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Everyone Who’s Fat Eats Too Much Steven R. Kanner, MD, MSM Orchard Health Care Copyright © 2005-2014 by Steven R. Kanner, MD
Some Background on Nutrition and Weight This section reminds you of important information that you probably know but may have forgotten or never heard in an organized fashion. Knowledge is key to success.
© 2005-14 Steven R. Kanner, MD3 Why Is Weight Medically Important? Overweight promotes the big three diseases of modern midlife — diabetes, high cholesterol, and high blood pressure. These three conditions together produce early death from heart disease, stroke and kidney failure.
© 2005-14 Steven R. Kanner, MD4 How Does Weight Loss Help? Returning to a healthy weight (what I call “trim weight”) for many people can substantially correct the biological abnormalities from early diabetes, mild hypertension and high cholesterol. It may not be sufficient by itself, but weight control always helps to manage those 3 diseases.
© 2005-14 Steven R. Kanner, MD5 To Whom Am I Speaking? This dialogue is for all of you who have had great difficulty in maintaining or reattaining a healthy weight. I am convinced that reaching and maintaining proper weight is possible for almost everyone.
© 2005-14 Steven R. Kanner, MD6 Who Are the Exceptions? If you always eat when sad or stressed, if food is the absolute center of your life, and especially if you eat when you aren’t even hungry, then you have a pathological relation to food and truly need behavioral management approaches to your issues. Education alone will fail.
© 2005-14 Steven R. Kanner, MD7 “How Do I Know if I Am Overweight?” Look in the mirror when you are shaving or doing your hair. If you can’t see the hollows above and below your collarbones, you are at least 10-15 pounds overweight. If you can’t even find your collarbones, you are even more overweight than that.
© 2005-14 Steven R. Kanner, MD8 “Seeing My Collarbones? What About the BMI?” The BMI is a popular but flawed measure that nobody really remembers how to calculate. Arnold Schwarzenegger is obese according to the BMI, but you can see the hollow above his collarbones. He is muscular, not fat.
© 2005-14 Steven R. Kanner, MD9 “So What Should My Weight Be?” You want to be “trim.” Trim people are not skinny nor boney, but they have minimal unnecessary fat padding. Trim weight is about 20-25% body fat for men (BMI 23), about 25-30% for women (BMI 21). We are talking about ordinary people in midlife, 30-70, not athletes.
© 2005-14 Steven R. Kanner, MD10 “What Does That Mean for My Actual Weight?” Men are trim: –6’2” at 185# –6’ at 175# –5’10” at 165# –5’8” at 155# I.e., about 5#/inch above or below 6’ and 175# Women are trim –5’8” at 140-145# –5’6” at 130-135# –5’4” at 120-125# –5’2” at 110-115# I.e., about 5#/inch above or below 5’6” and 130-135#
© 2005-14 Steven R. Kanner, MD11 “I Haven’t Been That Thin Since I Got Married” So? Did you grow taller since then? Are you much more muscular? If not, and you got married in your 20’s or after, you should not biologically be more than your marriage weight.
© 2005-14 Steven R. Kanner, MD12 “Weight Loss Is Tough; Can’t I Just Take Pills?” We have good pills for cholesterol (such as Lipitor) and hypertension (many) that reasonably control those conditions even if the patient doesn’t otherwise cooperate BUT… we don’t yet have really good pills for diabetes — even with insulin shots, overweight patients usually slowly lose the battle and develop serious complications in the kidneys, heart and eyes
© 2005-14 Steven R. Kanner, MD13 The Crux of the Issue Is Adult Onset Diabetes If you are fat, your blood sugar is much more likely to rise steadily over the decades and hence you march towards Diabetesland and its physical debilities. Once diabetic, it is very difficult (though not impossible) to reverse. But it is dramatically easier to change course by losing weight, becoming trim, and never reaching Diabetesland in the first place.
© 2005-14 Steven R. Kanner, MD14 “Okay, But I Fail Dieting” “I have tried Atkins, but got tired of sausage and cheese for breakfast, and really wanted some tomatoes and strawberries every now and then. “And I wondered why Atkins had died obese and with heart disease. That made me concerned.”
