Weight loss and the Biggest Loser: What you really need to know about the NY Times article

Patients, Facebook friends, and friends of friends contacted me in horror after reading the NY Times article on the Biggest Loser. Weight re-gain is inevitable. Most if not all of it.  And metabolic rate is screwed too. The control you believed you had? Doomed to dissolve. The hope you were given that you'd finally made it to your goal size or weight—or were getting closer—shattered. Overweight, obese, underweight or average size—the feelings knew no size boundaries. Fear. Anxiety. Hopelessness. Panic.

The pain of regain extended well beyond the 14 Biggest Loser contestants studied and their loved ones. It was felt by those of you who shared their struggle and their joy and sought inspiration from this outrageous, extremist show. 

The NY Times summarized the research: by 6 years after the show’s end, all but one participant studied had either regained some weight or gained beyond their starting weight; 4 contestants are now heavier than before they tortured themselves with this unsettling weight loss regime.

I know how you're feeling.

Nearly all have slower metabolisms now than at program’s start—over 600 calories less on average— with the biggest loser, Cahill at a loss of 800 calories burned per day; he now has to eat 800 calories less per day to maintain the same weight compared to at the start of the program. Many reduced their weights enough to improve their health, but the struggle to maintain the loss was constant and painful—physically and psychologically.

Where’s our anger at this abuse?

Four to 6 hours daily exercise was commonplace, with Cahill reporting 7 hours/day while on the show. Two or more hours included intense cardio workouts. And their intake? 1000-1200 calories was not unusual—an outrageous restriction even if the obese individuals were sedentary. That’s right. Just breathing or being at rest they would lose weight at that calorie level given average heights and starting weights. The degree of starvation was shameful and irresponsible. A set up for failure for sure. And did I mention there are now reports by participants of taking stimulants (provided to them by the program) to accelerate the weight loss—like ephedra and Adderall? 

It is simply abusive to lose weight the way they were directed to for the public’s entertainment. The extreme calorie deprivation resulted in a hormonally induced hunger and subsequent binge eating. No doubt, great shame and embarrassment resulted from their regain as they blamed themselves for their “failure”. Unfortunately, people replicate this self-abuse with crazy diets all the time, believing they can just jump-start their weight loss and then sustain it. Wrong, wrong wrong. 

What can you learn from this Biggest Loser study?

Yes, metabolic rate does slow with weight loss. This is not news. You knew it. You knew that when you were dieting and the weight loss you’d hope would continue simply didn’t happen. Your weight would plateau even though you were doing just what you were doing before. Even though you were “being good”. And so you made an adjustment. You’d eat a little less or exercise a little more or use behaviors like purging. And what resulted? More frustration, less “success” with weight loss. 

It may be time to be more realistic.

And for many if not most of you, rebound overeating or binge eating occurred. Because you’re a failure? Surely not! Because it wasn’t sustainable. Because you felt deprived—hungry, unsatisfied, fatigued, unfocused, vulnerable. Because hormone levels fought against you, as leptin levels—which helps us feel satiated—dropped with weight loss.

While the number of study participants—a mere 14 individuals—was small—the results were enormous. All but one regained significant weight. Yet the big news from this piece was the extent of the metabolic rate drop and the duration that it was sustained—observed when last checked 6 years after the end of the show! Now that’s scary.

What does this really mean for you?

While we don’t have all the answers, it appears that the degree of restriction impacts the outcome. Meaning, more rapid loss, more rapid gain. The “biggest loser”, Danny Cahill, had the greatest drop in metabolic rate—down 800 calories/day. He also regained the fastest, based on the NY Times graph accompanying the article. Deny your body and it’s gonna do what it needs to preserve yourself—it’ll try to slow the engine down, to conserve, to save some fuel for another day, to burn fewer calories. Yes, it does appear proportional. More moderate reductions in rate of weight loss, less drop in metabolic rate. 

Is my metabolism ruined forever?

The degree and duration of metabolic drop reported in the Biggest Loser research is simply not seen in other studies—a drop of 3-5% is more common. And most studies show that this drop reverses with increased food intake. 

Living with anorexia? 

Fear not—you have not permanently messed things up. The famous Minnesota Starvation Experiment demonstrated what those who treat eating disorders know from practice—that metabolic rate rapidly increases with re-feeding. (But continue to starve yourself and yes, your metabolic rate will be suppressed.) It requires a lot more calories than we’d expect for underfed individuals to restore weight. Ask any parent who is helping to renourish their child with anorexia. 

