Refuse To Regain

Is Your Irisin A'Risin?

by Barbara Berkeley, MD

The latest chemical substance to get scientists into raptures is irisin, a hormone that is produced in muscle cells but exerts its effect on fat.  We've all figured out that exercise and weight are somehow tied together and that this means that muscle and fat must communicate. Unfortunately, we've showed a woeful lack of imagination in tryng to come up with the mechanism. For decades, we've persisted in trying to jam the same puzzle piece into a space that doesn't fit.  We are determined to prove that the connection is calories.  It seems so logical.  If we burn calories through working out we must lose weight, right?  And yet the evidence that this is so remains annoyingly equivocal.  

While readers will occasionally write to me about great weight loss successes from becoming physically active, it is rare to observe this in clinical practice. The more common experience is to see people who have added exercise, but have not achieved anything more than a minor result.  As I've mentioned in the past, I have taken care of many very athletic people, even marathoners, who were clinically obese.  Could they have just been eating enormous amounts of food?  Of course it's possible.  But most of them were trying to lose weight by modulating their diet.  One would think that these prodigious amounts of exercise would force weight loss, but in their cases it did not.

On the other hand, it is observationally obvious that maintainers who exercise have a higher rate of success at keeping weight off.  This observation has been confirmed by data from the National Weight Control Registry, a large study which monitors those in maintenance.  While the NWCR subject pool is limited to maintainers who volunteered themselves (and thus are probably highly motivated), the data shows that successful study maintainers are exercising a lot (on average, about 1 hour daily). 

Irisin is a hormone that is produced from the breakdown of a protein that is produced when muscles are exercised.  In rodents, it's injection appears to turn white fat into the more metabolically active brown type.  Humans do not have very much brown fat, so it is difficult to speculate whether this finding is meaningful for us.  Even rats who made more brown fat did not lose weight when injected with irisin.  So why the flurry of interest?  Because high levels of irisin appear to improve the way the body metabolizes food, making it less insulin resistant and more weight stable.  The following is from a recent NY Times article on irisin:

But while irisin appears to have a critical impact on metabolism, it does not appear to play any discernible role in the effects that exercise has on the heart or the brain. And various issues remain unresolved. Why, for instance, if exercise increases levels of irisin and irisin increases the body’s stores of energy-burning brown fat, does exercise so rarely produce significant weight loss? The mice injected with irisin lost little weight. On the other hand, Dr. Spiegelman notes, they resisted weight gain, even on a high-fat diet, and their blood sugar levels remained stable. So it would seem that exercise, through the actions of irisin, can render you healthy, if not svelte.

As I have repeatedly said in this blog, research results only become important when they are repeatedly reproduced.  The irisin story is obviously in its very earliest chapters.  But the existence of such a hormone may well help to explain why exercise is so important during maintenance, and relatively ineffectual during weight loss.  For those who are currently losing weight, I don't discourage exercise, but I ask you not to rely on it.  Weight loss is about forcing the body to burn itself (which it would prefer not to do) through caloric restriction.  Think of your exercise as a way of rebuilding and retuning your muscles for later use.  Once you reach maintenance, these irisin producing factories will be fired up and ready to go--giving you a much improved shot at maintaining the body you've earned. 

A Calorie Just a Calorie? No Way

by Barbara Berkeley, MD

 A calorie is a calorie.

This is my least-favorite dietary mantra.  Why?  Because in the real world of real people and real weight loss, it isn’t true.

In scientific terms, a calorie is a specific measure that refers to the amount of heat needed to raise the termperature of 1 gram of water 1 degree centigrade. We can measure the amount of heat contained in any substance by burning it in a machine called a calorimeter.  Using this narrow definition, there is no question that calories are all the same.  One calorie of lettuce will raise 1 gram of water by one degree.  So will one calorie of M&Ms.

But the colloquial usage of “a calorie is a calorie” (let’s call this C=C) bears no relation to the scientific definition.  What's usually meant is this: diets that contain the same number of calories will have the same effect on your weight loss.  It doesn’t matter if those calories come from chicken breast or chocolate cake. 

Those who claim that any calorie we eat is equal to any other calorie,  routinely invoke the First Law of Thermodynamics as evidence.  This argument is a real show-stopper.  It’s hard to argue with the basic laws of universe!

