Long-term weight loss maintenance #4

Saturday, October 3, 2009

Dieting consistency
The topic of dieting consistency was also recently examined in the registry. Participants were asked whether they maintained the same diet regimen across the week and year, or if they tended to diet more strictly on weekdays and/or nonholidays (18). Few people said they dieted more strictly on the weekend compared with the rest of the week (2%) or during holidays compared with the rest of the year (3%). Most participants reported that their eating was the same on weekends and weekdays (59%) and on holidays/vacations and the rest of the year (45%). The remaining groups reported that they were stricter during the week than on weekends (39%) and during nonholiday times compared with holidays (52%).

We evaluated whether maintaining a consistent diet was related to subsequent weight regain after 2 y. Interestingly, results indicated that participants who reported a consistent diet across
the week were 1.5 times more likely to maintain their weight within 5 lb over the subsequent year than participants who dieted more strictly on weekdays. A similar relationship emerged between dieting consistency across the year and subsequent weight regain; individuals who allowed themselves more flexibility on holidays had greater risk of weight regain. Allowing for flexibility in the diet may increase exposure to high-risk situations, creating more opportunity for loss of control. In contrast, individuals who maintain a consistent diet regimen across the week and year appear more likely to maintain their weight loss over time.

Recovery from relapse
We also examined different patterns of weight change among registry participants followed over time. We were particularly interested in evaluating whether participants who gained weight
between baseline and year 1 were able to recover over the subsequent year. We found that few people (11%) recovered from even minor lapses of 1–2 kg. Similarly, magnitude of weight
regain at year 1 was the strongest predictor of outcome from year 0 to 2. Participants who gained the most weight at year 1 were the least likely to re-lose weight the following year, both when “recovery” was defined as a return to baseline weight or as re-losing at least 50% of the year 1 gain.

Although participants gained weight and recovery was uncommon, the regains were modest (average of 4 kg at 2 y), and the vast majority of participants (96%) remained >10% below their
maximum lifetime weight, which is considered “successful” by current obesity treatment standards.

These findings, nonetheless, suggest that reversing weight regain appears most likely among individuals who have gained the least amount of weight. Preventing small regains from turning
into larger relapses appears critical to recovery among successful weight losers.


SUMMARY
Results of random digit dial surveys indicate that =20% of people in the general population are successful at long-term weight loss maintenance. These data, along with findings from the National Weight Control Registry, underscore the fact that it is possible to achieve and maintain significant amounts of weight loss.

Findings from the registry suggest six key strategies for longterm success at weight loss: 1) engaging in high levels of physical activity; 2) eating a diet that is low in calories and fat; 3) eating breakfast; 4) self-monitoring weight on a regular basis; 5) maintaining a consistent eating pattern; and 6) catching “slips” before they turn into larger regains. Initiating weight loss after a medical event may also help facilitate long-term weight control.

Additional studies are needed to determine the factors responsible for registry participants’ apparent ability to adhere to these strategies for a long period of time in the context of a “toxic”
environment that strongly encourages passive overeating and sedentary lifestyles.

RRW is the cofounder of the National Weight Control Registry (with James O Hill). RRW coauthored the manuscript with SP, who is a coinvestigator of the National Weight Control Registry. RRW and SP have no financial or personal interest in the organizations sponsoring this research.

Long-term weight loss maintenance #3

FACTORS ASSOCIATED WITH WEIGHT REGAIN

Registry participants are followed over time to identify variables related to continued success at weight loss and maintenance. Findings from the initial follow-up study (15) indicated that, after 1 y, 35% gained 2.3 kg (5 lbs) or more (7 kg on average), 59% continued to maintain their body weight, and 6% continued to lose weight.

Participants who regained weight (>2.3 kg) were compared with those who continued to maintain their body weight to examine whether there were any baseline characteristics that could distinguish the two groups. The single best predictor of risk of regain was how long participants had successfully maintained their weight loss (Table 1). Individuals who had kept their weight off for 2 y or more had markedly increased odds of continuing to maintain their weight over the following year. This finding is encouraging because it suggests that, if individuals can succeed at maintaining their weight loss for 2 y, they can reduce their risk of subsequent regain by nearly 50%.

Another predictor of successful weight loss maintenance was a lower level of dietary disinhibition, which is a measure of periodic loss of control of eating. Participants who had fewer problems with disinhibition [ie, scores <6 on the Eating Inventory subscale (14)] were 60% more likely to maintain their weight over 1 y. Similar findings were found for depression, with
lower levels of depression related to greater odds of success. These findings point to the importance of both emotional regulation skills and control over eating in long-term successful
weight loss.

