About ten years ago, on our annual family visit to the Bahamas, I had a sudden insight into what might be causing obesity.  I had been treating obese patients for some years and had been watching them relapse.  I also was watching the frustrating progress of my own weight.  I had always been thin, but during my forties I had grown twenty pounds heavier despite my usual schedule of five-day-a-week high intensity aerobics.  The annual diet that preceded our vacation was no longer working and the few pounds that I was able to knock off came rushing back within a week or two of our return. 

In 1992, Don and I had moved to a country property.  Both of us had grown up in the crowded suburbs of New York City and longed for some contact with plants and other living things.  I, particularly, had always wanted animals.  About the best we were able to do in our small row house in Jersey City was provide shelter to a parakeet, a series of hamsters and some goldfish.   Now (thanks to my industrious and long-suffering husband) we became the caretakers of sheep, goats, horses, donkeys, turkeys, chickens, a dog, a parrot and a whole host of cats. As it happens in these situations, these animals gave us much more than we ever gave them.  The learning curve involved in their care was steep and the knowledge they imparted was fascinating.   

Our horses grew lean and shiny-coated on their summer grass, but became sluggish and fat-bellied when fed “sweet feed” (a molasses coated mix of grains).  Our golden retriever ran exhausting loops around our farm, but got fat on a standard dog food and as a result of eating morsels of feed that were dropped by the horses.   In an effort to slim him down, I learned of the “Bones and Raw Food” movement favored by some dog enthusiasts.  The idea was to re-acclimate dogs to foods that were more natural to them genetically.  I switched him, with excellent effect, to a dog food that paid attention the original nutrient balance of canines.   Our cat’s veterinarian was also invested in the idea of feeding cats the diet they were most genetically programmed to eat. 

Interestingly, our animals didn’t get fat from eating too much or exercising too little.  They were never overfed.  In fact, it took a startlingly small amount of the wrong foods to cause overweight.  Who would imagine that a 1200 pound horse could grow a big fat belly from an extra half a coffee can of grain a day?  Who would predict that a horse that size could graze on pasture all day and all night and remain as lean as Secretariat?  Who indeed?  Those who knew anything at all about horses!

It was with these new experiences swirling in my subconscious that I had a moment of sudden clarity in the Bahamas.  I remember that I was about to have breakfast at the hotel buffet.  I was making my usual calculations:  if I ate that chocolate muffin now and skipped lunch, maybe I’d be ok having my favorite chocolate mousse for dinner.   I plopped down into my seat feeling the irritating scrape of two fat thighs rubbing together.  Looking out through the windows onto the beach, it all came together over the turquoise blue of the sea.   Those palms were growing here, not in Cleveland, because they had certain programmed requirements.  The trim seagulls trolling the sand were looking for their particular diet of fish.  Our horses ate grass and stayed in perfect weight balance.  What I, their caretaker, was eating had absolutely nothing to do with what was natural to my organism: the human organism.  Even without researching it further, this seemed immediately obvious. 

I sat there and remembered the day that one of our high school teachers, a smoker, lectured us on the dangers of nicotine.  He lit a cigarette, took a deep drag, and exhaled through a clean, white handkerchief he had pulled from his pocket.  A dirty, yellow ring formed immediately, staining the white cloth.  “But if you know smoking does that,” we insisted, “why are you still doing it?”  With only a moment’s hesitation, he replied.  “I’m not going to anymore.”  He took the packet of cigarettes from his shirt pocket, ripped it in half and threw it in the garbage pail by his desk.  It was his moment of clarity.  He never smoked again.

I pulled myself out of my chair and approached the buffet feeling a strange and similar commitment.  It was fascinating.  What was likely to be “human” food?  The eggs?  Probably.  Some meat?  Likely.  The grits and butter?  I wasn’t sure.  But I would find out.  And I soon did, contacting various experts on original forms of human diet and researching what I discovered was already a well-established dietary approach for many.  

In the past ten years, nothing has occurred either in terms of my personal or professional experience that has changed this basic tenet.  We are healthiest when we eat a diet that is familiar to our ancient genes.  We also will lose excess fat and remain lean if we do so.

But ten more years has added the benefit of additional observation in the real world.  For many years, particularly in the mid twentieth century, we humans stayed lean on diets that were full of hot dogs, apple pie, hamburgers, ice cream and devil dogs.   Yes, but we exercised more …right?   Not on my block, where staying out till 8 pm in the summer meant sitting on your stoop and playing aggressive, calorie consuming sports like “hit the penny” and potsy. 

So, new observation number one is that something has changed.  While we’ve probably always been best served by eating a close approximation of the original human diet, we used to be able to get away with cheating quite a bit.  Now we can’t anymore.  Why not?  The possible candidates are legion.  An environmental exposure to some toxin or chemical.  A small change in the way our genes are expressed which may be stimulated while we are in utero (epigenetic change).  An increase in the load of fructose or some other specific substance or additive in our diet.  The reaching of a specific threshold, beyond which our bodies can’t tolerate fake food.    It would be interesting to know, but it almost doesn’t matter.  If you want to win at hide and seek---don’t ask why you’re still at large----just  high tail it back to base and yell, “Home Free All!”  That base--- and I hope you’re headed there---is our original diet. 

Observation number two is that many people use “low carb diet” as a shorthand for the original human diet.  And this is not a bad way to look at it, but it misses some fine points.   I personally adhere to the belief that we get fat because we start to store and trap fat inappropriately.   Since insulin is the primary hormone that controls fat storage, I favor the belief that this problem occurs when insulin gets out of control and stops working properly.    If we drop most carbs out of the diet, leaving only carbs like veggies and low sugar fruits,  our insulin falls back into the low range and fat can be released and gotten rid of.  Fat also can’t be stored if insulin is low.   The original human diet is low in carbohydrate because it lacked all grains and most sugars, so there is an approximation there.   However, the idea of eating more originally is to avoid other potential pitfalls of the modern diet, not just obesity.  For this reason, I also advocated eating animal proteins that look more original…meaning have more omega 3 and fewer omega 6 fats.  We can do this more easily today with the availability of grass fed meats and free range poultry.   We also may want to pay attention to modern additives like growth hormones and antibiotics—certainly not ancient.

Observation three is that we get fat because we are “stuck on fill”.  I’ve used that term before to mean that the system (controlled primarily by insulin) that decides if we will burn food or fill the fat cells with it is actually stuck like a jammed valve.  This valve can get stuck when we eat too much modern food laden with carbs.  But it also can get stuck through forced overfeeding.  We can essentially eat ourselves sick.   As most of you know, I loathe the blame placing that goes on around overweight.  I’ve been known to wade into discussions with verbal guns blazing when I hear these words, “I don’t know why fat people can’t just stop eating!”   Being fat means having a storage disorder that triggers more hunger.  Whether this is because big insulin surges are making hunger or because all of the needed energy is trapped in fat cells and the body needs more food to go on, we’re not sure.  Whatever the cause, for most overweight people, reducing fat mass by lowering carb intake (and therefore insulin) will get rid of the big hunger.   The last ten years have taught me, though, that there is a subpopulation of people who do eat strictly for emotional reasons.  Once they become overweight or obese, the problem is intensified and the weight gain can be large and rapid.   I think it’s important to recognize this because the treatment for this particular group of people should include therapy.  Having said this, I have found that 80% of the overweight people I see in my office think that they eat emotionally. They’re right.  We all do. Eating emotionally in the United States of 2011 is a given.  But is it their major problem or just a sidebar?  Until you have tried a diet that lowers insulin significantly and have given hunger levels a chance to abate, it is hard to know why you are eating.  You may find that your drive to eat is more biological and less psychological than you thought.

