Laugh Yourself Thin: Making Happiness, Fun, and Pleasure the Keys to Permanent Weight Loss

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Author: Melanie W. Rotenberg M.D. | Mitch Rotenberg Ph.D.

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Laugh Yourself Thin

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Laugh Yourself Thin Making Happiness, Fun, and Pleasure the Keys to Permanent Weight Loss

Melanie W. Rotenberg, MD With Mitch Rotenberg, PhD

Copyright 2010 by Melanie W. Rotenberg, MD All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, except for the inclusion of brief quotations in a review, without prior permission in writing from the publisher.

Library of Congress Cataloging-in-Publication Data Rotenberg, Melanie W. Laugh yourself thin : making happiness, fun, and pleasure the keys to permanent weight loss / Melanie W. Rotenberg with Mitch Rotenberg. p. cm. Includes bibliographical references and index. ISBN 978-0-313-38636-7 (hard copy: alk. paper) — ISBN 978-0-313-38637-4 (ebook) 1. Weight loss—Psychological aspects. 2. Weight loss—Humor. 3. Laughter—Health aspects. I. Rotenberg, Mitch. II. Title. RM222.2.R675 2010 613.2'5—dc22 2010020178 ISBN: 978-0-313-38636-7 EISBN: 978-0-313-38637-4 14

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This book is also available on the World Wide Web as an eBook. Visit www.abc-clio.com for details. Praeger An Imprint of ABC-CLIO, LLC ABC-CLIO, LLC 130 Cremona Drive, P.O. Box 1911 Santa Barbara, California 93116-1911 This book is printed on acid-free paper Manufactured in the United States of America The information published in this volume or any related e-book, Web site, or database is provided for informational purposes only and is not intended to supplement or replace the advice of a trained medical professional. The information provided here should never be used for the purpose of diagnosing or treating a medical or health condition. Readers should consult their own physicians before making any decisions or taking any actions that might affect their health.

This book is dedicated to our son. Aaron, growing up in our joyful and off-beat household, you have happily borne the brunt of our jokes. But, in so doing, you have learned the ways of the humorist. Your comedic talents and level-headed disposition have led us to conclude “Our work here is done.”

“I can’t see my shoes.” —Aristotle*

*Just

not that Aristotle.

Contents Acknowledgments

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Introduction: Laugh the Pounds Away Forever

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PART I: ATTITUDE AND BEHAVIOR ONE: Turn Your Head and Laugh: Happiness, Joy, and Pleasure in the Pursuit of Weight Loss

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TWO: I’m Allergic to Food, It Makes Me Swell: Thought and Mind for Success

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THREE: Tossing Your Cookies: Food Behavior That Works

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FOUR: Laugh Your Butt Off: Activity Behavior That Works

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FIVE: I’m on the Duct Tape Diet: Handling Hunger

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PART II: INPUT—FOOD AND DRINK SIX: Eat Right, Die Anyway: What Are Good Foods?

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SEVEN: Put the Muffin Down and Slowly Back Away: What Are Not-So-Good Foods?

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EIGHT: Water Intolerant: The Right Drinks

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NINE: Living Extra Large: How Much, When, and How to Eat?

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PART III: OUTPUT—METABOLISM AND ACTIVITY TEN: That Which Doesn’t Kill You Makes You Fatter: Increasing Metabolism

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ELEVEN: Dinosaurs Refused to Exercise and Look What Happened to Them: The Right Activity

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Conclusion: I Told You That There Would Be a Quiz at the End!

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Notes

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Resources and Further Reading

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Index

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Acknowledgments First and foremost, I must thank my agent, Ellen Pepus, of Signature Literary Agency. Without her terriﬁc guidance, great advice, and gentle coaching, this project would never have come to fruition. Thank you as well to my editor, Debbie Carvalko, and all the wonderful people at Praeger/Greenwood for encouraging my passion to teach and entertain. And a big thank you to all who offered stories and advice or their time by reviewing the manuscript. The friends and family who assisted include Debbie Bernier, Joe Bernier, Amelia Torre, Marcia Weinstein, Marylee Fennell, Terri Hamilton, Laura Fausone, Dawn Mineo, Pam Wheeler, Dawn Fuller, Bob Taylor, Rick Fennimore, Fred Mullins, Christine Folkes, Susan Jackson, and Sherri Garafolo. I am truly grateful to all the enthusiastic participants of the annual conference of the Space Coast Writers’ Guild. You people helped me ferment this crazy plan, and I do appreciate all the wonderful guidance through the maze of the book industry. Real gratitude goes out to comedian Kevin Hughes, for inspiring my husband and me to start writing humor and for encouraging me to get up in front of a crowd and tell jokes. And I’d like to give a huge thank you to my son, Aaron Rotenberg, and my husband, Mitch “Long-Suffering” Rotenberg, for putting up with me all these years.

