The Truth About How To Lose Weight

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My patient, Mrs. Withers (not her real name), was forty-five and morbidly obese. “I swear I’ve cut my calories down to almost nothing,” she told me, “but I haven’t lost a pound! I eat the exact same thing every day: a banana for breakfast, a turkey sandwich on wheat bread for lunch, and a piece of fish or steak for dinner. And no snacks in between! I used to eat twice as much, easily. I just don’t know what I’m doing wrong!”

She was literally on the verge of tears. I fully understood her frustration, as well as why her attempts at dieting hadn’t worked. Most of my patients who try to lose weight long-term ultimately fail, though not for lack of trying. Both physiologic and psychological mechanisms are in place that make sustained weight loss incredibly difficult. But as I told Mrs. Withers, if you understand some of the mechanisms you’re up against in trying to lose weight, you’ll be able to leverage that understanding into weight loss strategies that work.


Body mass index (BMI) is now the standard measurement used to assess body fat composition, calculated by dividing your weight in kilograms by your height in meters squared (calculate yours here). The National Institute of Health now defines anyone with a BMI>25 as overweight and anyone with a BMI>30 as obese (although it’s worth noting BMI fails as a good measure of obesity for people who are extremely muscular). Unfortunately, more than 50% of Americans have BMI’s over 25. Overweight and obesity have clearly reached epidemic proportions.

Having a BMI>30 is statistically associated with numerous diseases such as diabetes and hypertension and, even more importantly, with an increased risk of death. Unfortunately, studies also show that 90-95% of overweight and obese people who successfully lose weight subsequently regain it within 5 years. Given the great value placed on thinness in American society and the health risks of obesity, it’s not surprising that so many people continually turn to fad diets popularized in the mainstream press in efforts to lose weight.


The first law of thermodynamics, which states that the amount of energy stored in your body = your energy intake – your energy expenditure, applies to all biologic systems. In humans, mechanisms keep this difference very close to zero, but small differences over a long period of time can have a large cumulative effect. On average, between the ages of 25 and 55, Americans eat only 0.3% in excess of what they burn but this results in a weight gain of 20 lbs. over that time!

Body fat content is highly regulated. In recent years, evidence has accumulated supporting the set point theory of body weight. Mechanisms have been identified that enable the body to “defend” its usual weight, whether that weight is excessive or not. Small decreases in body weight cause your body to lower its energy expenditure even if you cut your calories, which explains how people like Mrs. Withers can cut down their food intake and literally not lose a pound. Further, studies have shown that if you were once overweight, in order to maintain your new lighter weight you have to eat fewer calories than a person who weighs what you do now but who was never obese! Clearly, some people seem to have an increased propensity to store fat and to maintain a lower resting metabolic rate, making weight loss more difficult.

Even further, recent evidence suggests our body fat content is highly regulated by insulin and that a diet high in carbohydrates elevates insulin levels, which then promotes fat storage rather than fat burning.

When I explained all this to Mrs. Withers, she heaved out a heavy sigh and asked, “What about the Atkins diet? Doesn’t that work?”


The low-carbohydrate ketogenic diet was first devised by an English surgeon, William Harvey, over a century ago, and has been “rediscovered” several times throughout the last hundred years by different authors:  in 1953 by Pennington, in 1961 by Taller, in 1967 by Stillman, and most recently (and for the second time) in 1992 by Atkins. Essentially, the low-carbohydrate diet is a protein-sparing modified fast (PSMF) in which calories from carbohydrates are replaced by calories from fat and/or protein. In Dr. Atkins’ New Diet Revolution, Atkins advances the following claims:

  1. On the ketogenic diet, you can eat an unlimited number of calories and still lose weight.
  2. Ketosis reduces hunger.
  3. High insulin levels cause obesity. If plasma levels of insulin are reduced by eating a ketogenic diet, this will lead to weight loss.

Can you can eat an unlimited number of calories and still lose weight? No. This would violate the first law of thermodynamics. There is evidence that when people set out to eat a low-carbohydrate diet, they lose weight because in fact they end up eating fewer calories. It’s been shown that the accelerated short-term weight loss seen in the low-carbohydrate diet over the first 10 days is due to loss of water.

Does ketosis reduce hunger? Of the few well-controlled studies that are available, none show a reduction of hunger as a direct result of ketosis. However, there is evidence that when about 500 kcal/day are consumed on a low-carbohydrate diet (an extremely low number of calories to eat per day!), hunger is indeed reduced. Possible causes might include the high protein content of low-carbohydrate diets, some particular characteristic of the protein-sparing modified fast as of yet unidentified, or the monotony of such a low-calorie diet. The last possibility is supported by evidence that hunger is greater when people consume a preferred food than when they consume a less preferred food, and that people consume more food at meals with several food choices than at meals with only one choice.

Do high insulin levels cause obesity? There is indeed a growing body of evidence that supports the notion that a low-carbohydrate diet reduces insulin levels, which promotes the burning of fat for energy.


Substituting fat for carbohydrate in the low-carbohydrate diet would seem to put people at risk for developing high cholesterol. However, multiple studies have shown that on low calorie diets, if weight loss ensues, cholesterol profiles improve—or at least do not worsen—regardless of what kind of food you eat. This suggests that the beneficial effect of weight loss on cholesterol is more important than the detrimental effect of eating a relatively increased percentage of calories from fat.


While ketogenesis itself has been shown not to affect weight loss, there is evidence that the higher intake of protein that typically occurs with the low-carbohydrate diet might. Studies have shown a consistent, spontaneous reduction of total calories consumed by people eating protein-laden diets compared to people eating carbohydrate-laden diets—by approximately 470 calories/day. There seems to be two mechanisms at work in the protein-laden diet to cause greater weight loss than in carbohydrate-laden diets:

  1. Eating foods rich in protein seems to cause people to feel more full and to suppress even the following day’s calorie intake more than eating the same amount of food rich in carbohydrates.
  2. A low calorie, protein-laden diet reduces your resting metabolic rate to a lesser degree than a low calorie, carbohydrate-laden diet. In other words, when you cut your calories down you’ll have a higher resting metabolic rate if the calories you do eat come predominantly from protein instead of carbohydrate. And having a higher resting metabolic rate means you burn more calories just sitting around.

I told Mrs. Withers that some of my patients do, in fact, find their hunger reduced when they eat a low-carbohydrate diet—while others do not. “How can you tell which you’ll be?” she asked me.

“You just have to try it and see,” I replied.


  1. First, recognize there’s no way to lose weight and keep it off that’s easy. Completely discontinuing an addictive behavior is far easier than moderating one—and obviously you can’t ever stop eating. People whose brains seem to want them to be obese must accept that, in order to achieve and maintain a healthy weight (which need not be perfectly thin), they will likely have to work at it for the rest of their lives.
  2. Exercise is an important adjunct to diet for weight loss. Exactly what exercise routine is best, however, remains debatable. Evidence exists that if you exercise past a certain level of intensity (“intensity” being variably defined in the medical literature) you’ll actually induce an increase in your resting metabolic rate that lasts up to 11-14 hours after you’ve finished exercising. Some think this shift may counteract the tendency of brains with higher weight set points to lower resting metabolic rates when weight loss begins (though just how much basal metabolic rates increase is debatable; it may not actually be enough to make a significant difference in weight loss). Interestingly, anaerobic exercise (like weight lifting) may actually be more effective than aerobic exercise (like jogging or aerobics) in producing this effect. On the other hand, studies of people who walked on treadmills (a low intensity exercise) while actually at their desk jobs (instead of sitting at their computers they walked at their computers!) also lost significant amounts of weight over the long-term. Unfortunately, while many people attempt to lose weight with low-intensity exercise, most don’t do nearly enough of it to be effective. Finally, the key to maintaining a good exercise program is to think creatively about how to fit it into your busy daily schedule. The glass is always half-full: any amount of exercise you manage to do is worth it. Even just 15 minutes a day.
  3. Get adequate sleep. Through complex mechanisms only partly understood, inadequate sleep is now known to make it more difficult to lose weight. In addition, it’s hard to exercise regularly or intensely if you’re chronically tired.
  4. To cut calories reducing carbohydrates is better than reducing fat, and is certainly better than reducing protein. Eating a low-carbohydrate diet means abstaining from processed carbs and high sugar-content carbs. This seems to reduce insulin levels, which seems to promote fat burning and decrease fat storage.
  5. Make all lifestyle changes gradually. Don’t expect to be able to run a marathon on your first day of exercise. Don’t expect to cut your calorie intake in half the first week. Pick an exercise you like (or at least don’t hate), begin it slowly, and build up intensity gradually. Consult your physician if you have health problems that may make exercising dangerous. Alter your diet gradually and make choices you can tolerate and maintain in the long-term. Ultimately, aim to find a low-carbohydrate diet you actually like. That’s how you maintain it in the long-term and achieve long-term weight loss: by finding a way to eat that promotes weight loss that you don’t have to struggle to maintain.
  6. Keeping a food diary may help. Studies have shown most people tend to underestimate the amount of calories they eat (Mrs. Withers turned out to be a case in point). Studies have also shown keeping a food diary itself tends to cause people to reduce their calories spontaneously. How long that effect lasts, however, may be limited.
  7. Figure out if you’re overeating for secondary gain. In other words, does eating fulfill some other purpose for you besides satisfying hunger? Many people overeat to deal with unpleasant feelings such as anxiety or depression. This actually works because pleasure of any kind is extremely distracting. If you find yourself eating for comfort, think creatively about substituting another pleasurable activity besides eating that can distract you from whatever unpleasant feelings you’re trying to avoid. And take steps to challenge those unpleasant feelings directly.
  8. In general, avoid diet pills. I advise this for three reasons. First, the diet pills that work (and many do) typically only yield an additional 10% weight loss (despite this modest benefit, some of my patients still want them—to date, however, no one to whom I’ve given them has chosen to stick with them). Second, once you stop the pills, that 10% of weight you lost will come back. Third, some diet pills aren’t safe (does anyone remember fen-phen?). Millions of dollars are being spent every year on research to find effective, safe diet pills so I suspect eventually we’ll have some good ones—but I see none now. As a side note, beware exaggerated claims made by manufacturers of over-the-counter diet pills. None of them that have actually been studied have lived up to their claims.
  9. Gastric bypass may be a good option. You have to meet strict criteria to qualify as a possible candidate (BMI>40 or BMI>35 associated with a serious weight-related health problem) and all surgery carries risk. However, with a BMI>30 you’re also at risk for a premature death. Also, this surgery cures diabetes and hypertension in 90% of patients who also have those diseases! No medication we have can do anything like that. If this path seems like it might be right for you, ask your doctor for a referral to a bariatric surgeon.

As I told Mrs. Withers the last time I saw her, losing weight and keeping it off is incredibly hard, but hard is easy compared to impossible. And though she hasn’t yet managed to lose a significant amount of weight, she yet may. As may you.

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  • Doc…I am not sure if I got this right. I spend 60 minutes a day on the treadmill. Running and walking a total of 4.5 miles. Everyday I run I also lift usually 30-40 minutes. I workout 4-5 days a week on average. Of course, I have become addicted. Bill W. and I are mates.

    You’re writing stated the beneifts of lifting help with weight loss. Where I am confused…are you saying too much time on the treadmill could be hurting the process?

    I have been at this exercise routine for 3.5 years. I have lost a bit of weight, gained a lot of muscle, but what I find does the trick for me is the combination of working out and putting down the bloody fork. I will be 53 this year.

    Thanks for the weekly read. My best to your lovely wife and your little miracle.

    Tony: Sorry, didn’t mean to confuse you. There’s almost no such thing as too much time on the treadmill (aside from risk of injury and risk of ignoring other important aspects of your life)! It definitely will NOT hurt the process of weight loss. I personally think the best exercise routine combines aerobic exercise with weight lifting. You also bring up the very important point that paying strict attention to your weight in pounds (or kilograms) fails to account for any improvement in your body’s composition. If you lose fat but gain muscle your weight may actually increase as muscle weighs more than fat. But you get the health benefits of a decreased fat percentage and you look and feel better too.