So please don’t be too quick to assume your fate. How do we know metabolic rate increases in this population? In addition to the Starvation Experiment and inpatient studies using indirect calorimetry—a  measure of resting metabolic rate or calories burned at rest, we also can see it indirectly—from increases in heart rate, body temperature and hormone levels.

I don’t have anorexia. I just diet to lose weight.  What does this mean for me?

“Just dieting” still lowers metabolic rate. If you are as extreme as the contestants, you may need to acknowledge your fate. If you are expecting rapid loss to be maintainable, think again. Torturing your body with hours of exercise each day as many of them did (or any amount, quite frankly, that leaves you starving) and/or restricting your eating and denying your hunger will fail you. 

Banning these? Time to change your approach
 to weight management.

Feeling deprived by omitting foods that satisfy you will lead you nowhere. Besides the reduced metabolic rate, the resulting deprivation leads to binge eating. And binge eating contributes to significant excess in calories and weight regain. Hopelessness follows, leads to the “what the heck effect” and eating recklessly. It all adds up to significant weight regain. And with chronic restricting, there’s also a loss of muscle mass which further reduces metabolic rate.

So now what?

Using more sensible, less extreme, more behavioral approaches to take charge of eating may seem less sexy, but has my vote. An 8 year study on lifestyle change resulted in long term weight loss (in 73% of overweight participants)— but not to the degree you might be hoping for. A 5-10% drop in weight was maintainable without losing sanity, and improved health. 

While the Biggest Loser participants tortured themselves dropping huge amounts of weight, and suffered as it rapidly increased, those with practical lifestyle changes lost less to start and after some initial regain, stabilized for years, suggesting better long term outcomes. The Biggest Losers? The study ended at 6 years, but based on the charts most seem to be likely to continue their weight gain trend.

So what can you do?

• Accept more realistic weight goals.  Modest paced weight loss (assuming weight loss is truly needed) may be most sustainable. 
• A 5-10% weight loss is enough to have a signifiant impact on your health—on blood pressure, blood sugar blood, cholesterol, fitness level and overall well being. 
• Focus on fitness goals. Regardless of your weight, find ways to move more, setting realistic goals.
• Address the quality of your intake for health. Include plenty of whole foods including grains, fruits, vegetables, nuts and lean protein sources—as well as fatty fish. But allow room for other foods you enjoy—yes, that includes cupcakes.
• Work on your eating behaviors, as I’ve addressed throughout this blog (see posts labeled mindful eating and binge eating)
• Cover your ears when your doctor says you must drop to the average BMI if you haven’t seen that place in decades, or ever. Clearly more harm than good will be done.
• Oh, and stop blaming yourself. Take charge of what you can control without physical or mental distress. And take some steps to love yourself as you are.

Thanks for reading. And sorry it's taken so long for a blogpost. Please take the time to share your thoughts--and share this piece with others.

Gluten Free or Gluten Freedom? You Decide. How a Gluten Free Diet Impacts Weight & Health

Do you really need to give this up?

Go ahead and eat how you’d like. Want to only buy organic produce? It’s your call—just don’t ask me to foot the bill. Into whole grains? Vegetarian or Vegan? Serious meat eater? Really it’s not for me to judge.

But you know I can’t just leave it at that. My concern is that if you choose to eat in a particular manner that it be without unnecessary rules that negatively impact your wellbeing—either physical or mental. And I’m concerned when you and others get caught up in the supposed health hype of the day, only to learn the hard way that it just wasn’t worth it.

Let’s talk gluten free

Yes, I even add gluten to my breads!

I hate pain and suffering. So if you have celiac disease and are suffering the effects of this autoimmune condition—this reaction to gluten that strangely results in self destruction of part of your small intestine, there is no diet I’d rather see you follow. Please follow it 100%. Period. Avoid cross contamination from wheat, rye, barley and its derivatives. Read labels and avoid it like the plague. And contact a Registered Dietitian who knows the ins and outs of following this diet to focus on what you can include, not just what you need to avoid.

And I hate deprivation. I mean, denying yourself great, fresh gluten-rich breads and hearty wheatberries and barley (see recipes from Food to Eat and Drop the Diet) to me is painful. I simply don’t see the why if you don’t have celiac disease. If you don’t have celiac choosing gluten free does nothing to enhance your wellbeing nor help you manage your weight. But you’re not alone for believing it will. At my 30^th college reunion recently, I confessed my profession to a classmate, a very bright MBA, Ivy educated attorney. This smart and sensible guy hopefully queried “Do you think I have to stick with this gluten free diet I’m on? Would I be okay if I just gave it up?” Yes, poor judgment knows no IQ limits! So LA classmate, this one goes out to you!

But aren’t there benefits of a gluten free diet?

What Gluten Free will do to your weight

Or these?