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Finally, the biggest thanks goes out to my patients, who inspire me to write, to teach, to learn, and to grow. Where would I be without you? Melanie Rotenberg, MD (aka “Dr. R”)

Introduction: Laugh the Pounds Away Forever

Roller Coaster Haiku Oh my Freaking God I think I’m Going to Die Oops, There Goes my Lunch

The weight-loss journey, for most people, is a lot like a theme park ride, a very stressful and scary one. It doesn’t have to be. Ideally, it should be more like a fun, exciting adventure, with a safe and pleasant outcome. Although I hope you will think this book is funny, please realize that the weight-loss concepts are serious. Healthy skinniness can’t occur without laughs, since negative emotions undermine successful weight loss. Laughter is the hallmark of a life lived better, a life full of pleasure and joy. LIFE IS ALL ATTITUDE—LUCKILY, I’VE GOT LOTS OF THAT A warning to my readers: my husband, Mitch, has a black belt in humor, and I use his material every chance I get. If you aren’t in the mood to

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laugh while you read, put the book down and back away. I am intent on making the experience enjoyable for you. In my spare time, when I’m not seeing patients, I’m writing or practicing comedy. I started doing stand-up routines just after my 40th birthday; you could say I’m having an unusual midlife crisis. When I asked Mitch if he would help me write this book, his response was “I’d rather put eye-hooks through my hands.” The man blurts out funny stuff all day long, and then I run and write it down. Let’s just get it straight—his blurting got him credit for co-authorship, but I did the hard work, and that’s why the book is written from my perspective. I also have to tell you this: most of the stories here about my patients, friends, and family are true, but the names have been changed to prevent unwelcome visitors to our house in the middle of the night.

GONE WITH THE CHIN One other thing you need to know: this is not a quick-ﬁx diet book. If you are looking for a way to lose a few pounds and then want to go back to your previous lifestyle, look elsewhere. This book is meant for people who are tired of traditional dieting and are now looking for permanent, healthy weight loss. I’ll teach you how to do it by taking a humorous, positive, joyful approach. Here you will ﬁnd information about wellness. I discuss not just food choices but approaches to eating, exercise, behavior, and thinking. I talk about mood and activity. I don’t tell you what to eat and what not to eat, but I do advise on good choices and not-so-good choices. I will talk about activity and exercise. I have to because, ultimately, regular exercise is how successful people lose weight and keep it off permanently. Besides, I am an exercise doctor, and I’d be a fool if I did not talk about something near and dear to my heart. Activity works, and in this book I’ll tell you why it works and how you can make it successful for you, even if you’ve never thought of yourself as an exerciser. Many of my patients in my medical practice can’t even get out of a chair on their own when they meet me, yet they all learn to exercise. I’m very creative. Most people gain back all the weight they lose through a traditional diet plan shortly after going off the diet. In fact, the saddest part of weight-loss research reveals that the majority of dieters not only gain back their lost weight; they gain even more than what they lost. This

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does not have to happen. It will not happen to you if you follow the scientiﬁcally based suggestions in this book.

It’s like everybody and their brother has written a diet book or a cookbook. Even dead people and fictional characters are getting in the act. I’m afraid it won’t be long until we see Noah Cooks for Two.

People gain back their lost weight for one very important reason: they haven’t embraced weight loss through a thinking and behavioral wholelife approach. For most people trying to lose weight, the word “diet” implies a temporary state of food restriction. Either types of foods or amounts of foods are restricted until the desired weight is achieved. However, there are three parts to successful and permanent weight loss: (1) thinking and behavior; (2) input, as in food and drink calories; and (3) output, as in metabolism and activity calories. Most diet books, even those written by physicians, have an overemphasis on the “input” part of the equation. A typical diet book will give you pages and pages of food rules and recipes. These books rarely talk about the behavior, attitude, and cognitive processes that go into how and what we choose to eat. They rarely give more than a page or two to the issue of activity and exercise. Weight loss can’t be permanent unless all three areas are addressed in a balanced manner.

Now remember, health advice works only if you act responsibly with the information. Which reminds me of the time my hospital offered a breastfeeding course but had to cancel it because more men signed up than women.

