Chapter 4: Obesity - More Physical Activity

Lack of physical activity is one of the nation’s most pressing health problems. An active lifestyle and successful weight management go hand-in-hand.

We are far less active as a nation than we were at the turn of the century. The modern conveniences and change in occupations (from farming and manufacturing to communication and technology) have led to a dramatic decrease in activities that expend calories. It has been estimated that we exercise 75% less than our relatives of 1900. Back then, wash day was an all day affair. Now it is 20 minutes on a Maytag.
Cooking was difficult. You needed to chop the wood for the wood burning stove, buy the ingredient from several different stores, walking to each of them. Even the preparation of the food, chopping, grinding, etc was a lot of work. Now, we buy prepackaged dinners and pop them in the microwave. Everything you need can be found in one giant super-store. In the house, we have remote controls, telephones in every room. It has been estimated that Americans would lose 5-6 pounds in a year if we took away the remote controls and had just one phone in the house. People might get out of the chair and move!

Think about you life and all the ways the modern lifestyle has helped reduce the need for physical activity. I have three jobs and 4 offices at the present time and consider myself a very busy man. Yet, I don’t expend much energy moving around during the course of the day. The parking spots are close to the office door. The exam rooms I use to examine patients are right adjacent to my office so I’m not walking very far to the next appointment. We use intercoms and phones to communicate with other staff in the office. My goodness, I wouldn’t want to get up and walk down the hall to talk to someone face to face. When I leave one office to go to another, it is a car ride and not a walk. One of my jobs is quite sedentary, mostly meetings, phone calls, and consultative work. Yet I sometimes come home feeling exhausted after a long day and comment to the wife, “I’m beat. Think I’ll talk it easy tonight and go to bed early.” That usually means the news or sports on TV or good book.

We have it pretty good in America. As a country, we are considered rich. Incomes are high compared to the world average and food prices are low. Rich countries tend to have more sedentary jobs than do poorer countries and are fatter on average. For years, economists have pointed out the decline in agricultural and manufacturing related jobs in America. We have moved to a more technology and communication focus in our job market, jobs that are typically more sedentary. It is interesting to note that studies have shown that being in a sedentary occupation for a year leads to a small increase in weight. Continuing in that occupation for greater than 10 years is associated with a significant increase in weight.

Exercise is not just about burning calories and helping people keep their weight under control. Everybody knows that regular exercise is good for your overall health. People who exercise on a regular basis outlive those who do not.

Benefits of regular physical activity
Heart benefits
Improved conditioning – better stamina
Improved strength and balance
Improved blood cholesterol levels (lipid values)
Improved sense of well-being
Increase self-confident
May help relieve symptoms of depression
Associated with a greater likelihood that any weight loss achieved will be a maintained weight loss

I remember a discussion I had with a friend about one of the many articles that described this phenomenon of greater longevity in active individuals. I had just read a New England Journal of Medicine article that concluded that “taking up vigorous exercise adds about 10 months” to your life. My friend jogs regularly, spending up to 10 hours per week on the activity. The 10 hours includes the time to change, job, shower, and dress again. We then did the calculations. Ten hours a week for a year is 520 hours or 21 and 2/3 days a year. So in 20 years, he’ll spend 14 months worth of time to gain the 10 months. The joke was that if you jog enough, you will live long enough to make up for the time you spent jogging.

That, of course, is a cynical way of evaluating the benefits of exericse. That same study showed that those who engaged in moderately vigorous activity had a substantial reduction in mortality from all cause (23% reduction) and far less heart disease (41% reduction). So you can’t just focus on the time it takes to exercise or longivity alone. Think of what it is like to live with heart disease for several years. It is severely limiting to people and nothing spoils those “golden years” like poor health. Many other studies demonstate that regular exercise can lower blood pressure, improve blood sugar control in patients with diabetes, help prevent bone loss in people prone to osteoporosis, help relieve constipation, raise the good HDL-cholesterol, and greatly assist people in managing their weight. People who are fit are less likely to fall and less prone to accidents.

And the other major bonus is how it makes you feel. My friend is happier when he jogs. After his workout, he is energized and feels more alert. It gives him self-confidence. For many people, the time to exercise becomes a time to look forward to. When you exercise, you are taking care of yourself. Many find it can relieve stress, allows time to plan and think through problems. Other use the exercise time to relax the mind. This is what is meant when people say that regular exercise can impart a sense of well-being and improve the quality of your life.

Yet most of us get far less exercise than we should and many of us get no exercise at all. Recenlty, the United States Department of Health and Human Services published a report entitled “Healthy People 2010” that outlined health goals for Americans. The report notes that only about 23 percent of adults in the United States report regular, vigorous physical activity that involves large muscle groups in dynamic movement for 20 minutes or longer 3 or more days per week. Only 15 percent of adults report physical activity for 5 or more days per week for 30 minutes or longer. Forty percent do not participate in any regular physical activity. The goal of the report is to reduce this number of inactive Americans by 20%. That shouldn’t be hard to accomplish, right? Wouldn’t seem that way, but Americans are just not that enthusiatic about exercise. Although participation in regular activity did increase from 1960 to the early 1980s, there has been little change in the level of participation over the last several years.

Why don’t people exercise? A lack of time is the most common reason people give when asked. An injury is the main reason people give for stopping. Smokers are slightly less likely to exercise and more likely to drop our of exercise programs. People who are overweight are less likely to exercise. Men are more likely than women to engage in regular activity and in sports. Physical activity declines continuously as age increases. Minority populations are less active than white Americans are and this trend is more pronounced in minority females. Better educated Americans exercise more than people with less education. Lack of role models among families and friends, bad weather, an unsafe neighborhood and lack of appropriate facilities – parks, bicycle, and walking paths, etc – also contribute to an inactive lifestyle.

Can you find yourself in the paragraph? Can you find enough excuses to keep your butt on the couch? Gee, I’m older, belong to a minority group, and don’t have a park within 5 miles. This book is about the truth so you are not getting off this easy. Most people could engage in some increased activity if they wanted to. They choose not to. There is time in the day to choose to be more active.

Some people don’t exercise because they think they have to really work at it to reap any health benefit - the “no pain, no gain” philosophy. It is true that enjoyment of activity is highly correlated with participation. In other words, if you dislike panting, heavy sweating, and sore muscles, you are less likely to pursue any activity that could lead to that physical state. Not too surprising. What some people really want to know when they ask me about exercise but are afraid to ask is - Tell me the minimum I need to do.

Studies have been done that demonstrate the health benefits of moderate-intensity physical activity. People who expend about 200 calories per day engaged in a moderate level of activity can expect most of the same health benefits as those who pursue the “no pain, no gain” approach.

So what is moderate activity? Examples include walking at a pace of 3-4 miles/hour, cycling for pleasure, racket sports, table tennis, golf (when you pull the clubs or carry them), leisurely canoeing, moving the lawn with a power mover, home painting, and home cleaning. Generally, about 30 minutes of these activities will burn about 200 calories. And you don’t have to get the whole 30 minutes all at one time. Intermittent activity has also been shown to confer substantial health benefits. So you can grab 10-15 minutes at a time doing calisthenics, or pedaling a stationary bike and work toward your 30 minute total for the day. If you do pursue lower-intensity activities – “light” exercise – you should do them more often, and for longer than 30 minutes per day.

Since most of us do not currently get the exercise we should, begin by incorporating a few minutes of increased activity into your day. Gradually build up to 30 minutes per day of added moderate-intensity activity. This recommendation is different than some of the advice you might have been given in the past. Physicians or other health professionals may have advised 20-60 minutes of moderate to high intensity aerobic exercise three times a week. The change in emphasize is based on research demonstrating health benefits accrue in approximate proportion to the total amount of activity performed. So you goal can be 60 minutes 3 times a week or 15 minutes 12 times a week. Same time – roughly same health benefit. So frequent smaller doses can reduce your risk of chronic disease and improve quality of life to the same degree.

For most obese folks, start slowly, and gradually increase the intensity of the activity. As I emphasized above, you don’t have to do your 30 minutes all at one time. It can be done intermittently over the day – three 10-minute episodes. Try being less efficient. You read that correctly – less efficient.

Be less efficient
Park further from the door at work, when you go shopping – force yourself to walk further
Use the stairs instead of the elevator
Quit using the remote
Move the phone across the room
You go out and get the paper instead of the dog.


You may find that it is easier to build the 30 minutes into your daily routine than it is to set aside time for exercise. In other words, walking to the bank when you had to go the bank anyway may be easier for you to do than joining a health club and going their for a 30 minute work-out.

How does all this work into your calorie equation? Remember the 100 calories = 10 to 11 pounds in a year rule. If you add 100 calories of exercise of activity to your day, continue to eat the same, you can lose 10-11 pounds in the next year. 200 calories of new activity per day = 20 to 22 pounds.

Walking is a great initial activity. As a general rule, on a flat surface, a 150-pound person will expend about 100 calories when walking a mile. A bigger person will expend more calories because it takes more energy to move a larger mass. You can calculate how many calories you will expend in walking a mile with the following simple equation:

Your weight x 100 calories = number of calories you will expend per mile
150 lbs.


For example, if you weigh 200 pounds; 200 divided by 150 is 1.33 times 100 = 133 calories. If you walk up hill, you will expend more calories than this amount; down hill – less.

Now remember that 3500 calories = 1 pound rule. To lose one pound at 200 pounds you would need to walk 3500/133 or 26 miles! That is a lot. You can see why it is important to understand calories. You might go out for a 1-mile walk and think you can reward yourself with a sandwich, right? Wrong! You would gain weight if you did that.

Most health professionals working with obese patients recommend that you expend about 2000 calories a week in activities or exercise. This will help you lose an additional ½ to 2/3 of a pound per week. More importantly, it is the level of exercise or activity that has been shown to improve how the heart functions and will contribute to other health benefits.