© 2005-14 Steven R. Kanner, MD15 “And I Hate Being Hungry” “Most diets I have tried leave me hungry at times and yearning to have one food or another.” “I can deprive myself for a few weeks in a good cause, but then I regain whatever weight I had lost.” “And most diets are just too complicated to remember. You need a college degree to eat supper.”
© 2005-14 Steven R. Kanner, MD16 You Aren’t Dieting Properly Part of the problem is the notion of a diet, often employed to mean some unusual food you eat for a few weeks or month or so to lose a little weight, at which point you go back to your normal eating pattern. That is a misunderstanding of “diet.”
© 2005-14 Steven R. Kanner, MD17 Diet Is Your Life; Diet Is Proper Nutrition Diet really means, or should mean, the description of the normal pattern of your food intake for the indefinite future. A proper diet provides complete nutrition and the correct number of calories for your energy needs.
© 2005-14 Steven R. Kanner, MD18 “How Many Daily Calories Do I Need?” The average woman requires 1500- 1800 calories per day. The average man requires 2000-2500 calories. If you exercise 30 minutes a day, you may need (or burn) another 250 calories or so.
© 2005-14 Steven R. Kanner, MD19 “Okay, Tell Me a Few More Easy Diet Numbers” There are about 3500-3600 calories in one pound of fat. To lose one pound of fat per week, you need to lose 500 calories a day. Every extra 10 calories a day will add up to one pound of fat over a year.
© 2005-14 Steven R. Kanner, MD20 “Can I Get Lose Weight and Still Get Proper Nutrition?” Absolutely. Weight loss or gain purely reflects the energy value of the food that you eat (measured in calories). Again, every 3500 calories up or down results in a pound gained or lost Exercise is helpful, but I estimate that exercise contributes at most 20% of loss.
© 2005-14 Steven R. Kanner, MD21 “What About Long-Term Nutrition?” To be healthy, you require proper nutrition, which (based on extensive scientific evidence) means a wide variety of vegetables, fruits, and whole grains, together with moderate amounts of low-fat protein and complex carbohydrates, and some fats and dairy products.
© 2005-14 Steven R. Kanner, MD22 Caloric Balance and Good Nutrition The key to the proper diet, and to attaining and maintaining proper weight, is to adjust your diet so your daily caloric intake is appropriate, and within that energy allowance to get a healthy distribution of foods that are tasty and satisfying.
© 2005-14 Steven R. Kanner, MD23 “How Fast Can I Lose?” Realistic successful weight loss for a man is 3# per month, for a woman 2.5# per month. Not 2.5-3# per week, but per month. These data are from my own patients who have successfully lost in excess of 15# and kept it off for the long term.
© 2005-14 Steven R. Kanner, MD24 Successful Weight Loss in Calories Calories do count. They are to nutrition what dollars are to finance. Successful weight loss of 3# per month is closely equivalent to a 300- calorie daily energy deficit for a man. For a woman, 2.5# per month is 250 calories per day deficit.
© 2005-14 Steven R. Kanner, MD25 Quick Study: Caloric Content of Foods Cheese: 150-200 cal/oz Red meat: 80-100 cal/oz Fish/poultry: 50-60 cal/oz Starches: 30-60 cal/oz Vegetables, soups, fruits & salads: 5-15 cal/oz
© 2005-14 Steven R. Kanner, MD26 Quick Study: Saturated Fat Content of Foods Cheese: 4-5 gram/oz Red meat: 1.5 gram/oz Fish/poultry: 0.5 gram/oz Starches: 0-0.1 gram/oz Vegetables, soups, fruits & salads: 0 gram/oz
© 2005-14 Steven R. Kanner, MD27 Why Can’t I Lose Weight More Quickly? Do the numbers: To lose 2#/week requires a loss of 1000 calories per day. For a woman who burns 1700 calories each day, she’d be left with only 700 and would feel hungry and deprived and would fail. For an average man, he’d be left with 1200 calories and would similarly fail.
© 2005-14 Steven R. Kanner, MD28 Losing Is Much Harder Than Gaining Weight It is dramatically easier to overeat than to undereat. Remember that. One big barbecue Sunday may easily represent 4000 calories, an excess of 1800 calories over the average man’s 2200 calorie requirement. At a successful 300 calories/day loss, it takes six days to recoup from one afternoon! Did you realize that?