    One note of caution: unless you’re exercising different muscle groups when you lift weights each day, be sure to lift weights every other day as your exercising muscles need time to recover to get the full benefit of weight training (I couldn’t tell from your comment if you’re doing this or not). If you’re exercising the same muscle groups two days in a row, you’re overtraining and likely impeding your progress with regards to increasing muscle strength and mass.


  • The dynamics of weight regulation are complex, and most certainly not fully understood. Recent data support the concept that Dr. Lickerman alludes to, that actually “being” obese alters both the way one’s body handles food and even promotes sedentary behavior and the body’s continued manufacturing of adipose tissue (rather than the opposite, i.e., sedentary behavior promotes obesity).

    Unfortunately, our culture has been sold on the idea that fatty food promotes illness, and that the ADA and AHA diets actually work, potentially missing the boat on the detrimental effects of highly processed, predominantly “empty” carb foods. While pure low-carb “blasts” ala Atkins are not considered “healthy” dietary lifestyles, recent publications have shown that low-carb, “high”-fat and protein diets actually improve lipids and diabetic control significantly better than traditional low calorie (and high carb) diets.

    Quite confusing for our patients! To even muddle things further, experiments have been done that show weight loss CAN occur outside of the traditional thermodynamic “rule” of weight loss, predominantly by carb restriction—and yes this even happens when taking into account water loss. Please refer to the remarkable book by Gary Taubes, Good Calories, Bad Calories.

    My recommendations are simple, and based on the dietary prescription from, and a combination of Paleo and Zone eating:

    “Eat lean meat and vegetables, nuts and seeds, some fruit, little starch, and no sugar.”

    Exercise as well is invaluable and a necessary component to wellness. It’s time to change our attitudes relating to the social attachments to eating, and look at dining as simply the method to fuel the body in an appropriate and healthy manner.

    Stephen: As you so rightly point out, the dynamics of weight regulation are incredibly complex and not fully understood, and my post only scratched the surface. I agree with the points you raise in your comment, in particular the notion the public has been sold a bill of goods over the last few decades that low-fat, high-carbohydrate diets work well. I think there’s good reason to think that advice has contributed to the epidemic of obesity we’ve seen over that time. I also agree that by restricting carbs weight loss can be accelerated but take slight issue with the notion that this happens outside the traditional thermodynamic “rule” of weight loss unless you mean by altering metabolic rates as I pointed out happens in my post. I think you’d agree the point here is that macronutrients (protein, carbohydrate, fat) have effects on our ability to lose weight by more than just their calorie content—that a growing body of evidence suggests they have differing effects on how our metabolic rates are regulated. Finally, I was most struck by your last idea about changing our social attachments to eating. I have to confess I’ve mostly always looked at dining as merely a way to fuel my body and only really had my eyes opened to how differently others look at this by my wife, who views eating as a major pleasure in life with all its attendant atmosphere and socialization. She’s definitely a “foodie” who sustains her enjoyment of food through vigorous exercise. Really interesting point, though.


  • Alex, I got up very early to read this blog hoping for some help for me to lose 10 lbs and get a my BMI <25. You generally know my medical, exercise, and diet so I won’t go into those here. What I do get from your blog is that my body’s set point is probably close to my present weight of 205 and there is very little I can do to reduce and sustain a weight of 195. Realistically, I can’t see increasing my weekly recreational exercise. Our diet is a combination “heart smart/Mediterranean” diet. I can cut back on the French Paradox and reduce my wine consumption. My weight has ranged from 195 to 225 for the past 53 years although the distribution of my body mass has shifted. What specific recommendations do you have for me?

  • BTW, I really look forward to your weekly blog!

  • Thank you Alex for interesting posts!! My mom and I are staying tuned.

  • I would definitely recommend keep a food diary. In the past, this has really helped me. When you know you will have to write something down, it makes it less appealing. I would also recommend writing down the calories too.

    The daily diary concept also works when you feel you need to cut back on spending—just write down everything you buy and you will be surprised!

  • I’m 45 years old, 5’2” and I weigh 148 pounds. I’ve done phentermine (over the net because my doctor refused to write the script) out of desperation. Finally, I’ve begun running 3 miles 4 days per week and power walking 2 miles per day 5 days per week at lunch time. I’ve altered my diet so that I’m eating lean meats and veggies, some fruit, but I can’t seem to drop coffee and sugar from my regimen.

    I don’t do any weight lifting and had to give up on yoga due to degenerative disc disorder. My question, if I want to lose 15 pounds at the rate I’m going in terms of time frame….what’s realistic? I started this process over 2 weeks ago and the scale hasn’t budged one inch! I’m already feeling the looming cloud of failure encroaching on my new found positive attitude…..any observations on what to realistically expect from my efforts would be appreciated!

    Charlene: One pound of weight loss per week is generally considered safe and desirable, but it’s hard for me to suggest a time horizon for you to reach your goal without knowing your total caloric intake and expenditure. It’s possible the weight on the scale hasn’t changed for many reasons (maybe you’ve gained lean body mass which weighs as much as the small amount of fat you’ve actually already lost, not all pounds come off equally as easily, etc), and it’s not too uncommon to see little change there early on when first beginning the lifestyle modifications you describe. It’s critical that you have realistic expectations from the beginning or you’ll become discouraged and quit doing things that, given enough time, are likely to work. Frankly, I wouldn’t even look at a scale for two full months. You don’t want to lose those pounds just right now; you want to lose them for good, which means whatever lifestyle modifications you’re making have to be for good as well—so focus on these healthy lifestyle modifications rather than the weight loss so you won’t be tempted to give them up even if the weight loss doesn’t go as well as you’d hoped. Jogging is the kind of exercise that can be done intensely enough to result in the possible increase in your resting metabolic rate for up to 14 hours after you’ve finished, so if your doctor tells you it’s safe for you to do, I’d push yourself there. Just make sure to increase intensity and duration gradually, and to warm up and down consistently. Finally, I’d think about finding some kind of substitute for the sugar in your coffee. That could represent enough calories to slow your progress down significantly. Best of luck and please feel free to let me know how it goes. Never give up!


  • Thank you for the response and I will ditch the scale and set my sights on a healthy life style rather than obsessing on how many pounds I’ve lost. By the way … I discovered a natural sugar substitute called Estevia(?) which is sweet enough for my coffee … I really appreciate your feedback!

  • A.L.

    Thank you for your response. I apologize for not checking back sooner. Just a thought: maybe you can add to your site some sort of indicator that there was a response to a reader’s post.

    Thanks for your thoughts on weight lifting. I did get proper training ahead of time. I work one body part a day. All is good.

    As for “foodies” it is my favorite subject. For me, Saturday night is date night. Even while I was married, my ex and I always went out to dinner on Saturday night … NO KIDS.

    I tip my hat to Rhea. The social part of my Saturday evening date…the conversation…be it amongst two or many is more important to me than the meal, but a good meal is a bonus. I make sure I find a good place to eat.

    Cheers all and thanks again for my weekly read.

    Tony LaPorta

  • First time reader here!

    I really enjoyed your outline on effective weight loss. As a future health care professional struggling with weight herself, I can relate to both your patient AND you as the practitioner. I’ve finally found a routine that works for me, and it incorporates many of the things you recommended to Mrs. W. Thermodynamics is key. It’s as simple as intake & output (calorie wise) but it’s hard to communicate a lifestyle change with science. I keep a food diary (two actually-what I plan to eat, and what I actually eat!) and an exercise diary. I also weigh & measure my food portions. This is a new development. I was completely taken aback when I found out what a serving of pasta was supposed to be! In addition to those healthy choices and habits, I’m trying to keep up with lots of daily fiber, lots of water, and very little sodium! These new habits have led to a 5.5 weight loss in 3 weeks, so I’m happy.

    Anyway, I’m enjoying your blog very much!

  • Alex, my wife, who suffers from CFS/FM/ME (who knows for sure?), directed me to your article “When Doctors Don’t Know What’s Wrong” (which I’ve hand delivered to my doctor, a wonderful and over-worked chap). Your good writing, confident but open tone, and healthy mix of science, common sense, and philosophy work well for us.

    I flowed over to your other postings and found them all well worth the while. Thank you for taking the time and care to write.

    Although I’m a professor of film studies and English lit, I’ve redirected much of my attention to nutrition and health-care, largely because I stand face-to-face with hundreds of adult students every week (and have for over 40 years!) who aren’t healthy enough to optimize their learning. Every class opens with a student-lead breathing exercise and a 10-minute discussion about nutrition, usually focusing on reading the labels of stuff they bring to class with them.

    I wrote a book to help them (and others) and I’m on my second and third books; the information and arguments for good eating and exercise I have researched have received great responses from around the world (especially in China!), but I have to say that the one thing everyone really needs I did not address—how to change. As a result, I seem to have a broad community of people with good information and intentions, but no real improvements in their health. I’m now weaving discussions of change into everything I write.

    I like what you have provided in your weight-loss article: work on your life style; worry less about weight loss; however, it still begs the question, “How do I change my style of living?” I’m working on that, but I’d love to hear your Buddhist perspectives on change and changing.

    One last thing—you often refer to studies but seldom point us to them. I intend to direct my students to your articles, but I’m going to have to do an awful lot of work finding the studies you base some of your conclusions on: they’ll ask. Could you start including at least the feature studies that appear to influence you? Extra work—I know!

    Thank you for your commitment and fine writing.


    Jerre: Thank you for your compliments on the blog and my writing. Regarding the dearth of links to studies: a valid criticism. The problem I keep having is that most of the studies to which I refer are available only on sites accessible by subscription that I use in my medical practice. Finding references to them in the lay literature is challenging. But your point is well-taken, and I will try to find the references on sites accessible to lay readers. Finally, regarding change. Much larger topic. In my view, changing in significant ways almost always involves breaking through delusional beliefs that lie unnoticed at the edge of one’s consciousness but that nevertheless represent solid brick walls standing in the way of healthier behaviors. In my very first post, Cigarette Smoking Is Caused By A Delusion, I began a discussion about it. Knowing something intellectually and knowing it in such a way that motivates different action are clearly very different. On the other hand, behavioral change can also be made to occur by leveraging the power of habit. Another large topic.


  • Interesting blog. I found it from the comments section of the NYT. I’ve been following the CRON diet (calorie restriction/optimal nutrition) for about two years now. It isn’t so much a diet as a lifestyle. The idea is simple: eat less and whatever you eat, make sure it is providing you with maximum nutrition. In that sense, it’s quite similar to the Paleo/Stone Age diet. I was never overweight (I’m 178 cm and 67 kilos, down from 73 kilos from a few years ago). The positive effects of eliminating worthless carbs and processed sugar are amazing: more energy, better overall feeling, and also maintaining a good figure, which is a secondary effect, not the purpose of the diet.

    The idea behind this diet is debatable: that by eating less you will live longer (i.e. less biochemical burden equals less generation of free radicals). This has been demonstrated in lab animals but not conclusively in humans yet. However, most that practice CRON are extremely healthy, as demonstrated by the absence of metabolic illnesses and excellent results from blood work, etc. that continue to improve over time.

    PS—as an overworked medical student, I find it refreshing to see your blog, to realize that a physician does indeed have enough spare time to write.

  • Your article is very interesting. I was wondering if you could address weight gain caused by medication (specifically medication for bipolar disorder). I have been on this medication for 12 years & have put on 50 lbs. & now have high blood pressure, high cholesterol & high blood sugar (metabolic syndrome) & of course, my self-esteem (never very good) has plunged into the gutter.

    I have gotten off the offending medication (been off it 2 months now), but I have not been able to lose any weight. I am 55 years old & female so I do know that going through menopause has decreased my metabolism & I have chronic insomnia, as well as high anxiety which I understand also leads to weight gain from cortisol.

    I have taken sedating medications & anti-anxiety medications in the past to combat the insomnia, but now that I’m taking meds for the high blood pressure & cholesterol (trying to get the blood sugar down w/diet & exercise & am taking a diabetes education class), I have discontinued the sleeping medication & anti-anxiety medication as I just don’t want to be taking so many pills.