A simple way to start a walking program is to get in the car and map out a 1 or 2 mile route with the odometer. At a good walking pace, you will eventually be able to walk a mile in about 20 minutes. Start with 5 minutes out and 5 minutes back. After a few days, when this is comfortable for you, add another minute; 6 out, 6 back. Keep doing this until to get to 10 minutes out, 10 minutes back. You should be able to do close to a mile within this time period as your conditioning improves and your weight comes down. Then work up to 20 minutes out, 20 minutes back if you want to.

The use of a pedometer may be motivational and useful for you. A pedometer is a device that counts steps when you walk. They have gotten pretty popular recently with several group, organizations, and even states advocating 10,000 Step Programs. Simply put, these are programs that suggest you strive for 10,000 steps a day. Since 2500 steps is about a mile for most of us, that would be the equivalent of 4 miles of walking per day.

Pedometers are interesting and can teach you a little about your usual level of activity. Leonardo da Vinci invented the pedometer. Thomas Jefferson gave one to James Madison as a gift in the late 1800s. They have changed some since Jefferson’s time. Most of the current models are electronic and some can even be linked to the Global Positioning Service (GPS). If you do link to GPS, you can know exactly where you are in the world to within three feet. I can’t see myself needing that service but I leave that up to you. Some models will even talk back to you or play music while you walk.

The one I use is pretty basic. It tells me steps, converts that to miles, and estimates my calorie expenditure. Remember these devices count steps. The calculations used to convert to miles and calories are just estimates and may be a little off. Don’t get hung up on a different between your car odometer and the pedometer. You place a pedometer at the waist, close to the hip bone for best results. It works best for walking. With running, stride length can vary and the conversion to distance could be off quite a bit.

When I first started wearing the pedometer, I was surprised by the amount of walking I did. Up and down the halls in the office, from room to room to see patients, off to a meeting, etc. The pedometer would often record 4000-5000 steps during a typical office day. However, I have other days when I’m writing, reviewing protocols or other administrative tasks and the device will record less than 3000 steps. This kind of awareness can help you adjust your calorie intake to the kind of day you are having. It also tells me when I need to spend a little more time on the treadmill or some other activity.

I have discussed recommendations and health benefits relating to endurance exercise, but don’t overlook two other important components of fitness, namely flexibility and strength.

Chapter 3: Obesity - Putting Your Calorie Equation to Work

Chapter 3: Obesity - Putting Your Calorie Equation to Work

If you don’t understand and manage your Calorie Equation, you will not be managing your weight.

We have now learned a great deal about metabolism. Time to develop your Calorie Equation. The Calorie Equation is based, of course, on the principles discussed in Chapter 2 but I want you to actualize it – apply it daily to your life. Take the numbers and turn them into foods, choices of foods, portion sizes, and activities.

Your Calorie Equation and how you make it work for you can be highly personalized. You may, as many of my patients do, work your Calorie Equation on a weekly basis. For example, you might prefer to start the week with 10,500 calories in your “bank”, rather than 1500 calories per day. Few people eat the same number of calories daily so why develop a plan that is more difficult to use. A weekly Calorie Equation allows greater flexibility in number of calories consumed each day and addresses the reality that activities, or the opportunity to engage in activities, can vary depending on the day of week.

A weekly Calorie Equation allows you to apply the Fixed-Free Plan. We will discuss this Plan in more detail later in this chapter. In simple terms, you set up a calorie plan that is based on a portion that is “fixed” – for example, a well-defined 1000 calories, and another portion that is “free” – for example, 500 calories – on a 1500 per day or 10,500 calorie per week Calorie Equation. If you eat the fixed calories for 3 days, you have saved up 1500 calories to be added to the remaining 4 days. This is a very useful strategy and will be emphasized in several other postings.

From the knowledge you gained from Chapter 2, you can calculate your energy requirments. If you have had your resting energy expenditure (REE) measured you can use that to construct your energy equation. If not,use the REE formula provided in Chapter 2 or use the factor method.

Remember some of the key Tips and Tools from Chapter 2

3500 Calories = 1 pound of fat
100 less calories a day is about 11 pounds lost in 1 year

And for a sedentary individual
Current calorie intake = REE x 1.3
OR
Current calorie intake = your weight x 9-11 if female, 10-12 if male (use the lowest factor if you are greater than 300 pounds)

Given the number of variables that effect metabolism as discussed in the prior chapter, you understand that “current calorie intake” is an estimate. You can refine it further as you track you calorie intake and expenditure against the weight you lose.

Let’s use an example to see how to set up a Calorie Equation. In this example, we will deal primarily with calories expended and food calories consumed. I will show you how to work activity or exercise calories into your Calorie Equation when we deal with the issue in the Exercise Chapter. The individual in our example is Jean.

First, Jean decides which method she would like to use to determine her average total energy expenditure. She decides to use the REE method. Jean is a 40 year old 5’6” female that weighs 232 pounds. She looks up her uncorrected-for-age REE on a Mifflin-St Jeor chart and reads off 1968 calories. Since she is 40, she multiplies that times 5 (40x5=200) and substract that from her uncorrected REE; 1968-200 = 1768. The REE needs to be multipled by 1.3 to yield her average total energy expenditure assuming an “average” sedentary lifestyle. Therefore, her average daily energy expenditure is 1768 x 1.3 = 2,298 caloires.

As I stressed in Chapter 2, these are estimates so don’t get wrapped up in decimal points and don’t be afraid to round off these numbers. So let’s call 2,298 calories the same as 2,300 to make it an easy number to work with in subsequent calculations.

Jean is now ready to consider a weight loss goal. She decides that 1 pound each week is reasonable for her. Since 3,500 calories = 1 pound, she would have to knock off 500 calories a day for 1 week to realize 3,500 calories (500 x 7 = 3,500) or consume, on average 1800 calories per day. Using the weekly Calorie Equation concept, she would normally need 16,100 calories (2,300 x7) to maintain her current weight of 232 pounds. To lose 1 pound a week, she would need to consume 12,600 calories per week.

If Jean decided on 2 pounds a week, she would need to cut her intake by on average of 1000 calories per day (1000 x 7 – 7000 calories divided by 3500 calories/pound = 2). She would, therefore, be eating just 1300 calories per day or 9,100 calories per week. That is a fairly restricted calorie intake.

Now, you hear stories or testimonials from some people advertising various diets claiming that they followed the diet and lost 5-10 pounds in the first week. In fact, some will even attach a money back guarantee to the diet. If you don’t lose the 5-10 pounds, you can get a full refund. Can you eat and lose this kind of weight in a week? Can that happen? Well, you do the math and tell me what you think.

Take the example of Jean. We have already determined that she needs 16,100 calories to maintain her weight of 232 pounds. A 10 pounds weight loss represents 35,000 calories.
16,100 calories – 35,000 calories is equal to a minus 18,900-calorie deficit for the week or a minus 2,700 calories per day. Would that be possible? In other words, she would need to eat no food at all and burn up 2700 calories a day in exercise (that is roughly 17 and ½ miles of walking a day) in order to achieve this 10 pound weight loss.

So what do you think? Do you think Jean can pick up the latest fad diet, eat it, and also realize a 10 pounds weight loss? I think a refund is in order.

But some people do lose quite a few pounds more than predicted in the early days of highly restricted diets. Where does that come from? It is water. Assuming someone is not using laxatives or diuretics to artificially pull water out of the body, there is a natural water loss that occurs when anyone starts dieting. Carbohydrates are stored with water in the muscles and liver. With depletion of these stores, the water is mobilized. As weight is lost, wastes that require excretion by the kidneys increase. This requires to kidneys to excrete more water as well. Ketones are an example of a by-product of fat metabolism that can increase with weight loss and require excretion by the kidney. The extent these ketones increase is related to the degree of carbohydrate restriction and level of calorie intake. The ketones are excreted as salts, pulling sodium, potassium and water out with them. Also, water intake often goes down when people start dieting unless they make a conscious effort to drink more water. Normally, about ½ of our water intake is derived from food. Milk has a water content of 87%. Fresh carrots are 88% water. Many solid foods contain very significant amounts of water. Whole wheat bread, for example, is 35% water.

There is also the usual water loss that occurs through urination, perspiration, bowel movements and breathing. Every time you breath out, for example, you lose water vapor, adding up to one or two glasses a day. Even if you're not dieting and pursuing the usual sedentary lifestyle, your body loses up to 80 ounces of water a day. That is why experts often talk about 6 eight-ounce glasses of water a day. Combined with the water in food, this will give you the water intake you need to stay in balance.

When you diet, particularly if the calorie restriction is aggressive, drinking 6 twelve ounce glasses of water a day may be necessary to keep up with the water losses that can occur. Of course, many of us in American drink almost anything but water – coffee, diet sodas, juices, a variety of non-caloric flavored beverages. These all count toward your total fluid intake as well. Water, frankly, is cheaper and better for you. Caffeine, by the way, is a mild diuretic and can actually enhance water loss.

So back to Jean and the fad diet resulting in the loss of 10 pounds of weight loss in just one week. Yes, it could happen. If she starved, ate absolutely nothing, we could account for 16,100 (Jean’s calorie requirement for the week) divided by 3,500 calories, or 4.6 pounds of real weight loss. The rest - 10 pounds minus 4.6 or 5.4 pounds - can be explained by water loss and dehydration. Jean would be feeling pretty lousy with her 10-pound weight loss. As soon as the fluids were replenished she would gain back that 5.4 pounds of weight in water.

Now, let’s return to Jean’s original Calorie Equation calculated using the REE charts or formula. If she had used the factor method, she would have come up with a very similar result. Her weight (232 lbs) times a factor of 10 is about 2300 calories as well. Again, these are estimates. You can re-determine your Calorie Equation as you track you calorie intake and expenditure against the weight you lose.



In order to put your Calorie Equation to work, you will need to learn about food. At first, these will seem complicated but it will become easier over time. If you follow the suggestion of Chapter 4 What Calories Do I Eat, it will become much easier since you will be consuming a lot of low calorie foods where portion size and caloric content are not as critical.

