“I Would Buy Myself A Candy Bar After Every Appointment With A Physician.”
In 2009, a couple of months before her thirtieth birthday, freelance writer and research assistant Summer Yule sat in her doctor’s office in Avon, Connecticut, as she was told she had stage 2A breast cancer. “My world was turned upside down,” she says.
For most of Summer’s life, she had been at the high end of a healthy weight, sometimes crossing over into being overweight. Introverted and uncoordinated, she was not particularly motivated to participate in group sports and was sedentary throughout her teens and twenties. “I didn’t consider myself a ‘fitness person,’ ” she admits, “and I felt at that point that I was in good enough shape that I did not need to make any changes.”
Even though she wasn’t active into young adulthood, she was interested in nutrition. “I ate a lot of fruits and vegetables and adopted a vegan diet during my twenties,” she says. “Looking back, I don’t believe this way of eating was optimal for my overall health, but I think the restrictions did ultimately help me with weight management.” Since many unhealthy food options, like cakes, cupcakes, and cookies contain some eggs or dairy, her veganism took those options off the table. Instead, she stuck with whole food options like whole grains and legumes.
After her cancer diagnosis, she decided to relax her dietary restrictions and returned to eating meat as she started chemotherapy treatments, thinking that having access to a wider dietary variety would help her to maintain her weight. With a history of low bone mineral density and iron-deficiency anemia, her change in diet alleviated those issues.
Chemotherapy dramatically altered Summer’s perceptions of taste and smell. “Combined with feelings of nausea, it was extremely difficult to eat, especially for the first few days after each treatment,” she says. “Thankfully, I was able to maintain my weight with the help of anti-emetic medications and trying to eat whenever I felt I could tolerate food.” Her last chemotherapy treatment was at the end of 2009, after which she faced a number of painful surgeries for a mastectomy and reconstruction.
To get herself through this rough time, Summer developed a lot of bad lifestyle habits. “I would buy myself a candy bar after every appointment with a physician,” she says. She was able to get away with her poor food choices because her appetite was suppressed, and she was eating very little in general. However, her lifestyle choices eventually caught up with her.
In 2011, with her perceptions of taste and smell back to full force and no longer feeling nauseous from chemotherapy, other medications, or surgery, she was enjoying food again and had a great appetite. She continued the dietary strategies that helped her maintain her weight during chemo, and she rapidly started putting on weight, tipping the scale at 195 pounds by the end of the year. “I attributed this rapid weight gain to a medication change,” she says. “Looking back now, I think a number of factors caused the weight gain. So, while a change in appetite related to medication changes may have played a role in my weight gain, it was not the whole picture. Initially, I was unable to see that.”
By the summer of 2012, shortly before Summer’s thirty-third birthday, the largest-size clothes that she had in her closet were becoming too small. “My husband wanted to have a family photo taken, but I refused since I was so ashamed of how I looked,” she says. That summer, she tripped on a curb in front of the library and twisted her ankle. It was a month before she could walk again. “That was the last straw and what I consider the event that finally spurred me to make changes,” she says. During that month, Summer and her family took a trip to an amusement park, and she used an electric wheelchair since she couldn’t walk comfortably. “When I looked through the photos from that trip, I was shocked at how I looked,” she says. “I could barely recognize myself anymore since I had put on so much weight.” The excess weight and lack of fitness had a negative impact on her quality of life. “Earlier that year, I went on a hike with my family and had to turn back because I was unable to pull myself up the rocky ledges on the trail,” she says. “I had had enough and knew that the time had come to start making serious changes. Reducing my risk for future chronic diseases was a motivating factor as well.” After learning she weighed 195 pounds, she stopped stepping on the scale. “My last doctor’s visit revealed that I was over 40 percent body fat,” she says. “It is highly likely that I was somewhere over two hundred pounds.”
