Monday, February 10, 2014

Finding Fit in a Fat World

I recently happened upon a lecture by obesity experts James Hill PhD and Keith-Thomas Ayoob, EdD, RD, FADA entitled Energy Balance in an Obese World. (1) There, I found a fresh approach to our most pressing public health problem - the sedentary and overweight American. Their reasoning and strategies stimulated me into personal action and reexamination - so I thought I’d share.

The facts are well known; you know this stuff. But they wrapped it up into a neat little burrito that I could get my teeth around, availing bite-sized pieces of action - and that is useful. Let me set the stage.
Two-thirds of American adults are considered overweight, obese, extremely obese or beyond. This fact has predictive value for where we are headed both personally and nationally given that the leading causes of chronic illness (i.e. disease, pain, suffering, early demise) are weight related and preventable. 

We gloss over disease, pain, suffering and early demise like its no big deal. Take a moment to ponder what that would mean for you personally if you experienced: knee or foot pain with each step, bending to tie or put on a shoe was difficult, shortness of breath made walking a hardship and stair climbing impossible, extreme fatigue at the end of the day, increased incidence of injury/illness, lost work and lost pay. Life becomes prematurely restricted - think about it. But I digress, as I am wont to do.

What does overweight, obese or extremely obese mean and how do we measure it? BMI= body mass index is the most commonly tool used today. BMI= weight (kg)/[height  (m)]2. While not terribly accurate for athletes, weight lifters, those with lots of muscle and very little fat, that ain't us, so BMI is a useful tool in knowing where we are. Go to to plug in your numbers and calculate your BMI.

Weight Status Avg USA Man = 70” Avg USA 
Woman = 64”
less than 18.5
Underweight less than 132# less than 110#
18.5 - 24.9
Healthy Weight 132 - 173# 110 - 139#
25 - 29.9
Overweight 174 - 209# 140 - 173#
30 - 34.9
Obese 210 - 242# 174 - 203#
35 - 39.9
Extremely Obese 243 - 277# 204 - 231#
greater than 40
Morbidly Obese greater than 277# greater than 231#

Remember that as we age, our body composition changes, we lose muscle mass and carry more fat. So even at a good weight, we still carry more fat. I see this in my own body. I weigh less than I did in high school but I was running track then, had more muscle mass and was very lean. Now I have more fat - and it seems to be accumulating around my waist! Egads! But I digress - yet again.

We have found that the “Caucasian” BMI charts do not work well for Asians. Asians are one of several ethnicities that poorly tolerate abdominal adiposity (fat) which quickly leads to diabetes. I see this in my Chinese family - where even 20# of extra weight has tipped my middle-aged cousins into diabetes. My own fasting blood sugars are rising despite the fact that I’ve lived my life in the far left columns of the BMI chart. Based on that, the Asian BMI scale follows. (2)
BMI Weight Status Avg Asian 
Man =  67”
Avg Asian
 Woman =  61”
less than  18.5 Underweight less than 118# less than 98#
18.5 - 23.9 Healthy Weight 118 - 152# 98 - 126#
24 - 26.9 Overweight 153 - 171#  127 - 142#
greater than  27 Obese greater than 172# greater than 143#

My family rolls their eyes at these figures but hey - don’t shoot the messenger.

What about kids? Twenty percent of America’s children are overweight or more. Rather than outgrowing this state, data shows they will grow into overweight and obese adults. Fat kids are not cute. They are headed down a difficult path where ridicule in grade school is but the beginning.
We cannot expect our children to follow a course different from that set by their parents. If we want our children to eat better, we have to eat better. If we want our children to be physically active, we have to set the example. You know the old adage… the apple does not fall far from the tree.