But a deeper look at the thermodynamic argument reveals many holes. The First Law says that energy cannot be created or lost, only transformed.  C=C  proponents interpret this to mean that any calorie that goes in has to be balanced by a calorie that goes out.  If the balance is tipped one way or the other, you will either lose or gain weight.   But  the equation for the First Law was designed to represent energy in a closed system, not in a biological system that exchanges energy with the outside world. It would be much more true if the body acted like a perfectly consistent machine and burned all calories with equal efficiency.  While all calories may be the same, the way in which the body burns calories is not.  This variation depends on the package which surrounds those calories.

The calories in food don’t stand alone.  They are intertwined with the other properties of foods… their protein, fat and carbohydrate contents for example. These properties have absolutely no effect on a calorimeter, but they have profound effects on the human body. 

This leads to an important omission in the thermodynamic argument.  While those who believe in C=C support their contention with the First Law of Thermodynamics, they never mention The Second Law.  (There are four, but only two apply to the physics of food). This Law states that when energy goes through a transformation, there is always some loss of energy as heat.  This dissipation of calories is a function of the efficiency with which the calories are burned.

In a 2004 paper on this topic Dr. Richard Feinman offered this useful analogy (the italics are mine):

 The efficiency of a machine is dependent on how the machine works and, for a biochemical machine, the nature of the fuel and the processes enlisted by the organism. A simple example is the inefficiency of low-test gasoline in high compression gasoline engines. If a "calorie is a calorie" were true, nobody would pay extra for high test gasoline. (The calorimeter values of a gasoline will be the same whether or not it contains an antiknock compound).    

This dovetails nicely with what I have observed clinically for many years;  that our body loses fat, works better and is less hungry when we feed it “primary” or ancestral foods.  I believe that these foods are our biological “high-test”.  As I often say to first-time patients, “Your body is a Ferrari but for years you’ve been putting kerosene in the gas tank”.  

Feinman’s article posits a “metabolic advantage” to low carbohydrate foods.  There are many studies that show that at equal calorie levels low carbohydrate foods promote greater weight loss than high carbohydrate foods.  While a single calorie of each of these foods will look exactly the same to a calorimeter, it doesn’t look the same to the body.  One possible reason for the difference in weight loss? The brain needs a certain amount of glucose, or blood sugar, to run.  On a low carbohydrate diet, the food we eat may not provide enough.  The body has to manufacture its own sugar via a process called gluconeogenesis.  This process uses energy and therefore burns calories.  Thus, the net available energy from a low carb calorie is lowered simply by the fact that it provokes another, heat-generating, bodily process.

A low carb calorie may be very different from a higher carb calorie in other ways.   It appears to suppress appetite better. A 2011 study in the journal Obesity reported that dieters who were fed a low carb diet for two years had significantly less hunger and a statistically significant decrease in cravings for sweets and starches when compared to those on a low fat diet. 

A diet that is higher in protein may have the same calories as another diet, but the protein content may cause increased thermogenesis…the loss of calories that occurs through digestion. This effect and others are laid out in a paper in the Journal of the International Society of Sports Nutrition http://www.jissn.com/content/1/2/21.

And then there is this important consideration: many of us who eat the SAD (standard American diet) have developed insulin resistance.  This is a condition in which insulin is produced in response to elevated blood sugar, but fails to work properly.  The muscles, which normally would burn off some of this sugar, have stopped responding to insulin.  Instead, there is diversion of calories into fat.  For people with insulin resistance, calories from sugar and starch provoke a very different bodily response than do protein or fat calories.  They should be avoided.

Perhaps the issue is not whether a calorie is a calorie.  It is the understanding that a calorie is not ONLY a calorie.  When it comes to food, the body reacts to myriad elements of the food package and calories may be only a minor part of that.  Even for those who already believe that calories are just a single aspect of food, the answer to the question of perfect diet remains elusive.  Much of the literature refuting the C=C position comes from scientists who support low carbohydrate diets. When designing studies that pit low carb against low fat diets, they tend to use the Atkins diet as the low carb choice. While I am firmly in the low carb camp I believe in low carb in the context of Primarian (or ancient-style) diet.   In our clinic, we see all of the benefits of very-low carb diets like the Atkins induction (brisk weight loss, decreased hunger, correction of metabolic abnormalities).  We achieve this, however, with Primarian plans which are less restrictive and easier to follow.  Unfortunately, there are few studies that have looked at the effectiveness of ancient-style eating for weight and health.  

