By Charles Gebhardt MD
Part I: An Overview
The Nature of the Problem 4
The Yo-Yo Dieting Phenomenon 7
Part II: The Causes of Overweight
A Simple, Powerful Tool and Some Easy Answers 12
Is Exercise the Answer? 15
Emotional Overeating 18
Why Are So Many People Overweight? 20
Body Shape Criticism and Discrimination 23
Applying these Insights 25
It’s not so Much How Much You Eat; It’s What You Choose to Eat 27
Fruits, Table Sugar and Corn Syrup 30
Whole Grains, White Flour and White Rice 32
Vegetable Fats and Animal Fats 34
Putting the Specifics of Part III All Together 35
Part IV: Working with Over-all Food Patterns
Trying Out Different Ways of Eating 38
Advice for Those with Diabetes or Cholesterol Problems 40
A Low Carb Approach 41
“The Mediterranean Diet” 42
A Vegetarian way of Eating 43
Part V: Beyond Food and Exercise
Looking Deeper into the Risks of Increased Fat Stores 44
Using Medications for Weight Control 46
Surgical Options 48
This is not just another weight loss book. Since it is based on my rather unique combination of training and experience, it may well be exceptionally helpful for anyone interested in body weight control. It is a little unusual because it was written by a primary care physician specializing in internal medicine. With this background and training, I have been able to incorporate my understanding of both the effectiveness and the limitations of modern medical knowledge in diagnosing and treating chronic diseases like diabetes, cancer, atherosclerosis and dementia. While there is much we still do not know about the causes of these illnesses, we do know beyond any doubt that both body fat stores and the kind of food our patients consume have very important roles to play in the prevention and management of these diseases.
What is a lot more unusual about this book is that I am trained in nutrition science and this has given me a thorough understanding of both animal and human nutritional needs. Because of this background, I am very aware of the diseases caused by malnutrition, what we need from our food to optimize our health, and how what we eat impacts our medical problems.
What further sets this book apart, I also have over three decades of clinical experience applying my medical and nutrition science expertise helping patients control their weight. This has allowed me to carefully test the theories and principles derived from research to select only what is both effective and practical in people’s lives. I have learned what works and what doesn’t work. I have also learned how to guide people past the obstacles they face in applying this knowledge in overcoming their weight control problems.
Over the years, I have found that what people need most is accurate and reliable information. Since most of what is available on the internet and in the popular media about weight control is misleading or even harmful, I find that just about everyone struggling with their weight is frustrated and discouraged. Good guidance can relieve this frustration. Beyond finally helping them with their weight, information that gives them a much better understanding of the difficulties they face may even improve their confidence and self-esteem.
People also need reliable on-going instruction about how to effectively apply this knowledge. Many have lost touch with their natural sensations of hunger and satiety through following misguided concepts and eating “rules.” They also need help to better understand and work with genetic pre-dispositions toward weight gain, with their taste preferences, and with their life circumstances so they can successfully adapt nutritional knowledge to their personal needs. I have also found that helping my patients to reconnect with their innate hunger sensations and their body’s weight regulation systems can be a tremendous relief.
While my main intent with this book is to use my rare combination of training and experience to provide information and guidance, it also provides another huge bonus. As I was catching up on the most recent research to make this book as up to date as possible, I was finding recent studies providing startling insights into the underlying causes of many of the deadliest and most disabling diseases that we face. This research is beginning to answer questions that have puzzled medical scientists for many decades and provide a unified picture of what is causing many of our most frustrating and deadly chronic diseases. This book will not only show the way toward improved body weight control, using its guidance will help prevent or better treat many of these diseases in the process. It turns out that these two goals, controlling body weight and avoiding chronic illness, are closely intertwined and our food habits play a major role in both.
Part I of this book: An Overview, will provide a general orientation to why this problem is so important and why trying to deal with it is so frustrating to so many people. Part II: The Causes of Overweight, will summarize what I have found to be the actual sources of this problem. Part III: Specific Food Choices for Weight Management, will discuss alternative food choices that will improve our health while helping with weight control. Part IV: Working with Over-all Food Patterns, will discuss a number of popular general approaches to food choices that allow for individual preferences and life circumstances while still meeting our nutritional requirements. In the fifth and final part: Beyond Food and exercise, I will briefly discuss using medications to assist with weight control as well as surgery designed to control weight and to help manage weight related diseases.
The Nature of the Problem
As I am sure you are already aware, the problem of body weight becoming high enough to begin to cause or aggravate severe medical illnesses is on the rise, especially among American adults. Over one third of adults in this country are classified as “obese” using the Center for Disease Control’s classification. It is also well established that some of our most deadly and disabling health problems, like diabetes, hypertension and disabling joint and spine diseases are associated with excessive body fat stores.
There is also no doubt that the threat of these problems, and many others that are associated with increasing weight, is strong motivation for many people to do whatever they can to stop gaining. As one indicator of this motivation, in the US alone, the money spent on weight loss programs, devices and foods marketed for this purpose now exceeds 100 billion dollars a year. Yet, despite all this concern and investment in time and income, the problem shows no sign of improving.
Why is this? From the perspective of a physician like myself specializing in dealing with this problem, I see several important reasons. One is that many people sit at a desk all day at work and are working too many hours to easily increase their level of activity. Another is that our culturally acquired taste preferences and food habits are often highly conducive to increasing body fat stores. To add to these factors, as mentioned earlier, much of the information widely available in print, on the TV and through the internet is misleading, or just plain wrong. Then, to top it all off, many of the programs marketed to assist with managing the problem actually make it worse! This misinformation and misguided solutions lead to frustration and a loss of confidence in being able to control the problem.
These obstacles to successful weight management are pervasive and difficult to get beyond. From experience, though, I know that many, if not all, can be overcome. Let’s begin to look at some reliable guidance. Let’s consider a couple of key insights I have gained over the years and explore their implications. The first:
The causes of excessive weight gain are very complex
If you consider the circumstances and needs of a large number of people suffering from overweight, you find a large number of different problems. While some causes are fairly common, nothing is universal, and there is no “magic bullet” that works for everyone. This understanding points out a fundamental flaw in many programs marketed as “the” answer to weight control. They are not flexible enough and adaptable enough to the specific, individual needs. What is required is an approach to tailored to personality, circumstances, genetic make-up and physical traits. As we go on in this this book, we will see how this might be done. It is complicated, but it can be done. I do it every day that I am helping patients in my office.
Next, let’s briefly discuss a second key insight to round out this chapter:
For almost everyone with a tendency to be gain excessive weight, this is a life-long problem.
This means that any temporary strategy is useless for long-term weight management unless it is followed by a maintenance program that is both effective and practical as a way of life. A closely related observation is that the same techniques that help with weight loss will need to be continued once the target weight is reached, if the loss is to be maintained. In light of this understanding, many weight loss strategies are not only a waste of money, they can actually be harmful. Drastic, short-term weight programs, if they work at all (many do, for a while), are usually followed by a regain of the weight lost. I will be discussing the reasons behind this in more detail later. For now, suffice it to say that almost always, after this scenario, the final weight after the regain is usually higher than before the start of the program or strategy. In addition, the participant is usually more discouraged than ever! These outcomes do harm to the participants.
If you are trying to improve your health through control of your body weight, applying these insights will immediately eliminate from consideration a lot of the popular weight control programs and fads being promoted at any given time. I strongly recommend that you begin your evaluation of any technique or plan by looking long and hard at the long-term maintenance strategy, asking: “Can I afford this the rest of my life and is it practical as a permanent life style?” If there is no answer at first glance, either find the answer or look for a better approach. As this book goes on, I will have much more to say about how to either find an effective long-term plan or, better yet, how to develop your own plan to meet your personal needs. If you are struggling with a tendency to gain weight and your future health is your concern, an effective long-term weight control strategy should be your primary goal – it is the only way to get there. Fast weight loss and short-term strategies are not real answers.
In the next chapter, I will help you to deepen your understanding of these insights by a discussion of what is often called “yo-yo dieting.”
The “Yo-yo Dieting” Phenomenon
If you are not familiar with the phrase “yo-yo dieting” it means the tendency to start a diet, often with great enthusiasm, to lose weight for a while, then to stop the diet and regain the weight lost, often ending up weighing even more than before starting the diet. This sequence becomes a “yo-yo” when it keeps happening over and over, much like the child’s toy that keeps going up and down at the end of the yo-yo string.
Unfortunately, this kind of experience is very common. In fact, it is probably more the rule than the exception for most people struggling to control their weight. One of the reasons it is so common is the influence of the large number of diet fads in weight loss books, on TV, and on the internet. These fads have a sort of life of their own. Typically, they get a lot of attention as they are launched, they grow, they reach a peak, and then they slowly die out.
Most of these diet fads are based on very unusual modifications of the way we usually eat. They usually greatly limit the foods allowed and often have timing rules specifying what you can eat and when you can eat it. The way they are promoted strongly implies that certain foods, when eaten in the allowed combinations and at specific times of the day, have some sort of mysterious power to promote weight loss. If they are strange enough or restricted enough, they will almost always produce significant weight loss — at least for a period of time. The promise of dramatic weight loss raises the expectations of those interested in them and, for a while, especially when they first appear on the scene, there are reports and testimonials circulating about how effective they are. The initial dramatic weight loss and very effective marketing helps them become very popular, but over time people learn that the initial weight loss is not maintained. Usually, within several years, they are gone. A list of past diet fads and failed techniques would be quite long indeed! Almost all go through this cycle, some last longer than others, but very few, if any, are based on sound nutritional principles.