    I still do take some medication for the bipolar disorder, just not the anti-psychotic. I also do individual therapy & Dialectical Behavioral Therapy to hopefully learn better coping skills to decrease the anxiety as I do use food for “emotional” reasons sometimes—similar to how I used to use cigarettes (have been able to quit smoking since I got on meds for bipolar disorder). I guess quitting smoking also contributed to the weight gain.

    Is my metabolism permanently affected from taking the medication for 12 years so that I will not be able to lose the weight I gained? I do exercise, though I admit I am not consistent on a daily basis as when a depression hits my motivation flies out the window & my eating behavior also turns into more overeating to the point of binge eating.

    Then I will counteract the overeating episodes w/near starvation when I get out of the depression to try to make up for the extra calories. I know that’s not supposed to be “good,” but I am getting desperate.

    Sara: Medications that cause weight gain do so through a variety of mechanisms but do not, in general, affect your resting metabolic rate permanently, so coming off the medication for bipolar disorder should have left you with the same metabolism you had before you started taking it. Now of course you have the same challenges as anyone else who wants to lose weight. Keep in mind that weight gain or loss is not correlated to any one day’s intake of calories, so that if you binge occasionally but then immediately return to your normal (hopefully healthy) eating habits, you shouldn’t see much, if any, effect from the binge on your weight. Regular, intense exercise really is the key, driven by a determination that just won’t quit (very hard to maintain when you’re depressed, I know). If depression causes you to skip exercising one day, that doesn’t mean it has to stop you from exercising the next. Keep getting back on the horse. If you follow a plan that can work (reasonable caloric restriction combined with the highest intensity exercise you can safely perform) and don’t give up, you will see the results you want. Good luck!


  • I’ve never had a problem being overweight until I quit smoking 6 months ago at age 68. I’ve gained 10 pounds and no amount of dieting and exercise seems to help. I’m tempted to start smoking again because being overweight is very bothersome to me. I hate the feeling of carrying this weight around. I felt much healthier when I was smoking.

    Faye: Weight gain is extraordinarily common among smokers who quit, as I’m sure you know. I completely understand your frustration, but I sure hope you don’t go back to smoking! Often ex-smokers turn to food where they used to turn to cigarettes, causing persistent weight gain. You might try a food diary to uncover where extra calories might be hiding in your diet. Also, if you can find a substitute behavior that provides you real pleasure but that doesn’t involve eating or smoking, that might help—something you can do easily and often (I sometimes suggest chewing gum, but most of my patients don’t find that pleasurable enough—you just have to use your own creativity to find something that works for you). Finally, I’d challenge you to increase the intensity of whatever exercise you’re currently doing (slowly and safely). The first law of thermodynamics is inviolable. If you reduce your calories enough and exercise enough the weight will come off. Don’t be discouraged! You can do it!


  • Hello—I found your website/blog 2 weeks ago and have peeked in and like what I’ve read. I’m here to admit I need help. I’m really determined to take off the extra weight and want to be smart about it and not waste my time with stupid dieting. I don’t believe in any of the miracle cures and have not tried very hard before. Thirteen years ago I was pregnant w/twins and I managed to only gain 55 lbs. I had gallbladder disease too, which wasn’t apparent until I got deathly sick at 30 weeks into the pregnancy. No other medical issues; I was as healthy as a horse. They were born via C-section at 32.5 weeks, much to my dismay. Before they were born whatever medication I was on in the hospital bloated me up like a balloon; literally you could squeeze my skin and water would drip out. I felt awful; I wanted to die. I was sick and vomiting for days and days until they were born, and then after the twins arrived, it was also a hellish time. It took over a year to heal the incision site as the hospital left sponges inside of me—strange but true—and I was tender and felt like my insides were put back together backwards. That’s the feeling I still have, that something was put back together incorrectly, as there is a huge bulging outward of my stomach the size of a football when I try to tighten it up. It is a nightmare, but my doctor says it is simply internal scar tissue and I have to learn to accept it.

    I’m ashamed to see myself this way, yet I can sit here and put the blame on a number of things too—and some are very real reasons for being overweight. However, it doesn’t matter—what is—is. I’ve shelved the irrelevant feelings for good and made a small commitment to taking this year, from June now to next year, or really how ever long this takes, walking up and down our road, only 1/10th of a mile each way—two times a day. Walk without stopping, walk with purpose. So far, since the beginning of June, I’ve done this each day with the exception of three times. Pat on the back for me for that. I’ve never had a scale and was not a heavy woman at all—though before the birth of twins at age 40 a set back of a broken hip socket when they were two years old put me way up on the scale; just couldn’t walk without hurting. I put that aside and finally got some physical therapy, but that’s where it ended—no time for any kind of surgery at all! The pain is back now; joints are hurting. I saw myself in photos just last week too, and it was so demoralizing. I don’t even look like the old me and that has made me deeply upset. I want to look forward to my body changing, but how do I get the flab to go away once this all happens? I’m 53 and it’s just again really shameful to see what has happened to me. I’m weirdly proportioned too; the C-section was vertical and that took the wind out of my sails when someone recently told me that no matter what I try to do, nothing will give me my old flat stomach again. That’s preposterous; plus, I don’t really want a flat stomach. I’ll settle for a rounded one, just not the overhang I have now. My doctor says just keep sticking with it. I have BP of 110/70, but that doesn’t surprise me—I’ve inherited great long-lived healthy genetics. But of course, I don’t want to count on that alone! The obese body won’t just magically melt. My stomach hurts from the incision all these years later and that was one excuse I’ve used against trying to exercise. So, the big thing now is overall weight loss for me, and at the same time, I want to increase the tone of my large stomach. Are there specifically things I can help myself with—to tone this area and to eat certain foods to decrease the bad flab around my waist? I am just fat all over, never was before, but now I am and again this is just awful to face and hard to admit, but I need help and I want to see results soon so I can be more motivated. Crunches are out of the question; that hurts beyond belief in my mid-section. I am on the NutriSystem program for over-50 year olds and I supplement these with slim-fast shakes in the morning and for a snack requirement—to give me the recommended daily 1,200 calories. I’ve started NutriSystem meals now for only 2 weeks. Please, can you offer me some advice on how to do this better? I appreciate your time and help. This is the first time I’ve ever written about what (lack of) shape I’m in, besides telling my doctor, and I stopped seeing her 7 years ago after the things she told me about my body.

    That sent me into a deep funk, I have to admit. Yet I’m in overall good health, don’t smoke or drink, and I’m not working but finishing my re-certification towards an English teaching degree (so also thank you for writing with great compassion; it’s OFTEN left out of the medical profession on several levels I’ve found!), and I write for several newspapers. I’m active on several levels in our small town, and I’m fairly well known. Working on a book, too. I do a lot of things for and with the twins who are now almost 13 and thriving and healthy and they are the loves of my life. Being overweight has not challenged me until this year—I just want to look like the old me with the exception of graceful aging. I like who I am, and have always been well-anchored to know that I am more than what I look like, but this is really really starting to bother me; I am NOT pretty anymore and despite all the mirror avoidance I’ve done, looking at myself honestly now has brutally shown me that I am very very fat and this has distorted my features. I have a good marriage and home life too. I’m not a lazy person, but I do hate exercise—like I’m certain many overweight people do. I know what you say is exactly true, that to turn up the intensity of the exercise and maintain the caloric content is essential, but isn’t there a targeted kind of help I can get for the very large stomach I now have? I’d love to have a “tummy tuck” but trust me, the c-section hurt so much, I can hardly bear to think of additional surgery on my body. Is it too late for firming and toning?

    Thank you again for any suggestions!

    Babe: Wow. Okay. First, I’ve had many patients who’ve had abdominal surgery (myself included) whose abdomens never felt entirely normal after surgery. Your doctor is probably right in attributing your bulge to scar tissue and that nothing can really be done about it without more surgery. Also, people deposit fat according to their genetics: some people, no matter how hard they try, can’t get rid of fat deposits in certain areas even as they succeed in overall weight loss. Unfortunately, spot reduction has been shown repeatedly not to work (so doing hundreds and hundreds of stomach crunches won’t selectively reduce fat from around your stomach—it’ll just tone up the muscle underneath). As I wrote in the article, the key really seems to be reasonable, tolerable caloric restriction coupled with exercise. Some evidence suggests that short bouts of really intense exercise produce as much cardiovascular fitness as longer bouts of lower intensity exercise. Lower intensity exercise also doesn’t seem to produce the elevation in basal metabolic rate for hours after exercise that intense exercise does, as I discussed in the post. So if you “hate” exercise as you say, I’d recommend trying to find an exercise you don’t hate—and do it as intensely as you safely can (may take you many months to build up to the intensity level you need, but that’s okay). You must make a friend of exercise. Set realistic exercise goals that advance every week so you have something to aim for and can feel some sense of success to keep you going. NutriSystem is fine if you think you can eat it (or something like it) for the rest of your life (of course, you have to restrict your calories more during a weight loss phase than during a weight maintenance phase). If you can achieve generalized weight loss, the final thing would be to approach the stomach. Without seeing you, it’s hard for me to offer good advice, but if the “very large stomach” you now have remains even after you’ve achieved general weight loss, you might want to investigate liposuction. A plastic surgeon or dermatologist who knows what he or she is doing can give you a good recommendation about whether or not it would be feasible for you (given your surgical history, which may actually not be a barrier) and what kind of results you could expect to achieve. Finally, it’s most important to set realistic expectations for yourself—which it sounds like you’ve done—while simultaneously reaching for more than you think you can actually achieve. I hope this helps and best of luck!


  • Hi, I read your comment on the NYTimes article and clicked on the link you provided. I read your post and some of the comments others have left. I’m a 23 year old female, 5’6″ and currently between 240-245 lbs. Two summers ago I had reached 310 and was considering gastric bypass, especially when I found out I had developed sleep apnea and diabetes. My internal medicine doctor who treated me for the diabetes prescribed me phentermine which I took and was able lose weight gradually (though they were weight loss spurts usually within the time frame of the 3 months I was allowed to take the meds (during the six month wait, I usually had to work hard to maintain the weight so as not to gain it back). I went down to about 267 lbs by the end of May last year and below 250 by the end of last summer. During this last year, I’ve been battling with continuing to lose weight but haven’t had much success. I haven’t been on the phentermine in over a year and my new doctor won’t prescribe it to me. I know some doctors are against using it but is there any way to convince my doctor that it is beneficial to me? I saw someone else up there decided to just buy it over the internet but I’m afraid of doing that because I don’t trust drugs which aren’t dispensed by a licensed pharmacist, legally. Plus, I don’t want to be dependent on a drug to lose weight.

    I’ve done all sorts of diets and even for the last 5 months became a vegetarian (I’m working at getting enough protein; it’s a bit hard but not impossible). I work out 3-4 times a week, doing really intense work outs that consist of lap swimming, cardio (elliptical, treadmill, stair climber), weights, pilates, and yoga. I recently started an aerobics/zumba class which feels like a good work out but I’m having trouble with the weight still. I also feel caught between my diet and my work out—I get so hungry or tired and I think my blood sugar drops really low which I try to remedy by eating something which sends my sugar way up. I feel so conflicted and I’m tired of being fat. I’ve been fat my whole life, don’t have a thyroid problem, yet both my parents are extremely healthy and within the norm for their weight range. Do you have any suggestions?