The moral is this: calories are not the be-all and end-all we’ve been led to believe.  While lowering calories is key to weight loss, the type of calorie you’re consuming is equally—if not more—important.

 

You're On a Diet...So Why Aren't You Losing Weight?

by Barbara Berkeley, MD

This post is an update of a previous entry.  Hope our new readers enjoy it and our long-term readers will consider re-visiting these ideas. 

Refuse to Regain is primarily designed for maintainers--- that small and exclusive group of people who have managed to lose weight and are stabilizing (or stable) at their new size.  But comments to our site reveal that many of those who read us are still in the process of active weight loss.  As a result, I wanted to devote a full posting to a question I hear with great frequency:  Why is my weight loss diet not causing me to lose weight?

New patients to my practice often say that they can't lose weight no matter what they do.  They chalk this up to a bad metabolism or to something that must be extremely dysfunctional about them.  Over the years, however, I'm hard pressed to remember anyone who was not able to lose weight once they began an effective diet.  No matter how impossible weight loss once seemed, it became possible once the diet was properly adjusted.  Naturally, this result depends on the dieter following the diet exactly as prescribed. 

Why then the frustration? And why do many diets seem to fail?  Here is what I've come to believe (followed by some suggestions that may help):

1. Diets Fail Because We Fail to Understand What They Are

I like to think of dieting as an unnatural act.  (Strange that I would make my living by encouraging unnatural behavior, isn't it?).  But seriously, if you could revisit ancient times, you would not find any humans forcing themselves to lose weight.  Having a bit of extra fat would have conveyed a survival advantage, so why would anyone have wanted to get rid of extra pounds?  Our twenty-first century bodies still behave this way.  In fact, they seem to completely ignore weight as we gain it.  

Knowing the body's propensity to defend itself against harm, one would think that storing a lot of dangerous fat would cause the appetite to shut down, or perhaps prompt the release of a cascade of hormones to dissipate the excess. But that doesn't happen. We can carry even hundreds of pounds of extra fat without the body paying any attention.  Perhaps the reason is this: our ancient genes (the ones we still harbor) never thought we could gain a dangerous amount of weight.  Since it used to be a good thing to store some extra fat, our genes never developed a program for aborting weight gain.

Since the body ignores our fat, how do we create weight loss?  We do it by recreating an ancient situation...one that forced the body to notice its own fat.  That situation was a significant food shortage. In actuality, a modern weight loss diet is simply the process of tricking the body into believing that there is a famine in the outside world.  Once the body gets the idea that there is very little food coming in, it suddenly wakes up to the presence of stored fat and starts to use it up.   This state of awakening was doubtlessly designed as a survival response hundreds of thousands of years ago. Let's call this bodily state: "The Ancient Famine Response".

This response consists of two parts, one of which makes dieters happy and the other frustrated.  First, the body starts looking for energy to sustain itself in the face of famine.  It turns its attention to its own fat, recognizes it, and starts burning it.  Second, the body wisely decides to burn this fat as slowly as possible in order to outlast any extended food shortage.  It does this by slowing down its bodily processes, heating itself less, and using other tricks to conserve energy.  This is annoying to dieters, but is a built-in and unavoidable feature of the Famine Response.

Having discussed the reason we lose weight, let's next think about what would have constituted normal eating for the same ancient ancestors.  Since they hunted and gathered, they probably had days of ample food one day and days when food was scarce.  To adjust to this, human bodies likely developed a very flexible system for using food. If food is temporarily in short supply, the body can slow down , burn fewer calories, and be more efficient.  If we eat more, the body can speed up.   These mechanisms allowed our ancestors to stay at stable weight even when food intake fluctuated.  Let's call that the "Normal Ancient State".

Most of us start a diet with all intentions of following the rules exactly.  That works!  We lose weight because we are consistently telling the body that there is very little food coming.  We've mimicked the"Ancient Famine Response" or, as I sometimes tell patients, "we've turned on an emergency light in the brain".   But we soon start to get creative.  We eat things which seem to be minor but which aren't on plan Or, we don't eat on some days and we eat more on others.  All of these behaviors put us back into the "Normal Ancient State".  We can't figure it out, because when we look at the intake for a whole week, we ate very little...certainly many fewer calories than we used to eat before dieting.  Why aren't we losing???  It's because food intake is intermittent and not sufficiently restrictive.   The body adjusts to intermittent eating, lowers its burn, and keeps weight stable, just as it's programmed to do.