The seductive messages of these fads have some very harmful consequences. First, they create unrealistic expectations about how fast a person should lose weight in an effective program. As one result of these fad promotions, most people have a greatly exaggerated idea of how quickly weight can be lost and still be kept off. This sets them up for “yo-yoing.” People eventually quit these peculiar and un-physiologic fad diets for many reasons. They often fail to work, their cost may too high, or they eventually get to be quite boring. In addition, they often cause a degree of malnutrition that makes people feel lousy, due to what these unhealthy food patterns do to their body. Ironically, the more effective they are in bringing about rapid weight loss, the less likely they are to be continued (this is a good thing, though, since too rapid weight loss can be quite harmful, if continued long enough). Another undesirable consequence is frustration on the part of the initially enthusiastic dieter who, after succumbing to the taste fatigue and the malnutrition, stops the diet and feels physically spent due to abuse his or her body has endured. This yo-yo pattern is so discouraging that many people eventually just give up their weight control efforts completely.
There are two ways to this avoid “yo-yoing.” First, be sure your expectations are realistic for what you are trying to do. The rest of this chapter will help you with this by providing a rough but reliable guide to what is a reasonable rate of weight loss for any approach with a reasonable chance to be long lasting. Second, be sure you understand what your body must get from the foods you eat so you do not allow yourself to become malnourished while trying to promote your long-term health. Several of the chapters that follow will help you with this.
What, then, are realistic rates of weight loss? What I am about to recommend is based on several decades of experience treating thousands of people — many for long periods of time. While these guidelines are not based on scientific research, they are derived from very careful observations of what works and what does not work. They are not absolute in any way, but they do provide reliable guidelines.
It is the rate that you can lose weight effectively over years and still keep going that we are focusing on here. I want to be clear, though, that I am not talking about the larger losses that can easily show on our scales during the first month or two of starting an effective weight loss effort. Much of this loss is just water. It is important not to get overly concerned about this rapid weight loss at the start, nor to let expectations become unrealistic due to this initial drop, if it occurs.
Let’s start by discussing the effective rates of weight loss for those with the most weight to lose. As you might expect, the heaviest people can lose the fastest while still maintaining their losses long term. As a point of reference, let’s define this somewhat arbitrary “heaviest” group as those who weigh twice as much, or more, compared to average. Over the long term, I have found that those in this heavier group can rarely exceed about 6 pounds per month and keep losing. What? Six pounds per month! What about all those “super” diets that guarantee 10 pounds in a week or more? Well, even for this heavier group, these rates of weight loss cannot be maintained.
Now, we turn to an intermediate group. This group I will define, again somewhat arbitrarily, at less than twice their normal weight for height, but still more than about 30 or 40% above average. This is the group I most frequently treat. They can expect no more than about four pounds to be lost per month if they want to be successful long term. Some do a little better while some don’t do this well, no matter how hard they try. This is an average which has a long-term view built in. People losing faster than this are usually over-doing it and often leaving themselves hungry much of the time. There are a few individuals that can significantly exceed this rate and keep it off, but not very many, probably less than one out of one hundred. This is a rate of weight loss you can sustain over the long haul without getting yourself into a host of possible problems which will force you quit.
Keep in mind also, that when you start in a heavier group and lose successfully, your rate of weight loss will slow as your weight comes down. This is the way your body responds to weight loss, even when done in the best way possible. Your body is built that way to survive periods of starvation.
The last group is the mildly overweight people (but they often don’t see themselves as mildly overweight). They are still close to average weight and their degree of overweight usually has not yet been causing health problems. These folks can generally expect to lose only one or two pounds per month if they are to maintain what they accomplish permanently. This requires a lot of patience! It is also easy to misinterpret what your bathroom scale is telling you when you are losing weight this slowly, since you can easily gain or lose three or four pounds of water in just one day, and this will make it very hard to recognize such slow weight loss on a scale. If you get impatient, though, and try to lose faster, you run the very real risk of starting the yo-yo pattern that I have been warning against.
The unrealistic expectations of how much weight can be successfully lost and still maintained is a major cause of failure for people trying to reduce their body weight. If you are in this group with unrealistic expectations, readjust your sights and you will be in a much better position to succeed. I will restate this as a maxim for easier recall.
Unrealistic expectations about what is a reasonable rate of weight loss will almost eliminate the chance of long term success.
Part II of this book will cover what is known about the causes of excessive body fat stores based on what has been learned from well-designed scientific research and from what I have discovered over the years through applying this knowledge to help my patients.
The Causes of Overweight
As I mentioned earlier, since there are many different factors that may lie beneath a given individual’s tendency to keep gaining weight, and these factors vary from person to person, a weight loss program must be highly flexible if it is to help most of those who may want to use it. One of the ways I emphasize this concept to my patients is to say: “If you were to evaluate 100 people with weight control problems, you would find 100 different problems.” Every individual has different needs and may respond to any program, medication or strategy in unpredictable ways.
What this tells us is that a rigidly structured weight loss plan will help only a minority of those who try it. On the other end of the spectrum, it also implies that the best plans will involve experienced practitioners that can adjust and tailor the plan to the effectively meet specific needs. I attribute a lot of my effectiveness in treating this problem to having acquired a lot of experience which I can draw on to fashion a strategy that is most appropriate to my patient’s circumstances.
To begin to deal with this complexity, I will describe a very useful tool to help sort out the causative factors behind weight problems. If you are working on your own weight control issues, it will help you better get to the root of what is going on. It will also be useful for other therapists who want to target effective techniques to specific needs, or who may want to improve their ability to separate the tough to treat situations from the easier ones.
The tool involves developing a clear concept of a person’s body weight changes over the course of their lives. When you find significant changes in weight, exploring the circumstances surrounding the changes is often extremely helpful. If you know how to interpret what it is saying, and how to tie it in with what else is happening in that individual’s life, it is a veritable gold mine of useful information. Applying this concept to the weight change history of thousands of patients has led me to many of the insights you will find in this book.
Sometimes, a good weight history uncovers a simple factor that is the key to a person’s problems. These easy answers are a bit rare, but it is very important to find them when they are present. Finding and resolving them can be the complete answer. The rest of this chapter is a list of some of these easy solutions.
HYPOTHYROIDISM: For trained medical professionals, this is easy to diagnose and simple to treat. Appropriate lab tests give clear answers. On the one hand, it is important to be aware that even if a low thyroid is present, it may not be the most important factor causing a weight problem. On the other hand, if it is present and untreated, it will almost always undercut the chances of success. I have seen a few cases where it was not even suspected after a thorough medical history and examination, and yet it was the whole problem. I always check.
SUCCESSFULLY QUITTING SMOKING: Over the years I have learned that if steps aren’t taken to avoid weight gain, just about everyone who quits smoking cigarettes gains weight for the next six to twelve months. Most people are aware of this, but I still come across some who do not realize why they are gaining weight after successfully stopping their cigarette habit. Not only that, weight gain is a also a very common reason for people to start smoking again. Because of this, for people who have recently quit, I at least consider the temporary use of weight loss medications to counteract this effect. This usually works nicely.
COMPLICATIONS OF CERTAIN MEDICATIONS: The weight change history is also very important in discovering this cause. Just about everything I know about how common medications affect body weight was acquired by exploring people’s weight gain histories who were using them. Just about everyone knows that steroids like prednisone are a common cause of weight gain, but sometimes medications that you wouldn’t expect to cause a gain, like a blood pressure medicine or even an antihistamine, can be the culprit. Many of the older diabetes drugs as well as insulin treatment are frequent causes. On the other hand, some of the newer diabetes drugs are actually excellent weight control medications. Some antidepressants can help with weight loss while others commonly cause weight gain. There is no substitute for a good weight history performed by a knowledgeable health professional if you are taking long term medications for chronic medical illnesses. Just about any medication can cause weight gain in certain individuals. If this is even part of the problem, eliminating it is essential. For a rare few, it could be the whole problem.
DEPRESSION: Depression can also be the sole cause of excessive weight gain. Some depressed people lose weight, for others, weight does not change much. But, unfortunately, many gain when they become depressed. Occasionally, increasing body weight can be the clearest symptom of an otherwise hard to recognize mild case of depression. More severe depression can produce a vicious, self-reinforcing cycle since the emotional impact of weight gain can easily aggravate the depression, which then can further increase weight.
Since I always look for depression and treat even mild cases, I have gotten very good at treating depression. I have learned that if depression is present, addressing it effectively is almost always essential to successful weight management.
PERIODS OF ENFORCED IMMOBILITY: Weight gain following a period of immobility is common. Usually, people pick up on this one easily. Sometimes, though, an individual just doesn’t make the connection and needs help understanding how to best handle this kind of situation.
While weight gain associated with a period of prolonged inactivity is straight forward, the interaction between our level of physical activity and our body weight regulation is not simple. For just about everyone concerned about their weight, it is very important to clearly understand the interactions between physical exertion and weight control. There is so much confusion and misunderstanding about what exercise can and cannot do to help someone trying to control their weight that I will devote the next chapter to this topic.
It is a very common weight loss strategy for people to estimate the number of calories they expect to “burn” through exercise and then try to use up the fat they wish to lose by activities like jogging on a treadmill or walking their favorite path. It is also a common belief that the reason obesity is becoming more and more of a problem in modern society is because we are more and more sedentary in our lives. What I have noticed over the years, though, is that the role of exercise in weight loss is not so simple. Recently, well designed research further confirms my observations that these common assumptions are wrong and they underscore the complexity of the interaction between our level of physical activity and our body weight.