Observation four is that serious maintainers must stop playing with addictive substances…and by this I mean sugar and starch.  I have a number of patients who actually use the word “play” when describing their mini-binges with doughnuts and potato chips.   What they don’t realize is that the food is playing them, not the reverse.  Insulin stimulating foods are seriously addictive.  Enough so that several of the new obesity drugs in the pipeline rely on the same mechanisms that block other addictions like those to heroin and nicotine.  Since we don’t want to remove everything pleasurable from our diet, it is vital to establish a number of things that give you a carb-like “hit” but without the after-cravings.  I have referred to these in previous posts as NTTs or Non Triggering Treats.  

So in summary:  as 2011 begins, here’s where I’m sitting.  We are fat because a problem in our fat storage mechanism which “gets stuck” and diverts too many of our calories into fat cells, trapping them there.  This process can be reversed and permanently bypassed by getting rid of starches and sugars in the diet.  You should continue to eat vegetables and low sugar fruits.  Most people will be able to eat low fat dairy (milk products do stimulate insulin, but don’t seem to be an issue for many).  I personally don’t eat grains, whole or otherwise.   I also avoid legumes like starchy beans.  

The fat storage problem we so easily acquire in today’s world is like the first push on a stack of collapsing dominoes.  It throws off blood pressure, messes up cholesterol, inflames the insides of your arteries, exposes you to intensified cancer risk, and creates diabetes.  Reverse this disorder and you reverse all the others along with it. 

I remain open to new studies, new information and new ideas.   As of January 2011, I believe that the basic concept as I’ve described it makes sense both scientifically and experientially.  It works.  I’ve seen it.  I live it.  Each of you will find your own variations.  I wish you health and success.

Happy New Year to all!

Imagine if you will, a world in which all of our current assumptions about what makes us fat are erased. It's hard to do, because we are all so certain that we get fat from eating too much.  That little tune has been played for us every day of our lives in excruciating repetition.  We are so brainwashed that we've never stopped to consider whether it's true.
Suppose what makes us fat is not what we are eating but something that gets disordered in our fat cells? 
Suppose these cells, because of a hormonal imbalance or disrupted signal, start to suck in too much fat and get out of control?  Imagine now that these voracious cells not only gobble up everything we eat but jealously lock all that energy up, thus making it unavailable to the rest of the body.  Under the rules of normal physiology, our fat cells release fat whenever it's needed for momentary energy needs.  But not anymore.  Not this rogue fat.  This misbehaving fat isn't releasing anything.

Imagine now that you set out to walk from your bedroom to your living room.  You ate a half hour ago, but now everything you ate is locked away in your fat cells where the rest of you can't get to it.   What fuel is going to power you?  Your brain directs you to eat, pronto!   How can you be hungry again you wonder.  How can you have such little will power?  Why can't you just forget about food?  What's wrong with you anyway?

Far fetched?  Not at all.   For years, scientists have made various animals fat by manipulating their hormones or operating on certain areas of their brains.   These manipulations have created a disorder in fat storage such that fat is inappropriately sucked into the fat cells.  Animals will often eat more to compensate for the fact that their other cells are starving, or they may stop moving around to avoid burning calories they don't have.  In the case of certain rats who are genetically manipulated to be obese, starving them still leaves them fat.  Their fat is not available for burning, so instead they burn up their muscles and vital organs until they die, still with fatty tissue intact.  All of this is well documented in the Taubes book I've recently been referencing, Why We Get Fat and What To Do About It.  The example of the genetically doomed rats will undoubtedly leave some wondering whether they too are genetically engineered to be fat no matter what they do.  While there may be a tiny fraction of us with some unavoidable genetic variance, we can be fairly assured that this is rare.  We know this because obesity rates were  low until just recently.  Genetic variations of the required magnitude would not have occurred in the past 20-30 years.
In his book, Taubes discusses concepts developed by Julius Bauer, a German geneticist and endocrinologist, in the late 1920s.

"Bauer considered the fat tissue in obesity akin to malignant tumors.  Both have their own agendas, he explained.  Tumors are driven to grow and spread and will do so with little relation to how much the person who has that tumor might be eating or exercising.  In those who are predisposed to grow obese, fat tissue is driven to grow, to expand with fat, and it will accomplish this goal, just as the tumor does, with little concern about what the rest of the body might be doing."

The abnormal (fat) tissue seizes on foodstuffs, even in the case of under-nutrition, Bauer wrote in 1929. "It maintains its stock, and may increase it independent of the requirements of the organism.  A sort of anarchy exists; the adipose tissue lives for itself and does not fit into the precisely regulated management of the whole organism."

Ever have that anarchy feeling?  There's probably a good reason that this fat thing seems to be so out of control....make so little sense.

While there are many signals and hormonal components that regulate food intake, the primary hormone that puts fat into the fat cells is insulin.  Many overweight people are making way too much insulin, a problem that leads fat cells to avidly store and trap too much fat.  The overproduction of insulin is usually the result a insulin resistance, a situation in which muscle cells become deaf to insulin while fat remains responsive.  This insulin resistance may start once we have eaten too many starches and sugars, or as the result of developing in the womb of a mother who ate many S foods, or simply as a result of aging.  Some people have a tendency toward it and other don't.   Whatever the cause, though, once the cycle gets started, the fatty tissue goes rogue, expands beyond the needs of the body, creating hunger and stealing energy from other bodily cells.
We can respond by starving ourselves, but we may wind up like the rats who burned up their muscles because their fat was entrapped and couldn't be released for body needs.  I often notice that people on low calorie vegetarian diets (which rely on grains, breads, etc..) have an emaciated appearance, as if they are losing muscle mass.  I caution that this is strictly an unscientific observation, but it would make sense if they are losing weight while still eating a diet with significant insulin stimulus.  Again, using nothing but subjective observation, I note that our patients who have lost large amounts of weight on low carb, low insulin diets look very well balanced---often as if they had never been heavy.
If fat is a rogue that gets out of control as a result of disordered insulin signaling, guess what?  Being overweight is not the fault of your weak will or your big appetite.  It's just the other way around.  Your inability to stop eating or tendency to store fat easily is a side effect of the chaos imposed by a run away tissue.
If we know this and work to get rid of excess insulin secretion, relief is in sight.  Fat will again flow freely from fat cells and hunger levels will decline.  If we remain in a low insulin state, it will be very difficult for the body to find a way to store fat again.  We will have tamed the beast. 
But ultimately, will power does factor in.  We still have to have the strength to turn our backs on the starchy-sugary diet that's created all of this.  Can you do it?  You can. 

For most people, the prospect of meeting a favorite movie star or sports hero would set the heart aflutter.  Call me a nutrition geek, but I get palpitations from meeting the researchers and authors whose work on obesity I revere. 

Several years ago, a friend from residency, who is now chief of endocrinology at a major academic center, invited me to meet Gary Taubes; the author of "Good Calories, Bad Calories".  Taubes is a science writer with a long track record of producing sophisticated and meticulously researched articles for Science, the NY Times, and other highly respected publications.  In recent years, he had become especially interested in the science of obesity; writing a number of controversial articles that supported carbohydrate restriction and called into question the conventional wisdom of low-fat eating.  "Good Calories, Bad Calories" was the  a book that collected all the research that supported his contention (and mine) that the idea of controlling weight by eating less than you burn is insanely simplistic and that it is insulin-stimulating foods that cause weight gain and illness.  A dense, lengthy book (the paperback version is 640 pages), GCBC defeated many readers.  For me though, every page was a "eureka" moment packed full of research that supported everything I had learned clinically in more than 20 years of working with overweight patients. It became my bible, my favorite book, my go-to reference, the book that had my back.  The pages of my copy were so underlined, annotated, and studded with stars, arrows, and exclamation points as to be barely readable.