So what was new and compelling in this lecture? 
The authors looked at energy balance as the interplay between energy intake (calories in), energy expenditure (calories burned) and energy stores (body fat). Additionally, they urged tracking these factors and taking baby steps, small behavioral changes, one small change each month toward the goal. 
Measuring provides insight. Measure food intake, measure physical movement, measure caloric expenditure. All of this can be done easily and painlessly with new and very inexpensive tools.
We want to blame our obesity on low thyroid or incretin (gut hormone) insufficiency or insulin use or any number of things. And while these conditions do affect metabolism, they will be accounted for in one’s personal energy balance formula. Understand that we’ve not changed genetically. Our burgeoning waistlines do not signal changes in the genome. In nature, genomes change very slowly. When we examine the triad of energy intake, expenditure and stores, our ability to store is basically unchanged (unless enhanced by insulin, for instance), while our energy intake and expenditures are markedly altered.

Let’s break this down: energy balance as the interplay between energy intake (calories in), energy expenditure (calories burned) and energy stores (body fat). When weight is stable, there is energy balance. Metabolic rate, food intake and physical activity affect our energy balance. When exercise increases - increased food consumption usually follows. When energy intake is restricted, energy stores are mobilized or hoarded. Changing one component affects the other two.

Nothing new or compelling here LB. But wait - there’s more!

First: Energy Intake = calories in. You know this - our diets have changed and we eat more processed foods. They are calorically dense and nutritionally deficient, our tummy does not get the “enough” signal and we keep eating,  unconsciously looking for nutrients. Some foods are engineered to be “addictive” - like soda for instance. Hidden beneath that sweet fizz, is lots of salt - which drives thirst - that 7-11 hopes will result in the purchase of another Big Gulp.
As weight increases, so does energy expenditure to move that larger body - fueling the Fit-Fat myth. That myth has been busted in a longitudinal study looking at the 10-year consequence of living obese.
One of my colleagues is on a one-month challenge to eat every meal at/from home - no take-out, no eating out, no meals on wheels. Homemade meals - what a concept. His shirts are looser after just ONE WEEK!
Track energy intake. The easiest ways to make a change is to first examine what you are doing. Study after study demonstrate the value of food logs. There are numerous, free, food APs for phone and computer that make tracking as easy as pushing a button - literally. My personal favorite is MyFitnessPal - an AP that lets me easily track proteins, calories, salt, and phosphate. Visit: 

Notice if you are feeling resistant and resistance right now. What says the chatter in your head? That chatter likely says nothing new has previously stopped you.

Energy Expenditure
= caloric burn. 
I will outline four easy calculations resulting in the approximate number of calories required to maintain weight and the number of calories required to lose weight. Bear with me; it will be worthwhile.

Let's do the numbers
Basal metabolic rate (BMR) is the number of calories burned at rest. BMR is different for each person and largely related to height, weight, sex and age. I am a small, active woman. I notice that consuming 1200 calories/day will maintain weight and more than that results in weight gain. To lose weight, I must cut calories down to about 1000/day. Out of curiosity, I used a BMR calculator and it confirmed my experience and what I just reported here. My BMR = 1091 calories/day. You know - it doesn’t take a lot of calories to keep this crotchety little carcass cruising.

How is this helpful?
Step 1: Go to  , plug in your numbers to calculate your BMR.
Step 2: Calculate your metabolic factor (MF) according to the table below. 
But first, some definitions to help distinguish slow, moderate and fast metabolism. 

Slow Metabolism: You look at food; you gain weight. You can gain weight eating salads and have great difficulty losing weight. You take diabetes medications or have low thyroid.
Moderate Metabolism: You can gain or lose weight if you try. Maintaining a stable, healthy weight takes intention and conscious eating but is not a problem.
Fast Metabolism: You are the skinny guy or gal who can eat ANYTHING. Gaining weight is difficult. Losing weight can happen overnight. You seem to shed pounds watching the X-Games on TV. 

Over 40 years old: 
Slow Metabolism- use 20% as your MF
Moderate Metabolism- use 30% as your MF 
Fast Metabolism- use 40% as your MF

I put myself in the moderate metabolism category: stable weight, no hardship in gaining or losing weight. So I use MF = 30%.

