Part 15

Basic Outline of Weight Loss Principles

Why Weight Matters
What SHOULD You Weigh?
  1. Height, weight and BMI
    1. Basic problem is that simple height versus weight calculations including BMI fail to account for differences in lean body mass
  2. Body composition analysis
    1. Bioelectric impedance, skin fold thickness, underwater weighing are all subject to error for various reasons.
  3. Gold standard body-fat tests like DEXA and whole-body MRI are VERY expensive and time consuming and therefore not useful in the real world.
  4. Bottom line is that you SHOULD be at whatever weight is best for your health and that is VERY roughly a weight that makes your BMI between 20 and 25

Fat Distribution: Where on your body you carry fat affects health more than absolute weight or even total body composition.
  1. Visceral vs. subcutaneous fat:
    1. Visceral or intra-abdominal fat (fat inside the abdominal cavity surround organs) is far more harmful to health than sub-cutaneous fat (having "big hips" for example). Visceral fat increases risk for type II diabetes, hypertension and mortality. The combination of visceral fat, insulin resistance and hypertension is called the "metabolic syndrome".

What Causes Obesity
  1. Proximal cause
    1. The proximal or immediate (and rather obvious) cause of obesity is long-term energy (calorie) surplus (i.e. "eating more than you are burning"). This is true by definition and is neither surprising nor useful because energy balance is REGULATED by the body and attempts to simply and directly convert calorie surplus to deficit result in hunger and metabolic impairment.
  2. Intermediate cause
    1. The intermediate (underlying but not ultimate) causes of obesity are increased appetite and or reduced basal metabolism or reduced thermic effects of food. Probably all of these factors play a role.
  3. Ultimate cause
    1. The ultimate causes of obesity, the "wizard behind the curtain" include several factors:
      1. Genetics
        1. It is well established that risk for obesity runs in families. Since we cannot change our genetics, there is not a lot of point in focusing on this too much except to say the following: being born with a genetic predisposition  towards obesity is highly unfair because it means that you have to fight a battle that some other people do not. It is NOT however hopeless. You can overcome a genetic tendency to gain weight  but it DOES demand work.
      2. Metabolic poisons
        1. Certain substances including several found in modern foods "mess-up" the hormones in the human body that regulate weight.
      3. Culture
        1. Culture affects "normal" food choices and these in turn affect weight. Traditional Mediterranean cultures involved food choices that keep most people relatively thin whereas modern American culture promotes obesigenic food choices.
      4. Psychology:
        1. Visual variety, large plate or glass size, sodium level, smell, color, colorfulness, shape and "artistry" of presentation all increase calorie intake
      5. Physical health
        1. Insulin resistance "pre-diabetes" and chronic inflammation both promote obesity
      6. Medications
        1. Certain medications are well-known to promote weight gain. These include:
          1. Insulin injections
          2. Tricyclic antidepressants (amytriptylline, etc.)
          3. Certain SSRI antidepressants including Paxil but NOT Prozac (fluoxetine)
          4. Beta blockers
          5. Atypical antipsychotic medications (Respirdol etc)
          6. Antihistamines: Benadryl, Claritin etc.
          7. Corticosteroids: Prednisone, Medrol, Cortisol etc.
      7. Mental health
        1. Depression can cause either weight loss or weight gain.
      8. Climate:
        1. Cold and dark (winter) climates promote weight gain through their effects upon metabolism and appetite.
      9. Socioeconomic status:
        1. Poverty in America is today strongly linked to obesity. Interestingly, poverty used to be associated with healthy weight, but as American poverty changed from a rural phenomenon to an urban one, people's food choices and options changed dramatically. Poor people used to have at least enough land to grow a garden and therefore they ate healthy. Today, trapped in cities, America's poor eat cheap and highly processed "junk calories" like sugar, white starch, trans-fat, etc.

