the truth about weight

This one is a doozy but dispelling the myth of calories being the main determiner of weight is critical to debunk from the start, so try to stick with me.

There are very few misconceptions about health that bother me as much as this one, partially because I believed the calories-in/calories-out theory for longer than I’d like to admit. Worse, I repeated this falsity to my patients regularly and heard it echoed by my colleagues for many years, providers whom I really respected.

And let me be clear, none of us were knowingly giving bad advice to the patients we so deeply strive to serve. In school, this is the general equation of weight we are led to believe, along with the sentiment that if patients aren’t losing weight, then they just aren’t trying hard enough. It couldn’t possibly represent a failure of the medical system or us as providers (gasp!). The reality is, if providers had it all figured out, we wouldn’t share these same weight struggles or helplessly watch our friends and families battle the same. But gosh, don’t we all just hate admitting failure. 

We do a terrible job addressing weight in traditional healthcare environments. How many times have you seen a healthcare provider and they either:  

1. Avoided the topic of weight altogether (even if you were hoping it would be brought up or tried to bring it up)  

or

2. Slapped an ‘obese’ or ‘overweight’ diagnosis on your chart and gave you some vague instructions like ‘eat less and go to the gym’ before moving on 

Have you ever had a provider ask you for your consent before discussing weight? What about providing you with specific, actionable steps to reach your weight goals if you were wanting to make a change? How many of you have ever had a provider refer you to a nutritionist or personal trainer?

In defense of healthcare providers, most of us genuinely DO want to help our patients get better, but we aren’t given the tools, whether it’s the time or information, needed to help patients move the needle (sigh, this is another topic for another day). It really hurts me to think about how I mishandled weight discussions in the past. But when we know better, we do better and now I can help you to know too.  

The truth is, weight IS an important discussion to have with your healthcare provider. Not because we want you to fit into some societal norm or arbitrary group, but because obesity IS a risk factor for nearly every disease (at least 230 comorbidities and complications of obesity have been identified), associated with a shortened life expectancy, and is a very real problem – afflicting around 42% of U.S. adults. Obesity is both a cause and a symptom; it is often a sign of something deeper going wrong at a metabolic level. And I would be remiss not to mention that metabolic issues can occur at any size, so it is not a hard and fast rule- there are metabolically unhealthy lean individuals just as there can be metabolically healthy individuals that we classify as ‘overweight’ or ‘obese’ based on BMI alone. 

The Myth of the Calorie as King

First, let’s tackle one of the biggest lies we have ever been told: weight can be boiled down to calories in + calories out. Meaning, if you eat 1200 calories per day and burn 1300 calories per day, you will lose weight, and vice versa. This theory of weight is otherwise known as the energy balance model (calories are the unit of measurement for energy for the body).

If you are a human living on this earth, you have undoubtedly heard this sentiment, and the foundations of obesity management are based on it: if you eat less and move more- voila! The weight vanishes! This is taught in every conventional textbook and reiterated in every dietary guideline. But why, if it is this simple, are we continuing to get larger and larger as a society despite being shamed into eating less and less and moving more and more? If this is true, why don’t we drop down to 0 lbs if we stay in a calorie deficit for long enough?

We are simple creatures; we want to boil everything down to a simple formula that is easy to explain and calculate but like so many concepts in health, weight is incredibly nuanced. This simplified view of obesity doesn’t account for the many complicated factors at play. We intuitively understand that eating 100 calories of broccoli won’t affect us in the same way as eating 100 calories of candy will, but how does this play into the weight conversation? 

It wasn’t until I began to view obesity as a hormonal, chronic, relapsing, multifactorial disease that I could finally shift my patient teaching in a way that actually helped. 

We Need to Talk About Insulin

Enter the newer theory of obesity: the carbohydrate-insulin model. This model posits that fat gain occurs from the body’s response to consuming foods that cause big increases in blood sugar (AKA high glycemic index foods) which triggers a big insulin response. It’s the source of dietary calories (i.e. broccoli vs. candy) that causes many hormonal and metabolic responses that ultimately change our weight set-point and determine how much fat we hold onto. Understanding insulin is the driver of our weight is a game-changer.

