New Year's Resolution 2 = Lose Weight

Weight Control

Over the past ten years, I have lost 75 lbs. No surgery. No drugs. Diet and exercise. At the recommendation of my PCP, I enrolled in a commercial weight loss program known as HMR located at Harvard Vanguard Medical Associates. Much of what I say in this paper is influenced by what I learned at that program, though my ideas have changed over time. At one time, my weight was down 75 lbs. I’m pleased to have kept as much weight off as I have. My weight control has been supported by a weekly group of staff members I have met with since I left HMR.

I had and continue to have many of the diseases of obesity: diabetes, high blood pressure, high cholesterol, hernias, varicose veins, gall bladder attacks, and sleep apnea. I no longer have GERD (gastro-esophageal reflux disease or heartburn), and I thankfully never experienced significant back or joint pain, cancer, heart disease, or fatty liver. I’m also off a large dose of insulin and onto an injected non-insulin alternative.

Being obese or overweight is also a condition many of my patients suffer from in part because of their mental problems and in part as a result of the psychiatric medication I prescribe, and so I have a special interest in this problem. I am pleased to be able to share my thoughts on the subject.

How Did Weight Control Become So Difficult?

The human body evolved over millions of years. For almost all that time, we had little choice about what to eat. We ate what was available. It was fresh, local, low in calories, and nutritionally complete. Only in the developed world over the past several generations has food become so plentiful, so affordable, and offering such unhealthy choices. Before that, the problem was famine, and the people who did not have a taste for high-calorie food did not survive to pass their genes down to us. As a result, those of us alive now tend to prefer food and drink which have lots of calories, and our eating habits are making us sick and killing us.

At the same time, many of us are sedentary. During the evolution of humans, daily life required heavy exercise, and it made sense to avoid physical activity and conserve energy for hard times, and so we are evolved to do so. We use cars and buses, elevators and escalators rather than walking short distances or climbing stairs. We fail to burn calories moving ourselves around, and our bodies lose muscle, which burns more calories even at rest than fat. We also use heat in the winter and air conditioning in the summer, and so we do not use calories even to shiver or sweat. As things are, weight control is an uphill climb for most of us.

What Attitude Should I Bring to Weight Control?

None of us gained weight overnight, and we’re not going to lose it overnight. It’s a cliché but dieting usually does not work. If possible, it is best to plan to make changes in how we live and make the changes last a lifetime. Changes are going to be easier to continue if they are relatively easy to follow and something we enjoy. We need to decide for ourselves if the changes should be gradual or drastic, strict or partial. I believe it’s useful to remember that the purpose of eating is to provide the body with the fuel and nutrients it needs to be healthy. Eating is enjoyable, but the purpose is to fuel the engine, not to indulge the pilot.

The changes I made for myself were to walk to work every day, six days a week. 1.3 or 1.4 miles each way, to avoid most restaurants, particularly fast-food restaurants, to adopt a mostly plant-based diet and to avoid junk foods like chips, fries, ice cream, and cookies. I try to tell myself “I remember what chips taste like. I don’t have to eat them now.” But these changes have not been easy to achieve. For example, I told myself to walk to work for three years before I ever did it. And if there is pizza in the house, it’s hard for me to resist.

Food Addiction

This is not a phenomenon I know by name. Perhaps surprising for an addiction psychiatrist with an interest in weight control. I think that living and working in a relatively disadvantaged community with many immigrants, I am rarely exposed to and hardly ever treat eating disorders, which mostly well-to-do Anglos tend to suffer from.

From what I read, a food addict is focused on their food of choice, typically fries, candy, chocolate, cookies, white bread, pasta, or ice cream. Symptoms of food addiction include craving their food of choice obsessively, being preoccupied with obtaining and consuming food, especially their food of choice, ongoing bingeing, or compulsive eating despite repeated attempts to stop, loss of control over how much, how often, and where eating occurs, negative impact on finances and social and family life, the need to eat food for emotional release, eating alone to avoid attention, and eating to the point of physical discomfort or pain.