    Nancy: I’m afraid I’m not a big fan of any weight loss drug currently on the market, including phentermine, not because any of them patients dependent on them for weight loss (which they do and as you say you don’t want to be), but because they’re only moderately effective. Studies show they only enable patients to attain on average an extra 10% amount of weight loss (which reverses when they go off the drug). I am a fan of bariatric surgery, however, in the right patients. The criteria for qualifying for bariatric surgery is specific and strict. One of them is having a BMI over 35 (which I calculate you do) in the presence of serious medical conditions related to obesity, such as diabetes and hypertension. I tend to think about this surgery in patients who’ve fought weight loss for at least six months, restricted their calories in a reasonably sustainable fashion, have exercised regularly and intensely, but who’ve still not managed to lose significant weight and have sleep apnea and/or hypertension and/or diabetes. The reason for including the co-morbid diseases in my calculation is that bariatric surgery cures 90% of overweight patients of diabetes and hypertension, an amazing statistic. Experienced surgeons now do this surgery laparoscopically which reduces complications and recovery time. A patient should never consider this type of surgery for cosmetic reasons alone as it is major surgery. However, as patients with BMI’s much over 30-35 are at a statistically increased risk of early death, especially those with hypertension and diabetes, and as the literature has demonstrated sustained weight loss in most patients who undergo bariatric surgery, for health reasons it is often a reasonable way to go. Those patients of mine who’ve had it done on average took between 6-12 months to decide to do it, meeting with me semi-regularly and discussing it repeatedly. I am not advocating for or against this for you but suggesting you might want to begin a dialogue with your physician to learn more about it. It does seem from your comment you’ve been following the best advice I could give for losing weight and are still struggling. Also, if you haven’t tried a program of supervised calorie restriction (one of the commercial ones where they prepare your meals), you might consider that first. I know several people who’ve had long-term success with some of them. You do need to pick an eating regimen that you can sustain throughout your life, however. With as much research as is going on in the field of weight loss I’m confident we’ll eventually have weight loss drugs that help people lose significant amounts of weight, but when those drugs will appear is difficult to predict. But options do exist for you now so don’t let yourself be discouraged!


  • I just discovered this website through the NYTimes comment section. I have found more helpful information from this blog than countless other sources. Thank you! Please keep writing!

  • Alex—I can give some simple, practical advice about eating that produced weight loss for me. I call it the WAIT Diet.

    Basically, you want to “spoil your dinner.” It works best if you only have healthy food in your house or at work…wherever you need to go. Sometimes you feel hungry when you are really only thirsty. If I feel hungry or get a craving, first I drink a glass of water—or water mixed with real juice (no sugar and definitely NO sugar substitute). Cranberry varieties are good as is lemonade—they are naturally sweet and STRONG.

    Then I wait….I do something I need to do for awhile. (A perfect choice is stretching or doing an activity—check email, clean up, read, etc). Then I have a snack…best is fresh fruit, yogurt, or nuts which can be mixed with dried fruit (get the bulk nuts in the health food store—they are better tasting, fresher and cheaper!). Eating less means you can afford QUALITY at the same price. Fresh fruit and raw vegetables are great. If you are truly hungry, they will taste yummy eaten solo.

    When I eat a meal, I USE ONLY A SMALL BOWL OR DISH. That is very important. And I NEVER eat fast food. NEVER. I try to keep natural snacks with me—but if traveling you can get decent snacks at a gas station…like peanut butter crackers and milk. Or nuts. Or even an ice cream. And always have water. And chewing gum. (Gum is amazing—quenches thirst AND hunger for a while!).

    I am a lazy cook, so I will do endless stirfry sauces (use one pan/cooks quick) with a carb like rice or noodles or potatoes. I eat organic meat which can be cut up with some veggies and quickly cooked—adding your own spices. And SOUP is superb if you are really hungry…the broth helps fill you up! ALWAYS USE A SMALL BOWL and eat slowly/chew completely. For snacks, boiled eggs are nice—but just eat one or two—or celery & peanut butter. Also—cold cereal with fresh fruit is quick and easy.

    I typically eat breakfast, then a snack or two in the day, and have an early dinner. And a snack at night…fruit or sometimes ice cream…but in a very SMALL bowl. Anything in a small quantity is okay as long as it is real food. Another very very important thing: brush your teeth Immediately after you eat. That will quench your hunger for seconds. It clears the palate and finishes the process of eating.

    Wait…use only a small bowl…drink lots of water… at quality fresh food…eat healthy snacks to spoil dinner…brush immediately after eating! And if you are eating with the family, you may want to stop for awhile until you adjust. Why not? Or have some tea with them while they eat—or get them on the better food along with you. Just do not buy fast food, junk food, or processed food, and you and the whole family will be better. And save lots of money. (Think Farmer’s Markets!!!)

    That’s my 2 cents!

    Melody: Thanks for these really interesting practical tips. I especially like the concept of “waiting” when you’re hungry. My own experience mirrors yours: when I get an intense hunger pang, if I only wait about ten minutes, busying myself with other things, it tends to go away.


  • I found your blog on google and read this great post. I just added this site to my Google News Reader. I look forward to reading more here in the future.

  • Hello. I’m an intern in Family Medicine and find it hard to warn my patients of the dangers of being overweight when I weigh over 400 lbs. I’ve always been large in the football lineman type sense. When I met my wife 15 years ago I was, in fact, a “lithe” 279 lbs and felt great (but also only 22 years old). I’m always thinking about dieting and losing weight but make the similar excuses of not having time, etc. At my present weight, I find it hard to start exercising due to the side effects of being so overweight, i.e., bad sleep, sluggishness, large habitus not fitting in gym equipment. So, how do you feel about quick starting a weight loss program with either a low-carb or hCG/low calorie diet with the goal of quickly losing 50 lbs over several months to help me get going. A nurse at my hospital has recently lost 90 lbs using hCG which makes me curious. My goal would be to lose 50 lbs quickly and then slowly lose another 150 over 2-3 years. Any thoughts?

    Big MD: I can’t recommend the hCG diet. The best studies I’ve seen on the hCG diet show hCG is no more effective than placebo. People do lose weight on the diet but almost certainly because of the calorie restriction, not because of the hCG. I completely understand the special struggle you’re having at 400 lbs. to initiate a program of exercise—especially as an intern—but I’m not a fan of accelerated fat loss during any stage of dieting. I’m much more in favor of a sustainable change in lifestyle that reduces weight slowly (allows skin a chance to contract, by the way, so you’re not left with huge bags of it). Might I suggest low-impact exercise your frame might be more easily able to tolerate: swimming, spinning (aerobics on a bicycle where you can set your own pace and gradually increase your intensity as your fitness builds), etc? As always, check with your own doctor before beginning any kind of diet or exercise program.

    Don’t be discouraged! You had the discipline and will power to make it through medical school and now a residency. Those same attributes are all you need to succeed at weight loss. Make a realistic plan, set your mind on the goal, and take action! Best of luck to you!


  • I can endorce your comment about high protein low carbohydrate diets reducing hunger. I have used a commercial diet system based on 5 100 kcal high protein low carb meals and a regular low carb meal per day with great success, losing 60 lbs so far. I can’t say there is no hunger at all, but hunger is greatly reduced, and the diet goes from being an unbearable ordeal to fairly comfortable most of the time.

  • Thanks for your great article! You always give such sensible advice.

    What would you say to someone who is 100 lbs overweight (BMI=40) but who has already tried *everything*?

    I did the high-protein/low-carb and it worked for a few weeks, then leveled off. I was still painfully hungry all the time, though I didn’t cheat. As soon as I gave it up, the little bit of weight I lost came back. I’ve tried all sorts of diets with similar results. FYI, I NEVER eat fast food. I am active. I swim, walk, ride horses, hike, work on my farm, clean the house, bike, and go to college full time. I love hiking and can walk for hours (at least until my feet start hurting too much). For a while I was at the gym 5 days a week. Anyone who says a fat person is lazy ought to stack hay with me some morning. 🙂

    I feel like a normal, happy, energetic person—trapped in a manatee’s body. I am 37, female, in good health except for the pain of fibromyalgia. My BP, cholesterol, etc are always in the good/ideal range. Thyroid test and fasting glucose levels always come back normal.

    I just get so hungry sometimes I can’t even function. Often when I’ve eaten a meal, I don’t feel like I’ve eaten at all, even if I eat slowly, only eat healthy foods, and wait >20 minutes. I tried cutting out sugar and I never buy ice cream, chips, or cookies. I try to drink enough fluids. The cravings don’t go away even when I stay on the diets for a while. I’ve tried eating diets focused on low-fat, higher-fat, high-protein, low carb, good carb, vegan, raw, Slimfast, SouthBeach, you name it. I’ve tried cutting out caffeine, but it didn’t do anything. (I do not drink, smoke, or use drugs).

    My doctor shrugs me off saying “eat less.” My nutritionist handed me a Food Pyramid and simply said “watch portion sizes.” My ob/gyn told me to lose weight, but kept trying to put me on the Pill which helped me gain weight (which I finally got off of). I feel like I can’t get any useful advice. Is my only hope bariatric surgery? But if I have no sense of being full, can’t I still just keep eating right through the modified stomach?

    And what do you say to someone who is doing hour-long workouts at the gym plus daily bicycling around town, but they’re never feeling any more fit or losing weight? I just don’t have the time to be exercising more than 2 hours every day. It’s frustrating.

    Is there any other health professional someone like me could consult with? What am I missing? Is there a metabolic specialist or someone else I should try? What if money was no object?

    By the way: II am in currently in nursing college to become a RN, then hopefully on to grad school to be a NP or PA. I want to be a role model of good health & fitness for my patients.

    Calico: It sounds like you’ve been making every effort to lose weight. It’s difficult for me to give you specific advice without knowing the in-depth details of your medical history and life circumstances. If your doctor has ruled out the common medical causes of obesity (eg, hypothyroidism, Cushing’s syndrome, etc.) then you may unfortunately be the victim of genetics and the weight “set point” your brain seems to want you to remain. As you’ve discovered, not everyone has their appetite diminish on a low-carbohydrate diet. The one thing I’m not clear about from your comment is just how much really high intensity exercise you’ve tried. Stacking hay sounds pretty intense but I don’t know how often you do that.

    Bariatric surgery may, indeed, be a good option for you with a BMI=40. You’d need to talk to your doctor or a specialist about it. Most people who end up doing it take a while to be able to fully wrap their minds around it, so do your research and take your time. The two most common operations are done laparoscopically and don’t involve stomach reduction. For some reason, most people who undergo this surgery do find their appetite diminishing almost immediately (must be mediated through something physiologic rather than anatomic but we really have no idea).

    I know how incredibly frustrating trying to lose weight can be. Even if you have tried high intensity exercise with no success or decide bariatric surgery isn’t for you, know that there are a lot of really smart people working on pharmacologic interventions. Eventually something that really works should become available (though just when no one can predict). Just don’t give up!


  • Great articles, great advice. Obviously written from a perspective of loving compassion.

    I never had weight issues prior to being diagnosed hypothyroid 10 years ago. My goal weight now is what my “fat” weight used to be. Without going into all the depressing details of my health issues and weight loss failure, I honestly no longer believe the “calories in, calories out” equation. Sadly, I have given up trying to lose the 40 lbs I have gained in the last 10 years after being diagnosed. In the spring of this year, I started exercising 5 days a week (3 days of 1/2 hr cardio + weights) and 2 days a week of a 1 hour high intensity cardio + resistance bars and bands class. I did not increasing my food intake. After 5 months I had not lost any weight. In fact, I gained 6 lbs. and it was NOT because muscle is heavier than fat. I had not lost inches, either. No matter how much I exercise or how conscientiously I eat, my weight just will not budge. I have resigned myself to a future full of rabbit food and a slowly escalating scale. I guess I am at the point where I have to look at exercise merely as a vehicle of maintaining health rather than a means to an end—namely, achieving weight loss.

    I know there are no magic bullets out there but are we hypothyroid, menopausal women doomed to a life of super-sized pants?

    Thanks again for the great articles.


    Kathy: It’s unusual that the weight which hypothyroidism made you gain didn’t resolve once you received treatment. I’m at a loss to explain your failure to lose weight given what you say you’ve been doing. I presume your doctor has your thyroid function now in the normal range and you’re not receiving any drugs that might influence weight retention/gain. I really wish I had a magic bullet for you…


  • Re Nancy’s post, here are a couple of points re the vegetarian diet:
    1. No one in this country is ever diagnosed with too little protein in their diet. It’s a myth propagated by the meat and diary industry. I’ve asked dozens of doctors and none of them has ever treated anyone for protein deficiency.
    2. Broccoli has twice as much protein as steak, ounce for ounce. Do your homework and you’ll find veggies, grains and nuts have PLENTY of protein.
    3. Meat and dairy are what’s killing people in this country. Too much bad fats and improper proteins. Milk was designed to make baby cows fat quickly. Guess what it does to people. Cheese is ALL fat. Eat from the produce section of your supermarket and stop eating anything out of a box and you’ll outlive all your meat and dairy eating friends by years.