Back to weight loss: calories are just a convenient way to measure our bodies’ fuel. Weight loss occurs when there is more fuel burned than taken in. Activity (output) is just the way we burn the fuel that we get through food (input). If we put out more calories than we take in, we lose weight. Maintaining that loss permanently is just maintaining the balance between input and output. It’s really very simple.

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STUDIES SHOW THAT WOMEN PHYSICIANS ARE 100 PERCENT MORE LIKELY THAN MALE PHYSICIANS TO HAVE BABIES I have a lot of experience with health and weight loss, personally and professionally. When I was pregnant, I suffered severe morning sickness and ate anything I could to calm my queasy stomach. (Patients don’t think it’s very professional when the doctor barfs on them.) By the time I gave birth, I was 50 pounds heavier than before my pregnancy. It took me a long time to lose that extra weight, but I’ve kept it off for more than a dozen years. More important, I’ve been a disability physician for a couple of decades, and I’ve counseled thousands of patients on weight-loss techniques. Obesity is the number one cause of disability in the United States and also the leading cause of preventable death. Youthful ﬁgures and activity levels are not just for the young but can be in the grasp of anyone who is willing to make health a priority. My goal is to teach people how to avoid becoming chronically sick or disabled in the ﬁrst place and then stay in great shape for the rest of their lives. I have a wild fantasy that if enough people read this book, I’ll put myself out of the disability business for lack of patients. Truly, that would make me ecstatic. Read this and enjoy a slimmer, more vibrant, fun, and happy life, permanently. The key to weight loss is to start from a good point and go to a better one—the joy, laughter and happiness that you develop will be all your own. —Melanie Rotenberg, MD

(Oh, and one more thing: pay attention throughout. My husband and I are professors. Don’t be surprised if there’s a quiz at the end.)

PART I Attitude and Behavior

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ONE Turn Your Head and Laugh: Happiness, Joy, and Pleasure in the Pursuit of Weight Loss

People want quick results, but there are no healthy ways to rapidly slim down. Health spas often promise serious weight loss with only one expensive session of an exotic treatment. Usually it involves being slathered, enveloped, and heated. None of those techniques really work; they are only sucking water out of your system. However, I guarantee that you will experience rapid and dramatic weight loss with the piranha swim.

Laughter is the key to weight loss. Well, really, it’s those things that cause laughter, like happiness, fun, and pleasure. But we can use laughter as a good gauge of how happy and content we are. Stress, negative emotions, and misguided thought patterns are a leading cause of obesity. Yet diet books almost never address an overweight person’s mental state or level of joy. They might have pages of dietary restrictions and recipes, but rarely is there more than perfunctory prose on relieving negative emotions. There might be a chapter or two on exercise, but nowhere is there a description of the cardiovascular beneﬁts of a good pillow ﬁght. And we all need a good pillow ﬁght on a regular basis. The way to lose weight and to keep it off permanently is to lower stress, depression,

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and other negative emotions through positive thinking, humor, fun, and lots of laughter. A lighter approach to life leads to a lighter waist line. A recent study by Dr. Mark Wilson at Emory University brings home this point. He offered unlimited nutritious food to two groups of monkeys, high-status, contented, happy ones and their miserable, stressedout, low-status subordinates.1 All the monkeys ate about the same number of calories. However, when Dr. Wilson substituted high-fat and sugary junk food pellets in unlimited supply, the high-status monkeys ate about the same calories as previously, but their stressed-out brethren couldn’t stop munching. Those miserable primates continued to eat the junk food all day long and well after sundown, similar to human snackfood grazers. The researcher concluded that eating high-calorie foods is a common coping mechanism to deal with daily life stressors, even in those who don’t have a cranky boss, prolonged commute, or nasty mother-in-law. YOUR PERSONAL WEATHER FORECAST—CHANCE OF SCATTERED BRAINS Unfortunately, the majority of modern people live stressed-out, demanding lives. Most of us spend our days rushing from responsibility to responsibility, with little time to relax, enjoy, or meditate. A while back, my son saw my driver’s license and read the words “organ donor.” He exclaimed, “Oh, cool, mom, which organ did you donate? ” That’s when I informed him that normally people wait until they’re dead to donate their organs, but, in my case, I had already given my brain at the office.