After consuming large quantities of food, a person with a food addiction may also experience shame, guilt, and reduced self-worth. Bouts of bingeing may alternate with intensive food restriction, compulsive exercise, or self-induced vomiting. I was interested to learn that most food addicts are of normal weight.

A food addict would likely benefit from psychotherapy and perhaps psychiatric medication.

Concerns before Trying to Lose Weight

Before trying to lose weight, it’s important to make sure that other problems are not in the way of making progress.

1. Sleep apnea. People who are overweight, particularly older people, are prone to sleep apnea, which means not breathing during sleep. The throats of people with sleep apnea close when they go into deep sleep and experience the paralysis which naturally occurs in that phase of sleep. Sleep apnea sufferers then cannot breathe and so come out of deep sleep, typically without being conscious of the change. They tend to snore loudly enough to be heard through the door. A bed partner will notice the snoring and the episodes when the person stops breathing. What tends to be most obvious to the person who suffers from sleep apnea is that they are so sleepy during the day that they fall asleep without deciding to, such as when they are reading, watching TV, or as a passenger in a car. The condition is evaluated at an overnight sleep study and is usually treated with continuous positive airway pressure (CPAP), a machine which puts air through a mask into the throat of the sufferer to keep it open. Weight loss is difficult or impossible for people with untreated sleep apnea because losing weight requires self-control, which is difficult or impossible without being rested.

2. Drugs or alcohol use keeps a person from thinking clearly and makes self-control difficult or impossible even if the person does not have a drug or alcohol problem. The issue is similar to what sometimes happens to patients who are opiate addicts but never had a problem with alcohol or cocaine. They have a couple of drinks, sniff a line of cocaine and their relapse is under way.

3. To stop using tobacco products is the single most important step any of us can take to protect our health. Weight control is a lower priority. To be an overweight nonsmoker is healthier than having an ideal body weight and continuing to smoke.

Calculating Weight Loss

I always believed that we over-complicate weight control. I thought that for nearly all of us, it is as simple as calories in minus calories out. And the arithmetic is straightforward. I just weighed myself, and I seem to weigh 193 lbs. Multiply that by 10 (or put a zero at the end of it) and the net calories to maintain my weight is 1930 a day. Subtract exercise (about 7 calories per minute of walking). A wrinkle recently reported: past the age of 60, metabolism decreases by 1% a year. Because I am 75, the net calories to maintain my weight is 15% less, or 1640. If my net intake is more than 1640 calories, I’ll gain weight. Less, I’ll lose. A pound is about 3500 calories. Weight control is difficult to accomplish but straightforward to calculate.

Exercise

If I want to lose weight, can’t I just go to the gym? Exercise is definitely a good idea. It burns calories, it tones the body, it turns fat into muscle, making you look better and feel better, but almost no one can exercise enough to take off a substantial amount of weight in a reasonable amount of time. I would have to work out for over 8 hours to lose a pound. A combination of diet and exercise makes more sense to me. You can download a table of calories different kinds of exercise burn for people of different weights by clicking in the space below. The table is from HMR.

Physical Activity Chart.docx

Download DOCX • 16KB

What kind of exercise makes sense? Mostly cardio but strength training a few days a week also seems to help. About your exercise, please listen to your body. If it’s telling you it wants more, give it more. But if it’s telling you it hurts, stop whatever you are doing, give yourself time, and use stretching or massage until the pain goes away.

Medication for Weight Loss

Start with the medication you are currently taking. Many medications, including the antidepressants, mood stabilizers, and antipsychotics I prescribe are notorious for weight gain. Ask your doctor to go over your medications with you one at a time to see if they are getting in the way of your controlling your weight. I got my doctor to substitute Victoza (liraglutide), which is associated with weight loss [especially in the high-dose version sold as Saxenda], for insulin, which is associated with weight gain. More recently, a cousin of Victoza, semaglutide, was found to be associated with dramatic weight loss.