***
Would you eat more food from a plate or bowl simply if the plate or bowl were larger? According to many scientific studies, you would. And you wouldn’t even be aware that you ate more. Research has shown that the quantity of food people consume is influenced by simple manipulations, such as plate and serving size.75 In a study at Cornell University, people attending a movie were given popcorn in different-sized containers. Those served with large containers ate 45.3 percent more popcorn.76 The influence of the container size was so powerful that, even when the individuals were given stale popcorn, they still ate 33.6 percent more popcorn when eating from a larger container than from a smaller container. In case M&Ms are your snack of choice, that, too, is subject to the size of the container from which you’re eating, even when portion size is the same between small and large containers.77 Even when people serve themselves, they place more food on their plates if the plates are bigger. What’s even more interesting is that when people are asked if they served themselves more food with the bigger plate, they don’t think they have. People are not aware of how much they’re eating. And that’s a problem, because contained in the amount of food that you’re not aware you’re eating are… Wait for it…
Calories.
Calories are everywhere we turn—in the news, on food labels, in menus, on our (larger) plates, and in our glasses and cups. Some may even hide under your bed. We are consumed, figuratively and literally, with calories.
Technically speaking, a calorie isn’t so bad. It’s rather small, after all. One calorie is the amount of heat energy needed to raise the temperature of one gram of water by one degree Celsius. That’s kind of esoteric, unless you plan on heating a gram of water on your stove and measuring its energy. What’s important to understand is that when we talk about calories, we are talking about energy. Despite the bad rap that calories get, a calorie is neither good nor bad. It just is. It’s energy. How can energy be a bad thing?
Calories are used by nutritionists, dietitians, and food chemists to measure the amount of energy contained in the chemical bonds of the nutrients in food. Every food and beverage label includes the number of calories per serving. Because a calorie is such a small unit of energy, the unit “kilocalorie” is used to make the number more relatable. One kilocalorie equals a thousand calories. When you see a nutrition label or menu say that something has a hundred calories, it really means a hundred kilocalories, which is 100,000 calories. That number would scare a lot of people (and take up a lot more room on food labels), so food companies use kilocalories instead, writing it as Calories with a capital C. (For the purpose of simplicity and to avoid confusion, I use the term “calorie” throughout this book to mean “kilocalorie.”) All those calories you eat and drink every day are used for various bodily functions in a large, complex process called… Wait for it…
Metabolism.
The word metabolism gets thrown around a lot, but is often a confusing subject. Metabolism is the sum of all chemical reactions inside your body. As it pertains to body weight, it is the process by which your body converts the food you eat into energy that it can use. That energy, which you learned about in high school biology class, is ATP (adenosine triphosphate). To produce ATP from food, the chemical reactions of metabolism use oxygen from the air you breathe in and produce carbon dioxide that you breathe out. (In addition to ATP and carbon dioxide, other byproducts of metabolism are water, heat, and, in the case of protein metabolism, urea.)
In 1780, French scientists Antoine Laurent Lavoisier and Pierre-Simon Laplace were the first scientists to study and quantify this process of metabolism. By measuring how much oxygen guinea pigs consumed and how much carbon dioxide they produced while sitting in a calorimeter (a device for measuring heat energy that is sealed off to the outside environment) and doing normal guinea pig activities, Drs. Lavoisier and Laplace could calculate, based on the chemistry of the aerobic combustion of carbohydrate and fat, their metabolic rate—how many calories the guinea pigs used. Pretty ingenious, huh?
The processes that control and affect metabolism are an enormously complex subject that includes the interdisciplinary fields of biology, physiology, chemistry, and physics. Adding the conditions of food intake and exercise makes the understanding of metabolism even more complex. For example, when Lavoisier and chemist Armand Séguin studied the influence of food intake and muscular work on metabolism, they discovered that resting energy metabolism increased by 50 percent due to food intake, 200 percent due to exercise, and 300 percent by combining food intake with exercise. The calories you consume every day are used either for immediate energy or stored for later use. The partitioning of calories all depends on your immediate metabolic needs.
In simple terms, when you deposit more calories than you spend, you gain weight. When you spend (withdraw) more calories than you deposit, you lose weight. Thus, your body’s caloric bank account is the balance between how much you deposit and how much you spend. Successful weight loss is a permanently balanced bank account: the deposits are never more than the withdrawals, and they are often less. In order to balance the bank account permanently, the daily deposits need to be controlled because, in this particular bank account, it’s much easier to make deposits than to make withdrawals. However, excess deposits are not desirable. Managing deposits every day is key to successful weight-loss maintenance.
Habit 3 of successful weight losers is controlling calories. The members of the NWCR make a lot fewer daily caloric deposits than the general population. Table 1 shows the number of calories the NWCR members consume per day from the several studies that have reported it, along with the amount of weight they lost at the time they entered the NWCR.