Calories: A calorie is an amount of energy, in the case of nutrition and diet, a calorie is defined as the amount of energy (heat) needed to raise the temperature of one liter of water by one degree centigrade. Dietary calories affect weight NOT because of their potential to generate heat, but rather because instead of generating heat, calories can be used by the body to make fat molecules which are then stored in fat cells.
  1. Car analogy
    1. I like to explain body weight this way: imagine that your body is a car with a very special gas tank made out of rubber that can expand like a balloon. The more gas you put in the tank, the bigger it gets. If you use nine gallons of gas every week but put ten gallons in the tank, pretty soon, you have a very large gas tank.
  2. Energy Balance
    1. Calories, as we have seen, are energy that can be used to perform work. In the case of the human body, the work performed by calories is mostly chemical work: building large biological molecules from smaller ones. Basal metabolism, the sum total of all the necessary biological chemical reactions in the body consumes a large number of calories: somewhere between 1500 and 4000 calories daily depending upon the person. Other calories are used to perform mechanical work like walking or lifting objects. When the body receives more calories than it needs for basal metabolism or movement, it stores the excess by making fat. This is how weight gain and energy are linked.
  3. Calorie Intake
    1. Humans obtain calories from eating food.
  4. Calorie Output
    1. Humans lose or burn calories in several ways that we shall explore shortly
  5. Energy Balance Equation:
    1. Intake -output = net calorie surplus (or deficit). When intake > output, we gain fat and visa versa. This again is the proximal cause of obesity.

Weight Loss
  1. Weight loss and energy balance
    1. When calorie output exceeds input, we begin to lose weight
  2. Feedback loops
    1. Body weight is regulated, largely by "feedback loops".
    2. Feedback loops are used often by biological systems.
    3. An example of a weight feedback loop is the appetite suppressing hormone called Leptin.
      1. Leptin is made in fat cells in all people
      2. Leptin enters the bloodstream, travels to the brain and suppresses appetite.
        1. The more Leptin, the less hunger we feel.
        2. The less hunger, the less we eat.
        3. The less we eat, the more weight we lose
        4. The more weight we lose, the smaller our fat cells
        5. The smaller our fat cells, the less Leptin they produce
        6. The less Leptin produced, the greater our appetite and the more we eat.
        7. And so on….
Leptin regulation is an example of a feedback loop

  1. Hunger
    1. Hunger is one of the two great barriers to weight loss
    2. Hunger is not negotiable: in the end hunger always wins
    3. Long-term weight loss cannot occur in the presence of hunger
    4. Hunger is a basic survival urge controlled by many feedback loops including Leptin.
  2. Metabolic impairment
    1. Metabolic slowdown is the other great barrier to weight loss.
    2. Simple calorie restriction produces metabolic slowdown.

Diets, Supplements and Foods for Weight Loss
  1. The simplistic view of diets: Just eat less
    1. For reasons cited above, this fails: you get hungry and your metabolism drops. Starvation, semistarvation, radical calories reduction never have worked in the real world.
  2. Diets
    1. Safe diets that work but aren't livable
      1. Medically supervised very low calorie diets (VLCD's). Optifast is a good example. These diets are great for rapid weight loss, but there MUST be a long-term plan that involves a different and livable approach.
      2. Ultra-low carbohydrate diets: Examples include "The Atkins Diet".
    2. Diets that are neither safe nor livable
      1. Diets that are insufficient in protein (or protein quality)- "The Cambridge Diet" of the late 1970s (Killed many people).
      2. Diets that cause severe electrolyte abnormalities- "The hCG Diet"
  3. Commercial Diet Programs:
    1. Weight Watchers:
      1. The "King of the Hill" among commercial weight loss programs---and for good reason. Very good program.
      2. Jenney Craig & Nutri-System: Pre-packaged food. High quality programs, somewhat high price.
  4. Diet Supplements
    1. Dietary Supplement Health and Education Act of 1994 (DSHEA) 
    2. Problem with OTC supplements
      1. Little controlled testing
      2. Appearances are deceiving
      3. Adulteration
      4. Ephedra
    3. Some dietary supplements may be both safe and effective
      1. Green tea
      2. Chromium
      3. Omega-3 fats
  5. "Diet" Foods
    1. Shakes
    2. Bars
    3. Frozen meals
    4. Others