Of the medications I prescribe frequently, there are some which are notable. In my parents’ day, stimulants were given for weight loss. I have seen dramatic weight loss in people I prescribed stimulants or Wellbutrin (bupropion) for, but not in more than one patient in 100. The low rate of weight loss with stimulants makes me skeptical about the effectiveness of Adipex-P (phentermine), which supposedly works because it is like a stimulant. Vyvanse (lisdexamfetamine) is approved for the treatment of binge eating disorder. Revia/Vivitrol (naltrexone) is a medication I prescribe regularly for alcoholism and opiate addiction and have occasionally given for eating disorders, but no patient I have given it to has lost weight.

The medication I used to prescribe which seemed to be somewhat effective for weight loss is the medication for epilepsy Topamax/Trokendi XR (topiramate). Topiramate seems to work best if taken at the relatively high dose of 150 mg twice a day. Of note, though it is mostly well tolerated, it can cause nausea, hair loss, or difficulty with word finding among other side effects, and I have stopped prescribing it. Another medication for epilepsy, Zonegran (zonisamide), is supposedly effective for weight control, but I have not prescribed it more than a handful of times, and it causes nausea so frequently that almost no one I have prescribed it for could tolerate it. The GLP-1 agonists for Type 2 Diabetes (Rybelsus or Ozempic/semaglutide, Trulicity/dulaglutide, Tanzeum/albiglutide, Adlixin/lixisenatide, Victoza/liraglutide, and Byetta/exenaglutide) are all associated with weight loss which can be substantial, but I do not have enough experience with them to vouch for them.

Alli is sold over the counter and supposedly works by blocking the absorption of fat. It can produce a variety of intestinal side effects. I do not believe any of my patients has tried it. Belviq (lorcaserin) is weight-loss drug which acts on the serotonin receptor in a way which is like fenfluramine, the part of the phen-fen drug combination which seemed to have caused heart valve problems which resulted in phen-fen’s being taken off the market 20+ years ago. Lorcaserin has not been shown to produce similar problems. To my knowledge, none of my patients has taken it, and I have never prescribed it. I do not know how effective it might be.

In short, medication appears to be of limited help in weight control.

Weight-Loss Surgery

Known as bariatric surgery to doctors, it works by making the stomach smaller, by decreasing the body’s ability to absorb nutrition, or both. It is a drastic measure for people whose combination of extreme obesity and severe weight-related medical problems put them at imminent risk of dangerous medical complications or death. People who have the operation can lose hundreds of pounds, which can save their life, but the operation itself carries substantial risks, in part because of the nature of the operation but mostly because of the medical problems of the people who need it. In addition to dangers common to all operations such as infection or bleeding, people who have the operation can develop a leak where their stomach or intestines have been re-attached, which is painful and dangerous, and even if the operation goes smoothly, patients can suffer any of several medical problems, such as vitamin deficiencies, diarrhea, GERD, or vomiting. After the operation, the patient may be able to eat or drink only about an ounce at a time. But if the patient’s eating reverts to what it was, they can stretch out their stomach and gain back the weight they lost.

To minimize the risk, surgeons who perform such operations require the patient to stop smoking, have a sleep study to rule sleep apnea out, and prove they can control their eating by losing a substantial amount of weight. Qualifying for the operation can take years.

Spot reduction

If I think my belly is too big, shouldn’t I do a lot of sit-ups? No is the answer. The only way to lose weight in a spot is to lose it everywhere. Doing a lot of sit-ups will make my abs stronger and bigger but leave the fat over them pretty much the same. In fact, doing a lot of sit-ups might make my belly a little bigger, since the muscles in it will grow.

Lipo

Won’t liposuction let me decrease fat in a part of my body? As a rule, liposuction and other kinds of plastic surgery are particularly helpful after dramatic weight loss to remove excess skin. My impression is that it is too expensive and too risky to take the place of ordinary weight loss measures. So-called cold sculpting might work, but I have had no exposure to it.