Numerous studies have shown that people do not estimate either portion sizes or calorie content in foods accurately. The problem is made worse by misinformation and misleading advertising about foods. It is extremely important for anyone who is serious about losing weight and keeping it off to become very familiar with the calorie content in foods and be good at estimating portion sizes. The Table provides a few suggestions that may help you estimate portion sizes. Better yet, use a food scale and measure exactly what you are eating, at least until you are confident you are a pretty good “estimator”.

Portion sizes

Help to assist you in estimating portion sizes


Your fist equals 1 cup or 1 medium whole fruit

Your thumb equals 1 ounce of meat or cheese

Your thumb tip equals 1 tablespoon of anything

Your fingertip equals 1 teaspoon of anything

Your cupped hand holds 1 or 2 ounces of pretzels, nuts, popcorn, or beans

Your palm equals 3 ounces of cooked poultry, fish, or meat
(minus your fingers)

Common measures and Equivalents

Fluids:
1 cup = 8 ounces
1 ounce = 2 tablespoons

Dry and fluid foods:
1 cup = 16 tablespoons
1 tablespoon = 3 teaspoons
1 ounce = 30 grams

Always use a standard measuring cup to measure the amounts you list in your calorie record.

Abbreviations:

Tablespoon = Tbsp or T
Teaspoon = tsp. or t
Ounce = oz
Cup = C
Slice = sl
Grams = g


In fact, the following are what I would call the essential tools for anyone who is serious about losing weight and keeping it off:

Essential tools

Calorie book
Food scale
Calorie record book

When you eat, guess the portion size, and then find out the true portion size by placing the food in a measuring cup or on a food scale. Look up the calorie amount. Write it down. See the chart below for guidelines on how to record food in your record.

Guidelines for recording foods in your food record

For mixed dishes prepared at home, record approximate amounts of the main ingredients eaten.

Example: For beef-noodle casserole, record –
2 ox beef
½ C noodles
2 T mushroom soup

For sandwiches, list the ingredients separately.

Example: instead of recording “ham sandwich” list as follows:
Bread, whole wheat 2 slices
Ham 2 oz
Lettuce 1 leaf
Mayonnaise 1 tsp.

Do not forget to list the following:

Spreads used on bread, rolls, potatoes, etc
Jams, jellies, preserves
Salad dressings
Sugar and “cream” in coffee
Milk and sugar on cereal
Fats and oils used in cooking
Snacks – candy, nuts, chips, popcorn
Soft drinks
Alcoholic beverages

Developing a skill around estimating calorie values is extremely important for long-term success. With the ever-changing food supply, in terms of preparation, portion size and packaging, this is on going project for the weight conscious individual. The chart of calorie values provides some estimates to help give you the idea but a variety of good calorie books are available to give you more precise values.

Calorie Values in Foods

There are many good calorie books available which can give you fairly exact calorie values for foods.

The foods listed in each group below are just examples with estimates of calorie values. Many other foods can be part of your daily meal plan.

Starch/Bread

Each of these equals one starch/bread choice (about 80 calories)

½ cup pasta or barley
1/3 cup rice or cooked dried beans and peas
1 small potato (or ½ cup mashed)
½ cup starchy vegetables
(corn, peas, or winter squash)
1 slice bread or 1 roll
½ English muffin, bagel, or hamburger/hot dog bun
½ cup cooked cereal
¾ cup dry cereal, unsweetened
4-6 crackers
3 cups popcorn, unbuttered, not cooked in oil


Vegetables

Each of these equals one vegetable choice (about 25 calories)

½ cup cooked vegetable
1 cup raw vegetables
½ cup tomato/vegetable juice

Milk

Each of these equals one milk choice. The calories vary for each choice.

1 cup skim milk (90 calories)
1 cup lowfat milk (120 calories)
1 cup whole milk (150 calories)
8 ounce carton plain lowfat yogurt (120 calories)

Meat and Substitutes

Each of these equals one meat choice (about 75 calories)

1 oz cooked poultry, fish, or meat
¼ cup cottage cheese
¼ cup salmon or tuna, water packed
1 tbsp. peanut butter
1 egg
1 oz. Low-fat cheese, such as Mozzarella, ricotta

Each of these equals 2 meat choices (about 150 calories)

1 small chicken leg of thigh
½ cup cottage cheese or tuna

Each of these equals 3 meat choices (about 225 calories)

1 small pork chop
1 small hamburger
cooked meat, about the size of deck of cards
½ of a whole chicken breast
1 medium fish filet

Fruit

Each of these equals one fruit choice (about 60 calories)

1 fresh medium fruit
1 cup berries or melon
½ cup canned in juice or without sugar
½ cup fruit juice
¼ cup dried fruit

Fat

Each of these equals one fat choice (about 45 calories)

1 teaspoon margarine, oil, mayonnaise
2 teaspoons diet margarine or diet mayonnaise
1 tablespoon salad dressing
2 tablespoons reduced-calorie salad dressing


Now, lets us assume you are female with weight 200 pounds. You have decided your factor is 10. You estimate that it requires 2000 calories to maintain your weight. You would like to lose 1 pound a week. You will need to drop 3500 calories per week since 1 pound equals 3500 calories. You, therefore, want to average intake of 1500 calories per day in the absence of any major new activity or exercise program.

So, if you are on a 1500-calorie diet plan, you have 1500 calories to “spend” each day. Think of these calories as your budget for the day. How do you want to spend them? You should be thinking a good nutrition with a variety of fruits and vegetables, but you also want to save up a little for a treat now and then. Remember, there are no forbidden foods, only calories.

Just today, I was scouting out some investment property with a friend and we stopped at Subway for lunch. My friend has diabetes, takes one medication to help control the blood sugar, and is overweight. He is constantly asking me about the latest diet fad or gimmick. In fact, on the nearly 1 and ½ hour drive to our destination, I was peppered with all kinds of questions ranging from the Atkin’s diet to a “new” product (a pill) guaranteed to enhance the metabolic rate and let you lose weight while you sleep.

I let him order first. He chose a 6-inch steak and cheese sandwich with chips and a diet drink. I then suggested he consider a selection from the “6 grams of fat” column of sandwiches and drop the chips. “Boy”, you are saying about now, “glad I don’t have a friend like that!” Normally, I’m not this obnoxious but he had been directing the conversation around this topic for the last hour so I felt it was reasonable for me to make this suggestion. He then chose the 6-inch turkey breast and decided he didn’t need the chips.

Now examine the calorie values:

6 inch steak and cheese sandwich = 390 calories
Bag of chips = 150 calories
Total calories 540 calories

6 inch turkey breast sandwich = 280 calories

The difference is 260 calories.

I then pointed out to him that a different choice like this one, done on a daily basis for 1 year would result in a 27 pound weight loss, just short of the 30 pounds that he would like to lose.

Now making this choice wasn’t necessarily easy because my friend enjoys steak and cheese sandwiches. However, it was made easier by examining the calorie values and the implications of the choice. What if his calorie equation called for 1500 calories a day? He now has 1500 – 280 for the turkey sandwich = 1220 calories left to spend for the day. On the other hand, if he really wanted the steak and cheese sandwich and chips, he would have 1500 – 540 = 960 calories left to spend for the day.

See, part of the choice should be based on what you want to eat later that day as well. My choice of sandwich was partly based on the fact that we have an office party to attend later this evening. That is going to mean more eating than usual because of the host of hor'dourves, drinks and main courses we will find there.

This brings up another issue. It is extremely hard to eat 1500 calories every day. What usually happens is one is quite good for a few days, averaging 1500 calories per day, when the “event” occurs – the Christmas party, someone comes to visit, the graduation party, etc. We then forget the 1500-calorie equation and overeat, often totally unaware of how many extra calories were consumed, then go back to the 1500-calorie plan. Well, the extra 1000-2000 calories consumed wipes out several days of hard work. I then hear the lament - “I tried 1500 calories and it didn’t work”

That is why a Fixed-Free Plan to the calorie equation is often useful. In essence, you should be thinking about a weekly calorie equation rather than a daily equation. For example, if you are trying to stick to a 1500 calorie a day plan, think of it as 1500 x 7 days or 10,500 calories per week.

To apply the Fixed-Free Plan, you decide how much of the 1500 will be fixed and how much free. Let’s choose 1200 to be fixed and 300 free. You then devise a fixed daily menu that is about 1200 calories. This should be rather straightforward and uncomplicated. For example, you might choose to have a simple breakfast of 250 calories, salad and sandwich lunch of 350 calories, and a prepackaged Health Choice Chicken Parmigiana dinner with bread and extra vegetables (about 500 calories) with a evening snack of popcorn or something else worth about 100 calories. Total 1200 calories.

You eat pretty much the same thing except for different prepackaged entrees for 3 days saving up 300 x 3 days of 900 calories on your Fixed-Free Plan. Therefore, on the 4th day, you have your 1500 calories to spend plus the 900 free you have “banked” for a total of 2400 calories. Now when the special event comes up, you can overeat and still be sticking to your 1500 average calorie /day intake.

Behaviorally, this is a good approach as well because it starts to develop the habit of eating less so you can overeat. In other words, overeating is part of life – it doesn’t go away just because you are now lean. The difference is that you now overeat with full-awareness of the calories involved and no longer feel guilty about overeating because you have planned for it, staying within the calorie equation you have devised for yourself.

I recently read an article directed at the female reader entitled “Tips to get your figure back”. The first tip was wear jeans. According to the article, there is no reality check like putting on a pair of jeans. The article went on to say that you will always know if your weight is going up or down if you wear this “good” pair of jeans once every week. That is ridiculous. Get on the scale to check your weight and know your calorie equation. Then you can replace the jeans with a smaller size if you want. My son, on the other hands, wants his jeans as baggy as they can be and still hang-on. I can’t figure this jean thing out.


Calorie Equation

Tips and Tools

1. Determine the number of calories you require per week to maintain your wieght
2. Set a wieght loss goal in pounds per week
3. Use your CalorieEquation to determine the calorie intake required to achieve this goal on a daily basis and a weekly basis.
4. Use a weekly Calorie Equation to allow some flexibility in calorie intake and activities.
5. Consider using the Fixed-Free Plan to better define the flexibility you want during your week and help you stay within your Calorie Equation.
6. Purchase a calorie book(s) and food scale.
7. Maintain a food record
8. Remember to drink adequate amounts of water on a daily basis.
9. There are no forbidden foods (mostly true), just calories.