Start following a GF diet and no doubt you’ll be much more mindful of what goes in your mouth—because you have to be. You read labels and you think before you eat. And that’s a good thing from a weight management standpoint. It’s hard to be an impulse eater while following a GF diet. Besides, how many rice cakes or GF cookies can you really eat? But if you don’t cook much and you rely on ready-made GF products, the quality of your diet may suffer—along with your weight. GF breads are more calorie dense, as they are missing the scaffolding that gluten provides to assist leavening. And GF breads and other products are often (although not always) lower in fiber—there’s no whole wheat, or rye or barley. (Of course you can add quinoa and brown rice, but these you need to prepare.)

Or this?

If you are following a GF diet because of celiac disease, then your weight may very well increase; with poorly controlled celiac (think pre-GF diet), there is malabsorption. You eat, but much of what you eat passes through without being incorporated into your body. Resolve the underlying issue by avoiding the culprit—gluten—and you will restore normal absorption and get all that you eat. And yes, that may result in some (perhaps very appropriate) weight gain.

But if you’re like the majority of individuals following a gluten free diet, you haven’t tested positive for celiac (through a blood test or via an endoscopy and biopsy of your small intestine). Rather, you follow this diet for a range of other reasons.

A tale of 2 RDs

My favorite, homemade rugelach. Recipe on this blog! Not GF!

It’s amazing what desperation will do. When the medical community fails you—when they have no answer for your symptoms or no cure for your disease, alternative, non-evidence based practices look very appealing. And what’s to lose? Yes, even rational thinkers can be sucked into the hope that this may solve our problems. As I’ve written about previously, my diagnosis with MS 12 years ago lead me to the gluten free diet. Anecdotal evidence abounds and the theories seemed believable. So yes, I followed a gluten free diet—meticulously. Labels were read and dining out was largely avoided—except for at establishments that took gluten free seriously. I was cautious about cross contamination as well—I had my own jar of preserves and butter—no gluten rich crumbs were to enter my body.

And then I stopped. It wasn’t just that I thought about my favorite breads and baked goods I could no longer eat—that was a challenge— or the time it took to prepare everything from scratch—I do that largely anyway. But when my 3 month MRI showed more new damage to my spinal cord it was a done deal. The GF diet did nothing for my disease. Mind you, I’m not blaming it for the worsening of my condition during that time period; the disease progression coincided with the GF diet, but there was no evidence that it was caused by it! Anecdotes like mine are rarely posted. You generally just hear the success stories, leading you to believe only the positive.  

Which brings me to another RD

Kay struggled with many of the classic symptoms you hear about, attributed to gluten intolerance—GI cramping, low back pain, diarrhea, fatigue, to name a few. And regrettably, her doctors failed to screen her with the simple blood test that picks up the majority of sufferers with celiac, nor suggested an endoscopy to take a look at what was going on. Rather than delay, Kay began a gluten free diet and by her report started to get relief from her symptoms within days—not fully, but significantly.

In Kay’s situation, this was likely celiac—just never diagnosed. I often see patients, though, who believe they have a gluten problem who likely don’t. One recent patient had been avoiding all gluten for many months, yet continues to have diarrhea 3 times/day. If it were a gluten issue, symptoms would certainly be improving. Another patient believes she fails to tolerate gluten and reports following a GF diet and feeling great. But a closer look revealed lots of hidden gluten sources—like on a daily basis. No, avoiding gluten wasn’t what was helping her—because surely she only perceived she was avoiding it. Rather, the placebo effect just might have been working its magic.

Dessert, not bread, from Tartine, San Francisco. Yum.

So why share all this? Because there is so much misinformation out there that it’s easy to get sucked into the craze of the days. And I believe that you should be educated about the impact of your diet choices—both physically and mentally—so you may make informed decisions.

And no, I have no financial interest in gluten-rich products, but I do love my favorites including Tartine (San Francisco), Seven Stars (Providence, RI), Guillaume (Montreal, Canada), and Clear Flour (Boston, MA). And of course Kings Highway Bagel in Brooklyn, NY, where I grew up. What are your favorites?

And for those who follow GF, what are your favorite, certified GF baked goods? Please share!

When fat things happen to good people. On being thin, fat, and your false assumptions.

"Such crazy thoughts in that Aussie article!"

Do you think that if only you do the right thing—eat a healthy diet, exercise, get enough sleep—then you will achieve your dreamed of weight, live free of disease and live happily ever after? This, dear readers, is a fairy tale. 