  • Thank you for the great article. I look forward to exploring your blog further.

    To anyone who is discouraged after a few weeks on a new exercise/weight loss program, maybe I can give you optimism from my experience as a 32 year old female.

    4 months ago I weighed about 180 lbs at just over 5’10”. Not slim, but fairly proportional. At that time I joined a gym with my partner, and we started exercising 3 – 4 times per week. Each visit consists of 1 hour of cardio, followed by 1+ hours of weight lifing, alternating between two muscle-group routines each visit. We cut the cardio in half when time-pressed. I also started watching my diet more, and particularly avoided fast food.

    About 3 months into this routine, I had GAINED over 15 lbs, for a max recorded weight of 196. Worst of all, my clothes didn’t fit anymore! It was very discouraging, even though I knew I was probably healthier and stronger.

    However, I continued my routine I renewed my focus on a lower-calorie diet, and my weight is finally receding at a rate of about 1 – 1.5 lbs a week (down a total of 6 lbs. now). It is not easy, but it is very rewarding to finally get noticable results (my clothes are starting to fit again, and the muscle tone looks nice).

    I try to remind myself that this is a long-term lifestyle, and that I must restrict my tendency toward recreational eating (I am one of those people who tends to equate eating with comfort, fun, social interaction, and even success).

    Also, for anyone who hates exercising, you can try to trick yourself into looking forward to it. If you love music, bring headphones and your favorite songs, and use the exercise as time to mentally relax and enjoy uninterrupted music time. The same can be done with audiobooks or podcasts.

  • This is a very interesting, very compassionate discussion. Thank you!

    I am 53, female and I weigh 338-lbs. I have dieted down to near my goal weight three times as an adult (losing over 100-lbs. each time). I accomplished this with the Pritikin program (low fat), a very-low-fat vegan diet, and via the HMR packaged meals. Each time I also incorporated a lot of aerobic exercise: biking, swimming, walking, using the aerobic machines at the gym, swing dancing, etc. for 8 to 12 hours per week.

    Each time, when I got close to my goal, my weight-loss plateaued for weeks/months and I started feeling famished. I was quite literally being driven mad by cravings morning, noon and night. I also felt exhausted. It was as if some force inside my body over which I have no control was MAKING me reverse the weight loss by making me hungry no matter how much I ate and tired no matter how much I slept.

    I live near a zoo and recently read that the bears there “naturally” fluctuate in weight between 500-lbs. and 700-lbs. depending on the season. That’s a weight-loss and weight-gain of 200-lbs. EVERY YEAR. Hmmmm. I began to wonder if a similar force was at work in my body, some kind of genetic-driven force that just “takes over” when it perceives somehow that my weigh is “too low” (even if “too low” is 220-lbs. on a 5’9″ frame?!?). Could all my past “success” at dieting and exercise to lose massive amounts of weight simply be fighting nature? Like a bear trying to use will-power to fight off late-summer weight gain and the sleepy time of hibernation?

    I’m not feeling very hopeful right now. I’m feeling defeated, in fact. How can I fight such a powerful force as the inexorable programming of my own genetics? Should I just try to get to a lower-but-too-high weight, like 250-lbs., tie a knot and hold on there? Is that the best I can hope for? Never being “normal” or “healthy” in weight but finding the spot that is low enough that I see some improvement in health, but not low enough to wake up the monster in my genetics that takes over and forces me to gain into the mid-to-high 300’s? I honestly don’t know what to hope for anymore.

    Jean: Maintaining weight loss is just so difficult. Your experience mirrors the experience of so many of my patients, supporting the current theory that our brains have a “set point” for our bodies’ weight that they work consistently to maintain. Why some of us seem to have “set points” in the obese range is unclear but almost certainly involves genetics as you suggest. But our genes aren’t always right! You clearly have enormous will-power to have lost 100 lbs three times, but fighting your brain’s “desire” for you to weigh more than you want to weight is exhausting. I can easily imagine why you feel so defeated.

    One benefit to bariatric surgery is that most people find it reduces their appetite long-term. It’s not something you decide quickly or without extensive investigation and discussion with your doctor, but it might be something for you to begin considering. The very best of luck to you!


  • Hi Alex,

    I can SO identify with the two women above. I had written you earlier because I was so discouraged after modifying my eating, exercising 5 days a week for three months and gaining six lbs. (and no, it was NOT muscle!).

    I have a question for you. I have recently come across two books “The Beck Diet Solution” and “The Alpha Solution” both of which emphasize the role of the brain/mind in weight loss and maintenance.

    The Beck Diet Solution’s angle is to re-learn your eating habits by training yourself to think like a thin person. The Alpha Solution emphasizes Neurolinguistic Programming to reduce food cravings.

    What are your feelings regarding these types of approaches to weight loss? Obviously, some people’s bodies, like the two women above, don’t all work within the long-held parameters of “Less calories + More exercise = Weight loss.”


    Kathy: Not having read those two books, I can’t comment specifically on their content. But to respond to your question, I think there’s tremendous opportunity for intervention between the experience of a craving and the choice to give into it. Where I think people fail is in thinking they can pit their intellect against their emotions/cravings and win over a long period of time. The desire to eat, whether simply to satisfy physical hunger or for some other emotional benefit, is just extremely powerful (as I’m sure you well know!). It seems to me to combat it best, therefore, you’d need to find some competing emotional driver (rather than an intellectual one). Further, in order to engage that competing emotional driver in an effective way, I think it needs to spring from a powerful belief. The trouble isn’t that obese people don’t want to be thin, of course, but rather that their belief that being thin will make them happier isn’t often stirred up powerfully enough against the onslaught of their actual hunger, driven as that hunger can be by their brain’s imperative to maintain a certain (obese) weight. Thinking like a thin person sounds like an intriguing idea, but it would seem to me that to be successful at doing so you’d need to have found a way to stir up some powerful belief to emotionally motivate you to limit your calories. Did that makes any sense? Is that helpful?


  • I’m a 47-year-old man, and several years ago, I hit 205 lbs. I’m 6′, so was overweight, but not obese. I reached the point where I was going to need new clothes, but decided instead to lose weight.

    I changed my eating habits, first by not snacking during the day, then by not snacking after dinner. I found that brushing my teeth and flossing right after dinner helped discourage me from getting anything, as I’d have to go through all that work. Stopping having snack foods around also helped.

    I live in Tokyo and take the train and walk to the station, so I’d get about 30 to 40 minutes of exercise daily. I started always taking stairs instead of the escalator or elevator, but didn’t really do any other exercise. I did watch what I ate, reducing red meats and increasing chicken and fish. I also starting eating more vegetables and fruits.

    I lost an average between 2 to 2.5 lbs per month, until I hit 170 bs, (35 lbs!) and have stayed in that range for a few months now.

    I’m still concerned about my waist size. Although it’s down several inches, I still want to get reduce it more, so I’ve started to bike to work, which takes 35 minutes each way. I’m also considering doing some weight training as well.

    Several things which helped. One was that I weigh myself each and every day. I was able to notice that heavy eating days would immediately have an affect.

    I also would fluctuate in weight somewhat. It wasn’t a straight curve and I would start to put a few pounds back on at times. When I would do that, I’d “draw a line in the sand” and tell myself that that particular amount was too much, so I’d work harder to get below the line. The first line was 205 lbs, and then when I got below 195, I drew a line at 200. If I started to get back close to 200, I’d take more care about eating and get the weight going back in the right direction. Then when I got down to below 190, I drew the line at 195 and continued this.

    I’m currently between 170 and 174. My line is 175, so as I’ve gotten closer to the line, I’ve started working harder at keeping to the plan. It’s not really a diet, and I don’t really restrict my intake too much, I just try to eat smart.

    I’ve got a 10-month-old daughter, my motivation to live a long time.

  • I really need your advice on how to lose weight. I am 15 kg overweight, and every time I try and go on a healthy eating diet (3 main meals + two snacks) and 40 min exercise per day, I feel positive and great. But if after that time I try a little bit of something sweet—piece of chocolate, a candy, my mind tells me I blew it, I am fat, and I would not stop until I finish the whole thing (or even go to the supermarket with shaking hands and buy a lot more sweet stuff). Yeah, by the end of it my stomach would be exploding, and I would be feeling so low and depressed that I would not be able to do anything for the rest of the day or week (until the next round of healthy eating)—study, gym, social life. I know this binge eating is very bad for my health, and I don’t want to get diabetes, and I have already gained weight after a year of such eating, I just don’t know how to stop! Can you please help?

    Alice: It seems the best opportunity you have to break this cycle isn’t before you try something sweet but once you have and your “mind tells you that [you] blew it.” It turns out that weight gain isn’t correlated to caloric intake on any one day but rather to caloric intake over time. This means you can indulge in moderate overeating on an occasional day and not impair your ability to control your weight at all. It’s common that people “fall off the wagon” on a single day and tell themselves the story that they’ve completely blown it and become so discouraged they give up their efforts at weight control. However, the data don’t support this story at all. The evidence suggests you can do this without any significant impact on your weight control efforts at all. In fact, I often tell patients to allow themselves a day a week or every two weeks to indulge a little. Perhaps if you used this truth to quiet the voice that tells you that you “blew it and are fat” when it speaks up and allow yourself the occasional indulgence you can avoid the real obstacle to your weight control efforts: overindulging and subsequently giving up on healthy eating and regular exercise. Don’t let yourself get discouraged by this behavior. Far better to actually plan days on which you allow it, knowing you will get right back on the horse the next day until your next planned “indulgence” day. I hope this helps!


  • My story is a little bit similar to Alice’s. My eating/exercise habits were almost identical to hers after my mum died 12 yrs ago (I was 16). My weight, which used to be a healthy 60-63kg shot up to 80kg (I’m only 5’5″). It took me several years of stops and starts and ups and downs before my weight finally got down to 70-72kg and stayed there for a few more years. And then between 2004-2006 I gradually lost even more weight through exercise and healthy eating, and reached 64kg and stayed there for a year or so without difficulty. However, after a stressful end of job, I got very sick and discovered I had lupus (SLE), hypothyroidism and anemia at the start of 2008! I had a really bad flare-up, which forced me to be stuck in bed for more than 6 months. The next 6 months weren’t exactly activity-laden either although I did do powerplate twice a week for 3 months. I also had a food allergy test done and cut out most grains, dairy, eggs, bananas, and potatoes. So I was basically eating a lot of green veg, protein from lean meat and oily fish, nuts, seeds, fruit and raw chocolate. I don’t drink or smoke. Despite my best efforts my weight gradually crept up and hit 70kg at the start of 2009. However, as I have gradually grown stronger, I’ve been able to increase my activity slowly each week. It’s been a long, hard battle but I’m happy to say that I can now go for a short run (20 mins or so) 3 times a week, and I try to walk on the remaining days to make sure I maintain a minimum amount of activity. I’ve been doing this for at least 4 months now. However I have not lost any weight. It’s very frustrating. It also makes me depressed. I’m at a loss—what more can I do? I don’t know if it’s worth mentioning that my sleep patterns are still a little bit off but it’s something I’m working on fixing!

    Given my health profile (esp. the hypothyroid bit) are there any things you can suggest to help me lose weight? I’d like to return to 64kg—just to feel a little bit more like my old self. It’s bad enough being ill but being overweight to boot is just too much…I’m only 30.

    Many thanks for your thoughts and time.
    Peace x

    Nadia: I have no magic answers but a few suggestions. Certainly, you must make sure your hypothyroidism is properly treated as untreated it will make weight control extremely difficult. Further, normalizing your sleep is probably extremely important. My rule is eight hours a night. Sleep-deprivation is turning out to be linked to weight gain (we’re even starting to figure out some of the mechanisms). Patients with SLE often feel fatigued, which can severely limit your ability to exercise. If you’re working with a good rheumatologist and can normalize your energy, you might want to gradually increase the intensity of your exercise. Intense weight lifting might be a good way to tone up your body and increase your basal metabolic weight as I wrote about in the post to accelerate fat loss. Good luck!