The day that I was to travel to the east coast to meet Gary Taubes dawned to reveal an old-fashioned Cleveland blizzard.  I was booked to fly on a small regional jet and believe me, I'm a nervous flyer.  Normally, I would have taken one look out the window at the wind and snow and cancelled my flight.  Instead, I tucked my trusty GCBC under my arm, packed an overnight bag and headed across icy, unplowed roads to the airport.  I sat on the tarmac as our tiny plane (one of those that bounces and creaks across the runway) was doused with pink and green de-icing fluid.  Moments later, the snow was once again accumulating on the windows and the wings were bouncing in the wind.  Was I nuts?  This was definitely a form of temporary insanity.  But moments later, we ascended shakily into the sky, broke through the clouds and continued on to Philadelphia where a cold sun was shining. 

At the university, I greeted my old friend and he ushered me into a large lecture hall where Taubes had just begun what was to be a long and detailed talk.  The assembled crowd was composed of serious academic researchers in the field of diabetes and obesity.  They listened politely and asked many questions, but seemed skeptical.  Taubes answered each question with a wealth of data and a great deal of patience.  It was clear that he was used to speaking to doctors and other scientists, most of whom had spent the past twenty to thirty years believing that dietary fat was the great villain.  I understood his position well.  My practical experience with obese patients was often ignored by peers who listened politely to what I had to say but went on to advise their patients that they eat "moderately”, follow a "low fat diet" and eat lots of "healthy carbs".

After the lecture, I had the great opportunity of spending an hour or so in discussion with my friend and Gary Taubes.  Naturally, I had him sign my copy of GCBC.  The inscription reads:  "This is the most annotated copy of my book I've ever seen."  Later, we all had dinner with other members of the department.  Gary and I avoided carbs while the others ate the rolls, ordered potatoes and (in some cases) fretted about their inability to lose weight.

In the years since the publication of Good Calories, Bad Calories, I have recommended it to many people but few have been able to wade through it and pretty much no one has enjoyed it with the blind excitement that I have.  Apparently, this was a common scenario and now Taubes has produced a scaled down version of his master work called "Why We Get Fat and What to Do About It" (Knopf).  While it (intentionally) lacks the intensive attention to research that characterizes GCBC, it does an excellent job of giving readers the basics.  I recommend it.  And if you are intrigued by what you read, I would suggest going on to GCBC to fill in the blanks. 

The bottom line? It is the overproduction of the hormone insulin that makes us fat.  This overproduction comes from two sources:  eating too many foods that require insulin for processing (the starches and sugars), and the overproduction of insulin that results from body cells that become "resistant" through aging or eating too many S Foods.  Dietary fat and protein do not stimulate insulin.  Consumed alone they cannot make us fat.  Most importantly, insulin prevents us from using the fat in our fat cells as fuel.  We are thus always running on sugar.  We crave more when we run out and we never get into fat burning mode.  We are built to run on the fat in our fat cells as a major fuel.  Most of us can't use it.

This knowledge is the currency of my world.  It is obvious to those of us who "do" weight loss as a career.  It has even---finally---become obvious to entrenched diet programs like Weight Watchers, who recently revamped its point system to reflect the fact that all calories are not alike.  Some make you fat. Others don't.

For those with limited patience or someone who can only borrow “Why We Get Fat" for a day, I particularly recommend the second section of the book called "Adiposity 101".  These facts are well presented and give you a good introduction to the problems created by insulin.  (A similar discussion can also be found in the third chapter of Refuse to Regain on Metabolic Syndrome).

One of the points that Taubes makes repeatedly is that nutritionists and doctors remain entrenched regarding their thinking about weight loss.  They insist that you can lose weight by eating less and exercising more when this formula has been an ineffective proposition for 95% of those who try.  It simply doesn't hold up long term.  He acknowledges that obesity doctors understand his thesis and support it and that docs who don't treat obesity are unwilling to listen to those who do.  That's true.  But it is also true that those who write about and research obesity, but don't treat it, are not privy to the daily observations of this knowledge in practice.  So let me add some brief critiques of what is otherwise an excellent book.

1. Genetically Consistent vs. High Fat, Low Carb

Taubes touches briefly on the wisdom of eating foods that are like the foods eaten by our ancient ancestors.  Theoretically, these are the foods to which we are best adapted.  Following that, however, he pins the blame for obesity on carbohydrates and exonerates fat and protein.  I agree unequivocally with his blame placing, however I remain very circumspect about the sources of our fat and protein.  Taubes is fond of bacon and steak.  I wouldn't have a problem with this if it were not for the fact that the meat we produce today is very nutritionally distinct from the meat we've always "known" how to eat.  Bacon contains carcinogenic nitrites and other preservatives.  Corn fed beef has a reversed profile of omega 6 to omega 3 fatty acids when compared to the meat of animals that graze.  If we hypothesize that we get sick from eating a diet full of carbs because we are not genetically prepared to eat large amounts of carbs, how can we ignore the fact that eating meat that is very modern in composition may be equally damaging?  The way I see it, logic leads me to believe that we get both fat and sick when we eat fuels that our body is not prepared to process genetically.  Trying to get as close as possible to original food sources makes the most sense.  There is no research on this by the way other than voluminous observation of hunter gatherer tribes that survived into modernity and were absent modern diseases.

2. How to Lose Weight

Many of the sources consulted by Taubes in this book suggest an Atkins-style diet for weight loss.  There are also many obesity clinics that still use something called the "Protein-Sparing Modified Fast".  This is essentially an extreme Atkins diet that has patients eat small amounts of mostly chicken, eggs and certain cheeses.  While these diets do cause weight loss, they also can lead to complications of dehydration, dizziness, and potassium and salt depletion.  We have found them to be completely unnecessary and I can't understand why people persist in using them.  Our diet has many more grams of carbohydrate than Atkins or the PSMF.  Our patients eat one piece of fruit and a lot of vegetables and salad each day.  It works beautifully and we achieve large weight losses.  We have rarely had a patient who is resistant.  In other words, it is very possible to lower insulin levels enough to get brisk weight loss without going to total carb elimination.  You just have to know which carbs to avoid and how much to include.

3. Calorie Lowering for Weight Loss

One of Taubes' interests is establishing a study that would document that fact that people on the Atkins diet could eat enormous numbers of calories yet still lose weight.  This would prove that weight loss isn't about the amount of calories at all, but is about how the body uses the calories it gets.  In other words, does it burn up the calories and get rid of them or does it store them?  In the practical world of the weight loss clinic, however, we have found that to get weight loss, patients need to get calories low.  Having tried the Atkins diet myself many times, I found that my calories were automatically limited by the boring nature of eating only meat and cheese.  I don't know if Taubes is right about his belief, but it seems beside the point.  Eating huge amounts of fat and protein doesn't feel good to many people, and weight loss can easily be gotten on a low insulin diet of about 1200-1400 calories that suppresses appetite as a side benefit. 

4. Exercise

Taubes makes the very interesting point that obese people are sedentary not because they are lazy, but because their energy stores are locked up (insulin traps fat energy and makes it inaccessible).  They simply don't have enough energy to exercise and therefore don't want to.  I agree with this.  Our patients who lose weight become much more interested in moving. You only need to read a few weight loss blogs to see how frequently obese, sedentary people turn into avid exercisers, even marathoners. Taubes discounts exercise as an important factor in weight loss.  So do I.  However, I still stick to my guns when stating that exercise is crucial for weight maintenance.  I don't know the technicalities of why it works, but we can suppose that it keeps the muscles efficient in their use of calories and allows for the whole bodily machine to run better.  Exercise is like the oil or lubricant for our metabolic system.  Keep it going. 

I highly recommend that you take a look at "Why We Get Fat" and see if it doesn't get you thinking.  I hope you will come out believing that restructuring your diet to permanently rid yourself of the bulk of your grains and carbs is the true solution for permanent weight control.   It has worked for me and it has worked for all of those I've been able to convert.    