Several key behavior changes that occurred over the year of follow-up also distinguished maintainers from regainers. Not surprisingly, those who regained weight reported significant decreases in their physical activity, increases in their percentage of calories from fat, and decreases in their dietary restraint. Thus, a large part of weight regain may be attributable to an inability to maintain healthy eating and exercise behaviors over time. The findings also underscore the importance of maintaining behavior changes in the long-term maintenance of weight loss.

Triggering events
Another variable that has been examined in the registry is the presence of a “triggering event” leading to participants’ successful weight loss. Most registry participants reported a trigger for
their weight loss (83%). Medical triggers were the most common (23%), followed by reaching an all time high in weight (21.3%), and seeing a picture or reflection of themselves in the mirror
(12.7%).

Because medical triggers have been shown to promote longterm behavior change in other areas of behavioral medicine (16), we examined whether individuals who reported medical triggers
were more successful than those who reported nonmedical triggers or no triggers. A medical trigger was defined broadly and included, for example, a doctor telling the participant to lose
weight and/or a family member having a heart attack. Findings indicated that people who had medical reasons for weight loss also had better initial weight losses and maintenance (17). Specifically, those who said they had a medical trigger lost 36 kg, whereas those who had no trigger (17.1%) or a nonmedical trigger (59.9%) lost 32 kg. Medical triggers were also associated
with less regain over 2 y of follow-up. Those with medical triggers gained 4 kg (=2 kg/y), whereas those with other or no medical triggers gained at a significantly faster rate, averaging 6
kg in both groups.

These findings are intriguing because they suggest that the period following a medical trigger may be an opportune time to initiate weight loss to optimize both initial and long-term weight
loss outcomes.

Long-term weight loss maintenance #2

THE NATIONAL WEIGHT CONTROL REGISTRY
Although it is often stated that no one ever succeeds in weight loss, we all know some people who have achieved this feat. In an effort to learn more about those individuals who have been successful at long-term weight loss, Wing and Hill (10) established the National Weight Control Registry in 1994. This registry is a self-selected population of more than 4000 individuals who are age 18 or older and have lost at least 13.6 kg (30 lb) and kept it off at least 1 y. Registry members are recruited primarily through newspaper and magazine articles. When individuals enroll in the registry, they are asked to complete a battery of questionnaires detailing how they originally lost the weight and how they now maintain this weight loss. They are subsequently followed annually to determine changes in their weight and their weightrelated behaviors.

The demographic characteristics of registry members are as follows: 77% are women, 82% are college educated, 95% are Caucasian, and 64% are married. The average age at entry to the
registry is 46.8 y. About one-half of registry members report having been overweight as a child, and almost 75% have one or two parents who are obese.

Participants self-report their current weight and their maximum weight. Previous studies suggest that such self-reported weights are fairly accurate (slightly underestimating actual weight) (11, 12). In the NWCR, participants are asked to identify a physician or weight loss counselorwhocan provide verification of the weight data. When, in a subgroup of participants, the
information provided by participants was compared with that given by the professional, the self-report information was found to be very accurate.

Participants in the registry report having lost an average of 33 kg and have maintained the minimum weight loss (13.6 kg) for an average of 5.7 y. Thirteen percent have maintained this minimum weight loss for more than 10 y. The participants have reduced from a BMI of 36.7 kg/m2 at their maximum to 25.1 kg/m2 currently. Thus, by any criterion, these individuals are clearly extremely successful.

Previously, we reported information about the way in which registry participants lost their weight (10); interestingly, about one-half (55.4%) reported receiving some type of help with
weight loss (commercial program, physician, nutritionist), whereas the others (44.6%) reported losing the weight entirely on their own. Eighty-nine percent reported using both diet and physical activity for weight loss; only 10% reported using diet only,and 1% reported using exercise only for their weight loss. The most common dietary strategies for weight loss were to restrict certain foods (87.6%), limit quantities (44%), and count calories (43%). Approximately 25% counted fat grams, 20% used liquid formula, and 22% used an exchange system diet. Thus, there is variability in how the weight loss was achieved (except that it is almost always by diet plus physical activity).

The earliest publication regarding the registry documented the behaviors that the members (n = 784) were using to maintain their weight loss (10). Three strategies were reported very consistently: consuming a low-calorie, low-fat diet, doing high levels of physical activity, and weighing themselves frequently. Recently, a fourth behavior was identified: consuming breakfast
daily (13). Each of these behaviors is described below. Registry members reported eating 1381 kcal/d, with 24% of calories from fat. In interpreting their data, it is important to recognize that55% of registry members report that they are still trying to lose weight and to consider that dietary intake is typically underestimated by 20–30%. Thus, registry members are probably eating closer to 1800 kcal/d. However, even with this adjustment, it is apparent that registry members maintain their weight loss by continuing to eat a low-calorie, low-fat diet.