Chapter 2 Obesity: The Basics of Your Metabolism

Chapter 2: Obesity – The Basics on Your Metabolism

Human metabolism is complex but there are basic truths that apply to all of us. Dramatic changes in metabolism are rarely the root cause of obesity in humans.


In the last few months, I have heard all these statements from patients. Over the last 20 years, I have heard them over and over again.

“I hardly eat anything and still can’t lose weight”

“I eat much less than my husband and he is 300 pounds” (from a 175 female)

“I was on Weight Watchers for 12 weeks and didn’t lose a pound”.

“I know what I eat and heard all this stuff before. I want to know the real reason I can’t lose weight”.

“My metabolism is very slow. I can eat less than 1000 calories a day and still gain weight”.

“I know my thyroid tests are normal but there has to be an explanation for why I can’t lose weight”.

It isn’t easy to lose weight. Obviously, if losing weight was easy, we wouldn’t have the huge problem with obesity that we have in this country. And because it is difficult to accomplish, we have all the hype surrounding weight loss. There are plenty of opportunities for people purchase the new “solution” or “miracle” in weight loss management. I am very empathetic to the difficulties of losing weight and the medical, social, psychological, and economic consequences obesity can have for people. I admit, however, that I get frustrated with the shortcuts that people want to take to deal with this important problem.

As an Endocrinologist, I have treated hundreds of patients with diabetes over the years. When a person develops diabetes, we strive to help that individual acquire the knowledge and skills necessary for them to become effective in self-management or their disease. Estimates vary, but most experts agree that the time required to provide just basic instruction (so-called survival skills) to a patient with newly diagnosed diabetes is between 15-20 hours. There is then a need for additional learning and support as the patient embarks on a new life with diabetes, facing new issues and circumstances sometimes on a daily basis. Guidance from trained health professionals, learning, and self-management are lifelong requirements of good diabetes care.

The first session in diabetes education is usally “What is diabetes?” Very basic information is provided about how insulin works in the body, why the blood sugar goes up. In short, it is necessary for the person with diabetes to understand some concepts about human physiology. Time to go to school again and learn some facts about how the body works.

The approach I have taken toward obesity is much the same. The individual with a weight problem has to go back to school and learn some basic physiology. How does the body store energy? What determines our metabolic rate? What is obesity? How did this happen to me?

Yes, human physiology is complex but there are some basic principles that anyone can understand and apply. In fact, many of my patients with diabetes have become experts with knowledge and skills far beyond mine when it comes to applying what they have learned through experience with their disease. I recall three teenagers with diabetes that wanted to compete in the triathlon. There are different types of triathlons but the type they were interested in was an Ironman triathon. The Ironman is a 2.4-mile swim, 112-mile bike ride and 26.2-mile run. Seems impossible, doesn’t it. These boys started training together and would carefully monitor their blood sugars, calories consumed, insulin taken and report to me the results. They figured out, among many things, how long they could bike without extra food and how much insulin to take prior to workouts. They taught me how that kind of training effected diabetes management. Besides that, those kids were incredibly inspiring!

Likewise, many of individuals I have helped to lose weight over the years have learned a great deal and can share those learning with me and other individuals trying to master the problem. That is one of the reasons group visits or sessions are so beneficial in the management of chronic conditions like diabetes and obesity. It provides the opportunity for people to learn from each other.

The point is that weight management starts with the basics. Apply the basic principles regarding metabolism. You can then develop your Calorie Equation. This is where it all must start. If you are unwilling to learn these basic principles or refuse to believe them, forget about losing weight. You may lose a few pounds in the short term but you wouldn’t keep it off. You will be setting yourself up for yet one more diet failure. Learn these principles and apply them and you will be laying the groundwork for lifelong weight control.

In the simpliest terms, if you are maintaining your weight, the energy equation can be written as:

Energy in = Energy out

At energy balance, energy intake must equal energy expenditure. For you physic buffs, this is so because human metabolism must adhere to the the first law of thermodynamics, like the rest of nature. That law states that energy is neither created nor destroyed.

The “Calorie”, of course, is the measure of energy expenditure we use in the field of human metabolism. It is technically a unit of heat. For our purposes, the exact definition is not important and I will be using the big C – Calorie and small c –calorie interchangeably in this blog. Again, physics buffs know the different but how many physics buffs are there anyway?

So at weight maintenance, we can rewrite the equation as follows:

Calorie in = Calories out

To lose weight, one must consume fewer calories and/or use more calories through physical activity than are required to maintain that weight. In other words, if you are maintaining your weight, you have an equation that is in balance.

Current Weight (W) = Food (F) calories - Calories burned with
Activities (A)
OR

W = F – A

In other words, if you want to lose weight, you have to consume less food or be more active. Da!! I’m sure you have heard this before but the truth of this equation doesn’t “grab” you. How do I make this equation “actionable”, something you can apply to your weight loss and maintenance plan and use on a daily basis?

In order to develop a few rules that you can trust and then use them to help you lose weight, I have to explain a few principles that will be, at first, a little complicated. We have to dig deeper and learn the facts about our metabolism.

In many books, there is a mystique created around the word metabolism. Just think of all the products that boost that they can speed up your metabolism. Some go so far as they claim they specifically burn fat, or can help you lose weight while you sleep. The latter claim really isn’t that bad since, unless you are dead, you are still burning calories during sleep. So everyone is “losing weight” while they sleep. However, to claim you can lose more during sleep through some artificial means of accelerating your metabolism is a stretch for most of these products. There are a few substances that do speed up the metabolism and we will get to them later in this blog.

Let’s start with a few definitions.

Total energy expenditure (TEE) is the total amount of energy expended in a 24-hour period.

Basal metabolic rate (BMR) is energy expended to maintain vital functions (keep you alive).

Resting energy expenditure (REE) is the energy consumed by a resting individual after an overnight fast in a comfortable environment.

Thermic effect of food (TEF) also called diet –induced thermogenesis is the energy expended to metabolize a meal.

Activity expenditure is the energy expended with any activity or exercise.

Let’s expand on these definitions. Basal metabolic rate (BMR) or basal energy expenditure (BEE) is, as the definition implies, the amount of energy needed to keep you alive with all body parts working. It is not practical to measure and has been replaced by RMR. They aren’t the same. REE is measured after the person wakes up, usually after going to the lab and resting there for 30 minutes or so, prior to the measurement. Because of the extra activity, REE is going to be about 10% higher than BEE. REE accounts for about 70% of our energy expenditure.

TEF is a reflection of the energy consumed during metabolism of foods. One can think of it as the energy required to absorb the food, move it around the body, transform it to into energy or convert it to a form that can be stored for later use. It should make sense that there is an energy cost to digesting and storing food within the body.

For example, we can’t ingest 100 calories of food and put 100 calories in storage within the body. There is a cost in energy from your mouth to the storage site within the body. This is a complicated area of metabolism since the energy cost for carbohydrates, fats, and proteins differ. Furthermore, the TEF differs under conditions of underfeeding, overfeeding, stress, or illness. However, TEF is considered to contribute only approximately 5-10% of TEE. Since this is a relatively small part of TEE, the variables associated with composition of the diet and situation are not going to play a major role in your response to calorie restriction or success in achieving a more ideal weight.

Activity simply refers to the amount of energy expended with activity that we will cover in an exercise posting . This is the second largest component of the TEE and is the most variable. As I will point out later, the variability is not just related to whether or not you are avid exerciser or not. Activity energy expenditure also takes into account spontaneous body movements like fidgeting, moving your arms when you talk, etc.
As you study groups of individuals, this spontaneous activity can account for 100 to 800 calories of energy expenditure a day. I will tell you more about this when I tell you about the “fidgeting diet” later..

The chart below shows you graphically the components of TEE.

Now, no one can be at their REE all day long. You have got to get up and move about in this world to get your work and play done. For our purposes here, it is a fair approximation that the usual sedentary American will need about 1.3 times REE to maintain his or her weight at that sedentary lifestyle. This is important so let me highlight it.


Weight maitenance = REE x 1.3


This includes the calories burned with the usual 8 to 5 desk job and all the morning preparation of getting ready for work, getting to work and back, and spending most of the evening on the couch prior to bedtime.

So in summary, we have TEE = REE + TEF + Activity.

In the sedentary adult, the REE is the major contributor, and predictor, of how many calories you need to maintain your weight. When measured, it sums the energy expenditure from the entire body. Thinking in broad terms, we are a combination fat mass and fat-free mass making up the two major “compartments” in our body. The fat mass is what we would like to keep under control. Some of us are 15-20% fat. Others, with weight problems, can be 40-50% fat. Fat tissue is not as metabolically active as fat-free tissue, such as muscle and your organs. In fact, organs are many times more metabolically active than muscle when you are at rest. It makes sense, therefore, that, as you become proportionally fatter as a percent of body weight that your metabolic rate will be lower per a representative pound of you than someone who is leaner. In other words, your REE may be lower per pound than a leaner fit individual.

Can you measure energy expenditure? Of course, we can, but until recently it was not practical because the methods to do so were quite expensive and the devices limited to major medical centers or universities.

The methods used to measure energy expenditure are called direct or indirect calorimetry.
The direct method involves measuring the heat released from the body. Indirect calorimetry refers to methods that measure energy expenditure by measuring ventilation and the exchange of oxygen and carbon dioxide by the body. For a variety of technical reasons, the method of indirect calorimetry is the most widely employed.
The most accurate way of assessing REE by indirect calorimetry is the whole room calorimeter. This technique places a person in a closed room that allows energy expenditure to be calculated based on measurements of air samples (indirect calorimetry) obtained from the room. Gas analyzers attached to the unit measure oxygen consumed and carbon dioxide produced. The balance of oxygen consumed and carbon dioxide produced varies according to activity and the utilization of different fuels by the body (carbohydrate, protein and fat). If an individual is moving about the room, and eating, the TEE is measured. If the person is resting, the REE can be measured. By altering the food provided and ingested, this technique can also be used to evaluate the ability of that individual to burn different fuels and measure the differences in the TEF.

