Tuesday, December 28, 2004

If Your New Year's Resolution is Losing Weight, Read On!

Is This the Year You Get Healthy?

It is rapidly approaching the New Year and, given the increasing prevalence of obesity in our country and the world, I am going to take a wild guess and say the most common resolution is going to be to lose weight. Just a wild guess, but I think I will be in the ballpark of most "Top 10" lists and polls on the topic. Since I have dedicated my medical practice for the past 10+ years to guiding patients through this process, I am going to offer some advice. The advice, such as it is, comes from several sources:

Personal Experience - During my internship and residency - a stressful but very sedentary period in my life - I ballooned up to 250 pounds. Now, loosely packed on a statuesque 69" frame (I was one who explained my weight as being a victim of being "big boned" or, for the non-Southerner, "large framed"), I was big. I sported a 40" waist and wore an size 44 jacket. I shopped in the leftover tables because, at least back then, they were not a lot of men buying 40 X 29 (29" was my inseam) pants. I remember I always wore an oversized white coat because, in the deluded mindset of an obese person, I thought it would visually "slim me down." Anyway, I have lost the weight and, for the most part have kept it off. Having had a heart attack at age 34 and a quadruple coronary bypass at age 42 was more than enough encouragement. Now, I proudly have a 32" waist (which I didn't even have as a high school athlete) and no longer wear a white coat, even in my medical clinic.

Professional Experience - I have been treating overweight (I guess I should use the more politically correct "weight challenged" but being "PC" will be the topic for a future rant) patients for over 10 years now. I can pretty much spot the ones that will succeed in losing weight usually with our initial evaluation. Just talking to patients gives you an idea of their motivation. Also, you can get an idea of how badly damaged their ideas about weight loss are. Sometimes I get fooled; usually, after 6 weeks, I sadly see I was right. Losing weight is a lot like quitting smoking. When you are ready, you will do it. Before that point, no matter what you hear or are prescribed, you won't. It's like a light switch. It's either off or on. Being ready - truly ready - to lose weight is (as I throw out yet another metaphor) like being pregant. You are or you are not.

Research - I have pretty much read everything there is to read - both in the lay literature and in the medical journals - about losing weight. It all basically says the same thing and that is what I advise in my clinic and what I will advise here. Early in my medical career I was taught the doctor's mantra in the late 80's and early 90's - people are obese because they eat too much. My advice to the desperate people asking my medical advice was: "Just push yourself away from the table and you will lose weight." What I was saying was: "It's your lack of self-control that is your problem. Quit being a glutton!" I was wrong and, the more I read about obesity, the more I realize how wrong I was. Obesity is a complex problem with genetic, physiological and behavioral components. And, since it has so many components, it is is truly difficult to treat. However, it can be treated.

That said, let's get started.

1. What diet do I recommend you follow?

Here is the first of, probably, many "shocking" answers: I don't care. If you believe in and want to follow one of the low carbohydrate diets - such as the Atkins or South Beach diet - that is fine with me. I can't really get behind any diet that sells you prepacked foods (Jenny Craig, WeightWatchers, etc.) because most people are not willing to buy their groceries at those prices for the rest of their lives. My personal and professional preference is a low fat diet. I recommend a diet with no more than 30 grams of fat per day. The remainder of your diet may be split into carbohydrate and protein depending on your personal tastes. Some people enjoy meat - protein -and that is fine. Chicken or fish and baked or broiled are best but, heck, you can have beef too if it is lean and not heavily marbled with fat. If you like hamburger, buy ground sirloin or chuck rather than the 50% fat standard hamburger at the meat counter. Fried foods are to be avoided at all cost. Some people like breads, rice and cereal - carbohydrates. I do not put any restrictions on these.

My point is: any diet will work if you follow it and exercise regularly. I am more concerned with your activity level than I am with what you eat. All diets share one common thing- they are reduced in total calories. They differ only in what foods make up the calories you do eat. You can follow your personal food preferences in selecting your diet. After all, this is how you are going to eat the rest of your life. So chose an eating plan you can follow for the rest of your life for that is how long problems with controlling your weight will last.

Editorial Follows: I hate the word "diet" because it means, to most people, a temporary "fix."The thinking goes "I will follow this diet for 6 months, lose my weight and then go back to what I was eating before." Do I need to tell you what the inevitable result of this approach is? When you stop your diet, and resume your usual eating habits, you will gain back at least 125% of what you have lost. Notice, I didn't say 100% - I said 125%. Obesity if not like a cold. It cannot be treated for 6 months or until you lose your weight. If you think you are "cured" you will regain your weight. Obesity is a disease, much like diabetes or high blood pressure. It cannot be cured - only controlled. You are making changes toward a permanent lifestyle, not a temporary change in habits. In order to keep weight off, you will have to be conscious of the being prone to gain weight - just like a diabetic is conscious of their blood sugar - all your life. If you have been overweight in the past, you will always be "pre-obese." The minute you turn your back and stop doing those things that are necessary for healthy living (exercising, sensible eating, you will gain weight again.

2. What should you do for exercise?

It my strong belief, born out of many years experience and observation, that exercise is the cornerstone of any successful weight control program. Following a structured, semi-controlled eating plan - better known as a diet - will certainly help you lose weight. But the only behavioral change that can guarantee that you consistently lose weight and keep weight off is to become more active in your daily life. You simply cannot avoid it - if you want to lose weight, you must exercise. Now, as to what exercise is the "best," it is very much like which diet is "best." Here's your rule: The best exercise for losing weight is the exercise that you actually enjoy doing and have the opportunity to do on a regular basis. It's like (another metaphor) murder investigations.You look for motive, opportunity, and method.

- Your motive is to lose weight and, ultimately, to keep weight off. Simple enough.