Suggestion:  Pick a diet that you can follow to the letter.  Stay as compliant as you possibly can.  Resist the temptation to go off the diet on some days and resume on others.

2. Diets Fail Because We Don't Have a Way to Get Calories Low Enough

In our practice, we create weight loss with a diet that has approximately 1200 calories.  Larger women and/or men may use 1500 calories or so.  This sounds simple, but it isn't.   Calorie counting is complete guesswork in the modern world.  Using packaged foods which have known caloric content can help.  Once you start eating out in restaurants, as most of us do, counting becomes impossible.   Although I do not like processed foods over the long run, dieting may be a good time to use them.  If you can construct a diet from bars, supplements, frozen diet entrees, low fat dairy products and other foods which have calories already listed,  you can be pretty sure of the number of calories you are getting. 

In our program, we use three diet shakes or bars (each 160 cals) per day and have patients eat a dinner which is composed of about 1/4 of a dinner plate of lean animal protein (chicken, fish, meat), a large mixed vegetable salad, a big portion of cooked green vegetables,  a piece of fruit, and a 100 cal fat free pudding.  You can work out your own plan, but knowing that you are getting the right calorie count is important. 

Suggestion: If you aren't losing, check your calories.   Make more use of foods which have calorie labels.  Try to avoid eating out if it is scuttling your weight loss. And of course, remembering the information above, remain consistent each day.

3. Diets Fail Because We Don't Get Our Insulin Low Enough 

Insulin is a mega-important hormone for dieters because it stores fat.  It not only puts fat away into the fat cells, but it also stands guard outside the cells to make sure the fat stays put.  Only by lowering your insulin levels can you break down fat.  Imagine insulin as a jailer that keeps fatty prisoners trapped on your body.  Put him to sleep and they can escape. 

Insulin is made whenever we eat starch or sugar because those two things turn into blood sugar once they are absorbed.  (Insulin's other job is to control the levels of blood sugar).  Dieters have already intuited the role of insulin. What is the first thing they do when they start a diet?  They begin with salad and chicken breast.  They eliminate bread, pasta, crackers, rice and dessert.  Insulin goes to sleep and weight loss follows.  But before long, their carb addiction begins to howl.  That piece of pita doesn't have that many calories.  That rice cake is a diet thing, right?  Wrong.  This part isn't about calories.  Wake up your insulin enough and you won't lose weight.

Suggestion:  Keep starch and sugar to a bare minimum when dieting.  (BTW, this works for maintenance too!).

4. Diets Fail Because We Rely Too Much on Exercise as a Weight Loss Tool

Exercise is great.  I love it!  But alone, it will not cause weight loss (unless you are running the ultra-marathon or something).    Remember the Ancient Famine Response: unless you create a consistent state of calorie reduction, you won't lose.   In my practice I have many skilled tennis players, marathon runners, volley ball enthusiasts, and other athletes.  If exercise caused weight loss, they would not be visiting me to get off the 30 extra pounds they've accumulated.   Be especially careful with the temptation to over-exercise.  This can create hunger and entitlement (as in, "I earned that bag of M and M's").  Exercise by all means, but during weight loss, put most of your faith in calorie reduction that is consistent and calculable. 

Suggestion: During weight loss, think of exercise as secondary to caloric reduction. 

Remember this:  magazine covers would lead you to believe that weight loss is simple and that pretty much everyone in America is having their pounds "melt off".  This is the big lie.  Weight loss is tough and takes a tough effort.  What remains true is that the rewards for this effort are great; the endpoint incredibly worthwhile.  So keep at it and always congratulate yourself for taking on such an important and challenging task.

 

Controlled by a Cookie: When Foods Become Drugs

by Barbara Berkeley, MD

Do you take medicine to treat your blood pressure?  Once you swallow your pill, can you control your blood pressure via sheer willpower?  While such feats of bodily control are reported by swamis and other advanced body-mind practitioners, they are not in the average person's repetoire.  And a good thing too, because the power of drugs to take over ailing body systems is the reason they work. Medicinal drugs are substances which enter from the outside and take control of inner processes.  They cause chemical changes that in turn change those who take them..hopefully with positive effect.  But, as we well know, drugs can have negative effects too, especially when their chemical properties are used to create pleasure.