Like everything else that impacts our weight control effectiveness, there is a lot of individual variation. No single approach works for everyone. There are some folks whose weight is very sensitive to changes in exercise and other activities, while there are others for whom even quite long sessions of very vigorous exercise on a regular basis doesn’t help their weight control much at all.
Despite all this individual variation, though, it is still possible to describe some useful general patterns. A lot of animal experimentation has been done in which various species have been studied to see how their innate body weight regulation systems adjusted to different levels of activity. No matter which species has been studied, the same patterns have been found. One type of research, exercise restriction studies, typically involves allowing the experimental animals to eat and drink as much of their natural food and drink as they want to consume. Researchers then devise ways to vary the animal’s activity all the way from no restrictions at all, down to the point where they are totally immobile, yet still allowing them to eat and drink as much as they want. The animals normally regulate their body weight quite precisely if free to move about at will, but as their activity drops below a certain level, they no longer maintain a normal body weight. When animals in these studies are restrained enough, their weight regulation mechanisms become disrupted and they eat more than they need to maintain their weight. They become overweight, sometimes even quite obese. Then, if these exercise restraints are eliminated, their weight tends to return toward normal. Research with human subjects show this same pattern, just like other animal species. If we are inactive enough, we tend to eat more than we need and an otherwise normal appetite regulation can break down. But once we become more active and reach our threshold of “enough” activity, our weight is usually much better controlled.
Another type of exercise research is even more important for us to understand than these exercise limitation studies. If, instead of restricting their activity, researchers force animals to increase it above normal, you might expect that they would lose weight even if they could eat and drink as much of their natural foods as they want. This is not what happens. Even at very high forced levels of exercise, if they have access to plenty of their natural food, the animals eat just enough extra food to balance out the increased energy they a forced to use. Their natural appetite regulation increases their food intake just enough to match the energy costs of the increased activity. Numerous human research studies also show that our innate appetite systems work just like those of other animals. Even at very high levels of activity and exercise, our appetite is up-regulated to precisely match our needs and prevent weight loss. Unfortunately, this tends to be true of both normal weight and overweight research subjects.
There are two lessons here. One is that, if possible, it is best for us to make sure we have enough daily activity and exercise to get us above our threshold so that we are not fighting an abnormally increased appetite. The other is that once we are above that threshold, increasing our exercise will not generally help us lose more weight, we will most likely just get hungrier and eat more to compensate.
Many times, people have told me how puzzled they are that they cannot control their weight and then when I begin to question them, it is their exercise level that they focus on. They say: “How can I be working so hard on such a vigorous exercise program and my weight doesn’t go down? Even as I exercise more and more, my weight just doesn’t respond.” Fairly frequently, a careful food history indicates that they consume a diet that is very conducive to weight gain. It is as if they think that it is only exercise that matters and a good exercise program will eliminate the need to work on a healthier way of eating. This brings me to another very important maxim:
A vigorous exercise program will not make up for poor food choices.
The flip side of this equation is also true. Even if someone is completely immobilized due to injury or disability, they usually can still control their weight with a careful attention to their food choices. It will probably be harder for them to control their weight, but not impossible.
A further point is also important: as your activity level drops, it is not easy to predict at what level of exercise your own activity threshold will be crossed and your appetite will become less well-regulated. You will have to find this out by trial and error. There is a lot of individual variation, but in general, I find that if people with an otherwise sedentary lifestyle undertake a moderate level of exercise for about an hour three times a week, this seems to be enough to get most people above their innate threshold. Of course, it does not matter to your body if your exercise is hustling on an assembly line at work or on a treadmill at a gym. Exercise is exercise whether you pay someone for the opportunity to do it or they pay you for your efforts. And, of course, this same exercise is not just valuable for weight control; it helps every aspect of body and mind. The human body has evolved in such a way that it does best when active and is not easily adapted to a sedentary life style. The take home message: unless your chosen form of activity is physically damaging to you, it is always a good thing to engage in.
I am often asked what kind of exercise is best. Probably the best is a lifestyle that is normally active and requires nothing additional. People that have physically demanding jobs, who do a lot of work around the house or who enjoy keeping their property or garden looking good often need no extra exercise. But counseling many individuals who lack these kinds of natural activity in their lives, I have found that what matters most is that they find something fun and comfortable for them. Something they enjoy. If they don’t like it, they probably will not keep it up. It needs to be a part of a practical plan they can continue for the rest of their lives. Making it into a social activity, or being able to listen to enjoyable music during workout sessions, or walking a favorite trail through the countryside, or even reading a good novel while walking a treadmill can be ways to make exercise more enjoyable and, consequently, easier to stick with.
So, the upshot of all this is that there may be an occasional person for whom an exercise program is all they need to control their weight, but most of us will need to optimize both our exercise and our way of eating. If we are not already naturally active, each of us will need an individualized approach that will require some testing and careful observation to arrive at an exercise plan that works for us and by matching both our personality and body’s needs.
We finally are getting to where the rubber meets the road for most of us in controlling our body weight: what we usually eat. Just like a very sedentary life style can disrupt our natural appetite mechanisms, there is another source of disruption that I will discuss next: emotional drives to overeat. This will be the topic of the next chapter.
The power of our emotions to motivate us is obvious and undeniable. Not only can they sometimes cause us to act in quite illogical ways, they can also make us ignore the innate hunger mechanisms that naturally guide us toward optimum health. In its normal function, our hunger will motivate us to eat enough for our needs and no more. In working with those who gain excessive weight, though, I often see people who realize they are in the habit of eating when they are not physically hungry. They crave certain foods since they know that these foods help them to feel better. This usually occurs when they are feeling stressed, worried, lonely or frustrated. Just about any negative feeling or state of mind can improve, at least for a while, as we consume food we enjoy.
There is no doubt that the pleasure we get from eating foods we enjoy has a natural consoling effect when we are distressed. Mothers instinctively use food to calm distressed infants, and our experience with this nurturing role of food when we are young adds to its consoling effect even further. But this natural role can become a problem for our weight if we are frequently feeling distressed and get in the habit of looking to our favorite foods to find relief.
If you are not certain if this applies to you, some careful self-examination may be in order. The first question you might ask is: “Do I ever eat when I am not physically hungry, and sometimes go on eating even though I am feeling full?” Another clue that may help is that when you are truly hungry, a wide range of foods will fill the bill, while emotionally driven eating usually causes us to seek out only those foods that we truly enjoy. A further clue is the way our feelings change as we are eating in response to emotions rather than true hunger. While the level of emotional discomfort is often improved during this kind of eating, the emotional discomfort returns soon after we stop.
If you find yourself in this “emotional overeating” scenario on a regular basis, recognizing it is likely to be the easy part. What to do about it is not so easy. You might try substituting something else you enjoy in place of food. Perhaps talking to a good friend, listening to your favorite music, or anything you really enjoy. An even better answer may require some courageous introspection. You could explore why you are feeling so stressed or uncomfortable in the first place. You could consider the circumstances that are causing the distress and what you might do to change them. If the situation can’t be changed, you might ask yourself what is it about your circumstances that is triggering your distress. Talking with a sympathetic friend, a therapist or a counsellor could be extraordinarily helpful, here. In my experience, you will need a solution to this disruptive pattern if you are to resolve the weight gain that results. This is very much like the weight gain that can result from untreated depression: it must be controlled if other weight loss efforts are to have a reasonable chance of success.
While the causes I have discussed up to this point are important, they affect only a minority of those struggling to control their weight. In the next chapter, though, I will address what I have found to be the main cause of the inability most people to bring this problem under control: the malfunction of the appetite mechanisms and metabolic processes that normally exert a subtle but powerful control our body weight.
Why Are So Many People Overweight?
If it was just a simple matter of eating smaller meals, not many people would have trouble with their weight. The criticism and rejection that overweight people are subjected to, alone, would be a powerful enough motivation to prevent weight gain. Add the awareness of the risk of the medical problems caused or aggravated by weight gain and it should be obvious that if all that was needed was a decision to eat less, overweight would nearly vanish.
So, what is going on here? Research studies that are now many decades old have given us important clues. For instance, careful studies of people living in highly controlled research environments, where everything they ate was measured and recorded for months at a time, show that many overweight people eat less than their normal weight counterparts.
Other studies have shown that overweight individuals have abnormal appetite and metabolic adjustments in response to overeating when compared to their normal weight counterparts. When normal weight subjects eat more than they need for prolonged periods in carefully controlled studies, their metabolic rates will increase to help burn off the excessive calorie intake and their appetite will decrease. In contrast, many obese individuals do not increase their metabolic rate in response to overeating, and their appetite does not decrease as it does with normal subjects.
Likewise, obese individuals experience a much larger drop in their metabolic rate when their food intake is restricted compared to normal controls. It is particularly informative that even when massively overweight folks are brought all the way down to a normal body weight through long stays in research labs, where their food intact is rigidly controlled, their abnormal metabolism and appetite patterns do not just go away after they reach normal weight. Once out of the highly artificial research environment, they quickly start regaining the excessive weight despite their best intentions and efforts. We do not have a complete understanding of why this abnormal regulation occurs nor is it easy to demonstrate outside of sophisticated research programs. What is very clear, though, is that abnormalities in the regulation of both metabolism and appetite are playing important roles in weight control disorders.
Let’s now consider some other clues that point towards an answer. For example, we all know people who can eat whatever they like, and be as active or as inactive as they wish, yet their body weight never changes much. They seem somehow resistant to weight gain and their body weight is completely self- regulating. At the other extreme of weight self-regulation, there are rare genetic defects (such as Prader-Willi syndrome) that cause an insatiable appetite and chronic overeating on the part of those who suffer from this kind of disease. These observations, and the well-established importance of the family history as an indicator of the likelihood that someone will struggle with controlling their weight, demonstrate that genetic pre-disposition is a key component of the problem.