Let's get serious.  How many people do you know who are---right at this moment---resolving to lose weight after January 1st?  Judging by the utter flood of TV commercials for Jenny Craig, Weight Watchers et al, that began right after Christmas, I'd say that the weight loss industry is thinking it's pretty much everybody.   

The New Year's resolution is a charming little tradition.  For a few days, we spend time reassessing our priorities and vowing to right our wrongs, fix what's broken.  But by January 3rd or 4th, life returns to business as usual and most of us have already forgotten our end of the year introspection.  Weight loss, in particular, doesn't respond well to resolution.  What is does respond well to is…planning.

Losing a goodly amount of weight is complicated business.  Our first mistake is to underestimate it.  On the other hand, if we size up the challenge correctly, there are a number of things we can do to vastly increase our chances of success.  So if you want to lost weight this year or if you know someone else who does, here's a battle plan:

1. Forget the January 1st Date!

You should only start a weight loss plan when you have everything in place.  Setting an arbitrary date like January 1st simply because the year changed from 2010 to 2011 is a bad idea.  Instead, allow for several weeks to get everything set up.  Set a "Quit Date" sometime later in the month.  This is what smokers are encouraged to do when they give up cigarettes and it can work for you too.  Pick a date that has some meaning to you (maybe it's the same number date as your birthday or anniversary, or maybe you just like the combination of digits). 

2. Pick Your Strategy 

Most people who start diets do so with only a vague idea of "cutting back" or "eating less junk".  The most effective diets are easy-to-follow plans that restrict food fairly severely and have simple rules.  Research has shown that most diets work---if they are followed strictly.  Your job is to figure out which type of diet you can follow to the letter.  Can you stick with Atkins the whole way, just fat and protein?  Would you do better with a Weight Watchers approach? Are you someone who is more likely to lose if you commit some money to the process?  Do you know that when you diet on your own you quickly lose focus?  Maybe you need to attend a group or see a dietician for accountability.  Do you have a friend or relative who has lost a lot of weight using a particular approach?  Should you interview them to see if that might work for you?

As a basis for starting this process, I can tell you what works for our patients.  We put them on a high quality meal replacement (either bars or protein shakes) during the day and have them eat a Primarian style meal for dinner.  This meal consists of a moderate serving of skinless poultry, very lean meat, or fish, a large salad with non fat dressing, a large serving of green vegetables (steamed, broiled or roasted) and a piece of fruit.  They generally finish the day with a low fat dairy product, like sugar free pudding or low cal yogurt.  We get excellent, consistent weight loss with this regimen but of course, in addition, our patients are checking in with us weekly.  Without trying to be too self-promoting, I will add that my book, Refuse to Regain, contains an eating plan in the middle.  Many people who have switched to this type of eating have lost between 30 and 50 pounds, so this might be another option.

IMPORTANT NOTE: Many people who have weight issues are on medications, frequently for diabetes, hypertension, and cholesterol.  Often these medicines need adjustment when food intake changes.  If you are on medicines and plan to diet significantly, make sure you check with a doctor or dietician prior to starting.  This is especially true for anyone on medicines to lower blood sugar or on diuretic pills.  These can be dangerous when combined with diets.

Once you have decided on your strategy, get everything set.  Make an appointment to begin on your appointed date or purchase your shakes and bars.  Or get your diet plan printed out or buy the appropriate books.  Put everything in one area and get it ready to go.

3. Set Up Your Exercise

While vigorous exercise is most helpful for weight maintenance, mild to moderate exercise will assist in keeping you honest during weight loss.  If you can do more as you go along, fine.  If not, don't sweat it, as long as you are losing.  Most importantly, don't exercise to the point where hunger knocks you off your 100% commitment to your diet plan.

Prior to your Quit Date, figure out how and when you will exercise.  If you are very out of shape, I recommend starting with short bouts (maybe 15 minutes or so) a few times a week.  Don't push it.  Your body is not used to exercise yet.  If you choose walking, figure out a place to walk in both good and bad weather.  If you choose classes like aerobics or spinning, register yourself so that you've committed the money.  If you choose a gym, see if you can hook up with a trainer for the first month just to keep things interesting.  If you choose exercise videos: find them and rent them.  Get everything in place.

4. Purge Your Environment

Just prior to your Quit Date it is very important that you purge non-diet foods from your home and office environment.  Get a big bag and have a throw-away or give-away party.  During the early phases of your diet, strong hormonal signals will be flowing from your brain that will lead you to late night searches for hidden potato chips.  Make sure that they are not there to be found.  Enlist the help of your family.  Tell them that they will have to eat these foods outside the home (or hide them from you...not to be eaten in front of you) for the duration.  Tell them not to give in to your pleas for these foods even if you resort to bribery, coercion, and other trickery!

5. Declare Your Intentions

I have found that the people who do best on diets are those who tell everyone what they are doing.  Many patients tend to want to hide the fact that they are trying to lose.  "It's nobody's business," they say.  Or, "I don't want people asking me a lot of questions."  Naturally, this is your own decision, but generally it seems to be the case that those who boldly declare that they're out to change the way they eat seem to take the commitment more seriously.  After all, they've made a statement.  It's tougher to renege on a promise you've made publicly.  Yes, friends may watch, ask questions, and judge, but you can deal with it.

6. Buddy Up

Most people don't really believe it, but weight loss is tough.  You'll need someone to help you keep going, to praise you and to cheer you on.  Spouses are great, if you can recruit them to work as a team and if you can resist the temptation to give in when they say, "Honey...how about we have the popcorn just this once?"  A friend who is truly serious about losing weight might be even better.  Weight Watchers groups have been an inspiring source for many.  Dieticians can be great.  Hey, there are even a few good diet docs out there!  Some people use their personal trainers as cheerleaders.  Recruit your team and have it ready on day one.

7. Keep a Record

This isn't just a diet.  It's a serious journey through a new landscape.  Take verbal pictures (and maybe some real pictures too).  Get yourself a nice leather notebook or one with a beautiful cover.  Get yourself a comfortable pen.  Put everything in one place and have it ready to go.  Write a little bit about your journey each day.  You don't have to write down everything you eat (unless you want to), but write a bit about how you felt, what was tough, what was fun, what got you down. 

I have one patient who took a picture of herself in the same clothes in the same place every single week throughout her 100 pound weight loss.  What a visual story that makes!

OK!  NOW you're ready to go.  Forget January 1st.  Your Quit Date may be later in January or it may not come until April, July or November.  The important thing is that you will have thought it through.  You will be prepared and you've given this tough challenge the attention it needs to achieve a successful result.  After all, what we're searching for is not simply a Happy New Year.  It's more a Happy New Life.

For most people who have struggled with weight, there is the persistent, nagging suspicion that permanent body change may be a fiction. When we look around, we see very few people who have lost weight and kept it off...yet every magazine cover proclaims the ease of bodily reconstruction.  Just walk off the weight!  Lose 33 pounds by Christmas! As author Gary Taubes once famously asked, "What if it's all been a big, fat lie?"

Way back in 1959, obesity expert Albert Stunkard published a seminal paper which showed the dismal failure rates of programs treating overweight people.  Stunkard demonstrated that, in multiple clinical settings, very few people lost weight and practically no one maintained the loss.  In a 1983 commentary on this work, Stunkard recalled, "This study grew out of an attempt to resolve a paradox--the contrast between my difficulties in treating obesity and the widespread assumption that such treatment was easy and effective."  Any reflective professional who deals with obesity will tell you that they often feel like Sysyphus, rolling an endless boulder up the mountain only to see it tumble back to the sea.  Dieters feel the same way. 

If we have been lied to, if it is in fact impossible to get rid of excess weight in any permanent way, we may want to circumvent the frustration and simply accept ourselves.  We may even want to rejoice in the size we've been dealt.   This outlook is attracting a growing number of people and has come to be known as Size Acceptance.  If you are unfamiliar with this viewpoint, you might want to take a look at websites like Big Fat Blog or the writings of Linda Bacon, PhD.