Physiology of Hunger How to love and live with your satiety center
© 2005-14 Steven R. Kanner, MD30 Physiology of Hunger If you are hungry, you will eat. There is a part of your brain, called the “satiety” center, that monitors the food that goes to your stomach and decides whether you have been adequately fed.
© 2005-14 Steven R. Kanner, MD31 Satisfying Your Hunger The satiety center responds to food in the stomach and to the sense of distension in the stomach. There is a 15-minute or so delay from food entering the stomach till it registers in the satiety center. You only stop prowling for food when your satiety center powers down.
© 2005-14 Steven R. Kanner, MD32 Deferring Hunger Is Poor Strategy You can ignore your satiety center and suppress hunger all day to have your one meal in the evening, but when the satiety center then turns on, it is ravenous and difficult to turn off for hours. So you overeat. It is much more effective to eat regularly during the day.
© 2005-14 Steven R. Kanner, MD33 Your Mother Was Right Having a breakfast, lunch, late afternoon snack, and dinner is the best approach to leveling out the food, keeping the satiety center content, and avoiding letting it rev you up to an eating frenzy in the evening.
© 2005-14 Steven R. Kanner, MD34 Meal Sizes for Men Breakfast should be 350-450 cal Lunch 400-500 cal Afternoon snack 100 cal Dinner 850-1150 cal TOTAL: 1700-2200 cal
© 2005-14 Steven R. Kanner, MD35 Meal Sizes for Women Breakfast should be 300-350 cal Lunch 350-400 cal Afternoon snack 100 cal Dinner 750-950 cal TOTAL: 1500-1800 cal
© 2005-14 Steven R. Kanner, MD36 High-Volume Low-Calorie Foods Produce Satiety Moreover, the most calorie-efficient approach to pleasing your satiety center is to emphasize the foods that are high in volume and low in calories. These are specifically vegetables, soups, salads and fruits, which typically range from just 5-15 cal/oz.
Finding the Errors How to correct bad eating, not to waste time changing healthy food
© 2005-14 Steven R. Kanner, MD38 First, “Don’t Eat Crap” This wasn’t my line, but it is too on- target to omit. You can’t sit around and nibble Cheeze-Its and Pop Tarts and such and believe you actually care about yourself and your health. Eat food, real food.
© 2005-14 Steven R. Kanner, MD 39 Mental Outlook on Food At the end of every day you should be able to say to yourself, “It was a good day. I liked my food. It was tasty and interesting. I was never hungry. I am not deprived. I’d like to do more or less the same thing tomorrow, but vary the menu.” If you can’t say that, you are not eating properly.
© 2005-14 Steven R. Kanner, MD40 Avoiding Error Is Paramount Don’t worry about being perfect. No one is. If your diet requires that degree of rigor, you’ll never stay with it. Concentrate on avoiding error. That outlook is less stressful and more effective than obsessing about every food item. Let’s think this through together —
© 2005-14 Steven R. Kanner, MD41 Errors Can Be Infrequent But Very Expensive People eat about 25 times per week. For many people, 20 of those eating episodes are just fine. Some Cheerios, a small sandwich, and so forth. The problem really arises with poorly controlled eating the other 5 times.
© 2005-14 Steven R. Kanner, MD42 Errors Are Usually Evening Meals The most obvious error is overeating in the evening, typically at home, or when out to dinner. Not every night, perhaps. But just eating a full appetizer and entrée at most restaurants means a 2500 calorie dinner (sometimes more), or 1200-1500 excess (which takes 4-5 days to recoup).
© 2005-14 Steven R. Kanner, MD43 Nothing Wrong With Cheerios The flip side is to look at your breakfasts. If they are anything like Cheerios with blueberries and milk, you are talking about a healthy 300 calories. No problem there. Then don’t worry about your 7 breakfasts. Look elsewhere for the problem. But if you have a Finagle-a-Bagel each morning, that is 400 cal of plain bread. That is a problem and needs cleanup.
© 2005-14 Steven R. Kanner, MD44 What About a Sandwich for Lunch? Isn’t That Carbs? Check out your lunches. If they resemble a small turkey sandwich on thin bread (not a big sub roll), or cup of soup and half sandwich, or salad with chicken and some water, there is no problem. Look elsewhere. If lunch is a large Chinese special, part of the problem is there.