More recently, we have examined other aspects of their diet. Of particular interest is the fact that 78% of registry members report eating breakfast every day of the week (13). Only 4%
report never eating breakfast. The typical breakfast is cereal and fruit. Registry members also report consuming 2.5 meals/wk in restaurants and 0.74 meals/wk in fast food establishments.

Another characteristic of NWCR members is high levels of physical activity. Women in the registry reported expending an average of 2545 kcal/wk in physical activity, and men report an
average of 3293 kcal/wk (10). These levels of activity would represent =1 h/d of moderate-intensity activity, such as brisk walking. The most common activity is walking, reported by 76%
of the participants. Approximately 20% report weight lifting, 20% report cycling, and 18% report aerobics.

Registry members also reported frequent monitoring of their weight (10). More than 44% report weighing themselves at least once a day, and 31% report weighing themselves at least once a
week. This frequent monitoring of weight would allow these individuals to catch small weight gains and hopefully initiate corrective behavior changes.

The vigilance regarding body weight can be seen as one aspect of the more general construct of cognitive restraint (ie, the degree of conscious control exerted over eating behaviors). Registry
members are asked to complete the Three Factor Eating Inventory (14), which includes a measure of cognitive restraint. Registry members scored high on this measure (mean of 7.1), with levels similar to those seen in patients who have recently completed a treatment program for obesity, although not as high as eating-disordered patients. These findings suggest that successful weight loss maintainers continue to act like recently successful weight losers for many years after their weight loss.

Long-term weight loss maintenance

ABSTRACT
There is a general perception that almost no one succeeds in longterm maintenance of weight loss. However, research has shown that = 20% of overweight individuals are successful at long-term weight loss when defined as losing at least 10% of initial body weight and maintaining the loss for at least 1 y. The National Weight Control Registry provides information about the strategies used by successful weight loss maintainers to achieve and maintain long-term
weight loss. National Weight Control Registry members have lost an average of 33 kg and maintained the loss for more than 5 y. To maintain their weight loss, members report engaging in high levels of physical activity (=1 h/d), eating a low-calorie, low-fat diet, eating breakfast regularly, self-monitoring weight, and maintaining a consistent eating pattern across weekdays and weekends.

Moreover, weight loss maintenance may get easier over time; after individuals
have successfully maintained their weight loss for 2–5 y, the chance of longer-term success greatly increases. Continued adherence to diet and exercise strategies, low levels of depression and disinhibition, and medical triggers for weight loss are also associated with long-term success. National Weight Control Registry members provide evidence that long-term weight loss maintenance is possible and help identify the specific approaches associated with long-term
success.

SUCCESSFUL WEIGHT LOSS MAINTENANCE
The perception of the general public is that no one ever succeeds at long-term weight loss. This belief stems from Stunkard and McLaren-Hume’s 1959 study of 100 obese individuals, which indicated that, 2 y after treatment, only 2% maintained a weight loss of 9.1 kg (20 lb) or more (1). More recently, a New England Journal of Medicine editorial titled Losing Weight: An Ill-Fated New Year’s Resolution (2) echoed the same pessimistic message.

The purpose of this paper is to review the data on the prevalence of successful weight loss maintenance and then present some of the major findings from the National Weight Control
Registry (NWCR), a database of more than 4000 individuals who have indeed been successful at long-term weight loss maintenance.

DEFINING “SUCCESSFUL WEIGHT LOSS MAINTENANCE”
Wing and Hill (3) proposed that successful weight loss maintainers be defined as “individuals who have intentionally lost at least 10% of their body weight and kept it off at least one year.”
Several aspects of this definition should be noted. First, the definition requires that the weight loss be intentional. Several recent studies indicate that unintentional weight loss occurs quite
frequently and may have different causes and consequences than intentional weight loss (4, 5). Thus, it is important to include intentionality in the definition.

The 10% criterion was suggested
because weight losses of this magnitude can produce substantial improvements in risk factors for diabetes and heart disease. Although a 10% weight loss may not return an obese to a non-obese
state, the health impact of a 10% weight loss is well documented (6). Finally, the 1-y duration criterion was proposed in keeping with the Institute of Medicine criteria (7). Clearly, the most
successful individuals have maintained their weight loss longer than 1 y, but selecting this criterion may stimulate research on the factors that enable individuals who have maintained their weight loss for 1 y to maintain it through longer intervals.