The growing size acceptance movement together with the very real failures of conventional weight loss treatment have given me quite a bit of food for thought.   As always, I can only give my own opinions and I remain respectful of those who disagree. 

Here are some of the questions raised by size acceptance as I see them: 1. Is long lasting weight loss unattainable?
2. Is overweight unavoidable for some?
3.  Is overweight unhealthy and if so, do we bear any responsibility for keeping ourselves healthy? Can we be healthy and overweight?
4.  What is causing us to be obese?  Who are the potentially responsible parties?

For me, here are the answers:
1. Is long lasting weight loss attainable?  Yes.  Long lasting weight loss is possible.  There may be periods of relapse or regain, but increasingly I see people who have been able to engineer permanent change.  This is not to minimize the profound nature of this change.  It is not for everyone.  But I do think that we are getting better at figuring out how to do this and at creating connections between those who have.  I am also hopeful that the FDA will finally approve medications that we can use during the early phases of weight maintenance.   Drugs that blunt appetite would be very helpful are allowing Maintenance Juniors (Just Reduced) to get used to a new eating style.  They might also bridge the period when hormones and brain chemistry are altered following the starvation-like period of dieting.

2. Is overweight unavoidable for some?  Yes.  Likely there are many people for whom weight gain is unavoidable in our current environment.  These people may have more sensitive responses to modern foods or may have been so metabolically damaged by modern eating that weight loss is too great a task.  However, I believe that there are fewer of these people than we might think.

3. Is overweight unhealthy? Unequivocally yes.  There have been many critiques written that cast doubt on the veracity of reported health consequences of overweight and obesity.  As a physician, however, I must say that the degree of ill health that comes directly from weight is utterly convincing and completely astounding.  How can I be sure that these problems are coming from weight?  I can be completely sure because I am able to watch them dissolve and disappear as weight is lost.  I am able to watch them re-occur as weight is regained.  In addition to the obvious big killers:  high blood pressure, atherosclerosis, diabetes, high cholesterol and an increased risk of cancer, there are the things that make life miserable like gastric reflux, gout, arthritic pain, shortness of breath, sleep apnea, fatigue and depression.

Do we have a responsibility to choose healthy habits?  That depends on your world-view.  America has never been a society that has looked down on those who chose to race motorcycles, smoke, or drink.  Those choices have always been the personal business of the individual.  However, the choices of individuals become more profound when they are part of a sweeping health epidemic.  There is no question that the societal costs of treating the panoply of obesity related disease are staggering.  Perhaps we finally do have some social responsibility to attempt to curb these costs.

Can we be healthy and overweight or obese at the same time?  We can certainly strive to be healthier at any level of body size, but certain realities remain: we cannot make up for the fact that our heart has to chronically power a body that is 30 to 100 pounds larger.  We cannot make the loading on our back and joints disappear if we remain overweight.  We also know that intra-abdominal fat is viewed as an invader by the body and causes a brisk inflammatory response which goes on internally.  While we can try to be healthier, we cannot be sure that we do not remain chronically inflamed: a state which leads to diabetes and vascular disease.

4. What is causing us to be obese?   This is the sticking point.  While it is completely legitimate to say, “This is who I am.  I choose to accept it", I remain troubled by one major thought.   Suppose this is NOT who you are?  Suppose you are only this way because you have been manipulated, brain-washed, culturally drowned, poisoned or otherwise hurt?  You can still choose to accept and enjoy your size, but the landscape suddenly looks a lot different. I can't be sure that obesity has skyrocketed because of the way our culture has accepted and promoted food.  I can't be sure that we don't all have a virus or haven't succumbed to an environmental toxin.  It may be a combination of the two, but nevertheless, a healthy skepticism about the SAD and an unwillingness to participate in it, seems to be the pre-requisite for making complete bodily change.  We see the same phenomenon in those who have gastric bypass surgery.  The surgery initially causes withdrawal from the SAD.  Eating modern foods causes the patient to feel sick.  Once a year or two has passed, some patients become able to tolerate SAD foods again.  Those who succumb regain weight.   Patients who remain SAD-free also remain lean. 

Having said all of this, I find that a big part of my job is convincing some patients that they should accept their size.  Torturing oneself with failed weight loss attempts, hating oneself for perceived inadequacies is no way to live.  Many of the people who come to my practice are charming, accomplished, lovely people who simply can't get past their weight and can't accept that losing weight is not in the cards.  That unhappiness is a tragedy.  Thus, it seems to me that there are two equally legitimate strategies for personal overweight.  One is to fight the fat...but with the knowledge that the fight is infinitely more difficult than we've been led to believe.  The other is to accept it and try to remain as healthy as possible at any given size.

The best advice I can give as a practitioner is this:  Rather than wedding ourselves to absolute beliefs about size, perhaps we would do better to periodically re-evaluate our positions.  We may want to attempt weight change now only to find that we accept ourselves at a larger size later.  We may be happy eating the SAD today, but decide that we want to trade in for better health as time goes on.   The one thing that we should never do is use our belief to hit someone else over the head.  Obesity and it's cultural roots are way too complicated to allow them to divide us into angry camps.  Like other ethically challenging decisions, the decision as to whether to accept size or continue to work against it remain deeply personal and should be respected.

Ever since Jonah was swallowed by the whale, the idea of being ingested remains a terrifying thought.  In horror films, aliens gobble people whole.  We fear being "swallowed" by the ocean, by storms and by quicksand. Perhaps we have nightmares about our planet being swallowed by a black hole.

We are frightened of being eaten, but we have little fear about what we, ourselves, choose to eat.

Unlike most posts on this site, this is not going to be a diatribe about sugars, starches or calories.  Instead, this is a diatribe about safety and why we should be circumspect about the things we choose to swallow.

Aside from breathing, eating is the only act in which we take something from the outside world and make it a complete part of ourself.  If you think of it, this is profound.  The old saw "you are what you eat" is true in a very real way.  The components of the things you ingest become the substance of your body.  So too, their toxins, the unexpected hitch-hikers, that accompany foods, drinks and medicines. 

As the wife of a gastroenterologist, I can tell you that there is an inordinate amount of food poisoning in our world.  Whenever someone gets a GI illness, they say they have the "stomach flu".  More likely, they've been poisoned.  Think about that:  poisoned! While there is the occasional epidemic of Norwalk virus or other gastroenteritis, most of our unexplained bouts of vomiting and diarrhea come from contaminated food.  This knowledge has made me think twice about the restaurants I am willing to trust. While it's always a crap shoot, if the chefs are a bunch of 18 year olds in a franchise at a highway exit, you can be sure I'm not stopping. 

There has been a lot written recently about contaminants that wind up in supplements and medicines.  It has always astounded me that otherwise cautious people---people who buckle up when they drive, wear bike helmets, and floss their teeth---think nothing of taking potions they hear about on the internet or peculiar supplements that are not vetted by the FDA. Even vitamins branded with names of doctors, clinics and celebrities.  Who is making these supplements and what in the world is in them?  Are you really willing to put them directly into your Ferrari of a body?

This week, I saw a new patient who asked me whether she should stop taking her vitamins while dieting.  When I asked her what she took, she produced a shopping bag full--literally.  There must have been 15-20 different supplements in there, all from manufacturers I'd never heard of.   Apart from the question of what these bottles actually contained, there was the larger question of whether healthy people should be taking vitamins at all.  No less an authority than the vaunted Cleveland Clinic says no. And I agree.  But then again, I’m particularly paranoid about my food sources.  I do believe in fish oil, but I'd feel a lot better if I knew the Norwegian guy who caught the fish personally. 

You can call me crazy, but it only takes so many salmonella and e.coli outbreaks to tell us that we need to look out for ourselves.  No one else is going to, at least not until after the fact.  Consider the latest example, fines levied against pharmaceutical giant Glaxo for shameful practices in the manufacture of major drugs.