Recent genetic research is starting to give us even further important indications of what is going on. Researchers have discovered dozens of gene loci within our DNA that correlate with excessive weight gain in large population studies. Closely related is what researchers are finding about protein messenger molecules that play important roles in regulating both metabolism and appetite. Each of these messenger proteins can have inherited defects in their structure that lead to abnormal weight control We can conclude from all this that the appetite and metabolic mechanisms that underlie our body weight control are quite complex and are powerfully influenced by our genetics. This is strong evidence that much of the problem is not under our conscious control.
Both the decades old appetite and metabolism research and the more recent genetic research reports match what I have observed while working carefully with the weight control problems of my patients. Over the years, working with many people, I have noted important similarities between people struggling with their body weight and those who are suffering from other chronic problems like hypertension, diabetes and degenerative joint disease. Let’s consider the similarities between diabetes and excessive body weight as an example.
You could describe diabetes as “disordered blood sugar control” that will eventually cause damage to many body systems if not controlled. Let’s imagine a continuum of blood sugar control that goes from normal at one end to severe diabetes at the other. At normal end of the continuum of blood sugar regulation are the people who can eat whatever they want and can be as active or inactive as they want and they never develop diabetes. Further along this continuum are those just beginning to have disruption in their blood sugar control. When this is discovered through appropriate blood tests, they can often bring their blood sugar levels back to normal just with careful modification of their food habits and activity. Even further along this continuum of blood sugar control, there are others who require medications added to their lifestyle measures to keep their blood sugar below toxic levels. At the extreme other end of the continuum, there are those whose blood sugar is still higher than desirable, even though they are conscientiously using high dose insulin injections, and are using very careful adjustments based on frequent blood sugar measurements.
Analogous to the disordered blood sugar control of diabetes, you could call weight control problems “disordered appetite control.” And, as previously noted, at one end of a continuum, some people just do not have to worry about their food habits or activity level – their weight always stays normal. Others have a mild problem with their appetite regulation and they are often successful in keeping their weight under control by learning to modify their food choices, their activity levels, or both. When the appetite control problem becomes more severe (like the diabetes patient who requires medications), to control ever increasing body weight and prevent the problems that may result, the individual may have to resort to unusual food choices (often called a “diet”) or even weight control medications to block weight gain. As the appetite defect gets even worse, if they want to stop the continuous weight gain, some are pushed to even more extreme measures, such as surgery, due to a very severely disordered appetite and metabolism. The conclusion that I draw from all this is that there is a widespread problem of disordered appetite regulation and metabolic controls that is a chronic medical condition just like hypertension, diabetes, atherosclerosis and osteoarthritis.
I do not want to give the impression here, though, that all the answers are in with these genetic studies. While they do show that our genetics have powerful effects that are not under our conscious control, they do not rule out other factors that may also be crucial and probably interact with our genetic pre-dispositions. For instance, toxins could be building up in our bodies from the numerous chemicals in our food supply that could be playing a role in disrupting our body weight regulation mechanisms. Also, there is now reliable evidence that modern food processing and storage techniques are part of the problem (I will discuss this in detail later). We just do not know all the details at this point, and there is a lot going on.
What I do know for sure, though, is that these research findings, and the extensive real-life observations that are in complete agreement with them, have very important implications. For one, most people who struggle to control their body weight are very likely to be dealing with the effects of multiple different gene variants which pre-dispose them to their weight control problem. What this means is that the cause of their problem is both quite complex and poorly understood. It also implies that everyone’s problem is unique and will require strategies targeted at their specific needs. This research strongly supports the contention I presented earlier: very few rules and guidelines about weight control will work for everybody. What you need is guidance to help you find strategies that will work for you.
Another important implication of this new knowledge is that a problem that has its roots in complicated genetic inheritance is not a character defect! The commonly held assumption in our culture, that it is just due to a lack of self-control, results in criticism and prejudice that clearly serve to make the problem worse. The next chapter will address this phenomenon and how it may actually play an important role in the weight control difficulties many people must contend with.
Body Shape criticism and discrimination
There is a very prevalent stereotype in our culture that everyone who is overweight is an overeater and the more overweight a person is, the more of a glutton he or she is judged to be. I say this is a stereotype because, as discussed in the last chapter, it just isn’t accurate. Of course, it is true that there are folks who do consistently eat very large meals, and as a consequence, they can become quite large. The actions of a few create a powerful image that is quite unfairly generalized to everyone whose body weight is above what our culture views as “normal.” This stereotype is clearly in play when an overweight person’s problems are being discussed by others and someone chimes in with a thinly veiled criticism like: “His only problem is learning to push away from the table.” I cringe when I hear this kind of statement since I know it is almost always unfair and uncalled for.
Even within the medical community, where you would expect at least a somewhat enlightened attitude, this stereotype is often also at play. The criticism is more scholarly sounding in this circle, though: “It is simply a matter of calories in compared to calories out.” As a direct result of this almost universal attitude, not only is it very difficult for the overweight person to find a medical environment where they are treated respectfully, terrible medical care can result. Just about any medical problem that a victim of this attitude may seek help for can be met with: “You just need to lose weight.” (The “Now get out of my office” part is usually just implied.) In this way, medical evaluation or treatment that may be otherwise helpful for them is denied.
Besides poor quality medical care, these widely shared negative attitudes also cause much unnecessary emotional pain and suffering. Imagine the overweight child and the criticism and rejection he receives from classmates. Consider the overweight adolescent who sits at home while others her age are out on dates. Among adults, who do you think is often the last hired? The list can go on and on. This prejudice and constant criticism easily leads to poor self-esteem and a lack of self-confidence. Beyond this, the emotional toll of these attitudes frequently leads to chronic depression. I would estimate that more than 80% of the folks I treat with overweight severe enough to be causing medical complications are depressed when I first meet and evaluate them. This is far, far, higher than the rest of the people I see with similar medical conditions but without the additional weight problem to deal with. As I pointed out earlier, it can easily become a vicious cycle: quite often depression causes weight gain which further aggravates the depression. Since constant criticism and rejection can cause or add to someone’s depression, unjust criticism and prejudiced attitudes can become part of the cause of the weight problem.
As I described earlier, my extensive experience with treating this problem leaves me with absolutely no doubt that it is much more difficult than the superficial “calories in versus calories out” and “pushing away” analysis would lead you to believe. Obviously, the people who hold these prejudices and target these criticisms at others have no understanding of the problems that overweight people face. Hopefully, this book and other sources of information like it will begin to help educate people to start to improve these mistaken attitudes and stop the unfair criticisms.
The next chapter should provide a helpful summary of the recommendations in the previous chapters, before we move on to further management strategies.
Applying these Insights
This chapter will summarize and organize the insights and guidelines covered so far in this book to make it easier for you to be sure you are not missing potential obstacles to weight control. First let’s review the steps that can be taken without the help of a trained professional:
- Carefully review how your weight has changed throughout your life to see if there are any helpful indications of what is causing your weight problems.
2. Review past weight loss efforts to be sure they were not undermined by unreasonable expectations of how fast weight can be both successfully reduced and maintained.
3. Examine your eating patterns carefully to be sure your weight gain is not driven by emotional eating. If it is, this should be addressed first.
4. Be sure your daily activity level is as close to optimal as possible. This will take enough time to test how increasing your activity or exercise affects your weight.
Next, I will list some steps that will probably require the help of a physician or other knowledgeable therapist.
- Be sure your thyroid function is ok. Blood testing is a good idea if not done within the last couple years or so.
2. Be sure that depression is not part of the problem. If present, it must be effectively addressed or the chances of success are significantly diminished
3. If you are taking long term medications, an experienced clinician should have reviewed them to be sure they are not causing weight gain as a side effect.
If you have done what you can to eliminate the causes and complicating factors listed above and your weight control problem is still not under adequate control, you will need to take the next logical step: working with your food habits and choices. Part III of this book was designed to guide you in using your food choices for this purpose. As you will see, there are even more important benefits to be gained from using this strategy that go far beyond just helping control body weight.
Specific Food Choices for Weight Management
The title of this chapter may seem illogical or even unscientific. After all, if we eat more we will gain more weight, and if we eat less, we will either lose weight or we will gain less, right? The truth is, though, that this logic fails to consider how our food choices impact both our appetite and our body’s metabolism. When our appetite and the metabolic processes that control our body weight are functioning normally, our weight is very precisely regulated without any attention or effort on our part. Our innate desire for food quite naturally guides us to eat more or to eat less depending on a combination of the nutrient stores within our body, how much we have recently eaten, and what our body needs to maintain health.
We now know, though, that certain kinds of food interfere with the proper and effective action of our body’s weight management mechanisms. Recent research studies consistently and conclusively show us that certain food choices disrupt our weight control and cause many of us to steadily gain weight. These studies also show us that the disruptive foods add to each other in their effect on weight. The more different kinds of problem foods and the larger the amounts you consume, the worse your weight control problem becomes. The more of these foods you eat, the more they will make you want to eat more than you need.
I frequently see my patients trying to use their willpower to over-ride this malfunctioning, but this is almost always only a temporary fix. While we can become wholeheartedly committed to cutting back on how often we eat, or to eating smaller portions, eventually our hunger will get the best of us and most of us will start gaining again. Almost no one wins this battle over the long term; when our appetite is disrupted, our weight continues to increase as the years go by.