Table 1: Caloric Intake of Successful
Weight Losers
|
Calories Per Day |
Pounds Lost |
|
|
66 |
||
|
1,306 (women) (80) |
63 (women) |
|
|
1,390 (81) |
69 |
|
|
1,462 (82) |
124 |
|
|
1,400 (83) |
62 |
|
|
1,399 (84) |
73 |
|
|
Average Women Men |
1,406 |
79 |
As you can see from the table, the number of calories successful weight losers consume per day has remained the same across the studies over the years, from the earliest of the NWCR studies to the latest. Successful weight losers consume a low-calorie diet of about 1,400 calories per day, with women consuming about 1,300 and men consuming about 1,700 calories per day. It’s possible that these successful weight losers consume more calories than this since people typically underestimate their dietary intake by 20 to 30 percent.85 Even with this adjustment, however, the NWCR members consume less than 1,900 calories per day. By comparison, the US adult population consumes an average of 2,120 calories per day (women consume about 1,820 calories per day and men consume about 2,480 calories per day).86,87
Where do all these consumed calories go? Your body has a considerable requirement for energy, even at rest. Two-thirds of your energy expenditure is required for maintenance of your body’s critical functions and homeostasis of its internal environment. This energy requirement, referred to as your resting metabolic rate, is about 1,300 to 1,800 calories per day, depending on body weight (the greater one’s body weight, the greater the resting metabolic rate) and metabolic efficiency. To put the NWCR’s daily number of calories in perspective, successful weight losers eat about equal to (and, in the cases of the heaviest individuals, slightly less than) their resting metabolic rates. In other words, they are not eating more calories than what their bodies need to maintain homeostasis. That habit is in stark contrast to that of unsuccessful weight losers who regain their weight.
This habit of controlling calories is not exclusive to the NWCR. Other research has also found that individuals who are most successful at maintaining their weight loss consume fewer daily calories, eat smaller portions, and consume fewer snacks.88,89 The NWCR has shown that caloric intake, and an increase in caloric intake from one year to the next, are both significant predictors of weight regain after weight loss. Thus, not only is controlling caloric deposits (i.e., the number of calories) important, preventing the slow deposit of calories back into the bank account (i.e., the change in deposit behavior over time) is also important.
For this idea of controlling calories and eating less food, we must thank Luigi Cornaro, a fifteenth century Italian nobleman who adopted a calorie-restricted diet at age thirty-five to address his failing health.90 His popular book, Discorsi Della Vita Sobria (Discourses on the Sober Life), describes his diet, which consisted of just 350 grams of food per day (about 1,500 to 1,600 calories, ironically similar to the NWCR average), including bread, egg yolk, meat, soup, and, interestingly enough, 414 milliliters (nearly three glasses) of wine. (For comparison, one slice of white bread has eighty calories and modern-day food labels are based on two thousand calories per day.) It worked. In less than a year, the diet cured him of his ailments, including gout, stomach pain, and fever, and he went on to live to 102 years old.
It wasn’t until early in the twentieth century that scientific research caught up with Luigi Cornaro. In longitudinal experiments in the 1930s using rats, scientists found that rats fed 30 to 60 percent fewer calories grew at a much slower rate, and lived nearly twice as long as rats that were fed more.91 Since then, many studies over the last eighty-five years have shown that, from rodents to primates, controlling calories extends lifespan and protects against the deterioration of biological functions, delaying or reducing the risk of many age-related diseases. And it is key to becoming a successful weight loser.
There are several ways that successful weight losers control calories. One is by limiting how often they eat out at restaurants. People who cook meals at home consume fewer calories, have better diet quality, and consume less carbohydrate and fat.92 NWCR members average just two and a half restaurant meals per week.93 They also shun fast food. In contrast to millions of people in the US and around the world, NWCR members rarely eat fast food, averaging less than one meal per week.94 Those who regain weight tend to eat more fast food. The most successful weight losers actually have very little variety in their diets and don’t splurge on high-calorie foods on weekends or holidays.