  • Hello doctor, I am back for your advice. The thing is I have been binge eating like that for 2 years now—3 days eating healthily, eating fiber, fruits veges and drinking water, and then I would suddenly give up and eat a very big amount of carbs and fats—lots of white bread, sweets and candy. When I did that, it made me go to the toilet №2, so I wasn’t worried. But after your advice, I finally understood that I don’t have to eat the whole fridge up, just try a small amount, so I have been eating healthy for 7 days now (yay, what a record) but the trouble is I stopped going to the toilet. I even tried laxative herbs, which didn’t work, so I had to eat a whole lot of carbs again, which worked. I really want my digestive system back to normal; can you please help?

    Alice: Though I can’t give you specific advice as I don’t know your full medical history, I can say, in general, constipation is often caused by too little water and fiber in one’s diet. However, some diseases can cause it as well, including hypothyroidism. If adding fiber and drinking more water doesn’t work, please contact your physician.


  • Dr. Lickerman—I always enjoy your comments on the NYT Well blog, and followed your link from the “C is for Cookie” entry there today, after posting my own comments.

    I just wanted to say that in reading through your suggestions, I see so many elements of the concept of “Health at Every Size” (HAES) flowing through them. In particular, the advice to your patients to think in terms of health rather than weight loss.

    I posted on Well of my experience in the 1990s with very low calorie diets (VLCDs). These were far from my only efforts to lose weight, which have included all the “standard” commercial programs, Meridia, PhenFen (but only for a week before I started to feel unwell…nothing permanent, luckily), cabbage soup, etc. You name it, I’ve tried it.

    In recent years, I’ve read more about the HAES approach to weight. I exercise regularly, eat a balanced diet, get plenty of sleep and perhaps most importantly, have learned to gauge my health using measures other than a scale. After increasing for years, my weight has been stable for some time, and has recently started to slowly go down as a result of increased intensity of exercise. All because I’ve stopped focusing on weight and started focus on what makes me feel well.

    Anyway, just wanted to say “thank you” to you for your compassion. Although I’m not your patient, it is good to know that there are physicians who don’t simply see a fat patient as a problem, but as a person.

  • I have been reading the New York Times online for about a month now and have just recently become familiar with these and other blogs for a class. After reading a few of your entries I am impressed by your conversational style and helpful content and next I will be figuring out how to link to your blog!

    I was recently researching America’s weight gain and the money being allocated to studies toward stopping the trend. I would be interested in your opinion of the recently formed group, Strategies to Overcome and Prevent (STOP) Obesity Alliance, and whether you have any ideas about what it will take to effect change in over half of the people in America.

    Lori: I find STOP’s approach reasonable and measured. But as to what it will take to effect change in half of the people in America, that’s much harder. I could say the portions marketed to consumers in America are too large and that healthier food is too hard to find compared to fast food, and several other things as well that have to do with the way society positions food. But the real answer I think still lies in each individual finding the motivation to live in such a way that their BMI comes down into a range that doesn’t predict increased morbidity or early mortality. Not easy.


  • At 33 I feel I’ve earned the right to claim I’m a genius at losing weight. I’ve got a great formula, it’s simple, it’s obvious & it works.

    Cut out refined sugar. Cravings for cake can be solved with an apple & frozen fruit w/milk a little sprinkle of sugar substitutes ice cream well. Lean meats, mostly fish and chicken. And lots and lots of plant matter—in other words, fruits & veggies. I’ve found that all the awful things I crave aren’t what I’m really craving, and if I keep myself on a variety of “natural” foods the cravings are satisfied. Then the work out, 20mins-30mins of cardio, heart rate @ 80-90% of maximum recommended. Than an hour or two of busting my butt weight training. The more I do it, the more my body craves it. The more I need to work out to feel good (it becomes an addiction).

    See, so simple. So obvious. The body can’t really want a snickers bar; snickers bars didn’t exist when our bodies (genetically speaking); so, what our body really wants is some kind of sugar (fruit) and maybe some nuts. An apple & a handful of almonds & suddenly that snickers bar doesn’t seem so exciting. We were meant to spend our days climbing hills & trees & chasing (or running from) creatures in the forests. So let our bodies work as hard as they were meant to. (Maybe a touch harder, to make up for all the time spent in front of computer screens…reading blogs) 😉

    My problem, I always gain it back. I start to get some where & either I can’t afford my gym membership, or my depression kicks in & I can’t get out of bed, or I don’t have the energy to cook dinner, so we get fast food. It simply doesn’t take long, backsliding that way, before I’m right back where I started. Then it all seems so overwhelming to begin again. (Last time, I’d been doing brilliantly when a man I’d been with for 4 years hit me, breaking the bones in my face. All this triggered the PTSD I’ve suffered since I was sexually abused as a 5 year old. I gained back 40lbs after that, and with him out of my life, I couldn’t afford the gym again). I know so much about weight loss, from all the research I’ve done, all the methodologies I’ve explored, I could be a personal trainer. (Not that any of my friends, male or female, most in much better condition than I am, can keep up with my workout when I am working out. They never try more than once…this makes an overweight girl giggle. 😉

  • Doctor L,

    I have found happiness in this world through weight lifting. I always hated exercise, but now I know that I only hated aerobic jumping, running, dancing—anything that hurt my joints (I have rheumatoid arthritis). I LOVE lifting weights, and I follow DVDs that combine high-intensity cardio (low impact) with weight training. In 6 months I’ve lost 30 pounds and I feel great. I’ve been on a zillion diets, and they all worked for awhile at great suffering. Now I eat high-protein lean meats, whole-grain carbs, small portions of my favorite things (cheese, nuts), and lots of plain water. My mood is brighter and I’m LESS HUNGRY because I’m not depressed!

    For those people who hate exercise, I say try weight lifting! Get a personal trainer if you are afraid of hurting yourself. I will never give this up.

    By the way, I’m a 55 year old post-menopausal woman, 5’10” and 170 pounds. Not skinny, but a perfect size 14 and I look great.

  • What foods would you recommend for a vegetarian optimal nutrition diet? I’m having problems thinking of good protein sources other than peanut or soy butters, both of which are “trigger” foods for me (same with nuts and seeds—it’s hard for me to stop once I’ve started). I’m almost 60, way past menopause, exercise daily (cardio and a mix of weightlifting/Pilates), and want to lose that inner tube around my middle! Also, I’m on meds for very high cholesterol (familial) which have done nothing to raise my HDL level.

    Thanks, Alex. This blog is a lifeline to me.

    Dulce: Your experience with cholesterol-lowering medication is typical: none of the medications we currently have, with the minor exception of niacin, do much of anything to raise HDL. There are basically two main ways to do that: 1) if your trigylcerides are high, lowering them will simultaneously raise HDL in some people (which can be done by losing weight and/or by reducing the amount of sugar and carbohydrates in your diet), and 2) intense exercise. Regarding your first question about foods for a vegetarian diet, I’m afraid I don’t consider myself expert enough in nutrition to give you a good answer. I do know that beans and legumes are an excellent source of protein.


  • Great post. I too have garnered a lot of personal empirical data and although I am slightly overweight, overweight nonetheless. However I know why. Pie. Yup, experimenting to nail down the perfect piecrust recipe (which I did) packed it on me. And the Amaretti and the scratch-made cakes over the last four months. In fact, it really was me “appreciating” my accomplishments that did it; we kept some of the results instead of giving them all away. So, now done, the pies are no longer being tested.

    I am a pastry chef gearing up to open our own bakery and café in the next few months. That probably makes me a drug-pusher to some. Yet I contend that I am your cook, not your doctor, but will encourage folks to eat sweets as a treat not a meal, and…and eat pastries made from real food, not those made from non-dairy concoctions that look pretty but taste like plastic.

    It all comes down to calories in, calories out. As you said, the first law of thermodynamics. The weight is coming off now, we are back to bike riding and moving about more. It ain’t rocket science.

  • Oh, please…if you take 100 people and ask them how best to lose weight, how many of them will be able to tell you? Obese folks are very well-informed consumers (pun intended) of not only food but also diets. Don’t you think that 100 out of 100 people will give you a satisfactory response? People aren’t obese because they don’t know how to eat well or move more. In fact, every bite is usually accompanied by guilt, remorse, and self hatred because they KNOW what they are doing is hurting themselves. And yet they can’t stop. To lose weight, they will have to treat the addiction. They will have to address the eating disorder. And gastric bypass, diet pills, Atkin’s, Jenny, South, North, up or down is not going to do it for them. They need to travel the path with a qualified psychotherapist who knows a thing or two about the most difficult nature of the deadliest addiction there is.

  • You concluded with: “As I told Mrs. Withers the last time I saw her, losing weight …is incredibly hard.”

    I have a simple mind and tell my patients, “Losing weight is easy. Making up your mind to do it is almost impossible.”

    The cruel “experiment” going on in Darfur proves the “easy” point as people are having caloric restriction imposed on them.

    Folks have no concept that 10 excess calories per day x 360 days a year is worth a pound of weight gain….that’s one potato chip.

    Kaiser Permanente, in Portland, showed (what you referred to) that simply writing down, in detail, everything that one eats is associated with weight loss aka waking up to what one is actually eating.

    In my 15 minute presentation to my patients, I recommend:

    1. “Calorie King” calorie counting book,
    2. Count calories with a running count,
    3. Quitting eating when target intake goal reached and
    4. Buy a bushel of watery vegetables e.g. celery, cucumbers for the times of urges to eat.
    5. Take a multi-vit w/ minerals
    6. And exercise, 30 minutes daily, breaking a sweat.

    And, as “we” are intent on averting the diabetic calamity, I tell interested patients
    1. not only am I sharing my view, and
    2. not only am I giving them my “best” medical advice, but that
    3. for their benefit, I actually EXPECT them to do it as I say to them, “See you in a month for review of your diaries and progress.”

  • Folks are not obese because they eat a potato chip a day. Folks are not obese because they don’t know that cucumbers are healthier than chocolate cake. Folks who are obese have probably tried counting calories already. Many of them can tell you how many calories, grams of fat, and fiber there is in just about anything. Here is an idea to solve the diabetic shift in out nation: Stop focusing on food. Rather focus on life. Stop focusing on weight, calories, BMI, PH, metobolics, and colonics. Focus on life. And if all else fails, for the sake of your life and your children…stop eating when you are no longer hungry. If you can’t, get help.

  • I’m sure I would qualify for gastric bypass, based on my extremely high BMI and my sleep apnea.

    I’m dismayed that you recommend the operation, though. It’s extremely dangerous (obesity has potent health risks; does this mean I should endanger my life further by having an extremely dangerous operation—with what appear to be terrible, possibly life-long after-effects of the operation?).

    Furthermore, this operation does not take away the *desire* to overeat (which, i think, is less psychological than physiological for extremely fat people, although the 2 are not separate).

    How terrible—to have a dangerous operation, possibly live through it—and still feel driven to overeat!

    People do not understand that obesity, itself, compels extra calorie intake. I wish they did. You hint at it, in your article, which I find, overall, quite good.

    *Please* address the dangers of gastric bypass, as well as its many failures (i.e., still driven to overeat, people who regain their weight, people who suffer vitamin deficiencies or worse, people who die from gastric bypass).

    Zara: No doubt about it: bariatric surgery carries risks, including all those you mention. However, the most common complications mentioned in the studies that measure them include anastomosis complications, marginal ulcers, abdominal hernia, and dumping (not minor, but manageable and not life-threatening). Further, a recent article found the complication rates vary by region, suggesting having an experienced surgeon perform the operation is critical. In my own practice, anecdotally, I have one patient who is an absolute disaster after having gone through it. She’s been left with chronic abdominal pain and has suffered severe vitamin deficiencies until it was recognized and she was begun on supplements. On the other hand, also anecdotally, I have two patients who’ve done just spectacularly well. Also, contrary to what you suggest, studies have found that many patients do become less hungry after the operation, suggesting the change in anatomy from the surgery somehow alters physiology and hunger mechanisms in some patients. However, your point is well taken. Bariatric surgery isn’t the kind of thing anyone should enter into lightly without a full knowledge of the risks and benefits.


  • I just found your web site through various links. I made a decision to change my life a little over a year ago. I refuse to “go on a diet” as I know from experience that diets don’t work. What has been working for me is to have my home free of all snack foods. No cookies, cakes, candy, chips, pop, etc. I can have those items, but only if I go out and only one. For example, I can get an ice cream cone but not a half gallon ice cream for my freezer. I’ve lost 70 lbs in 13 months. I need to lose that amount again.