If the impact of these problem foods was just a matter of how they make weight control more difficult, and giving up certain favorite foods seems too high of a price to pay, it might be reasonable to look to other ways of controlling weight. But this is not all there is to it. The research studies that are showing how these foods are causing weight gain are also showing that they are having much more serious effects on our health.
Don’t you wish to avoid a stroke or heart attack? Aren’t you frightened by the prospect of losing your independence in your later years through the loss of memory and dementia? Do you dread the prospect of cancer and want to do all you can to avoid it? While these diseases and others like them are deadly, debilitating and terrifying, we now know how to go a long way toward preventing all this stuff, maybe not 100%, but even dramatically slowing it down or greatly decreasing the risks is a major benefit! I will re-state this for emphasis.
The same foods that disrupt weight control also dramatically increase the risk of many of the deadliest and most debilitating diseases we might develop.
By far, the best option is to avoid the types of foods that tend to bring about all these horrendous consequences and move toward eating foods that are either neutral, or better yet, will be protective against them. The research uncovering all this amazing insight is of such volume, consistency and quality that it would be quite foolish to ignore it. Much of this is new information that has yet to be fully appreciated and assimilated into our health care systems, but we can begin to make use of it now, without waiting for others to catch up.
There is another important implication of these new research findings for people who are struggling with their weight. Many of my patients struggle with trying to eat differently than the rest of their families. Because of what we are learning about the enormous health risks of these problem foods, we now know that these changes are good for everyone in our families. Everyone should make the same changes even if their weight is not a concern.
Before we get into the details of these problem foods, there is a big problem with all this that I need to address. The problem is that it is natural that our meals, particularly our favorite foods, are some of our great pleasures in life. If what I am about to be recommending in the next few chapters is different than what you prefer, this would interfere with your natural impulse to eat what you most savor and enjoy. What if some of your favorite foods are damaging your health and increasing your weight?
There is an answer to this dilemma, but it will take patience and perseverance to resolve. The key is that our food preferences are learned. If you doubt this statement, consider the wide array of foods that different cultures find most desirable. And, if you look back at how your own food preferences, I believe you will find they have changed considerably over time. From my own personal experience, I have found the easiest way to make these kinds of changes is slowly and gradually. If you stick with it long enough you will begin to prefer the new food choices. But whatever you have to do to make these changes and stick with them, that you do so is vitally important.
What are these unhealthy foods that disrupt our normal appetite mechanisms and increase our risk of these deadly diseases? Many of them are otherwise healthy foods that have been rendered harmful by how they are processed before they reach our tables. Others are foods that are normal parts of our diet that become unhealthy when we get in the habit of eating too much of them. Luckily, we always have choices. Once we have a solid concept of what kinds of foods will cause our appetite to work against us, and which also increase our risk of disease, we can choose to move away from them and toward choices that will improve our lives.
The chapters that follow in this part of the book will cover the specifics of what the new research is uncovering. Each chapter will cover a group of alternative food choices. If you find that you are already eating foods that are in line with the recommendations, just skip to the next chapter. The more you can follow the guidance you will find here, the better your health will be in the future.
Fruits, Table Sugar and Corn Syrup
Fruits are very beneficial. They contain many nutrients and co-factors essential to our health including fiber, vitamins, minerals, anti-oxidants, and many other less well defined beneficial components. These components are known to protect our body’s cells from toxins, provide support for their normal function and help repair damage that inevitably occurs as we live our lives.
In contrast, table sugar and corn syrup, which have the same highly rewarding sweet taste as fruits, can be very detrimental to our health. Why does our instinctive desire for sweet tasting foods and drinks lead us so far from what is healthy for us? The answer is tied to with how we Homo Sapiens have evolved as a species over the last several million years. Through the vast majority of this evolutionary time, sweetness in our foods meant fruit and fruit meant health. Because of the health benefits of fruit, we learned to desire and prize this sweetness. Only in the last few centuries did we acquire the technology to extract sugars from certain plants and make them widely available for virtually everyone to consume in treats like candy and soft drinks.
When sugars are extracted from their natural food sources and refined, they become pure sources of energy devoid of all the health-supporting natural components present in the food from which they are derived. But even though they lose these beneficial constituents during processing, they retain the sweet taste that is so attractive and can even be almost addictive. When we consume them as additives to all manner of sweet foods and drinks, as empty sources of calories, they displace otherwise health-supporting foods from our daily food intake.
If we were to single out one food type that is the most detrimental to our normal body weight control, it would be sugar in beverage form. Sugars in sodas, tea, coffee and its many other common forms are powerful stimulants to weight gain. This group also includes fruit juice, which is a processed form of fruit lacking many of its natural nutrients. Just one glass of these sugary drinks stimulates our appetite for many hours (in some studies, several days). These same drinks are also some of the most potent causes of diabetes and hypertension. In addition, other research studies suggest that a high refined-sugar intake accelerates the aging process and makes our skin, our brain and other essential organs old before their time.
Sweets in their many solid food forms are also detrimental, if not quite so bad. This would be foods like ice cream, pies cakes, cookies and candy. They also displace healthy nutrient-rich foods from our daily intake and increase the risk of diabetes as well as other diseases. If that weren’t bad enough, the foods they are usually combined with carry their own risks, as will be discussed in the next two chapters.
Luckily, as I mentioned earlier, we have choices. We can drink water, unsweetened beverages, or those sweetened with non-caloric sweeteners in the place of the sugar sweetened beverages. Likewise, we can substitute fruit for the other solid food sweets we may be in the habit of consuming. Remember, the impact of these sugar-containing foods and drinks is additive. The more we eat, the more likely we will be to gain weight and the more likely we will develop diseases we prefer to avoid.
In the next chapter, we will consider another way that our food processing and refining activities are undermining both our weight control and our health.
Whole Grains, White Flour and White Rice
Whole grains, like fruits discussed in the last chapter, are highly beneficial foods due to their high fiber, vitamin, mineral, anti-oxidant and other natural and health promoting co-factors. And just like fruits, they protect our bodies from disease and even slow down the aging process.
In much the same way that sugar becomes detrimental to our health when it is extracted from its natural form, foods like wheat and rice become sources of calories almost devoid of nutrients vital to our health when they are refined. There are other refined grains in our diet, but I will focus here on rice and wheat since they make up well over 90% of the grains most people consume.
The story behind why we prefer refined grains is a little different from sugar since it is a taste we had to acquire. So, how did we get hooked on this stuff so detrimental to our health and well-being? For thousands of years since wheat and rice were first cultivated by the earliest farmers, whole grains were all that was available. In the nineteenth century, though, a greatly increased ability to grow grains and transport them to other lands developed as part of the industrial revolution. But the profitability of growing and selling these whole grains was limited by their storage life since they turned rancid or otherwise became inedible and unacceptable during long trips to market.
The answer to this limited shelf-life problem was to process them and remove the bran and germ. Machinery was developed to easily process large volumes of grains to transport for sale in distant lands. These highly processed and refined grains were much more stable and, therefore, much more profitable. People’s taste preferences eventually adapted to the economic and marketing forces and the refined grains became the standard. Back then, we didn’t know what we know now about how they affect the health of those who have learned to accept the refined foods as the most desirable.
So that’s the history, and it has two vital lessons. One is that we learned to prefer what our society accepts as proper and customary. And second is that this learning can over-ride our innate impulses to choose the most healthful foods. What we learn we can unlearn, given enough determination and effort. But before we move on, let’s review in a little more detail why we should invest the effort.
Just like with sugar, white rice and white flour will tend to distort your normal appetite and metabolism and increase your tendency to gain weight. The effect is additive and the more you eat of one or both, the worse the problem. These effects, as you might expect, also add to the same distortions caused by sugar, producing more and more pressure to gain weight as the amounts go up.
Also, just like sugar, these low nutrient foods both displace needed high nutrient foods from our diet and have their own direct detrimental effects on health. They increase cancer risk and they increase the risk of developing diabetes. There is also evidence now suggesting that they accelerate the aging process and probably contribute to risk of developing dementia. And, just like the effect they have on weight gain, the impact on health risk is also additive. The more you eat, the higher the risk.
While we are on the topic of foods containing starch, let’s discuss potatoes. The research clearly shows that french fries and potato chips are some of the most detrimental foods, but it also includes other forms of white potatoes. Sweet potatoes, though, don’t seem to be a problem. Why this should be the case is not completely clear, but I mention it for people who eat a lot of potatoes. White potatoes should be limited.
What this all comes down to is that we are faced with another set of choices. If you are in the habit of eating white flour and/or white rice in any substantial quantity, it is just a matter of switching from the refined to the whole form and giving your taste preferences the time needed to adjust.
In the next chapter, I will briefly discuss how the fats in our foods affect out weight control and our health.
Vegetable Fats and Animal Fats
The story behind the effects of the fats in our foods is more complex than that of sugars and grains. How they affect our body weight control is not the same as how they affect our risk of disease – although there is still a lot of overlap.
Let’s first start to consider how the amount of fat we habitually consume affects our appetite and weight control mechanisms. It is not a simple matter of: “if you eat a higher proportion of fat in your daily food intake, you will tend to gain more weight” (as is the case for sugar and refined grains). We now know that there is an important role of genetic predisposition. Some people will gain weight with a high fat diet and some won’t. In Part IV of this book, I will address ways for you to test how you react to these kinds of broad, sweeping changes in your food choices, like adjusting the total amount of fat you consume each day. For now, though, I will just address the kinds of fat you eat, rather than the amount. The message concerning the kinds of fats rather than the total amounts is much simpler.