PREVALENCE OF SUCCESSFUL WEIGHT LOSS MAINTENANCE
There are very few studies that have used this definition to estimate the prevalence of successful weight loss maintenance. McGuire et al (8) reported results of a random digit dialing survey
of 500 adults, 228 ofwhomwere overweight or obese [body mass index (BMI)>= 27 kg/m2] at their maximum nonpregnant weight. Of these 228, 47 (20.6%) met the criteria for successful weight loss maintenance: they had intentionally lost at least 10% of their body weight and maintained it for at least 1 y. On average, these 47 individuals had lost 20.7 +- 14.4 kg (45.5 lb; 19.5 +- 10.6% from maximum weight) and kept it off for 7.2 +- 8.5 y; 28 of the 47 had reduced to normal weight (BMI < 27 kg/m2).

Survey data such as these have the perspective of a person’s entire lifetime and thus may include many weight loss attempts, some which were successful and some unsuccessful. It is more typical to assess “success” during one specific weight loss bout. In standard behavioral weight loss programs, participants lose an average of 7–10% (7–10 kg) of their body weight at the end of the initial 6-mo treatment program and then maintain a weight loss of =5–6 kg (5–6%) at 1-y follow-up. Only a few studies have followed participants for longer intervals; in these studies, = 3– 20% maintain a weight loss of 5 kg or more at 5 y. In the Diabetes Prevention Program (9), =1000 overweight individuals with impaired glucose tolerance were randomly assigned to an intensive lifestyle intervention. The average weight loss of these participants was 7 kg (7%) at 6 mo; after 1 y, participants maintained a weight loss of =6 kg (6%), and, at 3 y, they maintained a weight loss of =4 kg (4%). At the end of the study (follow-up ranging from 1.8 to 4.6 y; mean, 2.8 y), 37% maintained a weight loss of 7% or more.

Thus, although the data are limited and the definitions varied across studies, it appears that =20% of overweight individuals are successful weight losers.

Skin Redundancy after Massive Weight Loss

A 30-year-old man presented at our plastic-surgery clinic to request body contouring after massive weight loss (Panels A and B; inset shows patient before weight loss). Two years earlier, the patient had undergone an open gastric bypass for morbid obesity, and he subsequently lost 418 lb (190 kg) (from 647 to 229 lb [294 to 104 kg]) and had a decrease in waist size from 84 to 48 in. Although the procedure cured his hypertension, he had recurrent rashes and skin breakdown of the residual abdominal pannus. In addition, he continued to have difficulty ambulating and could not urinate while standing or have sexual intercourse. These symptoms were cured by body-contouring surgery (Panels C and D), after which he weighed 204 lb (93 kg) and had a waist size of 38 in.

The rising prevalence of gastric-bypass procedures for morbid obesity has created a rapidly growing area of plastic surgery for body contouring after massive weight loss. After gastric-bypass surgery, patients commonly have rashes, skin breakdown, and psychological complications because of skin redundancy. Consequently, these patients often consult a plastic surgeon about undergoing abdominoplasty, mastopexy, brachioplasty, or thigh lifts to improve their functional problems as well as their appearance.

Nutrition and HIV: Start with the Basics #2

Factors in Wasting
Malnutrition and wasting can be caused by four general factors. Any of these problems should be addressed with your doctor, who should also refer you to a registered dietitian.

1. Low intake of calories and nutrients: There are many causes for low intake. Some people suffer loss of appetite from depression, infection, fever, medications, treatment with chemotherapy or radiation, fatigue, diarrhea, or nausea or have fear of eating. Other reasons are due to pain or difficulty chewing, tasting, or swallowing. Some people have financial problems or cannot get around easily and do not have access to food.

2. Malabsorption: This occurs when foods are not getting broken down into nutrients, or if they are, cannot be carried out of the gut into the circulation system. If you have diarrhea or vomiting, food and liquid is not completely being absorbed. Problems causing the malabsorption can be due to medication, malnutrition, or infection. Diarrhea or vomiting may be made worse when there is lactose intolerance or fat malabsorption.

3. Abnormalities in metabolism: Metabolism is the process of using nutrients to run the body. There may be an increased demand for calories protein, and nutrients.

4. The wasting of muscles from not being used: The “use it or lose it” concept is true. Changes in activity can occur when there are changes in work or social routines, or you just don’t feel mentally or physically well enough to keep up your usual physical activity or exercise.


Protein Breakdown
Without enough calories and nutrients from foods vital body tissue protein may be used for fuel. This protein breakdown process is called catabolism. The result is called wasting or cachexia with muscle “atrophy,” a decrease in the size of cells, tissues, and organs. Skeletal muscle loss may be visibly noticed and sometimes not. Weight may not change even though muscle mass has changed. Other body systems can be negatively affected, too. Other problems caused as a result of using protein for fuel include:

• A decreased in immune system competence,
• Increased risk of infections, like PCP,
• Atrophy of the small intestine villi, resulting in difficulty digesting, absorbing, and using nutrients.