Other Issues

But doesn’t the time of day you eat matter? It probably IS healthier to eat more, particularly protein, in the morning and less at night, but I could not find evidence that the time you eat makes a big difference.

And isn’t fasting helpful? Maybe a little, but not much, as best I can determine.

And are carbohydrates part of the problem, especially for diabetics? I spent time looking into the keto diet on the internet. The idea of such an extreme diet rubs me the wrong way. But it seems to work well, I’m unhappy to say. My belief has been that weight loss is weight loss and if you lose weight, your diabetes, cholesterol, and blood pressure will improve. That is true, but it may be that a very-low carbohydrate diet may accelerate process. I had the idea that people may lose weight with the keto diet but that they gain it right back. They do, but that seems to be true of almost all diets, and the keto diet does not seem to be any worse than others. But to my way of thinking, a low-calorie diet still seems to make the most sense. The Mediterranean diet, which seems to be favored for sustainable heart-healthy eating: lots of fresh fruits and vegetables with whole grain, olive oil, and limited protein. No processed meats or grains, no refined sugars or oils. Sounds sensible to me.

Drinking problems

The first issue to address if one of my patients wants to control their weight is what they drink. I generally endorse zero-calorie drinks. Alcohol is all empty calories and a poor idea for weight control for many reasons. Otherwise, the greatest contributor to what the nutritionists call “empty calories” is soda. I’ve had patients lose as much as 30 lbs by simply stopping drinking it.

What about juice? It does not make sense to me that apples and oranges are good for you, but apple and orange juice are bad. Here’s what I could find on the internet, from the department of pediatrics at the University of California at Davis:

Is eating whole fruit that much better than drinking fruit juice?

Yes! Whole fruits provide fiber by way of the skin and pulp. Fiber has been shown to decrease the risk of colon cancer, lower cholesterol and help control blood pressure. It’s also associated with living longer, studies suggest. In addition, whole fruits contain some vitamins that don’t make it into the juice. Some edible fibers in the skin and pulp are removed during the juicing process. Whole fruit also takes longer to eat causing a slower calorie intake, which can decrease the risk of obesity. Finally, fruit juice has more concentrated sugar and calories as compared to whole fruit.

Still not obvious, but at least explained.

Coffee: coffee itself is probably even helpful for weight loss. No calories. Tends to suppress appetite. It may also increase metabolism. Sugar has surprisingly few calories (only 16 per teaspoon) but of course is pure carbohydrate with no nutritional value. So-called non-dairy creamer is a problem. Unhealthy fats, a substantial number of calories, and pretty much composed of non-food additives. I try to steer my patients away from it. Cream makes up most of the calories from coffee. I encourage my patients to go from cream to half-and-half to whole milk to 2% to 1% to skim every month or two. Similarly, for people who use milk, I encourage them to go from whole milk to 2% to 1% to skim. Because the fat displaces milk sugar, cream has slightly fewer carbohydrates than skim milk. I believe that skim milk is healthier, though I may be wrong. Unsweetened almond milk has even fewer calories and a much calcium as skim milk, and it does not taste like nuts to me.

The one exception to the zero-calorie drink principle might be protein shakes, which can act as meal replacements rather than hydration.

Knowing the Problem

The next step I encourage my patients to take on the road to weight control is to record everything they eat for a day and to look up how many calories they took in. You can put the food into Google followed by the word “calories”, enter the amount you ate, and discover how many calories that is. The hope is to educate ourselves about where our calories are coming from so that we can adjust our eating accordingly. I do not use an app to help, but members of the staff group use myplate.com or other apps which calculate calories, keep track of exercise, etc. Some people find that a Fit Bit is helpful as well.

MORE Low-Calorie Food

Sounds nonsensical to suggest more food as a way of losing weight, but this is the logic: if we fill up on low-calorie food, not only will we reduce the appetite we might have for high-calorie things, but we train ourselves to have more of a taste for fresh, whole nourishment.

