So You Want To Lose Weight

 

Select a dietician..  Tell the dietician your age, height, state of pregnancy; also describe how active you are.  Ask for two diets: 1) The least you should eat without risking your health, and 2) How much you should eat the rest of your life to avoid regaining the weight.  #1 will be between 800 and 1200 calories per day, #2 1800 to 3500 calories per day.  While you are losing, if you take a vacation from #1, do not eat more than #2.  If even #2 seems unacceptably Spartan, for the rest of your life, do an agonizing reappraisal.  You may decide to declare (and carry out) a more physically active personal routine, which will entitle you to more food.  Continue this process until the enhanced diet #2  becomes tolerable to contemplate for the rest of your life.

 

After you have a grip on these fundamentals, you may seek additional help in getting started.  Compare with nicotine patches and Nicorette gum.  Amphetamines have an effect in reducing appetite when you first start taking them, dies away and you have to continue them to do as well as you were doing without the medication.  Compare with drinking coffee to stay awake studying for exams.  If you the drink coffee all during the second semester,,  coffee won’t help during the next exam period.  In other words coffee and amphetamines are both habit forming, but the consequences of caffeine addiction are not a health threat.  A street name for an amphetamine is “speed” and it is not benign.  Caffeine is not harmful except to Mormons and for them only because of lost status with their more devout brethren.

 

Here is a humorous digression which makes a small point.  A generation ago our family was eating in the Bergoff, a good but no-nonsense restaurant in Chicago.  We observed a rather ample lady in a neighboring booth engaged in mortal combat with the menu.  Finally she brightened up, opened her purse and took a diet pill.

 

In my youth we doctors hopefully searched for thyroid deficiency in overweight patients expecting to make it easy for them to lose weight by discovering and correcting their “glandular disturbance.”  Now we know that thyroid deficiency is not more prevalent in the overweight portion of the population compared to its incidence in all the rest of us.  When these people are treated,  they may lose a few pounds and promptly gain back to their original size.

 

So called weight-loss specialists like to “diagnose” thyroid deficiency in their patients.  I have records of such patient with normal thyroid tests without treatment both before and after their temporary “success” with a weight loss specialist.  When thyroid hormone is given to a person with normal thyroid function, nothing happens until a dose larger than that normally produced is given.  At that larger dose thyrotoxicosis is induced producing  weight loss along with heart disease and softening of the bones as occurs when thyrotoxicosis occurs spontaneously.  These consequences are not a good trade off for weight loss whether temporary or permanent.  As a matter of fact repeated losses of weight by diet do not enhance health compared to remaining heavy any more than famine enhances health with repeated losses and regaining of weight.

 

Speaking of repeated natural famines, such recurrent famines select survivors from those in a population who have gained weight most promptly after previous famines. The most viable remedy for these bearers of the “thrifty genes” is for them to get enough exercise for their already active appetite mechanism to turn on even more strongly to prevent undernutrition.  This explains why primitive tribes have obesity only in the ruling class where it is a badge of importance.  We observed this extra status problem of obesity as badge of social importance during a two year stay in Afghanistan a generation ago.  Under those conditions suggesting weight loss was even more unpopular than it is here, and there were no fringe practitioners advertising weight loss regimens.

 

Some of our current “weight loss specialists” do blood insulin levels to demonstrate a metabolic abnormality to be treated.   I called them “weight loss specialists” in quotation marks because this is not a recognized medical specialty (there are some main stream surgical specialists who emphasize surgery to enhance weight control in their practices).  Some people do have abnormal resistance to insulin, and this includes all overweight adults and it explains why obesity aggravates diabetes.  Insulin resistance is usually overcome by the pancreas simply secreting enough extra insulin to keep the blood sugar normal.  When this very large amount of insulin is insufficient, diabetes ensues.  Weight loss may restore balance, and the diabetic tendency may become undetectable at least for a time.  The bottom line: insulin levels are so variable throughout the day and depending on details of diet and activity that the measured blood levels are un-interpretable even  by experts.  The weight loss specialists that we have been talking about like blood insulin levels to justify the use of  metformin (trade name Glucophage) which acts as a moderately effective appetite suppressant in diabetics and non-diabetics alike.  The resulting weight loss is moderate and confined to the first few months of use similar to the use of amphetamines with the major exception that there is no habit problem.  This use of metformin in the absence of diabetes is not an EVIL with capital letters. For completeness let me mention that abnormal insulin resistance is readily detected by elevated blood triglyceride levels and reduced HDL cholesterol  (the good cholesterol).