Other methods that are quite accurate use a ventilated canopy hood and a so-called metabolic cart. This method also measures a subject’s oxygen consumption and carbon dioxide production to arrive at the resting energy requirement. Although a less complex system than a whole room calorimeter, the equipment is costly and the technique quite labor intensive.

There are now portable devices available that can measure resting metabolic rate fairly accurately. These handheld indirect calorimeters measure oxygen consumption and determine RMR and are being used in many weight management clinics and other health and fitness facilities. Devices include the MedGem made by HealtheTech and ReeVue made by Korr.

An alternative to direct measurement is the use of a predictive equation to determine RMR. Several have been developed with the Harris and Benedict equation one of the most popular. This equation derives from work done in 1919 and many experts in the field have suggested use of the equation should be abandoned in favor of others that have been developed using more modern techniques and subjects more representative of today’s overweight population.

My preference is the Mifflin-St Jeor Equation developed from a study of participants in the RENO Diet-Heart Study done in the early 1990s. As you can tell, it takes into account differences in sex, weight, height, and age to derive the estimate of RMR.
The equation was developed using weight in kilograms (kg), height in centimeters (cm) and age in years (y).

REE (males) = 10 x weight (kg) + 6.25 x height (cm) – 5 x age(y) + 5
REE (females) = 10 x weight (kg) + 6.25 x height (cm) – 5 x age (y) –161

The kilogram (kg) and centimeter (cm) measurement requirements make the formula somewhat difficult for us metric-challenged Americans so tables have been developed to make it easier for readers to find their RMR. (search on Mifflin-St Jeor Equation and you’ll find some calculators)

For those who prefer to do their own calculation, the following equation can be used:

REE (males) = 4.5 x weight (pounds) + 16 x height (inches) – 5 x age(y) + 5
REE (females) = 4.5 x weight (pounds) + 16 x height (inches) – 5 x age (y) –161
So, for example, if you are a 50 year old woman, 5’6” in height or 66 inches and 300 pounds, your estimated REE is:

REE = 4.5 times 300 pounds + 16 times 66 inches – 161
REE = 1350 +1056 - 161
REE = 2245
Now correct for age
REE = 2245 – 5 times age in years
REE = 2245 – 5 times 50 or 250
REE = 1995

REMEMBER:

Weight maitenance = REE x 1.3


Therefore, this 50 year old woman, living an average sedentary lifestyle, would need:

Calories to maintain her 300 pounds = REE x 1.3
= 1995 x 1.3 or 2594 calories

It should be obvious to you from looking at the equation and that chart that REE is closely linked to your weight. It increases with weight gain and decreases with weight loss. There is nobody who weighs 250 pounds who can’t lose weight on less than 1000 calories although I have had patients tell me this is their experience.

Another alternative to direct measurement and predictive equations is a very simple tool we will call “your factor”. The factor is the number that when multiplied by your weight equals the number of calories needed to maintain your weight.

Current weight x (the factor) = number of calories needed to maintain your weight

This equation assumes a sedentary lifestyle as well. You will notice that it does not correct for height or age and, therefore, is not going to be as accurate. In general, a man will require 10-12 times his weight to maintain his weight while living sedentary lifestyle. A woman will require about 9-11 times her weight to maintain her weight. More obese and older individuals have a factor in the lower end of the range. The number will tend to go up a little as you lose weight and do down if you gain weight.

In other words, a 125 pound woman will need about 125 x 11 or 1375 calories a day to maintain her weight. A 300-pound woman will need 9 times her weight 2700 calories a day to maintain her weight. This does not mean the 300-pound woman has a slower metabolism and that is what contributed to the obesity in the first place. Rather, the 300-pound woman has a higher proportion of body fat than the 125-pound woman does. Fat is essentially storage tissue and not very active tissue (doesn’t burn a lot of calories). Lean tissue like muscle is active and burns a lot a calories. The more obese person needs fewer calories per pound because more of the “pounds” are fat.

You will notice that the factor method is a good approximation of the TEE. For example, our 5’6” 300 pound 50 year old female had an estimated TEE using the REE equation of 2594 caloires. Using the factor method and a factor of 9, we arrived at 2700 calories.

In the absence of direct measurements, these calculations are good enough and can get you started on your weight loss program. You can fine tone your Calorie Equation as you monitior you weight loss at a particular calorie intake. If you have doubts, underestimate your estimated TEE by the REE equation or factor method by 10 percent.
For example, rather than “believing” your TEE is 2600 calories each day, recalculate it at 2600 – 10% or 2340 and work with that number. Don’t, however, believe, you TEE is 1200 calories when the calculations tell you it is 2600. It just isn’t so. That kind of “belief” is wrong and will simply perpetuate you weight problem. You have to understand the facts about your metabolism and be realistic. Stop fooling yourself!!

Now we are ready to construct your Calorie Equation. This will become the foundation for you weight management program.

To lose a pound of fat, we have to create a calorie deficit of 3,500 calories since a pound of fat contains 3,500 calories. Now someone reading the posting – that physics buff again - is going to say that isn’t true since a pound is 454 grams and there are 9 calories/gram of fat. Therefore, a pound of fat should contain 4086 calories. Well, that is true. However, fat is 10% water and water has no calories so subtract about 10% from 4086. Also, there is the issue of the TEF or cost of metabolizing fat. A few calories are burning in the process of absorption and digestion within the body. So the 3500 calories per pound of fat is very close.

We will call this the 3500 calories = 1 pound rule. Now let’s use the rule to make a few simple calculations.

How to calculate your weight loss on a particular calorie intake:
If you are a 40 year old woman, 5’6” in height and weigh 200 pounds, you are consuming about 200 x 10 or 2000 calories a day by the factor method or 2074 calories by the REE equation method. Let’s use the 2000 calorie estimate to keep it simple.

There are 3,500 calories in a pound of fat as we just learned. If you want to lose a pound, you need to eat 3,500 calories less than you need. For this woman, eating 1500 calories a day is 500 calories less than she needs to maintain her 200 pounds. If she does this for 7 days (500 calories x 7 = 3500 calories), she would lose a pound.

What if you eat 100 calories more a day for a year? 100 calories x 365 days in a year = 36,500 calories. 36,500 calories divided by 3,500 calories in a pound = about 10 and ½ pounds. In other words, just eating an extra 100 calories a day can cause you to gain 10-11 pounds over a year. On a more positive note, cutting back just 100 calories a day can help you lose 10-11 pounds in a year.

We will call this the 100 calories = 10 to a 11 pounds in a year rule. Think how this rule can help you map out a long-term goal. Say you want to be 30 pounds lighter in a year. You would need to knock off about 300 calories from current lifestyle. You could do this with 200 calories less food and 100 calories more exercise or some other combination of your choosing.

Now you can construct your Calorie Equation. Again, using the example of the 200 pound woman with an estimated current TEE of 2000 calories and assuming no extra activity:


Estimated current TEE 2000 calories
Weight loss goal 1 lb per week
Calorie deficit required 3500 calories (since 1 lb = 3500 calories)
Calorie deficit per day -500
Calorie Equation 2000 – 500 or 1500 caloires/day to realize
Desired weight loss goal


The simple truth is that only calories count. In order to be successful with your weight, you now realize you must have a fundamental understanding about how your metabolism works and how may calories you need to maintain your weight. As I mentioned previously, I often tell patients with weight problems that the requirements for self-management are similar, in principle, to the requirements of for self-management that patients who have with diabetes must learn.

Well, people with weight problems need to understand how their metabolism works and address the calorie requirements of their bodies. The Calorie Equation is the start of the process. Now, you will need to learn calorie values of foods so that you know how many calories you are consuming. As other postings will emphasize, this is not an easy task. It requires some study as you as learn calorie values and practice as you implement that new knowledge on a daily basis. For patients with diabetes, it requires many hours of initial instruction and a lifetime of ongoing monitoring and study to be competent self-managers. I’m not sure I can put a number on the hours you might need to become a competent “weight manager” but I am sure that you can do it if you avoid the hype and concentrate on the facts and practical suggestions contained in these postings.

Earlier in this posting, I alluded to a few things that can speed up your metabolism. There is a lot of hype surrounding some of these products. Don’t buy it.

We have hormones in our systems called catecholamines – epinephrine and norepinephrine. Lay people often refer to these hormones as “ adrenalin”. They are also called our “fight-fright” hormones since increased amounts of them caused the increased heart rate, sweating and that “prepared” feeling that occurs should when we get ready to fight or run from a scary situation. Naturally, such hormones effect metabolism and are associated with the need to divert calories to heat or energy production, a process often referred to as thermogenesis. Many of the products that as associated with claims that they speed up the metabolism are linked to the catecholamine system in our bodies.

Caffeine, contained in our beloved coffee, is a substance that is associated with an increase in the metabolic rate or enhanced thermogenesis. It is also found in tea, colas and chocolate. Caffeine belongs to a group of chemicals called xanthines that include theophylline, a drug some of you may be familiar with since it is used in the treatment of lung diseases like emphysema and asthma. In fact, its official chemical name is trimethylxanthine. Caffeine inhibits different enzymes that are capable of effecting how long the catecholamines are active in your system. In so doing, xanthines like caffeine, stimulate the nervous system and can cause people to feel more alert, less drowsy which is, of course, why we use coffee as our morning “wake-me-up”. However, too much caffeine can be bad for you resulting in restlessness, nervousness, agitation, inability to fall asleep, elevated blood pressure and a rapid heart rate. The effect of caffeine in usual doses on the metabolic rate is quite modest.

Ma Huang, also called ephedra, is a Chinese herb that has been used medicinally in China for more than four millenniums. In 1887, ephedrine was isolated from it, and it was nearly a half-century later before the full medicinal value of ephedrine was realized in the treatment of asthma and other allergic conditions. There is an American species of this herb, but it contains only trace amounts of ephedrine. It nevertheless played a part in folk medicine and was popular among Indians and early settlers who both attested to its health-giving properties. The most common use of the American species was to make a tea given various names including Mormon tea, squaw tea, and cowboy tea. These teas were considered good decongestants, tonics, diuretics, and fever and cold remedies.