Short Bursts of Weight Loss
Weight loss often occurs around the time of any infection, generally because that person feels too sick to eat or to eat enough. Along with weight lose there is the breakdown and loss of muscle. Muscle is also sometimes called lean body mass, tissue, or body cell mass.

If the weight loss is not stopped, continued loss of lean body mass with each infection can lead to malnutrition. During an infection, the body needs more fuel, calories, protein, and other nutrients to fight back.

Take aggressive action. Don’t wait and think it will pass. If you are not eating like you usually do for more than two days, call your doctor and insist on getting help. Ask for aggressive nutrition support. No one at home or in the hospital has to lose weight.


Get Your Nutrition Trip Together: A Five-Point Plan

1. The Diet
In general, practice eating high protein, high complex carbohydrates, and moderate fat foods, and drink plenty of fluids, 8-12 cups a day. Eat on a regular basis every few hours and whenever you are hungry. Take a general multiple-vitamin and mineral supplement daily and B complex daily. Attend to any nutrition concern. Individually, adjust this plan as conditions warrant.

2. Physical Activity
Practice getting some physical activity on a routine basis. Activity can make a physical and psychological difference. It can make you stronger, more alert and relieve stress.

3. Sleep
Set up a routine so that your sleep is steady and uninterrupted. Try not to sleep too few or too many hours each night. Get attention if there is a problem.

4. Stress Management
Do things that make sense and support your self-esteem. Correct the tasks or situations that hurt your self-esteem. Include ways to release stress and ways to relax.

5. Unconditional Love
Make decisions and do things for you out of self-love and self-respect. This is really the key point. When you are paying attention to loving yourself, everything else is easier.

Nutrition and HIV: Start with the Basics

Nutrition is a life-sustaining treatment and the role of nutrition in the treatment of HIV is critical. HIV affects each person differently. The key to good nutrition is to have a daily nutritional plan that meets your needs. Ask to speak to the dietitian at your clinic and develop a meal plan to fit your needs. If there is none, encourage your medical provider to hire one and in the meantime ask to be referred to a dietitian knowledgeable in HIV care. You must be the one to insist on making nutrition a priority.

The Importance of Nutrition
Nutrition means your intake: the amount and quality of foods you eat, the liquids you drink, and the dietary supplements you take. Intake can be measured by the number of servings you have of each food group, and by the calories and nutrients, like carbohydrate, protein, and fat, vitamins and minerals, as well as other important substances found in your food and drink.

Nutrition also means how your foods, liquids, and supplements get digested into the nutrients that then move from your digestive system into your bloodstream to be carried to different parts of your body and used in metabolism, the functions and processes, which support life.

Think of nutrition as links in a chain. The first link is what you choose to eat and drink. Second is how well it can be digested. Third is how effectively your body can utilize these nutrients. You need all three links. The one that you have most control over is intake. If any link in the chain is broken, malnutrition can result. Poor food intake hurts the first link, vomiting and diarrhea hurt the second, and fevers, abnormal metabolism, and infections hurt the third. Malnutrition can be measured and identified by body cell (muscle) and weight loss, and as decrease of blood protein called albumin, and other markers in the blood like hematocrit, hemoglobin, and cholesterol.

HIV infects the cells that line the gastrointestinal tract and can make eating, digestion, absorption, and elimination painful, difficult, and less effective. When severe, malnutrition can cause illness and death, even with higher CD-4 cell levels. Weight loss and lower albumin levels increase the risk of hospitalization and length of stay. It has been established that death follows when there has been a decline to 66% of ideal body weight and a decline to 54% of usual body cell mass.

What you eat makes a very real difference in how you feel and how well you do medically. People with HIV can have problems that directly hurt their nutritional health. Your nutritional health directly affects your immune system.

Weight-Loss Diets for the Prevention and Treatment of Obesity #3

Friday, October 2, 2009

The inability of the volunteers to maintain their diets must give us pause. The study was led by
seasoned investigators who were experienced in the performance of diet and drug trials. The participants were highly educated, enthusiastic, and carefully selected. They were offered 59 group and 13 individual training sessions over the course of 2 years. Nonetheless, their body-mass index (the weight in kilograms divided by the square of the height in meters) after 2 years averaged 31 to 32 and was moving up again. Thus, even these highly motivated, intelligent participants who were coached by expert professionals could not achieve the weight losses needed to reverse the obesity epidemic. The results would probably have been worse among poor, uneducated subjects. Evidently, individual treatment is powerless against an environment that offers so many high-calorie foods and labor-saving devices.