There is a considerable amount of strong evidence that high levels of saturated fat in your foods, as well as foods that are deep fried, are very detrimental to your health. They are strongly linked to heart disease, diabetes, cancer, dementia, and to an acceleration of the aging process. Accordingly, it is best for us to try to avoid red meat, especially that found in processed meats like bacon, sausage, hot dogs and many lunch meats. We should select baked or broiled over fried. These studies show that poultry (unless it is fried) is better than red meat for your health. Much better yet, improving your health rather than harming, are fish, nuts and vegetable oils. It turns out that a lot of fat in the diet, for most people, is probably a good thing, if the fats are from vegetable sources or fish.
There is also fairly strong evidence that saturated fats tend to cause weight gain. In general, the fat sources that are healthier for you, such as those high in omega-3 fatty acids, also tend to improve rather than disrupt natural appetite mechanisms. So, for both weight control and health, avoid red meats in favor of poultry, fish and vegetable sources of fat.
In the next chapter, I will give a summary of the last three chapters before going on to Part IV, discussing various overall meal plans that can be used to provide further control over our tendency to gain weight.
Putting the Specifics of Part III All Together
Here is a summary of the food recommendations included in the last few chapters. It should allow for a convenient review as well as an easy assessment of how much you stand to gain from simple substitutions of healthy foods for their less healthy alternatives. Following them, in and of themselves, will be very helpful for weight control. But, because of their crucial role in protecting and enhancing your health, they should be a fundamental part of any weight loss approach you might choose.
SUGARS: Avoid all foods or drinks sweetened with sugar or corn syrup. Most non-caloric sweeteners are ok in place of sugar. Honey is probably best avoided also, except in small amounts.
MEAT: Do your best to avoid processed meats like bacon sausage and hot dogs. Move away from red meats in favor of poultry and vegetables.
POTATOES: French fries and potato chips are some of the most harmful foods we can choose. Even white potatoes should be limited. Sweet potatoes seem to be fine, according to most research reports.
VEGETABLES, BEANS AND NUTS: Other than possibly avoiding those high in starch if they tend to make you gain weight, eat these to your heart’s content.
BREAD AND GRAINS: Choose whole grains and move away from refined versions like white rice and white flour based foods.
FRUIT: Include as much of these as you like, including dried fruit as an alternative sweetener, but avoid or minimize fruit juice.
FISH: Eat as much as you want, and consider adding more. Just not fried.
COOKING OILS AND SALAD DRESSINGS: Include as much vegetable oils as you want, especially olive oil. Avoid animal sources of oil.
If what you are already doing matches these recommendations pretty well, excellent! Know that this will go a long way toward protecting your health and slowing down the aging process. But what if you are at the other extreme, and violate nearly all of these recommendations? This is what has been called in some research reports the “Western Diet.” It is high in meat, including a lot of the processed varieties, high in sugars and corn syrup, and high in refined grains. Many foods are fried. These are the culturally favored foods that I am very familiar with here in the southeast part of the US where I live. Just about every aspect of this way of eating is injurious to health and conducive to the deadly diseases mentioned earlier. This may be why most of these diseases are more prevalent in this part of the country compared to virtually any other part of the world. This part of the country is sometimes called the “heart attack, stroke and diabetes belt” since these diseases are so prevalent here. By the way, body weight tends to be higher here, too.
If this in any way describes you and your food habits, you should take heart that even slight changes in your habitual food choices can make a big difference in your life. One long term study found that just substituting one serving of a healthier food like beans, peas or fish in place of one serving of red meat per day was associated with an increased life expectancy of six to seven years! And each little step you take in a more healthful direction adds to the others you have already taken. Even small changes, if continued permanently, can have a major impact.
Once you have done your best to incorporate these changes into the way you eat, it is important that you assess how well you are aware of your normal hunger and satiety signals. Many people have become so used to following food “rules” that they have lost touch with the innate messages from their body guiding them toward what their body needs. If what you are eating is healthy, you should throw out all the rules. Don’t eat when you are not hungry. Try to eat in a relaxed manner so you know when you are getting full. When you feel full, stop. Keep healthy snacks on hand for those times when you get hungry and you can’t have a meal yet.
There are some exceptions, of course. If you are not hungry in the morning, eating breakfast just because you think you should might cause you to gain weight. If that is what happens for you, skip breakfast. On the other hand, some people who skip breakfast find that they are ravenous at lunch and often overeat as a result. These folks need to eat enough so this doesn’t happen. Either way, do your best to pay attention to, and get in sync with, the natural ebb and flow of your appetite and feelings of satiety.
With this, we have completed another section of our step by step plan toward long term weight control. For some, what has been recommended so far may be all they need. For others, following the guidelines presented so far may still not be enough to stop a relentless weight gain. In the Part IV of this book, I will discuss the next logical step: using overall food patterns to control body weight.
Working with Over-all Food Patterns
Trying Out Different Ways of Eating
At this point, I will assume that you either have already been eating the healthy food alternatives described in Part III, or you have done your best to modify your food habits to be in line with them. If you have made significant changes, have you noticed that you feel different now compared to when you first embarked on these changes? Let me give you some background about why I ask this question since it is very important as we move along in this process of using food choices to control body weight.
Throughout my career, I have treated a lot of people suffering from malnutrition due to all manner of medical conditions that had kept them from getting an adequate amount of essential nutrients into their bodies. I have noted that just about everyone who develops significant malnutrition reports similar emotional reactions. They complain of fatigue and lethargy. Their mood also tends to be negative and they easily get depressed. They also think of food a lot. If the malnutrition gets bad enough they also have poor endurance and can even get weak. Then, when I have taken the proper steps to help them get the nutrition they need, these undesirable emotional states resolve.
Many poorly designed diet plans also cause malnutrition. When people, through a force of will, stop themselves from eating when they are feeling hungry, they are inducing malnutrition in themselves, especially if they do this a lot or for long periods of time. If a diet greatly restricts the variety of foods you are to be consuming, it also puts you at risk. Or, if you are in the habit of consuming a lot of relatively “empty calories” in the form of sugar, refined grains or saturated fat, you are also probably existing in a chronic, low-grade state of malnutrition. This is why I asked whether you feel different after changing your food habits toward healthier choices. People often report feeling healthier, more vigorous, and more positive when they get into the habit of eating what their body needs. As you follow the path I’m suggesting in this book, pay attention to how you are feeling as your food choices change. This is another benefit of healthier food choices, and paying attention to it will help guide you toward what works best for you.
Now we are ready to begin the search for an overall food plan that will best fit your needs to match life circumstances, preferences and your body’s nutrient requirements. If you get a reasonable variety of foods in your meals and snacks, and if you stick fairly closely to the guidelines in Part III, and if you eat enough that you are not overly hungry very often, your body should be getting what you need no matter what pattern of foods you follow. What I mean by overall food pattern is the large categories of types of food you usually eat. These would be categories like meats, vegetables, fruit and grains. One example an overall pattern would be a low carb approach where you would avoid grains and sugars, while concentrating on protein foods and high fat foods for most of the calorie content of your foods.
You may already know what kind of overall pattern works best for you. In that case, and if you still are not able to control your weight, you might try experimenting with a pattern you might have not tried yet. Otherwise, moving on to Part V seems the only option left.
If you are not sure about which overall pattern may be best for you, in the next few chapters I will include brief discussions about some common approaches that others have found useful. Try out different patterns to see what works best for you. Your goal should be to find meals that are satisfying and filling and which get you to the next meal without being overly hungry. Close attention to your feelings of hunger and how full you are feeling during your meals is essential. As I mentioned earlier, if you are used to ignoring your hunger in favor of following food rules about what to eat and when, I strongly recommend you ignore those rules and pay close attention to your feelings of hunger and satiety. Remember, too, to pay attention to your overall level of energy and feeling of well-being as you try different patterns. It may take some weeks of trying a pattern before you are able to see if your chosen approach is helping you with your weight goals. You must be patient.
The next few chapters will just be very brief introductions. Many of these popular patterns are discussed in good books that are readily available. Just apply the healthy eating guidelines, pay attention to how your body is reacting and feeling, and you should do fine with any of these approaches.
Advice for Those with Blood Sugar or Cholesterol Problems
If you are under the care of a physician for these kinds of problems, you should take his or her advice as your priority. You should never substitute the advice of someone who does not know you through the internet, TV or book. This includes this book. But if you need additional guidance as you are looking for effective weight loss techniques while you are dealing with these problems, this chapter may be of value.
FOR THOSE WITH HYPOGLYCEMIA: These suggestions will apply only to the most common form: reactive hypoglycemia. Other forms are more serious and are not managed through dietary intervention. The Part III recommendations of avoiding sugars, refined grains and white potatoes are the best initial step. For reactive hypoglycemia that is resistant to this approach, a low carb diet should be helpful. Be aware, though, that it may take weeks for food changes to improve symptoms.
FOR THOSE WITH PRE-DIABETES: Just as in reactive hypoglycemia, a low sugar, low refined grain, low white potato intake is best. But you should add to this an avoidance of red meats and other saturated fat sources.
FOR THOSE WITH DIABETES: For most individuals, the food pattern should be the same as for pre-diabetes. However, if you are struggling with advanced diabetes and hard to control blood sugar, a low carb intake can be a very useful alternative. Do not make these changes without discussing it with your treating physician, though. Switching to a low carb diet without careful adjustment of diabetes medications can result in dangerous hypoglycemia.
