Dr. Marissa’s Weight Loss Prescription

One of the most common questions I get asked by my patients is how they can effectively lose weight. It’s no surprise that this comes up so often as recent estimates place the rate of obese Americans to be around 33% of the population.1 There are also many more people who may not fall into the category of “obese” but are still slightly to moderately overweight (about 60% of Americans) and would benefit from a comprehensive diet and exercise program. There is so much misinformation given to the public regarding dieting that I decided to choose this as the first topic for my MedBlog. The average 15 minute patient encounter is hardly enough time to impart a comprehensive strategy for weight loss that encompasses all of the recent research and practical knowledge I have gained over the years of trying to help my patients achieve their weight loss goals. The following is a step-by-step guide that I developed and combines several strategies that you may have heard or read before but that are the ones that in my experience have shown to be the most effective.

Step #1: You must realize that there is no perfect diet.
We’ve all heard the outrageous claims of some of these bizarre diet plans. My favorites are the ones on the front of every women’s magazine in the check-out aisle at the grocery store. “Lose 20 pounds in 2 weeks by eating ‘fill-in-the-blank’ food” with a large picture of a pie, cupcake or some other confection on the cover. Wouldn’t that be wonderful? I’ve always had dreams of coming up with an ice cream diet where I could get the perfect body by eating Blue Bell all day. When I figure all the details of that one out, I’ll be sure to let you know. In the meantime, we are going to go over practical tips that you can apply to your every day eating that I guarantee will get you results if you follow them.

A recent study published in the New England Journal of Medicine showed us that the various popular diets (low fat, low carbohydrate, Mediterranean) were all effective when followed faithfully and had very similar amounts of weight loss at the end of a 6 month period. The different study arms were similar in another, more unfortunate way – once the patients stopped their diets they gained the weight back and were similar to each other at 12 months after the end of the study.2

Everyone’s body is unique with a specific metabolic rate and different food sensitivities. We will go over the basics of healthy eating in this article but you must understand that your health is not identical to anyone else’s and you may need to make adjustments that work best for you (this is where monitoring your progress comes in –see step #3). The best diet and exercise plan is the one that you can stick with.

I am going to give you several tips to help you lose weight. Ideally, you would be able to follow them all but even if you can’t manage all of them you will reap some benefits. Just understand that the more of these tips that you can apply to your eating and exercise behaviors, the more successful you will be.

Step #2: Remove the word “diet” from your vocabulary.
Just as you developed habits that got you into the body that you have now, you must develop healthy habits to reverse the trend of weight gain. The word “diet” implies a temporary state of adjustment. You must resolve to change your behaviors for the better, from now on. Of course you will have periods where you will be more strict with your intake and other times when you are in “maintenance mode”. I tell my patients who want to quit smoking – you need to determine in your mind that you are going to make some permanent positive changes for your health and well being in order to be successful and the same applies to your eating habits. Rest assured, if you go back to your original behavior – you will gain the weight back, and then some in most cases. This is one thing that I caution my patients when we begin medications for weight loss. Dieting and weight loss medications are a temporary fix to a long term problem.

Step #3: Know your starting point
Just as if you were running a race, the first thing you need to know is where the starting line is. I recommend purchasing a notebook for record keeping during this process. Weigh yourself and write down your initial weight (no clothes is the best way to prevent variability and always use the same scale as you will be doing this weekly to monitor your progress).Ideally you should weigh yourself weekly indefinitely. This has been shown to be an effective tool to help overweight patients monitor and maintain their weight loss.3 Some fitness experts also recommend measuring your percent body fat. This would be a great way to monitor your progress especially if you are building moderate to large amounts of lean muscle but finding and using a caliper or some of the other methods are not very practical for most of my patients so I’ll give you a link to check this out further if you are interested (http://www.accumeasurefitness.com ). You may also want to take measurements of certain areas on your body (waist, hips, thighs, chest, arm and lower leg circumference).

Find out what your BMI (body mass index) is and know where you are on the scale of healthy weights for your height. This is so you can find out where you are headed and have an idea of where you need to be. This is a far-from-perfect method since patients come in all sizes and frames but it is what the medical community and others (life insurance companies, etc…) use to give an overall measure of weight and its relationship to one’s health. For example, if you calculated Arnold Schwartzenegger’s BMI he would likely fit into one of the “unhealthy” weight categories. Obviously, we would not consider him to be obese because his weight comes from lean muscle. Until we are able to better estimate percentage body fat with an easy, reproducible method we will be using BMI to measure ourselves.