Single-Ingredient Food

Sounds like a good idea. I’m not sure of the evidence, but certainly fruits and vegetables are low in calories, full of fiber, and nutritional.

Mindfulness

If avoiding empty calories is a significant part of weight control, avoiding mindless eating may be even more important. Anyone who has been obese recognizes this pattern: you are sitting in front of the TV. At a commercial, you grab a bag of chips or cookies, a box of pizza, a jar of peanut butter, a package of chocolate, or something else you crave, and you eat it without thinking about it until it’s gone. Mindfulness is a Zen concept which encourages us to experience our inner and outer worlds, sensory, mental, and emotional, as fully as we can, without judging.

To eat mindfully, plan healthy meals and cook mindfully (appreciating the creative process and the sights, sounds, and scents of the food preparation). At the table, turn off the electronics, use your best china, and immerse yourself in the experience. Say a prayer or a quote to express your gratitude before you eat. Take a deep breath. Inspect, smell, and savor every bite. Notice your hunger with every bite. Drink water with every bite. Think what went into growing, harvesting, distributing, buying, and cooking your food. Notice your dining companions. Express compassionate instead of critical thoughts to yourself.

Mindful eating sounds like a wonderful idea to me, not only for weight control but to experience life in a calmer, more centered, and more grateful way. But the truth is that the behavior patterns are so different from what I typically do that I have so far found it impossible to achieve.

The Scale

In preparing this paper, I was surprised to learn that, as my colleagues in the staff weight control group have tried to tell me, people who weigh themselves every day lose more weight than people who do not. I had come to believe that instead of focusing on weight, focusing on maintaining healthy eating habits and checking weight every month or so made more sense, but it appears that being accountable is more effective.

Eggs for Breakfast

I read that eating eggs “or other high-quality protein” instead of a grain-based breakfast helps weight control. I have tried it for the past couple weeks, and it does seem to limit my appetite.

Artificial Sweeteners

Using them seems to leave a person craving sweet foods, which is a risky position to be in.

Changes in My Thinking

When I was in the commercial weight-loss program, I concluded that weight was determined exclusively by calories in minus calories out via exercise. What I have read preparing to write this has made me think that things may be substantially more complicated than that.

Sleep

I have noticed that getting a good night’s sleep helps control appetite and healthy food choices. When I am tired, my body knows it wants something, and I find myself tempted to return to my lifetime choice: to feed it. Even worse, being sleep-deprived weakens my self-control and I am drawn to eating the wrong things.

Easier Said than Done

Eat only if you’re hungry. The problem is that we eat for a lot of reasons other than hunger, and we tend to fight with ourselves about this obvious idea.

Environmental Control

Another concept I learned at HMR. If you don’t have it in the house, you probably won’t eat it. For years, there were certain aisles in the supermarket I would not go into so that I would not be tempted. In our current house, I am privileged not to have to share the kitchen and so can stock it with healthy food and keep things which are bad for me away.

Portion Control/Plate Size

An unsurprising concept: if we eat less, we weigh less. One of the members of the staff weight-control group is unable to control what she eats because she prepares the food for her family and they eat food traditional to their ethnicity, but she can control her weight by changing the amount she eats.

Along the same lines, using a smaller plate can help control portions.

Water

This is the ultimate low-calorie, no-fat, carb-free “food”. It is thought to reduce appetite, particularly if taken about 1.5 hours before eating. I also saw a claim that it increases metabolism, but I’m not sure if that could be true.

Progress Not Perfection

Those of us who are overweight can be unpleasantly self-critical. We also face criticism from other people. The more criticism we face, the worse we feel. The worse we feel, the more we eat. Not a productive dynamic. I believe it’s more helpful to give ourselves credit for the progress we make and to start over if we fall short.

In Short

Weight control is a difficult but worthwhile task. I hope we can undertake it with joy and not resentment.