Consider these two definitions of the word "drug":

1. a chemical substance that affects the processes of the mind or body.  

2. a substance used recreationally for its effects on the central nervous system, such as a narcotic.

 

Every overweight person I've ever encountered recognizes that certain foods have drug-like properties. During an intake visit, a new patient will generally put his finger right on the foods that are submarining him.  He or she will often use the language of addiction to describe these foods:  "I'm addicted to sweets",  "I'm a chocoholic", "I just can't stop eating bread."  It's not coincidence that such language should leap to the lips.   Foods DO alter the processes of the mind and/or body.  Foods ARE substances that are used recreationally and which do have effect on the central nervous system.  In fact, certain foods can be viewed very much as drugs.  Despite this, we believe that once ingested, we can control these particular "drugs" by sheer willpower. 

Perhaps you do not agree that food and drugs are similar.  After all, we are designed to eat food and even if ingesting food does cause changes within the body, they should be natural, expected changes.  Until recently, this has certainly always been the case, but let me suggest two reasons why things may have changed.

First: There can be no question that eating food is a natural behavior that provokes natural responses. I would make the case, however, that in a very real way we no longer eat "food".  Processed foods that are chock full of preservatives, colors, and chemicals have little resemblance to what our body is equipped to handle.  Foods that hit us with enormous punches to the insulin system---the sugar and starch foods---are also very new to human experience.   

Second: Many of us who eat the western diet or SAD (Standard American Diet) have developed inappropriate reactions to eating these newer foods.  This is especially true for those foods that turn into sugar after digestion (the sugars themselves and the starchy carbs like grain, cereal, pasta, flour based foods and potatoes).  If we have begun to develop a "broken" reponse...in the form of what we call insulin resistance... we will react in a new and negative way to eating.  We will experience more hunger, more craving and less ability to control these foods.

 

Recent research into the modern epidemic of insulin resistance suggests that those of us whose insulin is no longer properly interacting with our body may also have a problem with insulin's role in the brain. The brain's form of insulin resistance occurs when insulin-related signals which normally tell us to stop eating are blunted.  Thus, foods that cause insulin release are no longer equipped with the satiety safety valve that nature intended.  Indeed, these foods may make cause more hunger rather than less.   And who among us has not experienced the inexplicable carbohydrate craving that follows a day of bread, pasta and cookie consumption? 

 

Thus, my hypothesis is that foods become drugs when our body no longer tolerates them well.  As a child, you might have been quite able to eat a cupcake and simply stop.  As an adult, one doughnut might lead to an entire box.  When drugs are at the helm, you can forget willpower.  Be they medicines in pill form or cookies that are decorated like Grover, your physiology is co-opted and someone else is driving the bus.  

 

Sometimes I use the following analogy in the office:  think of your trigger foods as concealed aliens. Remember the movie Men in Black?  An innocuous shop-keeper might look harmless, but was actually a man-eating cockroach!  Drug-foods are like that.  They look attractive, luscious, and controllable, but allow them past your lips and you are under their control.  You can bemoan your lack of willpower all you want, but if you've given yourself over to the aliens you are likely to spend quite some time doing things you didn't intend. 

 

Many people simply can't understand how something as small as a cookie could cause them to abandon all resolve.  But there is the error!  A cookie isn't small at all.  The chemical signals and bodily changes that start the moment a susceptible person sees and smells that cookie are quickly overwhelming.  Eat that cookie and it is very possible that---diet-wise---all is lost. 

 

This illustrates  the problem I have with advice that suggests that it's ok to eat everything in moderation.  Yes, if you are a person whose food-processing systems are all in good shape, this may be a fine strategy.  In fact, if this works for you, you might well be unable to understand why it wouldn't work for everyone.  But most people who are overweight have gotten heavy because food has become drug-like for them.  To me, this is part of a larger picture which includes fundamental physiological changes in the way their body handles that food (mostly the starches and sugars).  If you have been wrestling with willpower and blame yourself for being weak, I advise you to start seeing the true nature of your trigger foods.  Start with a healthy respect for their power and a strategy of avoidance whenever possible.  Remember, if you don't take a drug it can't own you.