The New York Times reports:

Altogether, GlaxoSmithKline sold 20 drugs with questionable safety that were made at a huge plant in Puerto Rico that for years was rife with contamination. Cheryl Eckard, the company’s quality manager, asserts in her whistle-blower suit that she warned Glaxo of the problems but the company fired her instead of addressing the issues. Among the drugs affected were Avandia, Bactroban, Coreg, Paxil and Tagamet.

The article goes on to specify:

The plant was GlaxoSmithKline’s premier manufacturing facility, producing $5.5 billion of product each year. But Ms. Eckard soon discovered that its quality control systems were a mess: its water system was contaminated; its air system allowed for cross contamination between products; its warehouse was so over-crowded that rented vans were used for storage; it could not ensure the sterility of intravenous drugs for cancer; and pills of differing strengths were sometimes mixed in the same bottles.

Although F.D.A. inspectors had spotted some problems, most were missed. And the company abandoned even the limited fixes it promised to conduct, the unsealed lawsuit says. Ms. Eckard complained repeatedly to senior managers; little was done. She recommended recalls of defective products; recalls were not authorized. In May 2003, she was terminated as a “redundancy.” She complained to top company executives; she was ignored even after warning that she would call the F.D.A.. So she called the F.D.A. and sued. The agency began a criminal investigation and used armed federal marshals in 2005 to seize nearly $2 billion worth of products, the largest such seizure in history. Unable to fix the plant, GlaxoSmithKline shuttered it in 2009.  

Who is looking out for you?  Only YOU. 

Here's what I recommend:

1. Carefully consider your food sources and try to eat in places that you know and trust. Foods that stand out in the open, like salad bars, are risky unless you know they are frequently cleaned and the food kept cold and fresh.  

2. Don't eat unknown substances and supplements simply because they have an ad in Shape, Women's Fitness or the National Enquirer.

3. Don't assume that medicines are safe.  Take the fewest pills you can.  (But DO take meds if you need them!)

Your body is precious.  Vet everything that you decide to eat by giving it at least a few moments of consideration.  If it's worthy of you and your health, then enjoy.  If it's suspect, unknown, or of uncertain value, give it the heave-ho.

Picture this.  It's a grey fall morning in Northeast Ohio, the kind of morning when the nip in the air prompts people to get out the mittens and the knitted hats. There's a peek of sun now and then; a few moments of lucent optimism.  Each time the light glows, the leaves flash iridescent orange and red.  But it doesn't last long.  The clouds quickly reassemble and cover the sun.  Unlike the leaves that still cling to the branches, the leaves that litter the ground are brown, wet, and dead.  Winter is just a moment away.  

From the corner seat in our local coffee shop, I'm blogging and watching life go by. The first guy who comes in from the street has a prominent belly that's hanging way over his belt.  He orders a coffee, a doughnut and a blueberry muffin.  He pours sugar liberally into his cup of joe. 

The pastry case looks tempting.  There are five different types of muffins, multiple slices of pound cake, rice crispy treats, cookies and scones.  If you ask for coffee, the smiling staff has been trained to ask, "Anything else for you today?".  They appear to be slightly offended--mildly shocked--- if you don't get something sweet.

I flash back to a story from Don's medical school days.  He was assigned to take an eating history from a very overweight patient.  She reported that she usually ate cake for breakfast.  He came home and told me this and we were so shocked that the story was repeated for years.  That was 1980.  Now I sit and watch as the majority of people in our town leave this coffee shop with a bag full of cake for breakfast.  Actually, they've probably already had breakfast, because it's now 10 am.  

 A vertical rack offers a selection of newspapers with their front pages tilted forward attractively.  Bold headline, above the crease on USA Today:   DIABETES CASES MAY DOUBLE BY 2050.

 The pace of our sugary dissolution is apocalyptic, frightening.  Why are we all becoming diabetic and why doesn't anyone care?  Smoke in our house, flames licking at our feet.  Sometimes I feel like I'm a lone voice shouting FIRE.  It's like a bad dream.  The one in which you try to call someone with an urgent message, but your feet stick in the sand, your fingers turn to rubber when you try to dial the phone, the line is dead.  Over and over. 

 Last night we held our second Refuse to Regain Group.  Eleven maintainers showed up, all so anxious to learn from each other.  Many in our group have lost over 100 pounds and one person has lost over 250 pounds, but the tasks of maintenance remain the same.  In order to maintain, in order to beat off the world of illness, fat and diabetes, we must find a way to live outside the sugar and starchy American norm.  How we do this was the subject of heated debate.  Can we eat whatever we want, but just have three bites?  The National Enquirer reports that Kim Kardashian eats a bite of dessert and pours champagne over the rest to ruin it, perhaps the ultimate demonstration of our wasteful, profligate society and our search for ways to have our cake and avoid it too.  

 At the meeting, there was a clear division between those who had maintained weight for years and those who were just getting started.  The newbies were still wrestling with the Kardashian solution.  Surely there was a way to continue to "play" with pasta, potatoes, grains, bread, cereal and sweets.  Maybe on the weekends?  Maybe with steely self control?  Maybe by keeping a food diary?  Please, please let there be a way!

 The more experienced maintainers had long since made their peace with the elimination of sugars and starches.  They ate by consistent rules and had discovered certain non-triggering treats (NTTs) that worked for them. Their diets relied on large amounts of fruits and vegetables, lean proteins like poultry, fish and low fat dairy and some nuts.   When their weight went up a bit, they eliminated their NTTs temporarily. 

 What is causing our obesity and diabetes?  The honest answer is that no one knows.  Perhaps we've simply exceeded the amount of stress our insulin systems can tolerate.  Perhaps epigenetic changes that occurred in utero, in wombs that were exposed to much higher levels of sugar than earlier generations, have left us vulnerable to these foods.  Or, there may be new obesogens in our environment, chemicals that disrupt the normal ability of our insulin to choose whether sugars should be burned or stored.  We store everything and become fat and increasingly sugar intolerant.  (And please remember that all starches are sugar too, including whole grains). 

 It doesn't much matter, because the short term answer is clear.   Eat a diet that is consistent with your ancient genes and one that avoids as much starch and sugar as possible.  This removes the stress from an insulin system that is busted...either by overexposure or by some unknown obesogenic cause. 

 The tsunami is gathering.  The fire is already raging.  We are facing an untold epidemic of overweight, diabetic, atherosclerotic Americans.   You are in the line of fire.  I'm telling you the answer.  I'm shouting that the roof's about to cave in.  But so far, there aren't many people running for the exits.  They are still staring, glassy eyed, at the pastry case and pondering the Kardashian compromise.

Nothing peeks our national interest quite so much as transformation and redemption.  We also love instant gratification.  TV shows like "Extreme Home Makeover" and the new Tony Robbins show "Breakthrough", score big by pushing all three buttons.  But a key starting point for these shows--and one that is disturbing-- is that we must feel sorry for those who await transformation.  This is the "Queen for a Day" phenomenon.  Queen for a Day was one of the earliest daytime TV shows and was basically a shameless pity-fest.  Three down and out women would tell their sob stories, one more awful than the next.  The audience would then vote (by applause-meter) on which contestant presented the saddest spectacle.  The winner would receive a crown, a cape and a household appliance (generally a washing machine). 

Today's transformational epics begin with families that are penniless, children with handicaps and marriages that are stressed to the breaking point. They also feature another group that inspires pity: obese people. The Biggest Loser and all the many epics that focus on the redemption of the obese start with the same premise:  these are people who have lost all control and have descended to some rocky bottom.  This makes good drama, since there can be no uplift without beginning in a very sad valley. 