Said another way, if you think of your metabolism as a thermostat, your body has a default temperature (or weight set-point) it tries to keep you on. For example, maybe that point for you is 150 lb, and no matter what you do, you feel like you can’t get below this number. If your temperature (weight) climbs above this number, your metabolism turns on and speeds up to get back to its set-point. But the opposite is also true, if you lose weight (as people often try to achieve through low-calorie diets and over-exercising), your body slows down your metabolism, causing you to feel tired, slow, and hungry until you are forced to eat more and get back to your set weight.

This is why you can never “stick to your diet” and feel awful when you try- it’s not a lack of willpower, but it’s your body’s safety mechanism! Now you may ask, why would the body pick a set weight that is higher than you like or considered unhealthy? This set-point can change over time in response to a lot of factors, especially dietary choices that cause high blood sugar and insulin. You HAVE to focus on reprogramming the thermostat (resetting your metabolism) first before you can achieve lasting changes to your weight. In some cases this may actually involve eating MORE calories at first, an approach called reverse dieting which I will go into deeper in a future post.

Of course, the number of calories we consume plays a role in weight, but it is not the end of the story. Weight is so much more about what you eat than how much you eat. The foods with the highest glycemic loads include processed grains, potato products, and foods with a lot of sugar. Typically, fats and proteins have the lowest glycemic load. When you are metabolically healthy and eating nourishing, whole foods, you will find that calorie counting is unnecessary- your body will naturally regulate your weight to keep you at your now healthy set-point. 

So, where do you start?

If you get nothing else out of this article, the point I want to drive home is this: being overweight or obese is NOT a disease of willpower, it is not a choice, nor a personal failure. You CAN heal your metabolism and achieve your weight goals. If you have tried every restrictive, fad diet in the past but could never keep the weight off- understand that it is not your fault. We are only now beginning to understand the complexities of obesity, and the damaging myth of the ‘eat less, move more’ theory sets you up for failure. Remember, sustainable weight loss is the long game. Try ONE of these strategies to get started and slowly add more as you master it-

• Focus on adding more nourishing foods to your diet rather than what you are going to take away. Ensure you are getting plenty of healthy dietary fats and fiber in your diet which will increase satiety and naturally balance how much food you are consuming. Starvation diets are so last century- it IS possible to lose weight while feeling full and satisfied!
• Keep blood sugar (and by proxy insulin) levels lower by choosing nutrient-dense, whole foods (especially fats) over nutrient-void, highly-processed foods
• Add gentle fasting and ensure you are eating enough satisfying food during meal times to avoid snacking later, which also helps to avoid unnecessary spikes in blood sugar and insulin
• Pay attention to what you are eating when you are eating it (mindful eating) and how you feel afterward. Awareness is an essential step before attempting to make any changes. Once you realize that eating pizza for lunch makes you sleepy and unable to complete the rest of your work for the day, it’s much easier to choose differently next time

Want to dig into this topic further? I highly recommend reading the Obesity Code by Dr. Jason Fung. Want more support or have questions for me? I’m here to help! 

TLDR; Obesity is a complicated, chronic, relapsing condition that is largely controlled by hormones – not a personal failure or sign of low willpower

Weight loss is more about what you eat than how much you eat & starvation diets will never lead to long-term weight loss

Keep blood sugar lower by opting for more high-quality, dietary fats than highly-processed, nutrient-void food

Start small with weight loss efforts; no “quick fix” will lead to long-term success. Instead, choose sustainable and consistent shifts in habits 

References 

Ludwig, David S., et al. “The Carbohydrate-Insulin Model: A Physiological Perspective on the Obesity Pandemic”. The American Journal of Clinical Nutrition, https://doi/10.1093/ajcn/nqab270/6369073, 2021.

Perreault, Leigh and Blandine Laferrere. “Overweight and Obesity in Adults: Health Consequences”. UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Accessed 09 Nov. 2021.