The biggest stress in my life is keeping house. I’m not much of a domestic engineer. I was completely stumped one time when I had to wash a black-and-white-striped sweater and the instructions said to “wash with like colors.” To me that was a laundry IQ test, and I had to be Einstein to figure it out. And, speaking of chores around the house, I’ll never forget the patient I had who went home from the hospital with hospice care. That nurse was so terrific, she took days to help the elderly gentleman clean his completely unkempt house before he died. Exhausted, she finally reached the bottom of a huge pile of junk. The last thing she picked up was a book titled How to Clean Practically Anything.

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HELP! I’VE EATEN AND I CAN’T GET UP People say they want to lose weight for a lot of reasons, like “I want to look better in my clothes” or “I just want to get back to my college weight.” But the real reason is only twofold—either it’s for health or it’s for happiness. There’s no point to being thin, sick, and miserable. We all know people who are like that. Generally they’ve got cancer or they hate themselves, and, either way, you don’t want that for yourself. Mental and physical health is the primary goal in permanent weight loss. This book is about accomplishing both. When you set yourself on the path of mental and physical health, the weight loss will follow. If you try to shortcut the process, you won’t get very far. A positive attitude and a focus on pleasure and joy are an integral part of losing weight forever. Laughter is a key component to weight loss. There have even been research studies looking at laughter as a weight-loss technique. But I’m not particularly interested in seeing how many calories a day you can burn by watching reruns of television sitcoms. I’m more interested in the bigger picture—how can positive thinking and happiness bring about better health? We medical types know a lot about the physical implications of being overweight. We know that obesity leads to all sorts of bad medical outcomes, including cardiac disease, diabetes, arthritis, and cancer. Having extra belly fat even increases your risk of developing Parkinson’s disease! However, we’ve had a tough time getting people to lose weight. Even those who lose the weight usually can’t keep it off. But the focus has been lopsided. Most weight-loss programs concentrate on the physical issues, usually the food and sometimes the exercise. It is my belief that the most important component is often ignored: the brain. Our thoughts, emotions, and behaviors drive every action and decision that we make, and they certainly drive our weight problems. The bottom line is this: we know that permanent weight loss will not occur in people full of fear, unhappiness, and boredom.

IF STRESS CAUSES HIVES, I OUGHT TO BE ONE GIANT RED BUMP So if a person is stressed, depressed, or bored with life, attempts at permanent weight loss will be futile. The best hope we have for true success is to start with our most critical fat-preventing organ, our brain, and whip it into the best shape possible. The rest of the body will follow.

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This chapter is about ways to increase happiness, lower stress, improve coping mechanisms and social relationships, and reduce self-critical behavior in pursuit of thinness. All of these are crucial to mental and physical health and permanent weight-loss success. Even if you think your life is going well emotionally and mentally, there are things you will learn in this chapter and the next that will make the journey to normal weight much easier. Take the time to read Part I of the book (Attitude and Behavior, Chapters 1–5) before delving into the later sections. Chapter 2 deals with the proper mindset for weight loss, and Chapters 3 and 4 address the behavioral aspects (Chapter 5 is about hunger). Once you have read the entire ﬁrst section of the book, you will have a much better foundation to approach the speciﬁcs of the rest of the equation, that is, the input and output of fuel. When you have a good understanding of the thoughts and actions that lead to success, you can apply them to your own situation and immediately start making positive changes. THE UNIVERSE IS EXPANDING, AND SO AM I A study done at Northeastern University, in Boston, in 2003 showed that the more depressed adolescent girls were, the more likely they were to become obese later in life.2 That same year, Johns Hopkins published a study showing that in adults, there is a strong link between depression and weight, particularly in those who are very obese.3

I have a patient who is extremely overweight, as is his wife. Recently, the wife underwent surgery. While coming out of anesthesia, she was particularly anxious and upset. Her doting husband offered all his emotional support. Later that day, apparently still suffering the effects of the medications, she turned to her spouse and said in her most grateful manner, “Oh, honey, thank you for being there for me when I really needed you. You are my Rock of Giblubber.”

I’VE ALREADY LOST THREE SIZES: SMALL, MEDIUM, AND LARGE Think about ways to increase your pleasure and happiness in day-to-day life. Fun with food will lead to weight loss, not weight gain, as is often assumed. It’s an exciting paradox: the more you truly love and enjoy

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food, the less you will eat of it. (We’ll talk more about that in Chapter 9.) Weight loss should be approached as painless. Eating is pleasurable. Having fun and laughter around meals and playing with food are important. Additionally, exercise and activity are not burdensome but invigorating. Those who are most successful with permanent weight loss are those who consider regular physical activity an enjoyable, integral part of their daily life forever.