    My problem is exercise. Severe arthritis, artificial knees and hips, severe pain, on MS Contin, frequent infections…I can’t think of anything I can do that won’t cause severe pain. Even swimming is out due to infections, even staph at times. Do you have any ideas to help me? Thank you!

    Jennifer: That’s a tough one. Swimming is what I usually recommend to patients with painful arthritis. Not knowing the details of your pain, it’s difficult for me to recommend an exercise that won’t exacerbate it. Two ideas do come to mind, though: bicycling and yoga.


  • I appreciate your response, Alex.

    Anecdotally is all I go by; I know that’s a big no-no for scientists, but since I’m not one, all I can say is: the story of the woman from your office who has done terribly frightens me more than the other 2, since no one can assure me that I would not have the first woman’s fate.

    As for hunger, I’m going by Carnie Wilson, who, as you know, has not been shy about publicizing her gastric bypass and the results of it.

    Hunger is a strange thing, I think. One can be “hungry” for a donut w/o actually being hungry. How many people who go for this operation have the kind of hunger for binging on sweets or salty snacks? Probably most if not all of them, I’m guessing. It seems to me that the ability to manage this hunger is very difficult, regardless of weight, but especially for those who are fat. Then there is overeating, and perhaps a gastric bypass makes that less likely, but for how long? The body seems to have ways of adapting.

    Also, I don’t think having to rely on vitamin supplements, which are expensive and not as good as being able to get them from food, is so great. Poor absorption of vitamins is also a factor. Groups like OA (12 steps) purport to solve hunger for sweets and snacks, but I’ve seen many a fat person in those groups. Alex mentions her solution, but she will have to see how well she does, after 5 years.

    If 90-95% of people regain their lost weight after 5 years, and gastric bypass has so many risks (including the risk of regain), well, so far, I’m not convinced.

    Just because I’m fat doesn’t mean I think I should subject myself to an extremely dangerous operation w/extremely unpleasant to very dangerous aftereffects. Still, I wish something would work. We live in a world filled w/food. Not everyone gains a massive amount of weight, but the numbers seem to be going up. Maybe the pollution of our environment is playing a part in this, as hormones get affected by mercury and other nasty things.

    I know that I’m very low on vitamin D, so now I’m supplementing. I’ve read that the higher your BMI, the lower you vitamin D stores are likely to be. Imagine if low vitamin D is causing a lot of my obesity, and imagine if I don’t know that, get a gastric bypass and then, after the operation, I can’t absorb vitamin D anymore!

    No, there has Got to be more in-depth solving of this obesity puzzle. Time will tell. We might look back at this time of blaming obese people as a time of when ignorance was the norm, not knowledge—or compassion.

  • I made a mistake in names—I meant to write Jennifer, not Alex, when I wrote of the commenter who has banned all snack foods from her home.

    In terms of exercise, Jennifer, you might want to invest in a stationary bike that is recumbent? It seems to work well for me.

  • Thank you, Alex and Mara, for your comments and suggestions.

    The stationary bike may work. I’ll visit a friend who has one and see whether I can do it without significant pain.

    What I’m doing is recognizing I have an addiction. If snack foods are in my home I will eat them first. Always. Not having them here causes me to eat the healthy fruits and vegetables. I have built in a way to “cheat” by allowing myself to go buy one snack item, such as an ice cream cone or one Coke. That has taken away anything to do with guilt or a sense of failure. Another thing I do is weigh myself infrequently. I don’t own a scale so I check my weight at my doctor’s office. I’m losing only five pounds a month but am very satisfied because I feel much healthier.

    I will reveal I had gastroplasty about 25 years ago and went down to a size 6. I kept it off with diet and lots of exercise. As my arthritis got bad and I couldn’t exercise, I began overeating on the foods that go down easily, and I ended up gaining back the 200 lbs lost. So I know a lot about failure.

    I can only continue trying to live a healthy life. As to my weight in five years…who knows. I look at this as a lifestyle change and not a diet to endure for a certain length of time. What I’m doing can be done forever. I began doing this 13 months ago to improve my health. The weight loss is wonderful as a secondary goal and will add considerably to better health.

  • 3 words: The Diet Cure, by Dr Julia Ross.

  • Thanks for this excellent post.

    I’m one of the fortunate people who (so far) only struggles with an extra 5 pounds or so. From my personal perspective, I agree that the best way to lose weight is through modest exercise and eating healthy foods in moderation.

    I have a friend who had gastric bypass surgery and it has made a major difference for him, and perhaps has added many years to his life.

  • A great article—thanks!

    I am a 5’10” 57-year-old married female college professor. This morning I weighed 254 pounds; however, I have lost 25 pounds over the last 3 months. My ideal goal is to lose about 75 more pounds. I have been losing weight by cutting back on carbohydrates, increasing my fiber intake, eliminating sugar (my “new” favorite drink is ice water with lemon and splenda) and adding extra vitamin D and cinnamon to my vitamin regimen each morning. I like the diary idea and will start one today.

    My primary doc’s advice has been scant and not very helpful—”you should lose weight”—end of conversation.

    What ticks me off is the issue of exercise; people accuse overweight individuals of being too lazy to exercise. They make us feel lazy and useless. I love to exercise. Until I became pregnant I was active in several martial arts (Tai Chi, Aikido, Karate etc), and fought in the senior black belt division. I also lifted weights. I spent hours exercising each day. However, after numerous physical health issues (including 4 bad cervical discs, 2 bad thoracic discs, 2 cervical ribs causing thoracic outlet syndrome, and an out of place SI joint), I now can’t walk for more than a half a block without pain and can’t lift more than 5 pounds.

    Theoretically, a couple of surgeries could probably partially repair many of my health problems, but I’ve been also warned that surgery might make things worse. Dire warnings of paralysis from thoracic surgery, or paralysis in my hands if they remove the cervical ribs got my attention. So, I decided to put off surgery until (if) the day comes (that my first neuro doc predicted) when I can’t walk or get out of bed.

    About 3 months ago I stepped on the scale and found I weighed 278. I felt like I was painted into a corner. YES, gastric bypass surgery works but my insurance won’t pay for it. My son has cystic fibrosis, so our out of pocket costs for his care pretty much wipe out our savings. So, we can’t afford it. YES, exercise is important, but I can’t exercise. So, I’ve decided I could give up and keep gaining weight, or adopt a simple philosophy “change what you can change and forget the rest.”

    That’s what I am doing now…I decided the one thing I can change is my diet. I am focusing on developing a good, livable diet and reducing my stress levels. My (secret) hope is that as I lose weight I might be able to walk more, we’ll see.

    Even through all of my health issues, and even though my son has a potentially fatal disease, I still have plenty of reasons to smile. Focusing on them helps reduce my stress. Maybe I can’t walk very far, but I can still sit on my porch, enjoy the morning breeze and watch the birds fight over who gets to eat out my feeder first. My son has CF but he is also bright, good looking, has a crazy sense of humor and is senior class president; and a potential treatment for him is just around the corner. I was worried about how to pay for his health care once he hits 18, but the new health care bill has taken some of that worry away as he can stay on my health insurance until he’s 26. I have a secure, well-paying job with good benefits that I like, I have been married 33 years, and my biggest challenge this morning was keeping my cat away from the birds as they ate. 🙂

    Roe: Congratulations on refusing to be defeated! As long as you maintain that spirit, you will undoubtedly make steady progress toward your goal. I was so heartened to read you comment.


  • The Atkins Diet doesn’t say you can eat “unlimited calories.” It says to eat until you are satisfied, and then stop.

    Admittedly some people can’t stop…but that’s not following the Atkins Diet.

  • Alex, I also found this from a link on TPP’s NYT column. The posts are fascinating. I have no doubt you are well-meaning, and compassionate, and that you want the best for people. But do you ever just reread all this with a fresh mind? COME ON. 90% of the people here are telling you that: A. diets don’t work and B. they know all about calories and exercise and have tried everything already and C. no matter how you lose the weight, you eventually end up gaining it all back….BECAUSE YOU GET HUNGRY. It might be two weeks, it might be two years, but you will gain it all back…probably and a few more pounds, just for punishment (“you can’t fool Mother Nature”).

    As our obesity problems in the industrialized world are relatively new, we need to look at what has changed over the last 30-40 years…and an OBJECTIVE scientist would not say that we changed the food supply (more artificial foods, HFCS, transfats, diet foods, aspartame and splenda, etc.)….WE QUIT SMOKING (77% of us in the 50s vs. 23% of us today)….we have lives of much greater stress, more speeded up, more pressure all over….we have removed many small simple things that people did—not quite exercise—but simple things such as just getting up and walking across the room to change the TV channel—and we as individuals have no power to change this back (try to find a TV without a remote!). But BY FAR the BIGGEST CHANGE is the constant hectoring and lecturing and nagging and scolding and pressure to be “healthy” which is defined as “being skinny” (not merely being a normal weight, but being the kind of slender we see in magazines on models and actresses). If we do not do this ASAP, we are punished by humiliation, lectures, nagging, “weigh ins,” comparisons with others, reduced opportunities for jobs and socializing and clothing, and of course constant pressure to IMPROVE OUR HEALTH. Not a day goes by (literally) when we are not shown “proof” of some “research” that “proves” we will die of (yet another) awful disease if we don’t get our weigh down PRONTO. Fat causes EVERYTHING NOW—forget the environment, pollution, DNA, family history, the food supply—no it’s FAT, causing cancer, diabetes, arthritis, high BP, cholesterol, heart disease, even ACNE.

    And in none of this do we ever address HUNGER: the very thing that drives people to eat. There are so many GREAT EXAMPLES here, Alex, of people who really really try—who exercise, who restrict their eating, who work out, who follow all the “rules” and ARE STILL FAT and tell you THEY ARE HUNGRY and all you say to them is “it’s hard” (except when you say “its’ easy! just eat less!”) and tell them to go get gastric bypass surgery.

    Well, I’d LOVE GASTRIC BYPASS SURGERY. I’d even accept the considerable risks to my life and to my health—that my hair might fall out, that I’d never be able to eat normally again, that I’d have vitamin deficiencies—but MY HEALTH INSURANCE WON’T COVER IT. So there is no point in you the doctor telling me to have it!!! My health insurance contract has a special page for “weight loss surgery and drugs”—it is BRIGHT YELLOW, so you can’t miss it—and how they will not pay for almost anything, not for diets or weight loss drugs, not for Weight Watchers or nutritional counseling and only for gastric bypass if you are TWICE your maximum healthy weight (not merely 100 lbs overweight) and that would mean I’d have to weight about 330 lbs. Alex, I can no more GAIN 130 lbs than I can LOSE 75 lbs. So nobody will permit me to have this surgery, which as you say is the ONLY THING THAT WORKS even a little: all diets, all exercise programs are abject, provable failures in producing permanent weight loss.

    So why bother telling people to do this? You might as well say “climb Mt. Kilimanjaro….swim across the Atlantic….make yourself young or make yourself taller.” That would be stupid, right? I can’t make my eyes blue. I can’t give myself a beautiful singing voice. I can’t become 20 years younger. And I can’t MAKE MYSELF THIN.

    Since that is true: why can’t YOU and all the other self-proclaimed “diet guru’s” just ACCEPT that some people are FAT and some people are THIN and we should all just accept one another, and love one another, and accept that we cannot control everything in the universe—and that life is too short to make yourself miserable about what CANNOT BE CHANGED.

    If you accepted this, you could help a GREAT MANY PEOPLE live happier more meaningful lives.

    Or you can just keep nagging and lecturing and hectoring them to become something THEY CAN NEVER BE.

    It’s your choice. Make the right choice.