Ephedrine is a stimulant and closely related to the naturally occurring catecholamines in our bodies. For that reason, it is associated with a higher rate of metabolism. It has been widely promoted as a substance that can aid weight loss, enhance sports performance, and increase energy. Many products actually promote a combination of ephedra and caffeine.

Unfortunately, ephedra can also be dangerous and could kill you if used inappropriately. Numerous injuries and deaths associated with ephedra have been reported to the Food and Drug Administration (FDA). The FDA has been issuing warning related to ephedra for years. Because ephedra is a central nervous system stimulant, it can cause symptoms of sleeplessness, anxiety, and nervousness if taken in too large quantities. It can act as a heart or cardiac stimulant and be associated with elevations in blood pressure and cardiac arrhythmias (irregular heartbeats). People with heart conditions, high blood pressure, thyroid disease, and diabetes should definitely avoid Ma Huang or ephedra.

In February 2003, the FDA sent more than two dozen warning letters to firms marketing dietary supplements that contain ephedrine alkaloids. They warned them not to make misleading or false claims and proposed a warning label for all ephedra-containing products to highlight the potential for serious and even life-threatening side effects. Despite the FDA’s interest, the market for ephedra remained huge.

All that ended in 2004. On December 30, 2003, Health and Human Services Secretary Tommy Thompson announced a ban on the sale of ephedra. The FDA published a final rule on April 12, 2004, that bans the sale of dietary supplements containing ephedrine alkaloids

Naturally, a legal fight ensued. Some companies stood to lose millions in sales. The legal battle went all the way to the Supreme Court. Recently, the U.S Supreme Court ruled it would not consider an appeal brought by one of the distributor for ephedra-containing products to try an overturn the FDA ruling. Has this stopped the sale of ephedra-containing products? Of course not! Do a simple search on ephedra on the Internet and you will still find plenty of sites promoting and willing to sell you the stuff.

Bitter orange is another substances advertised as a “thermogenic”agent and “metabolic enhancer”. The FDA is taking a close look because it contains synephrine, a stimulant chemically related to ephedra. It is also called citrus aurantium and is found in foods such as orange marmalade. Synephrine is not as potent as ephedra but some extracts are sold that contain fairly high doses and could be harmful. Naturally, the hucksters try to get an edge on one another by combining bitter synephrine with caffeine or green tea extracts that can potentiate the risk.

Green tea and green tea extracts are also taunted as stimulants of the metabolic rate. Green tea contains caffeine but also contains ingredients called catechin polyphenols. These catechins block one of the enzymes (catechol O-methyltransferase) that break down norepinephrine. It sticks around longer, therefore, increasing the amount of calories burned by the body. Naturally, there are people out there who are promoting bottled green tea extract as they the “only clinically proven, ephedra-free diet product that can increase thermogenesis and shift the body's substrate utilization in favor of fat oxidation”.
For $40 dollars a month or more, you can pop these capsules and watch the fat just burn away. Do you really think that will work?

Everyone has heard of CortiSlim, advertised way too much on the radio. The simplistic message is “Stress makes us fat. Stress makes you release cortisol and cortisol stimulates your hunger and makes you fat”. Really?! Look carefully at the label and you will notice CortiSlim contains green tea extract and bitter orange peel extract. Taking these stimulants should relax you and reduce cortisol levels? Again, there are some half-truths in the advertising. Cortisol levels are normal in the blood and urine in people who are obese. However, people who are obese have higher production rates of this hormone. Because they metabolize the extra cortisol that is made at a slightly higher rate as well, the blood levels stay normal. Weight loss lowers these production rates. You don’t need CortiSlim. Prices vary but I noticed one promoter for CortiSlim selling it on the Internet for $50 per bottle containing 60 tablets. The “advanced dose” is 6 tablets per day. Let’s see - $50 every 10 days or over $1800 a year. You probably do need $1800 to use for something worthwhile. And you might be able to get some of the money back now that the Federal Trade Commission has alleged that CortiSlim was advertised with false and unsubstantiated weight loss claims. They also suggested that CortiStress was advertised with false and unsubstantiated disease prevention claims.

Nicotine also has a thermogenic effect. In fact, a pack-a-day habit of cigarettes can enhance thermogenesis to the tune of 4-5%. In other works, 100-200 calories per day depending on the dose of nicotine derived from the chosen brand. No one should pursue nicotine-containing products as a means of weight loss but it does help explain why many smokers are thinner and some of the weight gain that occurs after someone quits smoking.

Although the effects of fidgeting might belong, more appropriately, in the exercise posting, we don’t often think of fidgeting as exercise or activity. It is perceived more as a habit or characteristic of a particular individual. Nevertheless, it can have a significant effect on the number of calories required to maintain your weight each day. In fact, a study in the American Journal of Clinical Nutrition in December 2000 demonstrated that some individuals could fidget away up to 800 calories a day! There are, of course, people who can’t seem to sit still. Hands and feet are tapping or swinging even when sitting in a quiet room with no one around. Some people can’t stand still – like to pace, shifting their weight constantly foot-to-foot. Those are all calorie-burning activities and, if done over and over again, do add up. Great, now we will have the new breakthrough Fidgeting Diet, with detailed instructions on how to fidget for greatest impact. That book will probably sell well!

Or how about the chewing gum diet? Have you ever noticed how much effort a cow puts into chewing? It has been estimated that a cow chewing away as they do can increase their calorie expenditure by about 20%. What happens when a human being does a little extra chewing? Somebody searching for something to do investigated this issue by carefully measuring the calorie expenditure associated with chewing calorie-free gum at a controlled frequency in a metabolic laboratory in Minnesota. The frequency of chewing was selected after observation of several random gum-chewers walking around the institution. It was found that chewing gum can increase the energy expenditure by about 7-17 calories per hour. Now, let’s see – 10 calories an hour, 10 hours of gum chewing per day (sugar-free, of course) - that would translate into a 10 to 11 pound weight loss over 1 year and some very sore jaw muscles. Maybe this is the secret to how people in Minnesota stay warm in the winter – pop some gum every time you go out side and chew fast.

So by now you should be getting the idea about all the things that can influence your metabolism. We haven’t mentioned the effects of acute illness and injury on your metabolism. Losing weight under such circumstances is usually not your primary concern.



Influences on your metabolism

Age
Weight
Sex
Body composition
Distribution of body fat
Hormones
Illness
Weight gain and loss
Injury
Use of various stimulants i.e. caffeine
Fidgeting
Physical activity

It is probably important for me to mention how various hormones influence your metabolism. As an Endocrinologist, I have been referred hundreds of obese patients over the years that are asking me to examine the possibility of a hormonal abnormality as the primary reason for their obesity. Often, the specific concern has been “It has got to be my thyroid!”

Actually, hormonal causes of obesity are quite rare and generally easy to screen for with a physical examination and a few laboratory tests. Some of the more common hormonal causes of obesity are noted in the Table.

Hormonal causes of obesity

Hypothyroidism
Hypercortisolism
Cushing syndrome
Growth hormone deficiency


It gets more complicated when you start discussing some of the hormonal conditions associated with obesity. In other words, these are conditions where the patient is often obese. There is a measurable different in hormone levels but we are not certain whether the hormone alterations are due to the obesity and underlying condition or whether the hormone alterations may have contributed to the expression of the obesity or underlying condition.

Conditions where hormone alterations and obesity are commonly associated

Type 2 Diabetes Mellitus
Metabolic Syndrome
Polycystic Ovarian Syndrome


The metabolic syndrome is a relatively new term to describe a condition that has become extremely common in America as we have grown fatter. The identification of this syndrome is important since it is linked to a significant increased risk of heart disease – up to 30%. There are various organizations that have slightly different criteria for diagnosing the condition. The most commonly used criteria was developed by the National Cholesterol Education Program (NCEP) Expert Panel and is shown in the table below.



The Metabolic Syndrome
Defined by the presence of three or more of these components:

Central obesity as measured by waist circumference: Men - Greater than 40 inches Women - Greater than 35 inches
Fasting blood triglycerides greater than or equal to 150 mg/dl
Blood HDL cholesterol: Men - Less than 40 mg/dl Women - Less than 50 mg/dl
Blood pressure greater than or equal to 130/85 mmHg
Fasting glucose greater than or equal to 110 mg/dl

As you think about this definition, remember you only have to have three criteria. So if you have slightly elevated blood pressure, a slightly elevated triglycerides, and your waist circumference is a little bit larger than it ought to be, you have the metabolic syndrome. You also have an increased risk of developing and dying from heart disease.

The central obesity, the size of your waist, is though to be the main issue with the metabolic syndrome. Fat or adipose tissue in the abdomen (also called visceral fat) is a different kind of fat tissue than that found stored outside the abdomen or in the legs. Visceral fat is not just a passive storage depot where we put fat to use for energy at a latter date. Visceral fat is active tissue that secretes hormones and inflammatory substances called cytokines or adipokines that can lead to a damage of blood vessels, to high blood pressure, to hardening of the arteries and heart attacks. The amount of visceral fat is also closely linked to resistance to the hormone insulin.

I really should restate what I just wrote. It is, in fact, a revolutionary concept that adipose tissue is not only a reservoir for energy storage but an active secretory organ. The substances released in the bloodstream by fat tissue are surprising numerous. Almost all of them are bad for you in some manner or another. As mentioned, the amount of these substances secreted into the bloodstream is influenced by the amount of fat tissue you have and where you store it.

This has given rise to the concept of “lipotoxicity”. The idea that excess amount of fat tissue can be toxic to you. This is akin to the concept of glucotoxicity that we often talk about in diabetes. High sugars or glucose in the bloodstream are toxic to the eyes, kidney, and nerve tissue and can lead to retinal disease, blindness, kidney failure, and nerve damage with numbness in the feet. Likewise, excess fat stored within the abdomen and within the organs can be toxic to the body, contributing to insulin resistance and the development of blood vessel disease leading to heart attacks and strokes. In fact, many obese individuals have excess fat stored in the liver and that excess fat can be toxic to the liver leading to inflammation and even cirrhosis. Yet another example of the toxic effects of excess fat.