Many people say that they are inspired by these programs.  But I have always felt that, when the subject is obesity, these kind of shows merely reinforce the belief that fat is the fault of the fat person.  I dislike this perspective intensely because it deflects blame from the true culprit: our profligate and disturbed food-culture.  People are overweight because they become hypnotized by and addicted to modern foods which are designed for just such a purpose.  Once metabolically "broken", their increased hunger levels and strident cravings multiply the problem.  There is precious little consideration of the real causes of obesity in these TV shows.  In between vignettes of tears and transformation, we are mindlessly fed commercials that glorify over-consumption and turn their back on any responsibility for the illness they are causing. The big message: it's all a matter of personal choice and a little will power.

All of this brings me to the subject of weight loss contests.  The popularity of The Biggest Loser, coupled with the ubiquity of the obesity problem has seen weight loss challenges popping up in every organization, company and community.  Do these contests, with their focus on pounds lost and crowning winners do anything to address what is nothing less than a national crisis?  Until recently, I would have said no.  But that was before I met Bob K.

Bob is just a guy who has two young daughters and wants to see them grow up.  One day, he realized that he had become way too overweight (by about 90 pounds) and that he was seriously out of shape.  One of Northeast Ohio’s newspapers, The News-Herald, was looking for contestants in its second annual weight loss competition.  Always the extrovert, Bob saw a great opportunity in this situation.  First, he would write a letter that would get him into the contest.  One of the requirements for participants was writing a weekly blog that would be featured in the paper.  Next, calling on his background in sales, Bob would recruit various professionals to a team that would support his efforts.  They, in turn, would be happy to be part of his publicly acknowledged support system. 

Six months ago, Bob came to see me and asked if I would help him lose weight.  I wasn't sure how he would do because he was so focused on the competitive aspect of the project, but his enthusiasm eventually won me over.  Bob promised to do whatever I asked and assured me that his real goal was to completely remake his health.  This was particularly important since he had recently been diagnosed with diabetes, was taking blood pressure medicine, and had high cholesterol. 

During the contest, Bob's natural optimism received an enormous boost from the email support he received, from friends and co-workers who cheered him on, and from monthly reports that were printed in the paper.  He learned a new skill--blogging.  He developed relationships with several trainers and worked hard with each. I will never forget the day, about a month into the contest, that he invited me to view one of his workouts.  A trainer had him running very short sprints, a task that Bob could barely do without becoming severely short of breath.  I was worried about him and insisted he see his primary care doctor.  His back bothered him and a then a heel spur acted up. Despite it all, he persisted.  Determined to complete his project successfully, Bob followed every instruction I gave him just as he had promised.  He also worked extremely hard on his fitness transformation.  At the final weigh in, Bob had lost 85 pounds and was routinely running a distance of 5k.  

By the end of the News-Herald contest, I was a believer.  It wasn't just Bob. Many of the other contestants, inspired by the process, were able to make major transformations. Indeed it seems that the ability to declare a public goal and recruit supporters along the way is a strong motivator.  And significant life change is a very daunting task.  We need lots of ways to make it challenging, compelling, and even fun.  View my video of the contestants.

Do weight loss contests focus too much on weight loss and ignore the skills of maintenance?  Absolutely.  That is why, with the help of Bob K. and some of the other contest participants, I am working on a Refuse to Regain group which will keep everyone focused on solidifying their changes long-term.  My idea is to create a group, not just of maintainers, but of community representatives who continue to have a public voice and who represent the idea that permanent change IS possible.  We hope that, like the thrill of the now completed contest, our group will be challenging, compelling and yes, even fun.

Have you ever felt like making the right dietary choices was more like crossing a minefield?  One day you are strolling along, sure that you are on the path to righteous wellness.  Then BAM!  The landscape changes and you find that you are in mortal danger.  This week, an announcement that victimized calcium supplements was just such a land mine.  Millions of women take these supplements. They've been sacrosanct.  For doctors, recommending calcium pills seemed like a no-brainer, and most were happy to give such easy and seemingly important instruction.

But a few days ago, the British Medical Journal announced that healthy older women who take calcium supplements appear to have as much as a 30% greater chance of suffering a heart attack than those who do not.  This conclusion was based on a review of 12,000 women and was consistent regardless of the type of supplement used.  In the wake of this news, TV health pundits were already distancing themselves from calcium pills.  (CBS News Video )

Once again, real food proved the winner.  Women who got calcium by diet alone had no such risk. For almost any nutrient you can name, food sources provide the safest means of consumption.  As most of you regular readers know, I don't think much of supplements.  In fact, I stopped taking calcium long ago.  For years, that has been my guilty secret. All of a sudden I'm looking like a clairvoyant.

One would think that the big news here is the danger of calcium pills (it’s hypothesized that they may accelerate hardening of the arteries).  But in fact, there are two other elements that are well worth examining.  The first is the conclusion of this and other studies that taking calcium supplements doesn't prevent osteoporosis (why were we all taking the blasted things then?). The second is the fallout that will occur as a result of this, the latest nutritional bombshell.

The editorial that accompanies the British Medical Journal study said:

"Calcium supplements, given alone, improve bone mineral density, but they are ineffective in reducing the risk of fractures and might even increase risk, they might increase the risk of cardiovascular events, and they do not reduce mortality. They seem to be unnecessary in adults with an adequate diet. Given the uncertain benefits of calcium supplements, any level of risk is unwarranted."

Once again, the news that stuns here is that calcium pills never did reduce fracture risk.  Undoubtedly, we would have continued to pour endless dollars into these supplements (just as we do into taking all sorts of fancy, unproven vitamin supplements) had this particular study not gotten big media play.

But in fact, the biggest story in the calcium saga may yet be unwritten and may come from the whiplash that occurs as a result of our rush to get calcium from something other than a pill.  Because we change our diets based on the daily proclamations of science, our eating habits are as fickle as a passel of runaway brides. One change often ripples out to create a host of others.  Remember this one? In the 1990's various researchers declared that fat was the enemy.  The result?  An entire country loaded up on fat free products. In our headlong rush to avoid fat, we vastly increased consumption of carbohydrates and sugars. We soon became increasingly more obese and diabetic. Read some Frontline interviews on the Fat Free Years  

We are only a few days into the calcium story, but already we are being advised to get more calcium via foods.  That seems like great advice, but the type of food is not being examined much.  Nor is the fact that many of the countries with the world's highest rates of osteoporosis have the highest calcium intakes.  No doubt, cartons of milk, chunks of cheese and anything made with soy will soon sport attractive labels that remind us that these foods contain calcium.  Will we stop and think about rushing to increase our consumption of these foods?  I doubt it.  Most  people (and I include health professionals) believe that all we need to do is plug the latest hole, in this case calcium.  The fat free experiment should have taught us something, but I guarantee....it hasn't.

We will probably start running to soy (many soy products are fortified with calcium) and dairy for our calcium. 

Fortified soy milks and cheeses have been promoted as healthy alternatives for those who can't tolerate milk, or just because.  Very few people would consider the Harvard School of Public Health a fringe organization but their view of soy is cautious.  It appears that soy is not the miracle food it purports to be.  Studies do not support soy's ability to lower bad cholesterol meaningfully, nor to stop hot flashes or menopausal symptoms.  And the phytoestrogens in soy have unknown effect.  Several studies even suggest that soy may stimulate the growth of breast cancer cells.  Harvard Nutrition Source: Soy. 

Similarly, you may be surprised to read what Harvard has to say about dairy: "Look beyond the dairy aisle. Limit milk and dairy foods to no more than one to two servings per day. More won’t necessarily do your bones any good—and less is fine, as long as you get enough calcium from other sources. […] While calcium and dairy can lower the risk of osteoporosis and colon cancer, high intake can increase the risk of prostate cancer and possibly ovarian cancer." 

Let’s think a bit before we rush to make big changes.

An interesting dietary conundrum is the fact that many of the countries with the highest dairy consumption (the Scandanavian countries and the US for example) have some of the world’s highest rates of osteoporosis. 