    Concerned Citizen: It’s hard for me to know how to respond to this. It’s clear to me you’re horrendously frustrated, but I must correct two misstatements: I didn’t say gastric bypass is the only thing that works to help people lose weight. The post was meant to describe the physiology, as we currently understand it, that’s involved in obesity and weight loss in hopes that some people might be able to leverage it in their attempts to lose weight. People are of course genetically diverse and will therefore have different levels of success in response to weight loss efforts. Some do everything we in the medical establishment suggest and still fail, it’s true, but that is not the case most of the time, as you imply. Secondly, it’s not at all clear what’s caused the epidemic of obesity in America (and the world, to a lesser degree). You raise good possibilities, but the degree of certainty you express is unjustified.

    I wrote that weight loss is hard to express the empathy I feel for people who struggle with obesity. I disagree that being overweight is something people cannot control. That may be true in certain cases, but data is beginning to accumulate here that suggests success in long-term weight loss may be more common than most believe. Having said that, I certainly agree with you that we should accept overweight people as we do thin people (and also that our society doesn’t). There are very real health risks to obesity, not the least of which is the self-deprecation that often results when people fail to achieve their weight loss aims. I don’t think obesity/weight loss is a black-and-white issue as many proclaim, andI do think self-acceptance is more important than success in losing weight. I wish I had more to offer you, but the best was in the post, my attempt to provide useful information for folks who didn’t know about some of the things I discussed.


  • I was very moved by Concerned Citizen’s post and wanted in particular to respond to this part: “…no matter how you lose the weight, you eventually end up gaining it all back….BECAUSE YOU GET HUNGRY…”

    Dearest CC, I understand exactly what you mean. Unfortunately, people who are not us simply cannot—will NEVER—get it. Unless they are living in OUR bodies, they cannot comprehend the gnawing, nauseating, relentless, driving hunger that we feel even after eating 2,500 or 3,500 or sometimes 4,500 calories in a day. They just don’t get it. It’s like trying to explain color to the color-blind, or the icy cold of the Yukon to someone who’s lived their entire life right on top of the sea-level equator.

    The color-blind will say, “Hey, I can see the difference between a rock and a parrot!” But they can NOT see the intensity, the blinding difference between their shades of gray and our neon colors. The person from the equator will say, “Hey, sometimes I get chilly at night. C’mon! Don’t be such a drama queen. How different could it be?”

    They just don’t get it, and God willing—for their sakes—they never will get it.

    I was a thin child and a very indifferent and picky eater until puberty hit, so I know the difference between what THEY call “hunger” and what I now experience as HUNGER. Dieting to them is like fending off a kitten compared to defending yourself from a full-grown lion. Their idea of what it’s like to “eat less” is like comparing playing jump-rope at recess with climbing Mt. Everest.

    Even world-class, saintly empathy only gets them so far. There are no words in the language to adequately describe the difference between what they experience and what we experience. We shouldn’t even be using the same words; the experiences are that different.

    Would you use the same words to describe stepping up stairs to the second floor vs. climbing a sheer rock wall like El Capitan in Yosemite? Would you consider them comparable experiences? Just because both involve moving your body vertically in altitude?

    Of course not.

    Those who are not gifted with Olympian-sized empathy are even more baffled. “What’s the big deal with skipping a few meals? I do it all the time. What a bunch of lazy whiners. Just eat less and move more. Sheesh.”

    Until we have some way of measuring and reliably recreating the magnitude of the relentless, nauseating, crushing, destroying and utterly merciless hunger that a morbidly obese person experiences, the thin-to-slightly-overweight simply won’t get it.

    Instead of blaming us, they should be on their knees thanking God that they don’t get it. Because if they DID get it, they’d be one of us: socially tortured and reviled for a medical/genetic condition that we (speaking for myself, here) have fought with every tool we could find FOR DECADES and have been defeated by, not once, but hundreds of times.

    The closest I have ever come to helping someone understand is telling them, “OK, if you think it’s so easy to cut my eating in half, then you cut your BREATHING in half for the next two weeks and we’ll compare notes. Time your current breaths, and then get a stop watch, and start breathing half as often. How hard could it be?”

    So far? No takers. But if they let themselves REALLY think that through, they get a brief glimmer of an understanding of what it means to try to fight off a basic physical impulse just as relentless as the drive to breathe. That is, they get it for a second or two, right until their denial kicks in, their minds slam shut and they refuse to believe what we face could possibly be comparable.

  • This is an excellent post and touched on a number of important issues. I wonder if you have had any further thoughts about the impact of medication. I had been slightly overweight in my teen and early adult years. I had several bouts of depression and anxiety. When I took anti-depressants, I found that I experienced sudden and large weight gains that were impossible to reverse. While I could diet and exercise and lose some weight, I never got down to where I was before. I feel the medication permanently changed my chemistry.

    My daughter developed severe OCD at age 10. She was likewise put on medication and she also had a huge weight gain. She went from skinny kid to very large kid and overweight teen. She also struggles.

    I feel drug manufacturers are not being honest about the effects of their drugs.

    Leslie: Several classes of antidepressants can cause weight gain, but aren’t known to change body chemistry. Weight gain itself, from almost any cause, can do that. Even then, it remains possible to lose the weight, but it’s just really hard. Best of luck!


  • I never had too much to loose but at age 50, 5’8″, 145 lbs and 35% body fat (as measured on my bathroom scale my abdominal girth is 35″) all my weight goes to my ever increasing abdomen. I try to eat healthy 6 days/week and allow myself only 1 “free food” but I hate my gut! I started running marathons but I actually think that amount of endurance training has caused an elevation in cortisol levels for the stress of the 5 hours running! So now I am mixing it up in an all out battle of the gut. I lift weights 2 days/week and am trying high intensity intervals in place of long distance running and I am learning yoga for the stretching and connection of my body to my mind. Thanks for your blog!

  • Just to share my journey—after a lifetime of struggle to lose weight, I finally reached BMI of 41, and coming from a family of extremely obese and diabetic people I decided to get myself a lap band earlier this year. The operation took less than an hour, and I was home the following day. Five months later I am 16 kg lighter and have confidence I will be able to get to a very healthy weight for me in time. The key issue in weight regulation, which is why some of the commenters have been unable to control their weight despite all their efforts after taking a drug regimen for an illness. Willpower can hardly ever overcome an overset appetite, which is why 90-95% of people who lose weight put it back on. Now that I have a volume control on my appetite, and without the din of a too-loud appetite in my ear constantly, I can make much healthier food choices.

  • Hi Alex….hope you have been well! I found your blog and wrote to you for the first time on 4/1/2009. At that time, was 145 lbs and had just begun to try and drop some weight. Because I was so impressed by your blog, I bookmarked it for inspiration. Long story short, instead of losing weight I actually ballooned to 163 lbs; I say ballooned because on my 5’2″ frame it felt and looked like I ballooned!!

    On April 10, 2011 I made a conscience decision to honestly change my life and the result has been a loss of 25 lbs in 93 days. To lose the weight I had to change my mind about the reasons I wanted to lose weight. Next I had to get out of my way! By that I mean I had to check my ego because there is nothing pretty about the work that’s needed to make being physically fit a way of life.

    In terms of exercise I do a solid hour every single day….no excuses! I started by walking, gradually I moved to power walking, next level was to power walk with small hand weights. I then moved to running which is a test of my will every single day! When weather doesn’t allow me to be outdoors, I’m on my Stairmaster or treadmill. I have small free weights at home as well. I warm up and cool down; stretching is a must and I’m now up to 150 crunches every day. The sweating, huffing & puffing, and too tight exercise clothes in the beginning was awful to endure! People older than me would run past me so fast that I couldn’t believe my eyes. My clothes were uncomfortable and I felt embarrassed every time my shorts rode up or my bulges stuck out. But I didn’t give up I just kept (and keep) trotting along. I got out of my head and got out of my way!

    Also key to note, I gave up alcohol. Not that it was a problem or that I won’t ever have a glass of wine again but I felt like I needed clarity and so I just stopped. I also gave up sugar and I didn’t drastically change my diet but I found myself with less time to focus on food because I spend more time focusing on my workout.

    Are there days when I want to quit and not run another mile? Absolutely! Are there days when I make every excuse under the sun not to exercise? Absolutely! Are there days when I don’t want to give it my all when I’m working out? Absolutely! But I haven’t given in to those temptations. I think of the hour I’ve committed to being physical as sacred. It’s my time and if I choose to put other things first that’s ok but before I go to bed I have to get in 60 minutes of physical activity.

    I get up at 4am every day for work and I don’t stop working until after 6pm or 7pm everyday. If I choose to put work first and not quit at a reasonable time too bad so sad because I still have to get in that hour every day!

    The last thing I did was give up even looking at a scale for the first 90 days. I did that because you suggested it and it worked. I weighed myself this morning so I could drop you this note and wanted to say I feel absolutely no pressure or anxiety about loosing weight. There is no pressure because this isn’t a one time hit…this is a choice to change and if you’re sincere and clear about why you want or need to make a change it can be done.

    By the way, I’m going shopping for some new athletic wear since what I own is now too big for me. I just wanted to thank you for your sound advice and your blog has now become one of the first or last things that I look at every day because it and you are an inspiration to me….THANK YOU!


    Charlene: You’re an inspiration! Thank you so much for sharing your story. I can’t tell you how happy I am to hear about your success.


  • Hi,
    I’ve been trying to lose weight off and on since I was 17 (I’m 27 now). I’m 5’6″ and currently weigh about 165. The lowest I’ve ever weighed at my adult height was 148 and the highest was 183. I’ve tried so many different things to lose weight (even phentermine, ugh) but the only thing I’ve found that works is running 6-8 miles a day and eating no more than 1200-1400 calories. I’ve found that the only way I can consistently lose weight is if I “net” no more than 400-500 calories per day. What I’ve found is that I can’t sustain that level of exercise/diet for more than a few months, but nothing else has worked for me. Every time I go to my doctor for a physical she tells me I need to lose at least 20 lbs, but I can’t seem to get it off. The last time she told me that I was at 148. I’ve avoided going back because my weight has gone up even more since then. What can I do to get the weight off that I can actually sustain?

    Valerie: If you haven’t already, you might try focusing on a lower carbohydrate diet. Though I’m not a fan of the “science” he presents, the weight-loss strategy that Tim Ferriss describes in his book The 4-Hour Body has been helpful to many of my patients.


  • @Valerie
    5 foot 6, 148lbs – BMI 23.9
    5 foot 6, 165lbs – BMI 26.6

    Both weights seem healthy to me. Latest research re:relationship between BMI and risk show body mass index has “U-shaped” curve that has its lowest risk at BMI 27.3.


    Your doctor is out of line, and I’m surprised that Alex didn’t pick this up.

    Sounds to me like you need to get a new doctor, and learn to appreciate yourself the way you are. I would guess that your obsession with your weight, when you are in fact normal and healthy is the biggest danger to your overall health.

  • Great analysis, thanks for sharing!

  • This was really informative thank you. I’ve got a short question. There is a innovative workout program that has been fairly widely used. I have looked around a great deal of sites to find out if this actually works as people tell you it does. Many people agree it’s a awesome program. I too have been using it now for three weeks. I’ve got to say i agree with others. Could somebody tell me what do you believe? Below is a review with it. review Should I remain on this regimen because it is working seriously well.

  • One of the best ways to lose weight is running in the morning. And I mean not just running, but a short but intensive run right after waking up and befor your breakfast. It’ll make your body work the rest of the day and burn calories. Good luck…

  • I’m shocked that Dr. Lickerman is advocating a low carb diet. Yes, you may possibly lose weight, but at what cost to your risk profile for heart disease and cancer?

    A diet high in whole fruits and vegetables (all carbs) is linked to superior health outcomes such as longevity, low heart disease and also low cancer risk. The blood of vegans (all plant diet) kills cancer cells over 7x more effectively than the blood of people with the standard American diet. And low carb would be worse than that! Your immune system is directly affected by what you eat.

    For more information on this scientific experiment search “Ex Vivo Cancer Proliferation Bioassy”.

    Other resources—Dr. Gregor’s dvds on nutrition, Dr. Fuhrman’s books, and the documentaries “Forks over Knives” and also “Fat, Sick and Nearly Dead.”

    Lucy: By “low-carb” I didn’t mean to exclude whole fruits and vegetables. The statement you make that “the blood of vegans kills cancer cells over 7x more effectively than the blood of people with the standard American diet” has no support in the scientific literature I could find.