If you believe that eating nutrient packed, low calorie foods is solely responsible for whether or not you get cancer, or arthritis or MS, think again. And don’t be fooled by the preaching of Dr. Fuhrman in his book, Eat for Health, that health equals nutrition divided by calories, period. Health is not such a simple equation. And no, eating whole grain, veggie packed meals won’t protect you from an eating disorder either. 

If you think that eating 'right' ensures thinness, as was recently emphatically suggested in a popular newspaper article in Australia, it is yet another fantasy.

And if you torture your overweight self with the belief that you must lose weight--at all costs, and that your inability to reach target goals based on BMI charts is your personal failure, you’re wrong again.

“What is she thinking?” you’re thinking? Let’s start from the top. 

Eating healthy equals health

Yes, diet can impact many, many health measures. And I certainly encourage a balanced, varied diet filled with a complement of vitamins, minerals, antioxidants, and an appropriate level of fiber, to name a few. Yes, there are correlations in populations that have higher intakes of alcohol and saturated fat, for instance, with increased rates of cancer and high cholesterol, respectively. And a nutrient-rich diet chock full of antioxidants and lycopenes, like those found in tomato-based products, may help stave off such conditions as Alzheimer’s, cancer, and other diseases. But eating a proscribed diet will not guarantee your health. Nor will it ensure happiness, which is not to say I don’t encourage making healthy choices—I surely do. But do not, for a moment, think that if you are fortunate enough to stay healthy (or unfortunate enough to become ill) that it is solely by your hand. Credit your parents for their genes, to start.

Fallacies about thin

And do you know what? Eating well does not ensure thinness either. I see my share of patients who choose the most wholesome foods, but eat in excess—even those nutrient rich, heart healthy foods, like avocado and almonds, lean protein and kale. By excess I mean frequently eating without regard for hunger, and eating past a point of comfortable fullness. And eating well—high quality, nutrient-rich foods—even eaten mindfully and intuitively—may not keep you slim. Yup, it’s a sad truth that many of you don’t want to hear. And in fact, the very act of pushing your body to be a weight it is not meant to be, may put you in worse shape—both physically and psychologically. Just wait until you hear about these studies!

Stay tuned. That’s my next post, based on fascinating research presented at the Renfrew Conference I attended last weekend.

And those who are thin do not necessarily eat well and are often hardly fit by any standard. Do be careful about equating weight with health because they do not always pair up as you’d expect. Individuals may be thin because they are genetically predisposed to be, or they may be thin because, in contrast to what journalist and dietitian Susie Burrell believes—that they “know what to do to control their weight”—they may fall quite short in controlling it appropriately. They may be no better than someone who binge eats for emotional reasons at knowing “how to cope when things are tough”. Don’t be fooled into assuming that thinness is simply a lifestyle choice, a moral higher ground.

And I’d caution her, and you, not to overgeneralize about thin people’s skill at “assuming responsibility for self”. Just spend a few hours in my office; even those without eating disorders may allow anxiety or depression to stand in their way of eating enough. How responsible for self is the person who denies herself nourishment when low energy or headachy—hunger gone too far—or pushes herself to exercise even when she reports constant fatigue, or pain? 

Eat when they are hungry, stop when they are full? Some thin people may. But overgeneralizing about a segment of the population isn’t too intelligent. 

No, I didn't leave the rest over, for the record.

Thin people may self-regulate just fine. Or they may deny their hunger and fluid load or rely on high volume low calorie foods. They may eat nourishing foods, or a diet of junk—just not excessive in calories. Or they may compulsively exercise, hardly resulting in mental health, potentially leading to loss in muscle mass, heart problems and a range of symptoms if accompanied by undernourishment. Really, the only thing you can generalize about thin people is… that they are THIN. You can’t assume they are healthy, or happy, or good at self-care or self-regulation.

And of course the reverse is also true. The only thing you can tell by looking at a fat person is….? Yup. It’s that they are fat. You cannot predict their lipid levels or their blood pressure. You can’t tell whether they’ve never exercised or they exercise too much. And you can’t determine the quality of their diet.

My own parents are perfect examples of this, as I’ve written about previously. 

The mere suggestion that health is 100% in our hands I take offense to, as would the rest of the population which struggles with MS, and cancer, and ALS, and type 1 diabetes and arthritis and, and and… And I can say the same thing about a target weight or size. I hate to break it to you, but even if you do all the ‘right things’, you may not achieve your desirable, fantasized-about weight. And you know what? It’s not your fault.

Stay tuned for part two, (which I hope to get out within the week), which will address obesity, weight loss, and the risks and benefits of change.

Did this post push your buttons? Did it challenge your thinking? Did it offer some relief? Do let me know what you’re thinking! 

Thanks for reading, and if you liked this post, please share!