It is obvious by now that weight losses among participants in diet trials will at best average 3 to
4 kg after 2 to 4 years and that they will be less among people who are poor or uneducated, groups that are hit hardest by obesity. We do not need another diet trial; we need a change of paradigm.

A little-noticed study in France may point the way. A community-based effort to prevent overweight in schoolchildren began in two small towns in France in 2000. Everyone from the mayor to shop owners, schoolteachers, doctors, pharmacists, caterers, restaurant owners, sports associations, the media, scientists, and various branches of town government joined in an effort to encourage children to eat better and move around more. The towns built sporting facilities and playgrounds, mapped out walking itineraries, and hired sports instructors. Families were offered cooking workshops, and families at risk were offered individual counseling.

Though this was not a formal randomized trial, the results were remarkable. By 2005 the prevalence of overweight in children had fallen to 8.8%, whereas it had risen to 17.8% in the neighboring comparison towns, in line with the national trend. This total-community approach is now being extended to 200 towns in Europe, under the name EPODE (Ensemble, prévenons
l’obésité des enfants [Together, let’s prevent obesity in children]).

Like cholera, obesity may be a problem that cannot be solved by individual persons but that
requires community action. Evidence for the efficacy of the EPODE approach is only tentative, and what works for small towns in France may not work for Mexico City or rural Louisiana. However, the apparent success of such community interventions suggests that we may need a new approach to preventing and to treating obesity and that it must be a total-environment approach that involves and activates entire neighborhoods and communities. It is an approach that deserves serious investigation, because the only effective alternative that we have at present for halting the obesity epidemic is large-scale gastric surgery.

Weight-Loss Diets for the Prevention and Treatment of Obesity #2

The reduction in caloric intake was also not sustained. Weight loss averaged 6 kg at 6 months,
which fits reasonably with the planned daily deficit of 750 kcal. However, after 12 months, subjects started to regain weight, which suggests that they were eating more than planned. Final weight losses averaged 3 to 4 kg after 2 years. This weight loss is similar to the weight loss that can be achieved with pharmacotherapy, and it is a clinically relevant effect that will slow the onset of type 2 diabetes. 4,5 To that extent, all the diets were successful. But the weight regain during the second year, although slow, suggests that in the end many participants might have regained their original weight even if treatment had continued.

Within each diet group, some participants achieved much better weight loss than others. Participants who lost more weight attended more counseling sessions and adhered more closely to the prescribed dietary composition. These observations led Sacks et al. to conclude that behavioral factors rather than macronutrient composition are the main influences on weight loss. That is a plausible hypothesis, and it has been observed before, but the present data do not allow a firm conclusion to be reached, because differences in macronutrient intake were too small.

Even if the planned differences in macronutrient intake had been achieved, the absence of
blinding would have made it difficult to ascribe the effect of a particular diet to protein, fat, or
carbohydrate molecules. Weight-loss studies are behavioral studies; they require participants to eat less. Cognition and feelings have a huge impact on such behavior. Participants may eat less not because of the protein or carbohydrate content of a diet but because of the diet’s reputation or novelty or because of the taste of particular foods in the diet.

Specific effects of fat, protein, and carbohydrates on food intake and body weight can be determined only when all diets look and taste the same. Studies that have accomplished this goal with the use of porridges (similar to oatmeal) and standardized snacks or with covertly manipulated foods have been carried out for short periods, but few subjects would be willing to eat those foods for the several years that would be needed to examine long-term effects. Therefore, this issue is unlikely to be settled soon. If behavior rather than diet composition is the key to weight loss, macronutrient composition may be of secondary importance anyway.

Weight-Loss Diets for the Prevention and Treatment of Obesity

No medical condition has generated as many dietary remedies as obesity. All diets have their followers, but hard data on the efficacy of the diets are scarce. In this issue of the Journal, Sacks et al.1 report the results of a large, long-term trial that tested the efficacy of weight-loss diets that were high or low in carbohydrates, protein, or fat. Highcarbohydrate, low-fat diets became popular approximately 20 years ago, when it was thought that calories from carbohydrates were less fattening than the same number of calories from fat.

A high-fat, low-carbohydrate diet was popularized by Dr. Robert Atkins in the 1970s2 and recently enjoyed a revival. The appeal of high-protein diets is that protein is thought to provide more satiation per calorie than fat or carbohydrates. The trial by Sacks et al. lasted longer than most, the dropout rate was low, treatment was intensive, and compliance was assessed with objective biomarkers.1 Unfortunately, the dietary goals were only partly achieved. Protein intake was intended to differ by 10% of energy between the high-protein-diet group and the average-proteindiet group, but the actual difference, as assessed by the measurement of urinary nitrogen excretion, was 1 to 2% of energy (according to my calculations, which were based on a diet that provided 1700 kcal per day).