Putting it all together.
Step 3: 
 (My BMR)1091 X 30% (my MF) = 327 calories

Step 4:
(My BMR) 1091 + 327 (# calculated in step 3 above) = 1418 calories (intake to maintain current weight)
These calculations tell me that theoretically, I need 1418 calories to maintain my current weight with my current activities. That is not my experience of self. So… I must be eating more than I think - a common malady. Rx: food logs.
I noticed that every year it becomes harder to eat with impunity,  more difficult to stay slim and svelte because BMR decreases as we age. This occurs in part because of decreasing muscle mass. At rest, muscle burns more calories than fat. Want to increase BMR and burn more calories, even at rest? Build muscle. Likewise, depriving oneself of calories (by extreme dieting) in hopes of losing weight, lowers BMR - and the body hoards every calorie its fed, foiling the best laid schemes o mice an’ (wo)men.
What has changed in energy expenditure? 
We get older, lose muscle mass and move less. 
As a society, we are more sedentary. Bassett DR et al. studied an Old Order Amish community - who continue to live as they did at the turn of the 20th century and where obesity is nonexistent. He had them wear pedometers and found that in the course of their normal day, the men logged 18,000 steps or 9 miles/day. The women logged 14,000 steps or 7 miles/ day (3).
In modern times, knowledge-based jobs have turned our labors from physical to mental. Daily energy expenditure has decreased dramatically. The average office worker walks only 2000-3000 steps/day. Denizens of Colorado, the trimmest state in the union, walk an average of 6,500 steps/day. Despite that, they are seeing a rise in BMI.
Blue Cross of California - San Francisco installed two walking workstations about 18-months ago. My girlfriend started working on one for 2-hours/day. Her steps/day skyrocketed from 2000 to 20,000 and she lost 70# in 12-months. Every time we talk on the phone, her side of the conversation is mostly laughter… she laughs… incessantly.
Track energy expenditure. A simple $10 pedometer will do. A $60 FitBit will track your movement, calculate caloric-burn based on your personal data and allows you to log caloric intake onto their website. Their software will crunch your numbers. MyFitnessPal and FitBit can also be paired. (MyFitnessPal's food database is superior.)
I’ve been wearing a Nike FuelBand for just over one year; this is what I’ve learned. In the course of a normal workday: parking at the far side of the parking lot, always using the stairs, walking 1.6 miles at lunch, I take only 5,000 steps/day. On the days I eliminate my lunchtime walk, my steps drop to a dismal 2500/day. That’s useful information. I am more sedentary than I ever imagined! The FuelBand makes me keenly aware when my energy intake exceeds my energy expenditure. No secret - that will result in weight gain. None of this information is useful or valuable for information’s sake alone. Its only valuable if I use it as a change agent. I am more conscientious now about attending evening yoga or taking a short run on those days of minimal movement/steps.

Notice if you are feeling resistant at this time. But I can’t walk, my knees hurt or my hips hurt or my back or… Most bodies feel better when they move. According to our triad of energy balance as the interplay between energy intake (calories in), energy expenditure (calories burned) and energy stores, one must move - daily. A regular exercise routine can increase BMR, improving health and fitness as the body's natural ability to burn energy gradually slows. There are myriads of workouts: for people in wheelchairs, in water to support joints, gently for the pregnant, stretching for the injured, etc. There IS an movement program for you - FIND IT! 
Move in a pool, move on a mat, 
Move in a chair, move with your cat, 
Move on the stairs, move down the hall, 
Move while you can or you won’t move at all.

Third: Energy Stores 
The dominant strategy of the last few decades is to eat less, matching low caloric intake to low caloric expenditure and thereby depleting energy stores (fat). There’s lots of evidence that as a long-term, solo strategy, caloric restriction does not work. Why not?
Hunger. We can only calorie restrict so much before we become hungry. When I eat 1000 cal/day - I’m hungry.  My tolerance for that is finite. Medical fasts like OmniFast / MediFast = 996 cal/day. (This is that magic number below which our bodies switch into starvation mode and lowers BMR to hoard every calorie, making weight loss very difficult.) People lose weight on these fasts but don’t keep it off unless they add energy expenditure (caloric burn = exercise) to their program.
Energy expenditure decreases with weight loss (depletion of energy stores). What does that mean? It means, that as weight drops, it will burn fewer calories at rest and caloric intake will need to drop in unison to maintain weight loss. 
Let’s say I drop six pounds, my BMR will also drop and my maintenance caloric intake will drop to 1390 calories/day - a drop of 30 calories = 1 small piece of dark chocolate.
A 10% reduction in body weight requires a permanent, daily, 200 calorie restriction to keep the weight off. A 15% body weight loss requires a 300 calorie restriction. Try restricting calories by 300, every day, for the rest of your life. Its difficult to do and we get hungry. Weight maintenance can be achieved by eating less, exercising more or both. The people who have been most successful in keeping the weight off, have made up the difference not in continual restriction, but by increasing physical activity. 
Data tracking provides up-to-the-minute feedback that can keep you on target. I can evaluate foods before I eat them. Am I still on track or should I alter the portion size? Can you see that simply stepping on the scale each day is only one part of the equation and an after-the-fact metric? Tracking energy intake and expenditure in real time is easy and exponentially more powerful and meaningful.