WHO KNOWS IF A CLAM IS REALLY HAPPY? So what are the keys to happiness? In my experience, there are several keys that drive most people toward happiness. Loving and sharing in meaningful relationships is a big one. Having a purpose is very important. Being present-centered, living life here in the moment, is another. (Don’t dwell in the past or constantly dream of the future.) Having autonomy and control over one’s life is extremely important to happiness, as is being rewarded for effort. All of these keys to happiness are relevant to weight loss. People who are in meaningful, supportive relationships are more likely to follow good health habits. People who feel that their actions have a purpose are more driven and motivated and stick with a plan. Those who live now, in the present, are more attuned to their bodies’ needs. It’s been shown that personalities that are more autonomous and independent, sometimes called “having an internal locus of control,” are less likely to be obese. Finally, those who feel that they are getting positive feedback for their efforts are more likely to continue those efforts. That’s why there is so much emphasis in some diet programs on the regularly scheduled weigh-ins.

THE CABLE COMPANY SAID THEY’D BE RIGHT OVER, SOMETIME BETWEEN BIRTH AND DEATH If you want to get skinny for the long term, it’s time to embrace laughter, compassion, and contentment and abandon anger, cynicism, and pressure. There is a very clear and consistent relationship between how stressed and unhappy people are and how obese they are. Stress also results in anxiety; people who have the most work and life stress are the most anxious and overweight. A study by Paula Rhode, PhD, of the University of Kansas, showed a direct correlation between the frequency of everyday life stressors (like

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arguments with family members, waiting for the repairman, or being stuck in traffic) and obesity.4 Her results demonstrated that for weight loss to be permanent, one must address the psychological factors of daily stress and loss of control, thus preventing the need to soothe frazzled emotions through eating. When people have passion in their lives, true meaning, deep pleasure, and feelings of living a worthwhile life, it is much easier to achieve goals, including weight-loss goals. Ah, I know what you are thinking: “Sounds great, but I live in the real world.” So do I, and I’m a physician, mother, wife, daughter, sister, friend, comedian, volunteer, bad golfer, worse surfer, writer, speaker, and consultant, and I play a host of other roles. We all live in the real world, with loads of responsibilities. Unfortunately, sometimes people use their roles and responsibilities as an excuse to stay unhappy and not work toward changes. Don’t do that. I believe eliminating stress is one of the keys to permanent weight loss. You can be very busy and not be stressed. They are not the same thing. Indeed, having too little meaningful work to do results in boredom, which is a pervasive but often overlooked cause of stress.

CUSTOMER SERVICE IS OUR MIDDLE NAME. NOPE, WE DON’T USE IT EITHER How can you eliminate stress in pursuit of permanent weight loss? Learn more about yourself by carefully studying your reactions to everyday events. Start examining what really makes you happy and what turns you off. Gravitate toward those things that really give you pleasure, and don’t worry about what others may expect of you.

Nothing aggravates me more than dealing with rude and incompetent companies. I swear some of them must use the motto “Why buy from the best when you can buy from us?” The worst is when I want to talk to a real live person, and I have to navigate an unending phone messaging system or leave a message and hope that someone will call back. A friend of mine told me that her church recently got rid of purgatory, and now I understand why. We don’t need purgatory anymore; we have voice mail.

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Are there things that you do that feel purposeless? Realize that a role that feels important and satisfying to you (such as work or housecleaning) may feel unfulﬁlling to others. Examine your own values and emotions while in those roles. What do you enjoy about them, and what do you dislike? Are there responsibilities that you could eliminate, that give you too little pleasure? Are there ways to make them more pleasurable? Are there roles that you enjoy and would like to expand? Much of our lives is spent fulﬁlling functions that we never question. One of the best ways to decrease stress is to question assumptions that you have made about your day-to-day activities. Examine everything you do, take a step back, and begin to look for ways to increase your happiness and pleasure.

IF YOU’RE NOT BUSY LIVING, YOU’RE BUSY WORKING There are some pressures that may be daunting to you to change, such as work environment or overload. Back in 1976, psychologists demonstrated that if you stress lab rats by pinching their tails repeatedly for weeks on end, they will become severely overweight, much more than those rats that weren’t stressed.5 Do you come home from work feeling like the equivalent of that pinched rat? Americans are the most overworked, and therefore overstressed, people on the planet. It’s no surprise that they are also the fattest.