Extreme carbohydrate intakes also proved hard to achieve. When fat is replaced isocalorically by carbohydrate, high-density lipoprotein (HDL) cholesterol decreases in a predictable fashion.3 The authors used the difference in the change in HDL cholesterol levels between the lowest- and highest-carbohydrate groups to calculate the difference in carbohydrate content between those diets. That difference turned out to be 6% of energy instead of the planned 30%.

White sugar is bad for you.

Monday, September 28, 2009

Too much of anything is bad for you and this is where the issue is a problem for
white sugar. The Western diet now contains pounds and pounds of sweeteners (this
includes white sugar, high fructose corn syrup, glucose syrup, dextrose, honey, maple syrup and other edible syrups). As of 1999 Americans were consuming just over 147 pounds of these sweeteners per year!

Replacing honey for white sugar is really no better for you, for instance. In fact, a
tablespoon of honey has 64 calories and a tablespoon of granulated sugar only 49 calories.

The honey might be better for you than the granulated sugar (there’s really no scientific proof that it is) but it still has more calories.

There is no difference as far as your body is concerned between more refined sugars and more natural products (table sugar vs. honey, for example). Calories are calories and the way to eat healthier is to eat fewer calories.

Foods labeled “natural” are better for you.

There is no legal meaning for the word “Natural.” The FDA does not regulate this
word and just because something is labeled this way doesn’t mean anything. Often it can mean that a food is not good for you. Lard is natural, butter is natural, sugar is natural, high fructose corn syrup is technically natural as well as a host of flavorings that are extracted from natural products through highly complicated processing.

A good example of this is the recent advertising campaign by the company that makes the soda 7UP. They claim to have removed all “artificial ingredients” from their drink. This is debatable as some feel that high fructose corn syrup is not “natural.” Nonetheless, soda with all that high calorie sweetener is bad for you and labeling 7UP “natural” is misleading in my opinion.

Even some of the organic products that are on the market use flavorings considered
“natural.” This often adds up to nothing more than a highly processed product.

If a package is labeled “natural” it should actually be cause for wariness on your part and not a feeling of reassurance that the product is good for you.

Supplements make a good substitute for a healthy diet.

Eating supplements for meals is not a good substitute for eating healthy. The key
to eating healthy is a little bit of planning. By knowing what you like to eat and having it on hand you can put together a quick meal. Taking a little extra time to make a healthy sandwich will usually have fewer calories than many of the “diet shakes” that say they can help you lose weight. You get more other good things out of eating this way than just the essential nutrients.

Stick to real food.

Vegetarian diets are healthier.

Eating strictly vegetarian has been shown to be good for you. There is excellent
research to show that when people don’t eat meat they eat fewer calories than people who do. The research is, however, often done under controlled circumstances where the
vegetarian diet is also a lower fat diet.

This doesn’t mean that if you don’t eat meat that your diet is automatically healthy. There are a tremendous number of vegetarian recipes that are very high in calories and fat.

The best plan is to look at recipes and the nutrition facts. How many calories are there? How much fat and saturated fat? Are there trans-fats? How much protein? Eating healthy is about choosing foods that are lower in calories and fat. Watching salt is a good idea, as well as trying to eat foods that have been processed as little as possible. This is true for both vegetarians as well as omnivores.

If you exercise you don’t need to eat healthy.

Certainly exercise has a profound effect on your long term health. Regular exercise
that helps you burn calories has been shown to help you live longer. Adding some type of weight (resistance) training can help you live better.

This doesn’t, however, allow you to eat whatever you wish. I have had more than one
endurance athlete come in for a check up only to find that their cholesterol profile was terrible. Simple changes in diet brings this back in line.

Keep in mind that elite athletes don’t eat just anything. There is, in fact, a tremendous amount of research now about nutrition targeted at the proper diet for athletic training.

A slow metabolism prevents weight loss.

Researchers call the amount of calories that one burns doing nothing “resting
metabolism” or “Basal Metabolic Rate” (BMR). It is true that BMR can be important in
helping to figure out how many calories a person needs every day, but there’s never been solid research showing that people with “slow metabolism” gain weight any faster than others. In fact, as people gain weight their metabolism actually speeds up.

The key to weight loss is to eat fewer calories and burn more. Choose great tasting food that’s lower in calories, be careful with portion size and spend more time exercising.

Cholesterol is bad for you.

Cholesterol is actually a type of fat and in its raw form is a waxy yellow gunk. It is different from most fats because the cholesterol molecule is more like a steroid molecule. Your body uses it to produce different hormones.