Insulin is, of course, the hormone that helps regulate blood sugar levels. Patients with Type 2 diabetes have a genetic disorder that makes them insulin resistance. They require more insulin to do the same work done in a non-diabetic individual. Obesity is closely linked with the development of Type 2 diabetes and that obesity is usually “trunkal” – obvious in the belly, in men, often called the “beer gut”. If examined, much of this extra belly weight is visceral fat, inside the abdomen, around the organs, and within the organs.
Type 2 diabetes is also associated with high blood pressure, abnormal triglycerides and HDL-cholesterol, and much increased risk for heart disease.

The amount of visceral fat and the extent of the insulin resistance caused by that excess visceral fat are features Type 2 diabetes and the metabolic syndrome have in common.
The safest, most effective and preferred way to reduce insulin resistance in patients with the metabolic syndrome and Type 2 diabetes is weight loss. The visceral fat is mobilized and lost with weight loss to a greater extent than fat in other areas. A 10% weight loss can have a tremendous effect on the amount of insulin resistance, reducing the blood pressure and improving the blood lipids.

There are also hosts of other hormones understudy that may play a role in obesity. A major focus of this new research is on the role of a variety of gut hormones play in regulating metabolism and appetite. The list is quite long but includes gherlin, CCK, GLP-1, GIP and PYY.

Gherlin appears to be an appetite-stimulating hormone and is produced by the stomach. The secretion of the hormone peaks before a meal and falls after it. In humans, average ghrelin levels correlate with body weight: They are highest in skinny people and lowest in fat ones. If you diet, the amount of the gherlin increases. It appears to work by sending its signal to the feeding center in the brain, within the hypothalamus. Interestingly, the levels of gherlin drop dramatically in obese people who have undergone a stomach-reducing procedure known as gastric-bypass surgery. Maybe this is why such individuals don’t seem to have as much hunger or interest in food after the procedure. Some day, we might be able to control gherlin levels with medication, a new drug, something far less dramatic than gastric surgery.

Glucagon- like peptide 1 (GLP-1) is also under active study. A naturally occuring compound called exenatide that is found in the saliva of the Gila Monster (marketed as Byetta), and has the same properties as naturally occuring GLP-1, is used for the treatment of Type 2 diabetes. GLP-1 is made by intestinal cells and released with food intake. It stimulates insulin release but also acts to reduce the appetite. It sends a signal to the feeding center in the brain and helps produce a sense of fullness or satiety. This gut-brain talk makes some sense. We eat and hormones signal the brain to tell us we are full and should stop eating. It is interesting to note that about 80% of patients with diabetes that are treated with exenatide (Byetta) lose some weight. This drug has been very helpful to many of my obese Type 2 patients, improving their diabetes control but also helping them drop some pounds. Hopefully, studies will be done in the future to test the usefulness of exenatide in obese individuals without diabetes.

As mentioned, there are a variety of peptides produced by fat tissue that are under study including leptin and adiponectin. Leptin deficient animals are obese and it was hoped that leptin deficiency and its correction would be part of the obesity story in humans. In fact, leptin levels are high in obese individuals and leptin administration to obese subjects has been fairly disappointing as weight loss treatment. Adiponectin is one of the few good hormones to be produced by fat cells. Unfortunately, the level of adiponectin good down as one gains weight. Adiponectin helps to reduce insulin resistance and inflammation in the blood vessels. Further understanding as to the role of these hormones or mediators may open up new treatment opportunities in the future.

Having told you about these hormones, it is still calorie balance and the calorie equation that determines your weight. Yes, hypothyroidism, if untreated, may slow your metabolism and make you gain weight if you continue to consume the same number of calories as when you were well. If you ate less, matching the new requirement of a slower metabolism, you would not gain weight despite the untreated hypothyroid condition. I have seen many patients over the years that have been diagnosed with significant hypothyroidism and had not experienced major weight gain. Some, no weight gain at all.
I have seen far more people who insisted that their thyroid function must be way off and the reason for their obesity when, in fact, their thyroid status was perfectly normal.

Metabolism

Tip and Tools

1. TEE = REE + TEF + Activity
2. REE x 1.3 = total daily energy expenditure for the average sedentary individual
3. Use the Mifflin-St.Jeor equation to calculate your total daily energy expenditure.
4. REE can be directly measured as well but takes special equipment
5. Another way of estimating daily energy requirements is the “factor” method. Use your weight times a factor of 9-11 if you are female and 10-12 if you are male. Use the lower factor if you are over 300 pounds or over 50 years of age.
6. 3500 calories = 1 pound of fat (the 3500 calorie rule)
7. Plus or minus 100 calories a day is plus or minus 11 pounds in a year (the 100 calorie rule)
8. Only calories count.
9. The hormonal causes of altered metabolism are uncommon and easily screened for with simple laboratory tests
10. There are various stimulants available to increase the metabolic rate. They are not recommended and in the case of ephedra, dangerous.
11. The Metabolic Syndrome is quite common and imparts a 30% increased risk for heart disease. See if you are susceptible by measuring your waist size.
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Obesity Introduction:How to beat it - don't buy the hype

Chapter 1: Introduction: Obesity: How to beat it - Don’t buy the Hype

When it comes to nutrition and weight loss products, it is a buyer-beware market in America. Stop wasting your time and money and risking potential harm to your health.

“Doctor, I can’t believe my weight today,” exclaimed a recent frustrated female patient of mine. “I’ve gain 17 pounds in the last 2 months and haven’t changed what I’ve eating one bit.” That’s when I usually have to bit my lip to prevent a flood of comments about how ridiculous that statement is. “My doctor sent me to you to see if a hormonal imbalance was the cause of the weight gain.” I release my lip from my lower teeth. Afterall, at least she is trying to get help for her weight issue from experts and not wasting her time with the latest gimmick-diet. She also following through with her doctor’s advice, seems sincere and committed to doing something different. I think I can help this woman.

America is too fat. The statistics are staggering. Over 60 percent of Americans are now considered overweight, nearly 2 of 3. One in three Americans is obese. The adults to be, our kids, aren't looking any better: 15% of American children are obese. The average American is 11 pounds heavier now than in 1990. All of these statistics are obvious to any reader. If you have lived in America, you are aware that the people around you are getting wider and bigger.

This is not just a cosmetic issue. As a physician, I am reminded on a daily basis that obesity is associated with the development of many serious medical conditions, including Type 2 diabetes, hypertension (high blood pressure) and high blood fats (cholesterol and triglycerides). These obesity-related comorbidities can progress to heart conditions, strokes and a host of other life-threatening conditions. The extra medical cost to the nation is estimated to be in $117 billion range. Employers are worried too. Obese workers not only generate higher medical costs for the employer but also experience lower productivity and more days of work lost. Employers lose about $10 billion each year in lost productivity. These facts have prompted many employers to invest in weight management education initiatives in their workplace to stem the losses.

An alarming report was released by the Rand Corporation and published in the journal Health Affairs. It highlighted the increasing disability rates among young Americans. We assume that science and health care in America is advancing and the young people are getting healthier. On the contrary, the rates of disability rose from 118 to 182 per 10,000 people from 1984 to 1996 among 30-39 year olds. The rate rose from 212 to 278 per 10,000 people in the same period for 40-49 year olds. And guess what – musculoskeletal problems such as chronic back pain and diabetes, both linked to obesity, were the problems cited as causing the disability that grew most rapidly in number during the study.

Again, if you are reading this, you are aware of the health and economic hazards of obesity. You may have diabetes or some other health problem related to obesity. More important for some of you than health concerns is the emotional or psychological impact that excessive weight has on you. Most people are not pleased by their excess weight. It can be a source of anxiety, lower self-esteem, contribute to depression, and cause people to avoid thing or events they would otherwise enjoy. In a recent survey of American women conducted by a reliable source, fourteen percent of respondents planned to skip their high school reunion because of their excess pounds. Some people avoid gyms, beaches, and sports activities because of their weight. That is sad! You may be thinking this book can help you get rid of the weight and restore some of your health. That is my desire too.

Given the awareness I know is out there, how come America is fat? We’ve got all kinds of “experts” providing advice about dieting through books and magazines, promoted on infomercials and littering the Internet. We have all kinds of diet and low calorie foods to choose from in our supermarkets and on-line stores. Many of us have exercise equipment at home or belong to the local gym. Plenty of opportunity to eat “light” and burn those calories. We have also experienced great medical advances in the last couple decades. We now understand more about metabolism, and the active role the fat cells play in altering disease expression in our bodies.

So what is the problem? Time to wake up, America! It is time to deal with the facts about food and metabolism and quit buying the hype. Obesity is not a random disease that strikes without warning and indiscriminately. Yes, there may be a genetic tendency but very few Americans were obese in 1900. Has the gene pool changed over the last 100 years? No, it would take a few thousand years to significantly alter the genetic makeup of our species. We are obese because we choose to be obese. Obesity can be managed. It can be prevented.

Not that it is easy in the “toxic” environment that America has become for those trying to stay lean. Billions of dollars are spent each year on advertising to encourage us to make unhealthy food selections. Portion sizes have increased dramatically since the 1970s, and really “grew” in the 1980s. For example, foods such as French fries, hamburgers and soda are now two to five times larger than their original sizes. Some fast food places don’t even sell small sizes anymore, just medium, large and extra large. Let’s face it food is cheap relative to labor and other overhead costs. Give them large portions and they will come. The buffets in Las Vegas are notorious for offering a lavish spread. On a typical weekend day, the buffet at the Rio Casino will serve more than 7000 people. Those 7000 will consume 5000 lbs. of shrimp, 3500 lbs. of meat, 2000 lbs. of pasta, 5000 cakes and pastries. Even our coffee is no longer a low calorie beverage. Starbucks Caffe Mocha is made with expresso, cocoa, steamed milk and whipped cream. The 16-oz drink has 400 calories, same as 2 Dunkin Donuts. Predictions are that sales of snack and nonalcoholic beverage bars, which include coffee shops such as Starbucks and doughnut shops such as Krispy Kreme, are expected to jump another 8.1 % in 2004.