(http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html ).

It is also helpful to estimate your basal metabolic rate. This will become important when we talk about steps #5 and #6 (http://walking.about.com/cs/calories/l/blcalcalc.htm ).
If you have access to a physician it would benefit you to have some basic lab work done including a thyroid panel to make sure you are not fighting a losing battle against your own metabolism (specifically if you have hypothyroidism). I also recommend checking a fasting blood sugar and a cholesterol panel. If you are planning on starting an exercise program and are generally sedentary, you should have a pre-exercise medical evaluation to determine if it is safe to do so. If you have significant medical problems, diabetes, or known cardiac disease, it is recommended that you undergo a cardiac stress test prior to starting any vigorous exercise. Consult your personal physician to determine if these guidelines are applicable to your situation.
Make a food diary logging everything (and I mean EVERYTHING) that goes into your mouth for one week. This includes beverages, snacks and even gum. Include an estimated calorie count for each food entered and tally the total calories for each day. Make an average of the days and you will have a much better idea just how many calories you are consuming. Most of my patients find this exercise to be very educational. Many of them were eating what they wanted and however much they wanted, whenever they felt like eating it. When they find out just how many calories this entails – they are shocked. You should continue this food log for several weeks as you are changing the way you eat. This may seem like an annoying home work assignment but I promise you if you will do this, eventually reading labels will become habit and you will have a much better knowledge of what you are putting into your body daily and how many calories each of your meals is adding to your daily intake.

Step#4: Write down your goals
On the front page of your notebook write down your goal weight. If you are very overweight you will probably want to pick a short term and a long term goal weight so that you don’t become discouraged in the weeks and months ahead. I usually recommend an initial goal weight around 10% less than your current weight. Studies show that this is a very achievable goal when a reasonable diet and faithful exercise are combined.

Your eventual exercise goal should be about 1 hour a day most days of the week. This is what research has shown us helps patients to lose and maintain their weight loss most effectively. Obviously if your starting point is a totally sedentary state (only moving from the bed to the elevator to your desk then to your couch at the end of the day) then you will want to start off small, 15-20 minutes a day for 3 days a week, increasing first to longer workouts and then to more days of the week. Increases beyond an hour of exercise tend to show less weight loss and a higher risk of injury. If your goal is to burn more calories than is possible in an hour then try splitting up your exercise into 2 sessions a day. Look for another MedBlog coming soon with more information on exercise.

Step#5: Maintain a Negative Calorie Balance
This is the most important component of any weight loss program. There is a very simple energy equation that states if you consume more calories than you burn throughout the day then you will gain weight. Research tells us that a good portion of the population is gaining around 2 pounds a year. This is the kind of weight gain that is not noticed immediately but after a decade, there they sit (usually in front of the television), 20 pounds heavier. Conversely, if you burn more calories than you are consuming then you will lose weight. The best method to achieve the maximum amount of weight loss is to combine a decreased caloric intake with increased caloric expenditure (through exercise).
Go back to your estimated BMR number or your average calorie intake from your food diary. A good amount to aim for is 500 calories a day less than what you are taking in now. For some, this may be too dramatic a change and if so I would say start with a 15-20% reduction in your daily caloric intake. One tip that helps to keep calorie balance in perspective is by noting how many calories you burn exercising daily. Some treadmills, elliptical machines and exercise bikes have this feature built in. If you don’t have this available then here is a link that will give you an idea of calories burned with certain activities. (https://client.myoptumhealth.com/myoptumhealth#prelogin.learn.learnLanding ) It is easier to skip or at least eat less of that calorie dense “cheat” food when you have some idea how long and hard you will have to exercise to burn it off.

Step#6: Prevent the starvation response
Our bodies were designed to adapt and respond to periods of starvation. Now that we have easy access to great-tasting, cheap, calorie dense foods without much effort (think drive-thru) our bodies’ starvation response tends to work against us after we implement a weight loss eating plan. After a few days of a negative energy balance, your body will change the hormonal milieu of your system to encourage you to go into “storage mode” by slowing down your metabolism. One way to prevent this is by tricking your body by cycling your calorie deficit days. A schedule of 3 days of calorie deficit followed by 1 day of increased intake up to maintenance level (see your calculated BMR number above) will help you lose fat without losing the lean muscle you have built up with exercise. I have patients that prefer other patterns (2 days on: 2 days off, etc…) but the 3:1 ratio is the cycle that I have found to be the quickest and most effective at lowering body fat without burning off your lean muscle in the process. On your days off be careful to try to get as close to the maintenance calorie number and not to go too far over that amount so that you don’t wipe out a weeks’ worth of healthy eating for your one “cheat” day. It’s also not a terrific idea to have an entire day of cheat meals, try to have 1 cheat meal and enjoy it.