 

One more small but somewhat helpful point: to  feel satisfied the stomach responds to distension.  It is only a reservoir the meter food to the small intestines no faster than they can process it.  Almost all digestion takes place there, and when the intestines begin to feel overwhelmed by the tasks it is facing, all appetite ceases.  Remember how much more full we feel about 20 minutes after Thanksgiving dinner.  The intestines are coming to grips with the rich dessert and truly remonstrate.  To cash in on the knowledge of this phenomenon start your meals with some hearty food, then kill time with salad.  Thus your intestines will feel busy and your stomach will be distended as if storing a second helping of the hearty food.  Simultaneous satisfaction will emanate from both organs.  Salad first is for healthy people trying to get their money’s worth at a smorgasbord.

 

Summary of how to lose weight and not gain it  back within 5 years, the fate of 95% of even completely successful initial victors: plan a long campaign.  Learn from mistakes.  Adjust your routine to accommodate your residual appetite. Learn how to drink water.  Get the pop machines out of schools to help the next generation.

 

Mathematical Appendix

“Ignorance more frequently begets confidence than does knowledge.”  Charles Darwin

 

Physicians frequently hear the forlorn statement, “I can gain weight on 1000 calories per day.”  We are dealing with a real world example of Darwin’s aphorism quoted above. Some complex arithmetic follows which explains how this forlorn statement can be literally true in the real world.   Translated into plain English these patients are saying, “My metabolism is different, and you must give me some powerful medicine to help me.”   Small wonder that fringe practitioners get their foot in the door.

Imagine an overweight person recovering from a prolonged depleting fever, surgery or some other trauma. She is 5 feet 5 inches tall, age 60, rather sedentary and taking in protein, converting it to (lost) muscle and burning her own fat to make up her caloric requirement of 1800 calories per day.

 

Muscle is 80% water and adipose tissue is 15% water.  The 1000 calories (what she gained weight on) contains 58 grams of protein.  All of the following assumptions are to simplify the arithmetic without changing the result very much.  We are also neglecting the small amount of protein in fatty tissue and fat in muscle tissue, again without changing the bottom line very much.

 

1800 minus 1000 = a deficit of 800 calories per day.

 

Assume 4 grams of nitrogen lost per day mostly in urine.  Protein is 16% nitrogen.

Therefore 4 ¸ 0.16 = 25 grams of the 58 in her diet lost daily as waste nitrogen. (This “lost”  25 grams of protein did provide 100 calories, but it couldn’t contribute to new muscle).

 

58 minus 25 = 33 grams of protein in the 1000 calorie diet available to build muscle

33 ¸ by 453 grams per lb. = 0.0728 lb protein x 5 (to correct for the water content of lean tissue) = 0.364 lb muscle built per day.

 

800 cal deficit ¸ 9 cal per gm x 0.85 (to correct the water content in fat flesh) = 105 grams fat.  105 grams fat ¸ 453 = 0.231 lbs of fat burned per day to replace the deficit.

 

0.364 lbs muscle mass gained per day minus 0.231 lbs fat lost = 0.133 lb gained per day while losing 800 calories!   0.133 lbs per day x 30 = 4 lbs lost per month on 1000 calories of food and 1800 calories expended.

 

Similar calculations can be made by the dietician (or anybody else) to calculate actual caloric requirement as opposed to an estimated requirement based on an activity diary.  The needed data 1) actual weight change on a measured diet followed for a significant period (more than about three weeks) and 2) the fact that gained or lost adipose tissue has about 3500 calories per pound.  This figure comes from 453 grams in a pound x 9 calories per gram = 4077 calories per pound of 100% fat, but fat flesh is only 85% fat (15% water).  So 4077 x 0.85 = 3465 calories per pound of fat flesh.

 

Finally, here is why a maintenance diet for a person’s ideal weight results in a gradually diminishing rate of loss.  The more a person weighs the more energy they expend getting out of a chair, walking across the street, etc.  As they lose, the difference between energy input and expenditure falls to zero (it never quite gets there mathematically).  A mathematician would say that the proper weight is approached asymptotically.  I gain compatibility points by talking this way to overweight engineers.

 

John A. Frantz, M.D.   See also: 1)Diet and Exercise under Staying Healthy and

August 14, 2 003         2) Prescriptions Drugs and the Consequences of Inappropriate    

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  “Facts are like ventriloquists dummies.  Sitting on a wise man’s knee, they may be made to utter words of wisdom; Elsewhere they say nothing…..”

                                                                                         Aldous Huxley