Fourth: Baby steps or small behavioral changes
Big changes have not been shown to be sustainable for the masses. Hill and Ayoob recommended making one, small change each month.
Purchase/obtain the two basic tools: some sort of pedometer and a food log AP. Start wearing the pedometer and filling in your food log.

To stop or prevent more weight gain, burn 100 cal more/day than you currently do. This is a good first strategy and great place to start. How would you learn your current energy expenditure? Pedometer, FitBit, FuelBand, etc.
Theoretically, burning or restricting 3500 calories/week = 1-pound of weight loss/week or 4-pounds/month. That’s 500 calories/day and that’s a lot. That could be a combination of burning 250 more calories/day AND restricting intake by 250 calories/day.
Weight Watchers (the most successful program in the US) recommends weight loss of 2-pounds/month. That’s 250 calories/day - some combination of burning 125 more calories each day and reducing intake by the same amount… that is VERY doable.
Walking 2000 steps/day at a moderate pace is approximately 1-mile and 57 calories (for my height and weight). I would need to walk 2-miles each day AND decrease my calories by 130/day to achieve a 2-pound weight loss in 1 month.
Stop drinking sodas/juices.
Clean out then restock your refrigerator and pantry with healthier default snacks/foods.
Planned eating. Plan menus - studies show spontaneity is not your friend and grabbing take-out on the way home is rarely good for you or your waistline.
Planned physical activity: park in the farthest parking spot, take the stairs, walk at lunch, go to Zumba, Boot Camp, yoga, run, etc.
Find your Tribe: Join with others - its more fun and you will be more reliable if you are accountable to others.
Change in attitude: not if but WHEN am I going to be active today?

Don’t want to do the math? Use the default below. 
Women: start at 1500 cal/day including five fresh fruits and/or vegetables. 
Men: start at 1800 cal/day including five fresh fruits and/or vegetables. 
When was the last time you ate something raw and fresh?

Last year Kaiser North Valley (greater Sacramento and Roseville) extended an invitation to employees to participate in an exercise pilot program. Each employee would be given a FitBit and be asked to log food and exercise. Of course I applied and was summarily refused, “We are looking for people who are less active.” Harumph!
Apparently the pilot went well. You know, when you measure - you gain insight. Measure energy intake, measure energy expenditure, that’s what the FitBit does. Last week, North Valley Kaiser kicked off a larger exercise pilot program to include every willing, clinic employee. Those who registered were given a FitBit. 
Coincidentally, I’ve been thinking about willingness these days. Am I willing? Am I willing to be: kind, work hard, compatible, generous, thoughtful, loving, motivated, active, responsible, encouraging, supportive, bitchy, mean, snarky, spiteful, vengeful, etc., etc., etc. Willingness seems to be at the crux of everything. What and who am I willing to be?
I am willing to be a partner in vitality and health! I’m hoping to join a Kaiser FitBit user group with lots of friends and cheerlead them into moving more and smarter eating. Move More; Eat Smart!
Parting shots: 
A healthy lifestyle is nothing more than a series of healthy habits practiced over time. 
Its not difficult - its different.

Insanity: doing the same thing over and over again 
and expecting different results. ~ Albert Einstein 

3 Bassett DR et al. Med Sci Sprts Exercise 2010:42(10)1819-25