© 2005-14 Steven R. Kanner, MD45 Portion Control for Evening Meals Is the Key For most people, overeating at night is the key. So achieving portion control at supper or when dining out is the heart of the problem. The next section details how exactly to control your evening meals and summarizes the other principles we have covered.
How Exactly to Eat to Win at Weight Loss Recap of the major errors and a specific approach to controlling the evening (major) meal
© 2005-14 Steven R. Kanner, MD47 Recap: Satisfying Food and Weight Loss If your diet is well chosen, you should be able to enjoy your food, never be hungry and never feel deprived, and still lose weight at the 2.5-3# per month to eventually achieve trim weight. There is nothing incompatible between healthy food and modest, sustainable weight loss. In fact, they go together.
© 2005-14 Steven R. Kanner, MD48 3 Major Eating Errors 1.Inadequate daytime food intake sets you up for severe hunger and uncontrolled evening eating. 2.Inefficient food selection at dinner means failure to control portions of major meal. 3.Episodic overeating (dining out, parties, etc.) undoes many days of sustained health eating and is highly destructive to any weight loss effort.
© 2005-14 Steven R. Kanner, MD49 Solution #1: Level Your Food During the Day Be sure to eat breakfast (300-400 cal for a man, a bit less for a woman), lunch (400- 500 cal not 800), and a small late afternoon snack (100-150 cal, such as a piece of fruit). Daytime eating helps prevent uncontrollable evening hunger and eating. Dinner should be the completion of the day’s eating, not the beginning.
© 2005-14 Steven R. Kanner, MD50 Solution #2: Achieving Evening Portion Control Allow adequate time to eat slowly so the satiety center can catch up. Emphasize high-volume low-calorie density foods (vegetables, soups, salads, fruit). Think of dinner as a vegetarian plate with a side of protein. Weigh food on a kitchen scale till you really understand portion size accurately.
© 2005-14 Steven R. Kanner, MD51 Calorie-Efficient Satisfying Dinner Start off with a soup Then have a green salad Typical light vegetable soup is 100 calories and is filling Salad with any kind of vinaigrette dressing is about 80 calories
© 2005-14 Steven R. Kanner, MD52 Dinner: Two Vegetables Green vegetable 2 nd vegetable Always have a good portion of green beans, broccoli, etc (40 cal) Have carrots, squash, beets, turnips or another green veggie (80 cal)
© 2005-14 Steven R. Kanner, MD53 Dinner: One Starch Starch (≤ 4 oz cooked) if you want Starch can be a small potato, corn, half-cup cooked pasta, or two slices of bread. Atkins was wrong. He is also dead. About 120-160 cal.
© 2005-14 Steven R. Kanner, MD54 Dinner: Protein Protein ≤ 6 oz, whether fish, poultry, meat or soy. In this size, the type of protein doesn’t matter much. Poultry or fish are 360 cal, red meat about 600 cal. The body only needs about 4 oz. In Paris you get 6 oz, which is fine.
© 2005-14 Steven R. Kanner, MD55 Summary of Example Meal Vegetable soup, green salad, green beans, beets, small potato, 6 oz steak This is enough food to make you waddle from the table. It’s about 1000-1050 cal with steak, about 700-750 with fish or poultry.
© 2005-14 Steven R. Kanner, MD56 Solution to Error #3: Episodic Overeating Dining out needs to be approached carefully. Scrutinize the portion sizes. Split entrées. Consider just two appetizers and a salad. Assume the meal is twice too big. Try the soup first. Apply to same principles just reviewed for the normal evening meal.
© 2005-14 Steven R. Kanner, MD57 Summary-1 Weight loss by human beings in midlife is a fascinating problem of human engineering. The problem is simple: we eat too much. But changing that pattern is complex and extraordinarily difficult. Most people fail. I want you to succeed.
© 2005-14 Steven R. Kanner, MD58 Summary-2 This brief presentation has focused on reminding you compactly and clearly of the physiological facts that drive our energy needs and hunger, and of more effective ways for almost anyone to eat good food more effectively in the right quantity.
© 2005-14 Steven R. Kanner, MD59 Summary-3 I hope we will all be able to say, “It was a good day; I enjoyed my food; I was never hungry; I was not deprived; but I am at my proper weight and I am not diabetic. I have seen Diabetesland and I am not willingly going there. I am winning.”
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