United States Department of Agriculture (USDA) statistics show that American total daily caloric intake has risen from about 1,850 calories to 2,000 calories over the last 20 years. That is a significant increase - 150 calories per day. As you will learn in later postings, if you were that person eating 1850 calories per day and now eat 2000 calories, that calculates to an extra 15 and ½ pounds. If we eat more, and exercise the same or less, we will gain weight.

Men’s Fitness magazine does a survey each year to identify America’s fattest city. Fourteen categories are used in their evaluation system and it includes such items and number of fast food restaurants, ice cream and donut shops per capita and television viewing trends. The winner in 2003 was Detroit, beating out the prior year winner, Houston, because of a jump in television viewing, a worsening commute time, and scarcity of gyms. Certainly, all of these items would contribute to inactivity and promote weight gain.

Over the years, the message I’ve delivered about weight and dieting has been same. Getting to the message has changed as I’ve had to deal with explanations about the latest fad diet in the marketplace. In the early years of my practice, it was the Last Chance Diet, Rotation Diet, Gastric Balloon, the Popcorn Diet, and the Atkin's Diet. Lately, it has been the Zone Diet, South Beach Diet and the Atkin’s Diet again.

Most patients come to me having engaged in several “go-it-alone” weight loss efforts, these efforts often prompted by a new book or celebrity-endorsed diet plan. In fact, even for those individuals with significant obesity-related health problems, more than 80% of weight loss efforts are self-directed – not supervised by a physician or program. It has always been frustrating for me to spend time, over and over again, about why the newest fad diet will, like the last one, lead to yet another failure. The real reason why diets fail is that they are viewed as short-term interventions. I will “diet” now to lose the weight and then quit dieting and go back to whatever I was doing before. It is not the fad-diet per se that is the cause of the failure. It is the notion that a weight problem can be fixed in a few weeks or months.

The secret too staying lean is fairly obvious. One concern I had about finally sitting down to write my thoughts was that the truth about food, weight and dieting will not be very exciting to most people. My kids suggested “The Las Vegas Diet”, with maybe a showgirl on the cover. That would probably sell. Partial truths or unproven theories, often with celebrity endorsement, seem to catch the imagination of the American public more easily than the truth when it comes to food.

But, we simply can’t deal with the truth. We have an ever growing, $30-plus billion consumer-driven market for diets, herbals, homeopathic remedies, nutraceuticals, diet pills and dietary supplements. We buy low-calorie and low-fat foods, many of them prepackaged and expensive, join commercial weight-loss clubs, spend days at "fat farms," take over-the-counter diet pills of one sort or another and beg doctors for a prescription to the latest appetite suppressant. We submit to liposuction and think potentially hazardous and very expensive bariatric (gastric) surgery is an acceptable means of losing weight. Every new remedy or treatment is greeted with hope and a wave of enthusiasm. Everyone is looking for that one ultimate answer.

Most of these so-called new miracle diets and products are fairly harmless but, unfortunately, not all of them. Very low calorie diets can be harmful leading to several medical complications if not well formulated and closely supervised by knowledgeable health professionals. Several popular diets on the market that provide adequate calories do not provide all the nutrients required for health. Olestra can contribute to the loss of essential nutrients. Flenfluramine, part of the Fen-Phen diet was associated with a serious heart value condition. Dexfenfluramine, a close cousin of flenfluramine, can contribute to a potentially fatal pulmonary hypertension. Ma Huang, a supplement found in many herbal weight loss products, can contribute to high blood pressure, strokes, and cardiac irregularities. You hear of the occasional complication and even death from overly aggressive liposuction.

It is alarming to me that America’s struggle with obesity has elevated bariactic surgery to a fairly common and routine consideration in people with obesity. Again, celebrities that have had the procedure appear on TV and appear to doing so well. Don’t get me wrong. I have recommended the procedure to some of my patients over the years. It is necessary for a select few. However, I fear the unusual recent demand is being pushed by marketing and some hospitals looking to establish a lucrative specialty niche with this procedure. Surgery is risky in very obese people. In the best hands, 1 in every 100 patients dies from complication of obesity surgery. Up to 3% die in places with less experience. Non-fatal complications occur in 5 to 20%. Despite the risks, the number of procedures done in America is skyrocketing – from just over 23,000 in 1997 to more than 103,000 in 2003. These procedures are even being hyped as a viable solution for obese kids. Is this the best way to treat obesity?

The issue of nutritional supplements is one that usually gets a heated discussion going, and will be dealt with in this blog. In a country where the majority of us are overfed, we are busily spending and supplementing our nutritional intake with a variety of vitamin and mineral products. We not only are the most overfed people in the world, but probably the most wasteful when it comes to food and nutrition-related products as well. Where do you think all those extra vitamin and minerals end up? Yes, the toilet. No doubt, we also have the best-fed toilets in the world!

Sure, there are some supplements that can represent good medicine and we will point you to them later. But some of them are based on fraudulent claims, or quackery. A quack is “anyone who promotes medical schemes or remedies known to be false, or which are unproven, for a profit”. One in four Americans will be duped again this year, collectively spending another 20 plus billion on junk.

Are you the one in four to be duped this year? Surprisingly, people with a college education are more prone to use quack remedies than people with less formal education. People who are isolated with minimal or no support from family or friends, those with chronic or incurable diseases, people seeking relief from emotional distress caused by conditions difficult to treat such as obesity, baldness and impotence. Also, people with absolute faith in the written or TV word (“if it is in print or on TV, it must be true”) are the most susceptible individuals.

Some purveyors of unproven or worthless treatments are sincere, but nevertheless, mistaken. Most are manipulators, out for profit or fame. Some may have fancy titles. They tend to use the same sales pitch when presenting their products and remedies citing dramatic claims, and explaining how the traditional medical community doesn't understand this “science” or is limiting availability as part of a conspiracy. Holism is often a smokescreen for health fraud and a cult-like following is encouraged.

It really is a “buyer-beware” market out there. There are, at least, 1000 makers of various dietary supplements in the United States alone. The Internet gives us ready access to many others in other countries. Under a 1994 law, supplements can be sold without first proving they’re safe or truly deliver the benefits they advertise. The Food and Drug Administration (FDA) is powerless to control the manufacturers of these products. By law, the agency cannot regulate herbs and other so-called dietary supplements. The FDA can only step in when one of the supplements has been proven to be harmful, literally after the fact. Wait a minute! Yes, that is what I said; you can sell a supplement without proving any benefit and only get it pulled after it has been shown to be dangerous and already hurt a bunch of people. Currently, there is no way to ensure a bottle contains the promised amount of pure ingredients you intend to buy or consume.

To further emphasize the danger, the New England Journal of Medicine reported in an article in October 2003 about the hazards associated with a herbal weight-loss product containing aristolochic acid. This substance, aristolochic acid, is a potent chemical that can cause cancer and kidney failure. This association has been known for several years. Despite the well-documented risk associated with this substance, over 100 Web sites continued to sell 115 products that contain it after the publication of the article.

What is surprising to me as a physician is the number of very bright people who will ingest a herb and then debate the need for a new prescription drug that is clearly needed. “Doc, I’d rather do this the natural way.” Now the prescription drug as gone through 7-10 years of rigorous study to see if it works and is safe, and is carefully scrutinized by the FDA prior to release or approval. Even after approval, surveillance studies are put in place to monitor for unexpected side effects or problems that might occur once the drug is used in the “real world” of clinical practice. Yes, and a few hazardous drugs get pulled after approval but generally the process works pretty well to keep the public safe. Yet, that same person will take a herb, not knowing what the herb contains (many contain many different active substances) and unaware of any testing or rigorous study the herb has been put through (most haven’t had any). Furthermore, they often get a little “testy” should I become too insistent that they stop using the herb in question. Well, excuse me!

I bring the subject of fraud and quackery up to both alert you of the dangers of pursuing potentially worthless and hazardous remedies and diet plans. But also to point out that this blog doesn’t aim to generate a following. Nobody will be talking about the EndoDoc Diet because there is not a list of good and bad foods that will be provided. No long list of vitamins, minerals or herbs you’ve got to have. Most of you are already eating a reasonable variety of foods and getting most of your essential nutrients. You simply need to know a few truths or rules about how your body works and what it needs and you can be successful. Give the new eating pattern and lifestyle you develop from reading this blog the name of your choosing.

You will come to realize as you read the postings on this blog that the answer is not found in the hype surrounding the weight loss products and diets in the marketplace. The simply truth is they wouldn’t sell anything if they provided the answer because you wouldn’t buy them. You don’t need them.

So where do we start? First, you have to ready to lose weight and keep it off. Take out a piece of paper right now and list the benefits and sacrifices you’ll experience with weight loss. What are the benefits of weight loss for you? Better appearance? Reduced health concerns? Opportunity for advancement on your job? Happier marriage?

There will be sacrifices as well. Foods that need to be limited, time spent exercising, new cooking styles, and other changes in your lifestyle. Can you make these sacrifices over the long-term? If you don’t think so, another diet-cycle or failure is ahead for you – successful weight loss and maintenance isn’t important enough to you yet. The first step in deciding to go on a diet isn’t deciding what diet to go on, but whether you can do it with a reasonable amount of confidence that you will succeed.

Did you make your list? Do you think you are ready? “OK” you say, “Now what do I do?” Well, that is what we are going to try and answer for you. So keep reading.

To help you remember key points, I will end each posting with a “Tips and Tool” chart that you can use for review. It may be helpful to refresh your memory by reviewing these periodically.




Introduction

Tips and Tools

1. Make a commitment to change
2. Get your nutrition and diet information from reliable and credible sources.
3. Stop buying the hype and don’t be duped.
4. Review the tips and tools at the end of each posting to refresh your memory