It is actually pretty easy to eat a diet that is lower in cholesterol, but we now know that the types of fats we consume are as important as the amount of cholesterol we eat. It is the way that saturated fats and trans-fats interact with cholesterol in the bloodstream that can cause health problems.

Your liver produces about 300 mg of cholesterol per day, which is about what is needed for the body to function properly. But we also consume cholesterol in the foods that we eat. Because plants don’t produce cholesterol, any cholesterol that we eat must come from animal products. A lean cut of meat has the same amount of cholesterol as one with a lot of fat. The key is to eat the one that is leaner and thus lower in saturated fat.

Celery is negative calories.

It is true that celery has almost no calories. A medium
stalk contains all of 6 calories. It’s also pretty good
for you in that a large stalk has about a gram of fiber
and is high in calcium and trace minerals. Interestingly,
celery is also fairly high in sodium for a vegetable—about
50 mg for a large stalk.

The theory that many people put forward is that your body
uses more than 6 calories chewing and digesting the celery.
There are actually books written about this but,unfortunately,
there’s no research to support the claim.

The body uses between 10 and 15% of the calories you consume
for the total process of digestion. In someone consuming 1,500
calories per day that’s 225 calories in 24 hours. It takes the
same 225 calories for digestion whether you eat 1,500 calories
per day in celery or in bread. The difference is that you would
have to eat 250 stalks of celery per day to eat 1,500 calories
as opposed to about 15 slices of bread.

Here’s how celery can help people lose weight: it tastes good,
it takes time to chew, it’s filling and it’s low in calories.

Eating late at night or just before you go to bed makes you gain weight.

Calories are calories. Period. If you eat too many and
don’t exercise enough, you will gain weight. Eating late
and going to bed simply doesn’t matter.

When you eat too much your body has an amazing ability
to store the extra calories as fat. Eating later for most
people generally means that they have eaten more calories
than they need.

You have to work out for 45 minutes at a time to get anything out of exercise.

I am not an expert in exercise physiology, but the research
is clear that most people don’t get enough these days. There
are good studies that show that even walking 30 minutes three
times a week has tremendous benefit.

Ideally your target should be at least 30 minutes 5 times a week.
The good news is that breaking this up into two 15 minute segments
works fine. That’s not much—a couple of miles walking instead of
a single sit-com on television. Walking is a lot more fun than
watching the evening news and so much better for you. When you do
exercise, try to work a little harder at it each time you do. Begin
with a stroll for 30 minutes but within a month you can be up to a
brisk walk.

Dairy products make you gain weight or help you lose weight.

Dairy products are pretty good for you, but like any food
they have calories. The main issue is that many dairy
products have a fair amount of fat. Choose non-fat or 1% milk
if you drink milk. Most of recipes that call for milk work fine
with either 1% or 2% milk. There are many excellent low-fat
cheeses on the market as well.

I use non-fat yogurt for recipes as well as eating and there is
excellent evidence that yogurt is very good for you. There are
often a lot of added calories in flavored yogurt, so check the
label carefully.

Dairy products have lots of good quality protein as well as calcium.
Most have been fortified with Vitamin D to help your body absorb the
calcium. The low fat dairy products have essentially the same amounts
of protein, vitamins, carbohydrates and calcium as the highfat
choices.

The kinds of foods that you eat are more important than the amount you eat.

People will go out of their way to eliminate carbohydrates or fats
completely from their diet. Most of the time they end up eating the
same number of calories in other types of foods.

Calories are calories whether they come from fat or carbs. If you
eat too many calories for the amount that you are going to burn,
you will gain weight. Simple. It is the amount of food that you eat
that is important.

Fats are bad for you.

Fats have a lot of calories per gram (about twice that of
carbohydrates andprotein). Because most of the processed and
fast foods today have very high amounts of fat, it’s easy for
people to gain weight eating them.

There are a number of different types of fats that we consume.
When you read the Nutrition Facts on a food label, the total fat
is reported and it is made up of saturated fat,monounsaturated fat
and trans-fats.

The fats to avoid in your diet are saturated fats and trans-fats.
Fatty meats and high fat dairy products are high in saturated fat.
Trans-fats are found in many processed foods like stick margarine,
baked goods and snack foods. Both of these types of fats have to be
reported on food labels.

There are good fats, however, and choosing foods that have
monounsaturated fats like those in seeds, nuts, grapeseed oil and
olive oil have been shown to improve your cholesterol profile. Omega-3
fats are found in fish, some seeds, and nuts, and they appear to
decrease the risk of cancer and strokes.

Even though there are good fats, they still contain calories, and
watching the amount of total fat you eat is as important as the types
of fats.