of eating kale, don’t get turned off. Try it with a balance of fruits like apple and blueberry or other vegetables like carrots. The texture of the smoothie will be a little gritty because of the texture of the leaf, but you can get used to it.
  • Baby Kale – the texture is smoother and flavor is a little milder than kale, and you can mix it with other flavors as desired.
  • Dinosaur Kale – a bright green and tenderer variety of Kale.
  • Spinach – this is the most popular choice because of its mild flavor and texture, but don’t use it all the time. Spinach contains an acid that actually interferes with mineral absorption.
  • Arugula – the most nutritious of salad greens, its flavor has a kick for a different experience.

Balance Flavors and Vary Colors

In the same way you put many colors on your plate when you eat, you should try to do the same when choosing smoothie ingredients to get a great variety of nutrients. Think of all the colors in the fruit and vegetable world! So if you ground your smoothie with one of the greens above, add blue (blueberries), or red (apples or strawberries), or yellow (banana or pineapple or grapefruit), or orange (carrots) or light green (celery). Also, by balancing flavors, you will get a better end result. Instead of a smoothie of all sweet ingredients like fruits and vegetables like carrots, which would be a higher in carbohydrates, balance it out with some savory ingredients like celery and greens.

Fluids

You can use any fluid that works with the ingredients. One bias I have is to not use ice if you can help it.  Ice shocks the body, and adding stress is not the effect we are going for. If you need a little chill in the drink, use frozen fruits instead. Also, stay away from using fruit juices as even the purest has a high amount of sugar.

  • Water – of course! Remember, with all the fiber you are having in the drink, water is necessary.
  • Milk – cow’s, goat’s, coconut, soy, almond, etc.
  • Broth – choose a low-sodium, organic chicken or vegetable broth if making an all-veggie smoothie.

Smoothie as a Meal Replacement

Every meal should contain some protein, and if you are having the smoothie in place of a meal, it is important to follow that rule.  Some protein sources for smoothies are: tofu, greek yogurt, rice bran protein, dairy milk or a nut milk like almond or cashew milk. Do NOT use raw eggs in a smoothie as it is dangerous to eat uncooked eggs.  In cases where you are concerned that you won’t feel full, or if you are in a situation where you don’t know exactly when you will be able to eat your next meal, add some fats and fiber. Some great fat sources that also add some texture are nuts, coconut milk or avocado. As an extra fiber source, I have used rice bran protein powder or glucomannan. Glucomannan is a root fiber available in capsules – you simply open the capsule and pour the powder into the blender with the other ingredients. With protein and a little extra fiber, the smoothie will give you the fuel you need for hours.

It can be fun and creative to smooth out your stress with green smoothies. No two are alike and the possibilities are endless. Leave a message for us with great recipes that you have made up and let us know how it makes you feel.

Enjoy the holiday season.

 

By Lela Reynolds, Certified Holistic Health Coach, AADP

www.afriendinthekitchen.com

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Resilience

If you weren’t affected directly, by now you’ve seen pictures of the damage that Hurricane Sandy inflicted on portions of the Caribbean, Mid-Atlantic and Northeastern United States last month.  My heart goes out to everyone affected and I wish you peace and comfort.  

You’ve also likely heard the countless stories of strength, kindness & selflessness; stories that leave me in awe of the human spirit’s ability to recover and remind me why I chose the career path I did.

Traumatic events, whether a personal set back, loss of a loved one, a terrorist attack or natural disaster, challenge and shape who we are.   Responses to difficult events range enormously and I have always been curious why some of us are paralyzed in the face of adversity while others seem to flourish and bounce back more easily.  What is it that makes someone resilient?  And is it a quality we can develop? 

Resiliency is defined as the ability to return to the original form or position after being bent, compressed or stretched; the ability to readily recover from illness, depression, adversity or the like.

Research suggests that we can, in fact, build our resilience and knowing the characteristics of resilient people can help you do just that.  Resilient people are:

Accepting and have an internal sense of control: They recognized that the proverbial bell “has rung” and wishing that it didn’t won’t change anything.  They believe they can influence the outcomes of whatever happens to them by redirecting their energy and attention away from what they cannot control, to what they can.

Flexible and problem solve: They look for new solutions to problems, recognizing that what worked in the past might not in the current situation.  They identify clear action steps, regardless of how small, and then take action. 

Invested in social connections: They have strong connections with others and value and nurture their relationships.  

Optimistic and hopeful: They believe that the world is generally a good and safe place.  They are not immune to sadness and despair.  Rather, they recognize that misfortune, sadness and loss will always be a part of life and actively choose to focus on the positive.

Insightful and have perspective: These are the people who say “it could have been worse.”  They do not see themselves as victims and can focus on the bigger picture.

Spiritual: They have a sense of meaning and purpose to their life and believe others do too. 

Able to keep their sense of humor: They look for the comic relief in the face of challenge

I have learned a lot about resilience from friends and patients in these weeks. A friend who just returned to her home found a boat in her kitchen.  Her response: “Do I get to keep the boat?”  That same kitchen had been damaged in Hurricane Irene and was just rebuilt. 

Another friend and her daughter were saved by a neighbor after water suddenly flooded into her building.   She lost her home and belongs.  Her response: “At least I put a bra on that morning.”

A man on television whose property was damaged and was going on his 5th day without electricity.  His response: “What’s happening to me is inconvenient, not tragic.”

Although I hope your need to demonstrate resiliency is few and far between, the more we engage in behaviors and in a mindset that foster resiliency, the better equipped we will be when confronted with the next challenge.

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