FOR THOSE WITH HIGH CHOLESTEROL: There are only two major food concerns for controlling cholesterol: saturated fat and food sources of cholesterol. Saturated fat and cholesterol are usually found together in foods so minimizing saturated fats also decreases cholesterol intake. The one exception is egg yolks which are very high in cholesterol and should be consumed in limited amounts.
The next chapter will return to the main theme of Part IV, useful over-all food patterns.
A Low Carb Approach
This way of eating is very popular, probably because it is so effective in helping people to lose weight when they first try it. But what we are talking about, here, is a long-term strategy. Over the long haul, it may or may not work for you. If you are interested in it, the only way to find out is to give it a try.
This approach is automatically going to include a very high protein intake which many people enjoy. A high protein intake is especially useful when you are in the process of losing weight since it tends to both decrease appetite and protect against the loss of muscle and other essential body tissues during the weight loss phase. It also virtually eliminates the high sugar and high refined starches that can not only contribute to weight gain, but have also been shown to increases the risk of diabetes and other diseases. In fact, as mentioned in the last chapter, it can be helpful for people with diabetes who are already on medications since carb restriction can decrease the need for these medications.
What is called a “ketogenic diet” is an extreme version of this approach designed for rapid weight loss. While a high protein diet can be quite safe and healthy if done correctly, a ketogenic approach is a bad idea. The goal of this diet is a high level of ketones in the blood. This is very abnormal and potentially dangerous. Ketones go up when the carbohydrate intake in food is so low that the normal metabolic processes of the body are badly disrupted. High ketones in the blood signal malnutrition and should be avoided. Stay away from these diets.
There are a couple other precautions if you want to try a low carb approach. One is that people with kidney disease should talk to their physician first, since a high protein intake can aggravate kidney problems. Another danger is that a low carbohydrate intake will also automatically mean a high fat intake. To use this approach long term, special effort may be needed to minimize the saturated fat this kind of diet can promote.
With these cautions in mind, if a low carb diet seems like it may work for you, give it a try and see how you like it and how you feel with it. There are a lot of books readily available that help with using this approach. Remember to follow the healthy food suggestions of Part III and to give any new approach plenty of time before deciding whether it is a viable long term solution to your weight control problem.
In the next chapter, I will discuss another strategy that is also very popular, one called “The Mediterranean Diet.”
“The Mediterranean Diet”
I put the Mediterranean Diet in quotation marks since there is no single way of eating in the Mediterranean region of the world. Even the research studies that have used this term in the descriptions of their procedures and their conclusions vary to some extent in what they are referring to. But, despite this variety, the overlap in the main foods included makes this a useful description of a distinctive style of eating.
The foods that are almost always included as part of the Mediterranean diet have been extensively and carefully studied to measure their impact on human health and lifespan. This research has shown that this style of eating is associated with a reduced incidence of several cancers, as well as less heart disease, stroke, Alzheimer’s Disease and diabetes. The specific foods within this pattern include just about everything I already recommended in Part III as the ideal way to adjust any style of eating to prevent disease and live a longer, healthier life. It is just a small step from that chapter to this diet.
The “Mediterranean Diet” food pattern is very high in unsaturated fats of vegetable origin, and relatively low in saturated, animal derived fats. Red meat is rarely consumed, with fish and poultry taking its place, avoiding the most common sources of high levels of saturated fats that many of us have been in the habit of eating. Fruits, vegetables and grains make up a large part of the calorie content and are typically unrefined and unprocessed. A moderate amount of alcohol, mostly wine, is also included and found to be health promoting. Legumes (peas, beans peanuts and lentils) as well as nuts of all kinds are also frequently consumed, further adding to the high fiber, anti-oxidant and unsaturated fat content. A lot of olive oil is included and the research suggests that it has many health benefits.
Whether this diet approach will work best for you, as I have been repeatedly emphasizing, depends on what you find most enjoyable, most satisfying and which works best for you in promoting the natural regulation of your body weight. It is well documented to be health promoting.
In the next chapter, I will briefly discuss what is almost the opposite of the low carb pattern presented in an earlier chapter: a vegetarian diet.
A Vegetarian Way of Eating
Not everybody is cut out to enjoy strictly plant sources for their food, but if this is what you like, or you feel it is a better way of eating for some reason, it offers a lot of benefits. One of the biggest is the avoidance of the high level of saturated fat and cholesterol found in most meats. As mentioned previously, a lot of saturated fat in your food contributes to an abnormally high appetite, an increased risk of heart disease and even the risk of an accelerated loss of memory. Avoiding meat is also probably easier on your budget since meat is among the most expensive of foods.
Beyond avoiding animal fats, this way of eating, being high in carbs, almost always includes a lot of fiber. Fiber, particularly in the form of fruits, vegetables and unrefined grains, are known to protect against weight gain, diabetes and dementia. Of course, it is also excellent for someone dealing with chronic constipation.
The biggest concern about a vegetarian diet is getting enough of all the essential amino acids every day to support healthy tissue repair. We require a constant intake of eight amino acids and they must be in the proper ratios in our foods to be utilized most effectively. Animal proteins automatically are in this balance, but for a strictly vegetarian meal, to accomplish this it must have the plant proteins properly balanced. There are a lot of good books available to teach you how to do this and to provide a lot of useful recipes. An easier way is to include some animal proteins like milk, eggs or cheese on a regular basis. It doesn’t take much of these proteins to provide the amino acids that are too low in plant sources of protein.
If you are used to more standard American food choices and want to embark on vegetarianism, it will probably work best if you transition slowly. This would mean moving in the direction of where you want to eventually be in small steps. This will allow your tastes to evolve and give time for your body to adjust its metabolic machinery to handle the new way of eating.
This concludes Part IV describing some popular food patterns that may help with weight control. Of course, there are many other popular “diets” and approaches I haven’t listed. If you stick to the general guidelines of Part III, and you get plenty of variety of all the usual food groups, you should be fine with any of them. What matters most is how you feel in response to them and how well they help you with your weight.
In Part V, I will move on to the use of weight loss medications and surgery.
Looking Deeper into the Risks Due to Increasing Fat Stores
Up to this point in this book, an in-depth discussion of the health problems related to body fat has not been that important. This is because the recommendations I have been making so far have nothing but up sides and little or no risk. Eliminating medications that are causing weight gain as a side effect, improving physical activity when appropriate, and focusing on healthy food choices are worthwhile even if weight control isn’t an issue. But when we start discussing more risky strategies like weight loss medications and bariatric surgery, the actual risks resulting from excessive body fat must be carefully balanced against the costs and risks of these more invasive treatments. This chapter will explore the consequences of weight gain more completely to set the stage for discussions of medications and surgery to be used for weight control.
First, let’s consider how body weight affects life expectancy. What careful, large scale studies have shown may surprise you. Most studies have used body mass index (BMI), as a way of expressing weight in relationship to height. The Centers for Disease Control in the US, and many other similar institutions around the world, have agreed on the descriptive terms for various levels of BMI. For example, a BMI of 18.5 up to <25 is considered to be normal. A BMI of 25 up to <30 is described as “overweight.” Now this would make you think that the lower range is healthier than the overweight range, right? Actually, the research shows that the overweight group lives longer than the normal group. To me, this implies that a strong argument can be made, based on the scientific research, that mildly overweight (by currently accepted definitions) are healthier than those designated as “normal” weight. Moderately higher levels of body fat may not actually be as dangerous as we have been led to believe.
There are, of course, certain kinds of risks and complications of increased fat stores that are quite clear. If you have joint or spine problems, usually gaining weight makes these problems worse and losing weight improves comfort and mobility. If your ability to move about is limited by severe lung conditions or heart failure, just like with joint problems, gaining weight will further stress your lungs or heart and make things worse for you. Similarly, gaining weight aggravates sleep apnea and usually makes diabetes harder to control. In these kinds of situations where weight gain makes health conditions worse, and lifestyle changes have not improved body weight, more aggressive approaches like those described in the next two chapters are quite reasonable.
In the absence of these kinds of diseases, though, the situation is not quite so clear. But if body weight is increasing and using food and exercise fail to stop a steady weight gain, there is a distinct risk that weight-related problems will eventually develop. Waiting until diseases become established would not be a good strategy since it is much easier to prevent weight gain than it is to reverse it. It is always a judgement call, but in this circumstance, more aggressive management approaches also seem reasonable, especially if a conscientious effort to control weight through food choices and activity have clearly failed.
In the next chapter, I will discuss my experience in using weight loss medications to stop or reverse weight gain.
Using Medications for Weight Control
It is difficult to use medications effectively, but if you learn how to use them well, they can be very helpful. To use them to their best potential, the prescriber needs to thoroughly understand the medication’s proper role and must carefully select those that might be beneficial. In addition, the person taking the medication needs to understand what the medication can and cannot do.
The best candidate for the use of medications is someone who has been screened for all the easily reversible causes of excessive weight gain and who is already following sound weight control principles without success. This is because weight loss medications usually are not all that potent. They will not make up for poor food choices (at least not the medications currently available). But when someone is already making good choices and sticking to a healthy regimen, the proper medications have the potential to increase their weight loss significantly.
Occasionally, I come across an individual for whom it makes sense to violate this rule of only using weight loss medications when someone is following a good diet plan. Sometimes, when someone is discouraged and lacking confidence, weight loss medications help them to jump start their weight loss and to develop confidence and enthusiasm to stick with a good weight loss plan. Once they have experienced some success, they can stop the meds. Almost always, though, for a medication to be truly useful, it must be part of a long-term plan that includes sound food and exercise components.