In addition to eating at home, successful weight losers limit how many calories they drink, especially high-caloric beverages. Most people consume a lot of unnecessary calories from beverages. Indeed, some people actually drink more calories than they eat. Sodas, smoothies, coffee drinks, and fruit juices can contribute significantly to your total daily caloric deposit and become a big obstacle to becoming a successful weight loser. A single twelve-ounce can of Coca-Cola is 140 calories, with zero of those calories being nutritious. Even diet soda still contains artificial sweeteners and acts like sugar in raising insulin level and promoting weight gain.
When asked about their beverage consumption, 41.7 percent of NWCR members said that changing what they drink is very important for losing weight and 39.6 percent said that it’s very important for maintaining weight loss.95 To become successful weight losers, they increased their consumption of water and low/no-calorie or diet beverages and reduced their consumption of regular-calorie and non-diet beverages. Only 0.9 percent drink regular-calorie soda, 0.7 percent drink mixed drinks, 0.7 percent drink hard liquor, 0.7 percent drink regular-calorie sports drinks, 0.2 percent drink low/no-calorie energy drinks, and 0 percent drink regular-calorie energy drinks or fruit juice drinks. Nearly all (91.7 percent) drink water regularly. Only 36.4 percent drink unsweetened coffee, 26.0 percent drink low/no-calorie or diet soda, 24.7 percent drink low/no-calorie or diet-sweetened coffee, 19.8 percent drink unsweetened tea, 11.5 percent drink low/no-calorie or diet-sweetened tea, and 10.8 percent drink low/no-calorie or diet-sweetened flavored water. Of those who drink low/no-calorie sweetened beverages at least once per week, 78.1 percent say they felt it helped them control or reduce the total amount of food or calories they consume.
One of the main reasons for controlling calories is because keeping weight off is even harder than losing it in the first place. There may be a few reasons for this. One of those reasons may have to do with changes to metabolism after losing weight. Research comparing resting metabolic rate before and after weight loss and between formerly obese people who have lost weight and people who have never been obese has found that weight losers burn fewer calories throughout the day than what would be expected for the new, lower body weight and compared to people of the same weight who have always been that weight.96-100 The result is a resting metabolic rate that is, on average, 3 to 5 percent lower in the weight losers, a difference that can be explained by a low resting metabolic rate being more common among formerly obese people than among normal-weight people who have never lost weight.101 This “metabolic adaptation” to weight loss seems to persist for years after losing weight and even when weight is regained. A study on the contestants from TV’s The Biggest Loser found that, despite substantial weight regain in the six years following their participation on the TV show, the contestants’ resting metabolic rate remained suppressed at the same level as it was immediately after they lost all the weight on the show.102 And it was about five hundred calories per day lower than expected based on the measured body composition changes and the increased age of the contestants.
Why does this occur? Any deviation from one’s body weight—whether weight loss or weight gain—causes adjustments of caloric intake and expenditure as the body actively defends against the weight changes and attempts to return to its original weight. There may be a physiological set point or range for weight (about ten to fifteen pounds) and reducing weight below that set point or range causes physiological compensation. Thus, losing weight may create a metabolic state that favors weight regain in order to return body weight to some optimal or regulated level. Therefore, to maintain your reduced weight, you may need to eat fewer calories per pound of body weight than people who have never been overweight.
It’s important to note that not all research has shown that this metabolic compensation occurs with weight loss. For example, the one study on this topic from the NWCR, which compared forty-six normal-weight individuals to forty NWCR members who had lost an average of 53.1 pounds (range = 30.0–135.2 pounds) and maintained at least a thirty-pound weight loss for an average of 9.8 years (range = 1–43 years) found that the average resting metabolic rate for the NWCR members was not significantly lower than that of the normal-weight individuals (1,368 vs. 1,402 calories per day, respectively).103 The researchers found no indication of increased energy efficiency (i.e., burning fewer calories per pound) in the successful weight losers. So, although some studies have shown that metabolic efficiency develops after significant weight loss that predisposes individuals to regain their weight, many people still have a normal resting metabolic rate after they lose weight.