- Opportunity is making the time to exercise. Yes, I know you are busy. We all are. Yes, I know you have a job, several small, children and and really demanding spouse. Yada, Yada, Yada! I would hope you have enough self-esteem and sense of self worth that you believe you could and should spare 3-4 hours per week to making yourself more healthy.

- Method is the tricky one. If you would love to cross-country ski for exercise and live in Alabama, that is probably unreasonable. ["Probably" because you could get some rollerblades and ski poles and "ski" all over your neighborhood] If you want to swim and live in Montana, that may be difficult as well. Seek an opportunity and method of exercise that is easy to get started doing and to keep doing. The simplest is just walking. If you can't get outside, then use an exercise video. My patients really like the "Walk Away the Weight" video series. If you have arthritis and walking aggravates your joints, you should try an exercise bicycle, CardioGlide, or rowing machine (they are all basically equal in effectiveness)

3. Why Should I exercise?

What happens when you don't exercise, and you starve (diet) for a few weeks and do manage to lose a few pounds?Here's what happens: you may lose body weight but what you have lost, research shows, is usually 50% fat and 50% muscle. If you have starved off 10 pounds, congratulations! You have just lost 5 lbs of fat and 5 lbs of muscle. Now, guess which body tissue most determines your resting metabolism and, ultimately, how likely you are to keep this weight off. If you guessed your muscle mass (or "lean body mass"), you're right! Fat tissue is metabolically inactive and burns very few calories during a normal day's activities. Muscle tissue is very metabolically active and uses calories all day, even when you are not exercising. If you lose muscle, your metabolism drops proportionately. [Parenthetically, that explains why men usually lose weight faster than women. Men, genetically and morphologically, have a higher muscle mass and, thus, a higher metabolism than a woman of equal weight.] So, what have you accomplished by starving off this 10 pounds" You have lowered your metabolism and, thus, made it even harder for you to keep the weight from coming back.

This is the much publicized "Yo-Yo Dieting" problem. Most people have done this over years and years - lost and regained, lost and regained - that, when they get in their 40's and 50's, they find it increasingly more difficult to lose weight. Why is that? Simple. It is because they have lost muscle mass every time they have lost weight through starving (diet) without exercise. Now, they have reduced their metabolism to that of an amoeba and they couldn't lose weight if they ate two crackers a day. If they would start exercising to build their muscle mass back up, they would probably be able to lose weight again. But only with improving their lean body mass which, in turn, improves their metabolism.

4. Does any type of exercise actually improve my metabolism?

I am glad you asked! While most people concentrate on aerobic exercise while losing weight, this is not really an optimal plan. Aerobic exercise got it's good reputation due to well-publicized authors like Kenneth Cooper and by the myriad celebrity videos. [Rhetorically, I ask: If you are a celebrity, you must know how to exercise properly, right? I mean who knows more about exercise than Jane Fonda, Suzanne Summers, or Carmen Electra? I can't think of anyone, can you?] I will freely admit aerobic exercise, such as walking, swimming, jogging, etc., is useful for general health and well-being. But, in order to increase your chances for long-term success, anaerobic exercise should be included in any exercise regimen. Anaerobic exercise is work that requires your muscles to work against resistance. As an example, weight lifting is anaerobic exercise. Pushups and sit-ups are anaerobic. Anaerobic exercise builds muscle mass and, thus, improves metabolism. Therefore, if you are 25 and are losing weight for the first time, you can probably stick with aerobic exercise and preserve your muscle while you lose weight. However, if you are in your 40's or 50's and have lost and regained weight more than 2 or 3 times in your life, you would probably benefit from 2-3 sessions per week of anaerobic exercise.


5. How much weight should you expect to lose?


Healthy weight loss is not 30 pounds in 30 days. Healthy weight loss occurs when the body can burn fat without sacrificing muscle. If you drastically cut calories to less than the body needs, the body will burn energy from any source it can find. Available sources are protein (i.e. muscle) and fat. In starvation mode (i.e. a diet), the body will burn fat as easily and as readily as protein. That is why exercise is so important during weight loss. If you are exercising and using your muscles, the body will concentrate on burning only fat for energy. You will preserve your muscle mass and how much muscle you have determines your metabolism. If you are exercising and cutting back on calories to a healthy level, you should reasonably expect to lose 1 -2 pounds per week. If you have 100 pounds to lose, you should plan on a year of consistent exercise and calorie reduction. In order to lose one pound per week, you only have to reduce your daily calorie intake by 500 calories per day [specifically, there are 3500 calories in a pound of fat tissue; reduce calories 500 calories per day for 7 days and, eureka!]. That will result in one pound of fat loss per week - if you are exercising. Don't be in a hurry! If you have gained weight for five years, you shouldn't expect to lose it in 2 months. As you probably already know: it's a lot easier to gain weight than it is to lose it. Be patient. Slow and steady wins the race.

6. Do diet pills work?


Equivocally, yes. Why do I equivocate? Because the current generation of medications(phentermine, phendimetrazine, diethylpropion) can be useful to give you an "energy boost"when initiating an exercise program. They also, at least for a few weeks, will help get your appetite under control. But the energy and the appetite suppression are short lived. They are useful and, I might add, safe for initiating a medically-supervised weight loss program. There is no longer any "Phen-Fen" to worry about. Phentermine and the other medications mentioned have all been available by prescription since the 1960's and have never been taken off the market.They have withstood the test of time. But they are not the key to a successful weight loss program. The keys to weight loss are, in order of importance, personal motivations, exercise and reasonable , healthy eating.

Well, there it is, folks. Your New Year's Resolution explained and all planned out for you. If weight loss is not one of your resolutions, good for you! If it is, maybe this will help you get some ideas about how to lose weight once and, more importantly, for all!

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