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Calories In – Calories Out

There is general agreement that the US, and the West in general, is in the midst of an obesity epidemic. Even if you think this is alarmist or overstating the situation, the data clearly shows a steady expansion of the American waistline. Weight loss is a multi-billion dollar industry and is an active area of research, and yet all the self-help books, low-carb diets, and whole grain foods do not seem to be translating into successful weight loss for the public. Why is this?

From my perspective the failure of the weight-loss industry and public health measures is due to a failed approach – focusing on factors that have a small overall effect on weight loss while neglecting those that have a huge impact.

From an individual perspective, weight loss is simple (although not easy). It is a matter of calories in vs calories out – you cannot escape this equation. This means eating less and moving more. Simple, basic strategies to help reduce caloric intake seem to be the most effective. This means portion control, and limiting calorie-dense foods. The latter requires knowing how many calories are in food you are likely to consume (that Starbucks Mocha Breve has 580 calories). Limiting total caloric intake also means keeping track of how much you eat – which is deceptively difficult to do. Most people fail on diets because they simply underestimate their total caloric intake.

A recent study published in American Journal of Preventive Medicine showed that simply keeping a daily diary of food intake doubled total weight loss in a 5 month study (participants who kept a diary lost an average of 17.5 pounds). This is a significant difference, and the amount of weight lost was also significant. This supports other evidence that methods for estimating and keeping track of caloric intake are very predictive of successful weight loss.

And yet this huge effect from a simple technique was overshadowed in the media by another recent study that showed that those on a low carb diet lost an extra four pounds over 2 years over low-fat dieters (for a total of about 10 pounds). Wow – 4 pounds over 2 years. The media touted this as vindication for low-carb dieting, when it really showed that the diets did not work very well, and any differences among them were practically insignificant.

Now we are told that a pill can reproduce the effects of exercise. The media hails this as a boon to couch potatoes. It did not take long, however, for others to point out that the studies performed on mice did not consider many of the known benefits of exercise. At least for now, there is no exercise in a pill.

The pattern is clear – the media thinks (and they may be right) that the public is interested in learning how to lose weight without calorie restriction and exercise. They would rather eat different food than less food, and exercise “smart” rather than frequently. But the data does not comply.

By obsessing over effects so small that it is controversial if they even exist, and if they do their impact would be minor – the media and self-help industry are likely worsening the obesity problem. Rather there should be an emphasis first on what does work. Here is a quick summary: (Standard disclaimer – this is for information only, not individual medical advise. Many people have individual health concerns that affect their diet and ability to exercise, so if necessary consult your physician.)

– Eat fewer calories. Do this by:

– Choosing lower calorie and less calorie dense food, and by avoiding large calorie extras.

– Avoid drinking calories.

– Use portion control (just don’t take that second helping).

– Track your food intake with a convenient and simple system, at least until you get a better feel for where your calories are coming from.

– Increase your calorie output by exercising more, at least three days a week, but more is better.

– Do something you enjoy as you are much more likely to keep up with it. Likewise, make it as convenient as possible.

– Little activities add up, so take the stairs when you can, walk when you can, and spend more time in recreation that involves moving rather than sitting.

– Weigh yourself weekly to assess how you are doing so you can make adjustments as necessary.

Those are the basics – you should at least start with these steps. The goal is long-term weight control, not a quick fix. That is the other problem with most “diets”- they emphasize short term weight loss rather than long term health and weight control. Forget about highly restrictive diets – no one sticks with them. Forget about really complex diet plans – no one sticks with them. Forget about plans where you have to buy special food – no one sticks with them.

Basically – do not think to yourself, “I just need to get these X pounds off then I can switch to long term maintenance.” The problem with this approach is that almost everyone gains all the weight back. You are better off just going to the long term plan initially – don’t be lured by the promise of rapid weight loss.

From a public health perspective the issues are more challenging. Education can help individuals, but does not have a huge statistical impact on the public. Measures that are helpful are those that make better food choices easier. At my hospital cafeteria, for example, the sandwich counter used to offer two choices for sides, pretzels or potato chips. That was it. Now they off carrot sticks or celery, so that’s what I get. The default choice contains many fewer calories. Those types of measures work.

The trend in marketing, however, has been counter productive. Products are promoted as low-fat or low-carb (depending on your preference) – but neither are necessarily low calorie. They simply replace fat calories with carbs, or vice versa. So people end up eating more total calories because they think they are eating healthy. It’s counter productive. Printing nutritional information on the side of the package is nice, but it hasn’t helped.

Bottom line time

The public would be better off if they completely ignored the weight loss industry, avoided self-help weight loss books and diets, and simply focussed on some basic principles, as outlined above. Public health measures should focus on making default choices more healthful and lower calorie. We are starting to see a trend in this direction, in response to public demand. You can now get apple slices instead of french fries as a side in your kid’s Happy Meal. I can get carrot sticks instead of potato chips with my tuna on rye. But if there is going to be a reversal of the obesity trend in the West much more has to be done.

Posted in: Public Health

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