Our Weight Loss Program
3 Facets:
  1. Dietary Change
  2. Exercise
  3. Weight-loss (anorectic) medication

Our Program
  1. The best weight loss program is the one that is easiest for you to follow
    1. No long-term hunger
    2. Simplicity
      1. Easy to understand
      2. Easy to implement
    3. Accessibility
    4. Affordable
    5. Easy to prepare
    6. Tastes good
    7. But above ALL, actually WORKS
  2. Using Science and Not Theory or Opinion to Guide Us
    1. Science is about TESTING to learn what is real and what is illusion, what really works and what doesn't.
    2. Everything I tell you is based upon science as published in peer-review major medical and scientific journals. When the there is conflicting evidence, I will tell you so.
    3. Epidemiology
    4. Interventional studies

Part 1: Diet
Food is more than mere nutrient. Food is also
  1. Drug
    1. Appetite drug
      1. Protein REDUCES appetite
      2. Sugar and high-glycemic-index starches INCREASE appetite
    2. Mood drug
      1. Some foods are addicting (sugar)
  2. Hormone
    1. Metabolic stimulants
    2. Metabolic poisons

So the idea behind our diet is to use our modern scientific understanding of the drug-like and hormone-like effects of foods to create a diet that causes weight loss without hunger or metabolic impairment. Here are the principles:
  1. Low GI
  2. Low or zero Sugar
  3. Higher protein
  4. High-plant
  5. High Omega-3 fat
  6. Moderate pufa and mag
  7. Zero trans-fat
  8. Low Saturated fat
  9. Low oemga-6 fat
  10. Frequent eating
  11. Probiotic
  12. Lower sodium
  13. More spice

Glycemic Index
The Problem of Sugar
Gut bacteria and weight
Salt and weight
Putting it all together: The Cave-man Diet
An alternative approach: Very Low Fat
  1. Our "old" diet
  2. Effective and VERY simple but more hunger
  3. Not entirely different from above but much simpler

Calorie Burning and loss
    1. Basal metabolism
      1. Huge
    2. Thermic effect of food
      1. Reduced by insulin resistance
    3. Exercise
      1. Aerobic <75% VO2max ("Fat burning zone")
      2. Aerobic near 100% Vo2max: "EPOC"
      3. Resistance training: slight increase in BMR
    4. Thermogenesis
      1. Heat is produced by all the chemical reactions and movements of the body. When that much heat isn't enough, the body can begin to make heat directly:
        1. Shivering
        2. "Non-shivering thermogenesis": Brown fat
    5. Malabsorbtion
      1. Not everyone can fully absorb all nutritional calories
        1. Enzyme deficiency
        2. Alli
        3. "Starch blockers"
    6. Bacterial absorbtion (see "probiotics)

Prescription Weight Loss Medications ("Appetite Suppressants")
  1. Approved by the FDA for "Short-term" use (Three months of less)
  2. Actually work far longer than three months in "off-label" use
  3. Off label use is common with many drugs
  4. Appetite suppressants are "efficacious"
  5. Appetite suppressants don't much suppress appetite
    1. The true effect is on
      1. Satiety
      2. Metabolism
  6. Tolerance
    1. Tolerance develops rapidly but is partial
    2. Tolerance can be partially overcome by changing medication but will quickly re-develop
    3. Tolerance is a feature of many kinds of medications
  7. Appetite medications only help if you work WITH them
    1. They do not eliminate hunger (nor should they)
    2. They do not make good food taste bad
    3. They do make binging or overeating impossible
    4. They do not work if you do not make a conscious effort to alter your diet
  8. Side effects
    1. Insomnia
    2. Irritability
    3. Hyperactivity
    4. Headache
    5. Nausea
    6. Euphoria
    7. Improved mood
  9. Medications
    1. Phentermine
    2. Phendimetrazine
    3. Diethylpropion
  10. Dosage
    1. The dosage calculus: "The higher the dose the better they work but the more chance of annoying side effects. The lower the dose, the lower the chance of side effects but the less likely they are to work.'
    2. The "right" dose is based upon body weight but is still hard to predict.