Step#7: Eat multiple small meals
In order to keep your metabolism up during the day, you should not go more than about 4 hours without eating something. In a perfect scenario you would take your target calorie intake then divide it by 5 for women and 6 for men and then plan your meals accordingly. This is not possible for some of us, so as an alternative I suggest a more traditional schedule of 3 larger meals (still smaller than what you have been eating) with a snack between each meal and another snack if you can squeeze it in 2-3 hours before bedtime. Look for an upcoming MedBlog on proper macronutrient ratios and examples of these meal plans.
Step#8: Eat breakfast like a king, lunch like a prince and dinner like a pauper
You have probably heard this tip before but its benefits cannot be overestimated. You should taper not only your calorie but also your carbohydrate intake throughout the day to maximize your fat loss. That way you have the entire day to work at burning off your earlier meals. Also, if weight loss is your new job, skipping breakfast would get you fired. Most of us do the exact opposite of this. I certainly am guilty of it. We are rushing around in the mornings, too busy to eat and before we know it noon rolls around and we are STARVING which causes us to over-indulge and consume way too many calories at lunch (probably something quick, easy and not very healthy –burger/fries/coke). Then we get home and enjoy a big family dinner. My personal favorite breakfast is oatmeal (instant if needed) with some low fat yogurt and/or fruit. More tips on specific food choices are coming up in my next MedBlog.
It is more difficult to follow these guidelines when you are the only one in your household doing it. This is where portion control comes in. If your family loves spaghetti night then instead of eating a plate full of pasta like the rest of your family, only have a small portion and eat more salad and consider skipping the garlic bread. Remember, these are lifestyle changes. I don’t want you to have to move out of your house or be miserable to lose weight. Just make a few adjustments to what you would normally eat and long-term you will reap the benefits.

Step#9: Drink plenty of water and avoid sweetened beverages
A good estimate is 8-10, 8 ounce glasses of water a day. This will need to be adjusted to factor in exercise. Water improves muscle function and endurance during exercise. Especially if you are following a higher protein program, increasing your water intake will help to flush out the metabolic by-products of your diet.
Recent studies are showing us that sweetened beverages may be one of the key elements to weight gain in the United States. Just changing from regular soda to diet soda or water (crystal light or unsweetened tea if you are not a water fan) will decrease your calorie intake significantly without much effort on your part. Be careful to note the sugar content of fruit juices and sports drinks such as Gatorade as well.
Alcohol is an extremely calorie, carbohydrate dense beverage. Especially during the stricter times in your weight loss program, plan to avoid it. Binging will set you back a lot, so stick to one alcoholic beverage if you decide to indulge.

Step #10: Don’t forget to MAINTAIN what you have worked so hard to achieve
As I mentioned previously, if you faithfully follow a diet/exercise program you will eventually lose weight. The harder part for many is keeping it off. Your body has its own “set point”-kind of like a thermostat but for your weight and body fat content. You have possibly noticed this when your weight hovers around a certain number, almost regardless of what you are doing and eating. When you go below this number the hunger signals are sent out and when you are above this number you may not feel as hungry. This is a tough mechanism to fight but once you make these steps a habit, it becomes much less difficult. I wish you great success in your efforts. Look for future MedBlog articles on nutrition, exercise and weight loss medications coming soon.
1. JAMA, accessed via CDC.gov. http://jama.ama-assn.org/cgi/content/full/303/3/235?ijkey=ijKHq6YbJn3Oo&keytype=ref&siteid=amajnls
2. “Weight loss with a Low Carbohydrate, Mediterranean or Low Fat Diet”, New England Journal of Medicine 2008(359):229-241.http://content.nejm.org/cgi/content/full/359/3/229
3. National Weight Control Registry, http://www.nwcr.ws/Research/default.htm
Recommended Reading Materials
Burn the Fat, Feed the Muscle by Tom Venuto, CSCS, CPT. www.burnthefat.com
Low Carb Dieting for Dummies by Katherine Chauncey, PhD, RD . http://www.dummies.com/store/product/Low-Carb-Dieting-For-Dummies.productCd-0764525662.html