Researchers who believe in ancient eating styles point out that diets which are high in dairy (not ancient), cereal grains (not ancient) and meat, tend to present high acid loads to the blood.  Fruits and vegetables are more alkaline when digested.  When things get too acidic, the body needs to release an alkaline substance to neutralize the problem.  If it is not readily available in the food we eat, calcium is the buffer that calms the acid load.  With chronic consumption of an acidic diet, the theory goes; there is chronic release of calcium from the bones leading to osteoporosis.

Once again, the Primarian, ancient or Paleo diet avoids the problem.  This seems to be the case with each new diet "discovery".   That’s no surprise if you believe, as I do, that the only thing we are "discovering" is how to eat as humans always did.  Somehow, though, that’s never the conclusion we reach. Instead, we run to make a big correction.  In doing so, we tilt our diets like sailboats whose masts are listing in the wind.  Not a good idea when diets and health are all about balance.

An ancient diet is primarily composed of fruits, vegetables, nuts, berries, lean meats, poultry, fish, seafood and eggs. Lean toward the plant matter and add high quality animal protein. When possible, the animals we eat should be fed a diet that is composed of their own natural foods (in other words, grass fed rather than grain fed).  Grains are not a part of ancient diet, nor are legumes like soy because there was no original genetic exposure to these foods. While I include low fat dairy in my Primarian diet (for the sake of making it more palatable to modern eaters), I suggest sparing use.  Animal milk is a new food for most humans and many have a problem with it, including lactose intolerance—a condition that effects the majority of the world’s population.

In our modern world, a good diet may be defined as a diet that manages to survive every challenge issued by scientific "discovery".   In the past 7 years or so since I became primarily Primarian, I haven’t had a moment of diet fickleness.  Nothing has made me rush to change my plan because each new diet finding has neatly aligned with exactly what I’m eating.  Low salt, high potassium, more omega three, less saturated fats, more fish, fewer pills...less visits to the doctor.

I've got it covered.  

Readers of this blog know very well that I (vastly) prefer healthy behaviors to pills for the prevention and treatment of most of our modern medical problems.  But the FDA's approach to potential weight loss medications is frustrating and, in my view, prejudicial.

First, there was the FDA's denial of Rimonabant, a weight loss med that has been in use in Europe for some time.  The FDA based its thumbs-down ruling on Rimonabant's potential to cause depression and suicidal thoughts.  Data from long term trials in North America and Europe, however, suggest that while these effects are real, they generally occur early in treatment and disappear after the first year (see  Rimonabant Data ). in the European market, this problem was dealt with by new labeling and by educating prescribers on proper drug usage.  American physicians are completely familiar with using medications that may have deleterious side effects.  In particular, most of our popular (and excessively prescribed) antidepressants carry warnings about increased suicidal ideation.  Beta blockers, routinely used for heart conditions and blood pressure, can intensify or cause depression; as well as anxiety drugs like valium or xanax, narcotic pain relievers, and a host of other medicines. 

For the past couple of years, there has been a buzz around a new weight loss med called Qnexa.  Like its highly effective but controversial cousin Phen-Fen, Qnexa is a combination medication.  For some time now, obesity specialists have believed that weight gain must be blocked via multiple channels.  This means mixing drugs in order to strengthen their individual effects. 

Qnexa is a combination of two medicines:  phentermine and topirimate.  The first component, phentermine, is the same drug that formed half of the Phen-Fen combo.  It is an appetite suppressant which has mild stimulatory effects.  When given alone, it has not caused any of the problems seen with Phen-Fen, and has been used safely for many years.  Most weight loss doctors use it (even me, although rarely), but its efficacy is limited by the fact that tolerance develops rather quickly.  Within a fairly short time, appetite suppression is lessened and the drug stops working.  Side effects include increased heart rate and blood pressure and the potential for extra or skipped heartbeats.  Some people report jitteriness or insomnia.  For most, these effects can be mitigated by carefully controlled dosing. 

The second component of Qnexa is a relatively small dose of Topirimate, more familiarly known by its brand name Topamax.  Topamax was originally developed as an anti-seizure drug, but soon gained popularity as a migraine preventative.  When patients taking the drug noticed associated weight loss and appetite suppression, it began to be used off-label for weight control.  Topamax can cause confusion, word-finding difficulties, kidney stones, and a serious problem called metabolic acidosis.  However, many people take Topamax without difficulty and at much higher doses than those included in Qnexa. 

Weight loss trials with Qnexa have shown it to be moderately effective, but yesterday, the FDA panel charged with reviewing the drug disapproved it citing side effects.  This dismissal is seen as a foreshadowing of the fate of two other drugs (contrave and lorcaserin) that are currently in clinical trials. 

At the moment, doctors basically have only two prescription drugs for treating overweight:  sibutramine (meridia) and phentermine (adipex).  Neither drug is particularly harmful nor is neither drug is particularly effective.  Despite this fact, these drugs are controlled as if they were the most destructive medications on the face of the earth.  In the state of Ohio, for example, use of the drug phentermine is limited to a three month period (unheard of for any other medication).  Doctors must document that their patient is, in fact, obese prior to prescribing the drug.  The patient must show a documented weight loss while taking the drug.  The prescription must be written for three consecutive months without a break.  If there is a disruption, the prescription will not be filled.  Pharmacists can question the honesty of the physician.  I have personally received calls from pharmacists who wanted to know whether a certain patient really had a BMI of 30. In their judgment, the patient didn't look heavy enough!   Patients who are given prescriptions for weight loss drugs are often treated as if they were asking for heroin.  Many of my patients have been told, very dismissively, "we don't carry that!" They are made to feel embarrassed and demeaned.  Contrast this attitude toward weight loss drugs with the attitude toward narcotic pain meds.  Any dentist can prescribe truly dangerous medications like vicodin or percocet in large amounts.  I can send a patient out of my office with a prescription for fistfuls of oxycontin and I can renew that prescription monthly ad infinitum.  No patient will ever be questioned or looked at askance at the pick-up counter.  And I can guarantee that I will never get a call saying that the patient in question looks like someone who doesn't "deserve" their medication.

Weight loss medicines don't work very well, but for some people, they are at least a small raft to cling to.  Both my patients and I have experienced prejudice around the prescription and consumption of such medicines, despite the fact that in the big picture of drugs and their side effects, weight loss medications are minor players. I believe that the refusal of the FDA to forward new weight loss meds smacks of the same prejudice and hypocrisy.

Are we saying that it is ok for medications to have multiple side effects so long as they treat "important" and life threatening conditions?  What could be more life threatening and important than a condition that is killing 300,000 people yearly in America and is consuming 147 BILLION dollars of our annual health care budget (CDC estimate)? 

I suppose I should be happy that the FDA is protecting our overweight citizens from medicines that they might take indiscrimately and which might cause them harm, but I can't get past the fact that they seem to be trivializing the obesity epidemic with their decisions.  Personally, I am looking for a medication to help stabilize people in the first year or two of maintenance.  That medication might be one of these denied drugs, used judiciously and for a short period.  Now I am left without any ammunition, forced to make a choice whether to use drugs in an off-label situation, which shifts all the liability to me.

All the blame for our lack of weight loss meds does not fall on the FDA.  One of the major reasons for caution with these medications is the history of the weight loss industry.  If it were not so full of charlatans and pill pushers, if people had better and more thoughtful treatment, and if more physicians understood more about the problem, we would not have such a skittish FDA.  As things stand, I can't blame them for wanting to limit access to drugs that have such potential for over-prescription and abuse.

Still.  These FDA rulings make me feel that, once again, the powers that be are making the statement that obesity is simply a matter of self-control, and unlike those "important" conditions, it can live without adequate medical options.  I wonder if we’ll feel the same when 90% of our population is overweight?