Even though most medications for weight loss are officially recommended to be used short term, I do not find this to be very effective. To be most useful, when medications have been found to be helpful, they need to be continued until an individual’s weight has reached a reasonable goal. This is because when you stop medications, the metabolic effects are lost and the individual can easily begin to regain the pounds they shed. Ideally, when the goal has been reached, good habits have been developed and are sufficiently effective that the medication can be stopped without regain.
The medications I use are ones that can be safely used long term – even many years if needed. I look at effective weight loss meds almost exactly like I look at medications for high blood pressure and high cholesterol, which most people need to stay on permanently to control these problems and avoid the damage that hypertension and atherosclerosis can cause. An effective weight control medication can often be used in lieu of the meds for blood pressure, arthritis, diabetes and other conditions that excessive weight can bring about or aggravate, since it is possible that weight loss might improve these problems even more effectively than medications specifically developed for these medical conditions.
The medication I use most often, and the one that I find most likely to help is phentermine. This is a prescription drug in the US and it is currently a schedule IV controlled drug. This is the least restrictive control, but in my opinion, there is no reason for it to be controlled at all. I have never seen anyone hooked on it, nor do I ever see it abused. If you read the original metabolic research reports from when it was being developed, you will find it inhibits fat storage in the fat cells of the body, and stimulates these same felt cells to release fat more quickly to be burned for energy. It has these beneficial metabolic effects as long as you keep taking the medication. The main mode of action of the drug is in adjusting fat metabolism while appetite suppression is often just a temporary side effect.
There are a number of other medications now available for weight loss, most of which have been recently been approved and released. They tend to be expensive, and to know how useful they will be will take years of experience. There are even a couple of new formulations that are combinations of two different drugs. To summarize, in my experience, when medications are needed and used properly, the right combinations can be quite effective.
When food choices, exercise and even the addition of medications fail to control body weight that is causing or aggravating disease conditions, surgical options may well be the only effective option. This will be the topic of the next chapter.
Surgery always carries with it some risk. The risk of anesthesia is minimal, but it is not zero. In addition, any time you must cut healthy tissue, you run the risk of infection and other complications that go along with this intentional damage. To balance out these kinds of risks, the benefit of the surgery must be clear. Several kinds of weight loss surgery offer a strong enough advantage in promoting long term weight control that they outweigh the risks. But, because of these risks, I recommend thoroughly trying all the non-surgical options first. This is just good medicine.
People must be carefully screened if weight loss surgery is to have a reasonable chance of success. I try to go through all the screening and treatment options I discussed earlier in this book before I even consider surgery as a possibility. I say “try” because sometimes people have such severe medical illnesses that enough time is not available to try less invasive options. If I do have enough time with someone, though, to complete a thorough evaluation and to try the best non-invasive approaches, I am then in an excellent position to advise them about the benefits of surgery.
One of the possible outcomes of a good evaluation is that I can help steer them away from surgery if they are not a good candidate. Who might not be a good candidate? One example is someone who thinks the surgery will completely compensate for a lack of self-control. To be effective after a surgical procedure for weight loss, the patient must follow guidelines and attend follow-up visits with their management team. Another example is a person who has emotional compulsions to overeat. Many programs require psychological evaluations to screen out these types of situations – and for good reason. Also, many of the skills learned in diet and lifestyle modification approaches will help someone be more successful after weight loss surgery.
If all the non-surgical options have failed and someone is a good candidate for surgery, is there a best choice? I divide the procedures into two categories. The most potent surgeries are the more invasive ones. These require cutting, and often stapling, the stomach and sometimes even a portion of the small intestines. While they are the most effective in terms of percentage weight loss, they are also not completely reversible and carry a higher risk than the second category: the laparoscopic banding procedures. The “lap band” procedures are becoming more and more popular because of their reversibility and lower risk. In general, if I am recommending surgery for weight loss, it will usually be a lap band. All the severe complications from weight loss surgery I have seen have been from the more invasive gastric bypasses and partial stomach resections.
The good news is that when a surgical procedure is successful (this is most of the patients who undergo the procedures), there can be dramatic changes in their medical condition. Some patients can stop their diabetes and blood pressure medicines. Sometimes sleep apnea resolves and arthritic joints often improve. It is generally the cost of the procedures that prevents good candidates from getting the surgery. Many insurance plans will not cover the costs.
If the cost is not an issue, and bariatric surgery is clearly the best option to pursue, there are two other hurdles to overcome. One is to be sure the surgical team is very experienced with the procedure chosen. The second, closely related, is that the surgeon must have an organized long term follow up plan as an integral part of the surgical option.
Writing this book has been a much more rewarding experience than I would ever have imagined. In ways I did not anticipate, it connected powerfully with my motivations to have chosen a career as a physician. I was originally attracted to medicine after witnessing the devastating effects of severe malnutrition on children in orphanages in Vietnam in the early 70’s. To help treat people afflicted with diseases of poor nutrition, I obtained training in nutrition science followed by my medical degree.
Treating severely malnourished patients has a dramatic, often life-saving impact, but these cases have only been a relatively small part of my practice over the years. Because of my nutrition specialty, though, other physicians have referred quite a few of their patients to me who were struggling with medical problems that were being made worse by weight gain. I have often been able to help, but I have felt I could be even more effective if I could find some practical way to provide needed education beyond the few minutes I had with them every few months in my exam room.
It was a simple, straight-forward idea that led me to write this book. I envisioned it as a way to impart what I have discovered over the last few decades applying sound nutritional principles in ways that worked in my patient’s day to day lives. Then, as I organized my experiences over the years to summarize in this book, I also reviewed what scientists have been recently finding about the many unanswered questions surrounding controlling body weight. I was astounded to finally find unexpected answers emerging from this research. Not only were investigators finally uncovering the causes of difficult to control weight gain, they were also uncovering the causes of many of the frustrating chronic diseases that plague us as we age. In many ways, the questions involving these diseases were even more puzzling and more important than those concerning weight control.
Through the years there have been tantalizing bits of information and insights about many of the worst diseases that plague modern man, but solid answers have eluded modern science. What researchers are now finding is beginning to provide a coherent explanation, and indications that it is all interconnected. It is becoming clear that disease promoting factors add to each other and accumulate throughout our lives, and the impact of this accumulated damage is expressed by the wide array of deadly diseases we see all around us.
Understanding the complexity of these interactions is incredibly important. We have been puzzled by the observations that many chronic diseases cluster together within the same individuals. The explanation is that while the disease promoting factors are the cause, which diseases will result depend on a person’s genetics and life circumstances. As the degradation due to these factors increases, more diseases erupt. This complexity also is explaining why it has been so hard to uncover these causes. Our analysis has been too simplistic. We have assumed specific factors are tied to specific diseases. Instead, we now are learning that destructive factors interact with each other and produce a wide variety of potential diseases. What this is telling us is that we need to work toward minimizing these disease-producing factors in our lives if we are to prevent these diseases, and when we do so we will be preventing many different potential illnesses.
This also explains why many of our medications designed to treat chronic conditions do a good job of alleviating symptoms, but they do not completely stop the steady deterioration of the underlying disease processes. The medications usually help correct imbalances that result from the damage to our organ systems, but they do not get at the actual causes. It may be that the primary value of this book is its message that we are now finding these causes and many of them are within our control.
What are these potent causes? One obvious cause is our genetic inheritance, but while our genes do occasionally cause specific diseases, almost always they merely help determine the specific organs that will eventually be damaged by other, more modifiable factors. It goes without saying that habits like drugs, cigarette smoking and excessive alcohol intake are clearly destructive. Another factor is our level of activity, or inactivity. We have long known that inactivity pre-disposes to disease, and that our bodies have evolved to require activity and physical stimulation. Yet another factor might be described as the over-all emotional stress that we live with. In ways that are only recently becoming clear to us, emotions like fear, sadness, frustration, guilt and anger take an enormous toll on us. We are now discovering how these emotions affect the metabolism and functions of our body’s organ systems and how these changes are both destructive and cumulative. The final category is the main topic of this book: foods that damage our body.
Again, these factors add to each other and even multiply each other’s damaging impacts. Improvement in any one of them will decrease the risk of a host of deadly illnesses and infirmities. Our habitual food intake is one of the most potent by far, while also being one of the easiest for us to change. It turns out that what we have been doing to our foods through refining and processing them, as well as those that we often consume in overly large amounts, is helping to facilitate most of our most dreaded diseases and shortening our lives. Our refining has been eliminating many of the antioxidants, fibers and as yet undefined health supporting co-factors from much of our fruits, vegetables and grains. The low nutrient refined sugars and starches that remain stress our bodies through higher blood sugar and insulin levels. Foods like saturated animal fats not only produce direct damage, consuming these in high levels further displace healthier, nutrient dense unrefined vegetable, fruit and whole grains from our diet.
Yes, not ingesting toxic drugs into our body and making sure our activity level is optimized is important. While not as easy to accomplish, eliminating stress and engaging in rewarding pastimes is also vital, to the extent we can. But almost all of us can improve our choice of foods. The steps are pretty simple. Honor and follow innate body wisdom by eating whenever you are hungry and stop when you are comfortably full. Also follow this wisdom as it naturally guides you toward a lot of variety in your food choices. Limit red meat and the saturated fats derived from it by substituting fish, nuts, whole grains, legumes, fruits and vegetables. Always choose unrefined, unprocessed, unadulterated foods whenever possible.
Any improvement in any of these areas will help. Multiple improvements will have more than additive effects. Longer, healthier and more rewarding lives will be the result. Uncovering these insights has been a wonderful experience and helping to pass them on to others through this book gives me great pleasure.