Research has shown that an altered metabolic state could also be due to a variety of other factors, including (1) a reduced ability to burn fat, thus favoring positive fat balance and fat gain, (2) lower levels of leptin (a hormone made by fat cells that inhibits hunger and decreases fat storage), and / or (3) increased insulin sensitivity (insulin regulates glucose metabolism by triggering the transportation of glucose from your blood into cells to be used for energy).104-106
In addition to the possibility of your metabolism working against you and making your life difficult, your brain has its own sense of what you should weigh, no matter what you consciously believe. Your brain responds to weight loss by using powerful tools to push your weight back up to what it considers normal. If you lose a lot of weight, your brain reacts as if it were starving, and your body will burn less energy during the day in order to conserve energy. Although this was a successful survival strategy to conserve energy during the time of our early ancestors when food was scarce, it is not a good strategy in our obesogenic environment, in which high-caloric foods are in overabundance. This means that a successful weight loser—someone who does not gain the weight back—must forever be vigilant in eating fewer calories and being more physically active than someone of the same normal weight who has always been that weight.
To examine this issue further, a NWCR study compared weight management during the holidays between 167 NWCR members and a separate sample of ninety normal-weight individuals.107 Holidays present a time that challenges intention and caloric control. Between company holiday parties and family vacations, it’s easy to let habits slip, not go to the gym, and eat more than a few gingerbread cookies. Perhaps anticipating the forthcoming temptations, the successful weight losers were very intentional. They were more likely than the normal-weight individuals to have plans to be extremely strict in maintaining their usual dietary and exercise routines during the holidays. They paid greater attention before and after the holidays to their weight and eating habits, such as daily self-weighing, and exhibited more weight control behaviors, including stimulus control techniques such as eating at one place in the home. They were more physically active and ate breakfast more often than the normal-weight individuals. They even ate less fast food. While 32.3 percent of normal-weight individuals avoided all fast food before the holidays and 35.6 percent avoided it after the holidays, 53.9 percent of successful weight losers avoided fast food before, and 50.3 percent avoided it after. However, despite practicing more extreme weight control behaviors to manage their weight over the holidays, the successful weight losers, who had lost an average of seventy-seven pounds and maintained at least a thirty-pound weight loss for six years, still had greater difficulty than the normal-weight individuals in controlling their weight: 38.9 percent gained weight during the holidays, while only 16.7 percent of normal-weight individuals did, and 51.2 percent kept their weight stable within a couple of pounds, compared to 74.4 percent of the normal-weight individuals. Successful weight losers who gained weight over the holidays were far less likely to lose the weight over the next month (and to return to their preholiday weight) than were normal-weight individuals, who can get away with a lot more (e.g., eat more fast food, exercise less).
This doesn’t mean that you don’t have any control over how much you weigh. The successful weight losers of the NWCR are absolute proof of that. Your choices still matter. Your willpower matters. Your intention matters. Research has shown that none of the physiological or metabolic factors related to weight loss seem to be major influencers of weight regain and that differences in behavior are stronger predictors of weight regain than differences in physiology or metabolism. The people whose stories are woven through this book are proof that you do have control over your weight.
Whatever the specific compensatory biological mechanisms that may exist after losing weight, one thing is clear: when you lose weight, you need to eat fewer calories per pound of body weight than people who have never been obese to maintain your reduced weight. And to do that requires controlling calories.
Creating the Habit
There are several ways to create the habit of controlling calories:
1) Eat from a smaller plate or bowl. Since forming new habits is all about creating contextual cues that make your actions automatic, even the seemingly insignificant environmental cue of a smaller plate can have significant consequences on controlling calories, as research has shown. If you always eat from a small plate, your brain will associate “food” with “small plate” and you’ll eat less food than if you always or often eat from a large plate. Buy smaller plates and bowls so you don’t have the option of filling up a larger plate.
2) Limit how often you eat out at restaurants. Although it’s easy to eat out while you’re running errands, on your way home with your kids from their after-school activities, or while at your job, doing so causes you to eat more. Eat at home as much as possible. This may take some planning. Pack a lunch to bring with you to your job instead of eating out. Plan your meals for each day, or even for the entire week. Reserve dinner for “family time.” Set up environmental cues to make eating at home a habit.
3) Count calories. When you go grocery shopping, read the nutrition labels to check the number of calories per serving and how many servings there are in the item. See if you can guess how many calories there are in the items you want to buy. Make a game out of it. By giving yourself a reason to look at the nutrition label, you’re more likely to do it and to create the habit over time. When you prepare your meals at home, keep track of how many calories you eat. Use a calorie-counting app like MyFitnessPal to input what you eat. Set a specific and measurable goal concerning the number of calories. Remember that successful weight losers consume an average of 1,400 calories per day. If you measure it, you can manage it.
4) Follow a consistent meal schedule. If the craziness of daily life gets in the way and you don’t think you can do this on your own, set an alarm for specific mealtimes. If you eat at consistent times every day, you’re less likely to overconsume calories whenever food is around. Use an alarm as your cue to eat. If this sounds familiar, it is. It’s an example of classical conditioning, which you may have learned in high school or college psychology class. When you pair a conditioned, neutral stimulus, like an alarm, with an unconditioned, biologically potent stimulus, like food, the conditioned stimulus will, over time, elicit a conditioned response, like salivation, that is similar to the response elicited by the unconditioned stimulus. In other words, the sound of an alarm, when paired with eating a meal, will, over time, condition you to only eat at specific times of the day.
5) Eat slowly. By slowing down the rate at which you eat, you’re more likely to stop when (or even before) you are full. Set a timer to help you create this habit. Pick a reasonable amount of time, perhaps fifteen or twenty minutes for an average-size meal. Don’t finish eating until the time has expired.
6) Drink only water. If you can’t give up coffee, that’s okay, but stay away from soda, fruit juices, sports and energy drinks, and anything from Starbucks. A water bottle can serve as a physical cue to drink water. Bring a water bottle with you in your car and keep it at your desk at work. If you fill up on water, you won’t have room in your stomach for something else.
***
To lose weight, Summer Yule maintained a strict diet, consuming 1,200 to 1,500 calories per day, along with initiating lifestyle changes. “I think I am like many people in that I do not like to be hungry,” she says. “I had to be creative to figure out new ways to compose low-calorie but satisfying meals.” At her lowest weight, Summer was 125 pounds. “It was nice to get to see the changes in my body and the numbers going down on the scale. Shopping for a whole new wardrobe was fun, too!”
At age forty, Summer currently weighs 130 to 135 pounds and has kept off sixty-five to seventy pounds for seven years. After her weight-loss journey, Summer went back to school to become a registered dietitian and learned the importance of individualized nutrition advice. “Specific strategies that work for me may not be what is best for someone else, so feel free to tweak what you see is working for others to fit your own life,” she recommends. She owns and manages SummerYule.com, a free recipe resource for adults aged thirty or older who want to lose at least twenty pounds. She joined the NWCR because she wanted to help others by contributing to the data on successful weight losers. “Maintaining the consistency needed for healthy weight management can be challenging at times, but it is not impossible,” she says.
Although she no longer has a specific calorie target she aims for, Summer is very in tune with how many calories she needs, and averages 2,000 to 2,500 calories per day to maintain her weight. As she did when losing weight, she still tracks her food on the MyFitnessPal app for accountability. “I consistently lose weight averaging under 1,900 calories,” she says, “and there’s a good chance I’ll gain weight if I start regularly consuming over 2,000 to 2,500 calories. I don’t sweat it if I have some days that are over or under this range; it’s what I am doing consistently that counts.” Most of her meals are rich in protein (meat, poultry, eggs, fish, and dairy) and non-starchy vegetables. “Over the years, I have learned that prioritizing protein, fiber, and fluid helps me to create meals that support both satiety and healthy weight management,” she says. For snacks, she prefers fruit, plain yogurt, and air-popped popcorn. She doesn’t subscribe to a particular way of eating, such as low-carb or vegetarianism, but she eats mostly whole foods with limited added sugar and refined grains. While she doesn’t officially restrict any foods or drinks, she rarely, if ever, consumes sugar-sweetened beverages.
Aside from diet, physical activity is an essential part of her weight maintenance. She typically averages one hour of exercise per day, six days per week. Day seven is errands day, during which she is on her feet a large portion of the day. “My most common physical activity routine is a 10K run or walk three days per week and a workout video the other three days,” she says. “I mix these up with seasonal activities, like cross-country skiing, sledding, and hiking.”
Summer says that one of the most challenging things about weight maintenance is that it can be a bit boring. “Something I’ve learned about myself is that I enjoy variety. Mixing things up with new workouts and different healthy recipes keeps me motivated to maintain my lifestyle.”
Habit 3
Control Calories.