Some people’s idea of work stress is different from others’. I’ll never forget the attendant who ran the canoe rental at my favorite remote vacation site. She sat under a palm tree and read novels in between handling her three or four customers a day. Last time I saw her, she was complaining about how she couldn’t wait to go on vacation. I wonder where she goes to relax: Manhattan’s Friday afternoon rush hour?

Take stock of what isn’t joyous and humorous, and approach reasonable ways to ﬁx the pressures. Note that if you constantly worry about your weight, you can take the issue so seriously you stress yourself into weight gain. Conversely, many people who are chronic dieters report that they feel exhilaration when they start a new diet. The excitement of a new diet likely comes from the enjoyment of envisioning your

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new body, your new energy level, and perhaps all the other things you think a slimmer body will bring to you (perhaps an improved social life). Unfortunately, traditional dieting is all about deprivation and discomfort. Abandon that mindset. But if you are the type that has gotten some enjoyment at the beginning of a new diet because you are envisioning what a thinner, healthier you will do, maintain that vision, but without all the pain. While you are examining what brings you more joy and less stress, think about things like walking, biking, singing, dancing, meditating, music, and sounds of the beach or the woods. I’m always surprised how few people I see outside enjoying nature and using their muscles. Exercise is an antidepressant and works as well or better than medications, so not only will it help you to lose weight, it will also relieve stress and improve mood.

HAVE A FOOD FIGHT, BUT STOP FIGHTING YOUR FOOD Traditional dieting doesn’t allow eating to be pleasurable because it comes with a deprivation mindset. But eating the healthiest foods for the body isn’t restrictive and is always sensual. (That subject is covered in detail later in the book.) Make a point to have fun around meals, with lots of laughter. One of my favorite memories from middle school was the day the cafeteria erupted into a food ﬁght, I remember laughing so hard I almost split my seams. (Yes, I am giving you permission to have a food ﬁght, but, no, I am not coming over to your house to clean up.) What’s wrong with playing with your food? Try doing this with a straight face: put black olives on all your ﬁngers, then eat the rest of your meal. You’ll be laughing so hard, you might forget to clean your plate. Eating for pleasure can come from the company you keep at your meals or the silence and quietness of the moment. In Chapter 9 we talk about increasing the enjoyment of savoring what you are eating with the art of meditation.

MY BOSS IS HAVING A NEAR-HUMAN EXPERIENCE I am good friends with a lot of nurses. Nurses are some of the most stressed-out people on earth because of all the problems in health care. It seems that no matter how hard they work, someone above them is saying that it isn’t good enough. As a physician, I observe the coping

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mechanisms of great, loving, smart people under tremendous pressure. What I’ve discovered is a very high rate of lousy coping mechanisms, including smoking, eating, and drinking to excess. These are very devoted people, putting everybody else’s needs ahead of their own. Does this sound like someone you know? If you are the caring, compassionate, put-everybody-else-ﬁrst kind of person, perhaps you are using selfdestructive coping mechanisms to deal with the stresses in your own life. Just remember, you are no good to those you love and care for if you are running down a self-destructive path. It’s time to put your needs ﬁrst, even if others aren’t used to it. You have the right and the responsibility to take care of your health ﬁrst. Think about the instructions you are given when oxygen masks drop on an airplane. You are told by the ﬂight attendant to put your mask on before helping others. Treat all aspects of your health that way. The stronger you are physically and emotionally, the better you are for those you love.

There is so much aggravation built into health care. I was scheduled to see my eye doctor for a checkup. Before the appointment, his office sent me a list of things to bring with me that day. You know you are going to be in the waiting room a long time when they tell you to bring your lunch, a sweater, a book, and a tent.

You have coping mechanisms for each major person in your life and each part of your life. But are they successful, positive coping mechanisms, or are they self-defeating? Do they reduce stress in the long run or add to it? If you take a drink when you get home from work and then a couple more before you can face the kids or the spouse and make dinner, is that the best way to treat your body and your mind? What would beneﬁt you both physically and spiritually and be better for you and your family? How about stopping for yoga class on the way home, walking in the park on the good weather days, meditating for 15 minutes in pure silence before the gang gets home, or dropping that extra project at work that’s been causing you all those extra hours? Perhaps your best coping mechanism could be setting limits for the superwoman or superman inside of you and refusing to push yourself harder or refusing to let others push you into responsibilities that you don’t want or need.

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HEY, DID THE BED GET SMALLER? Once you’ve targeted self-defeating coping mechanisms, you must replace what you don’t want with something that is uplifting. If you only vow to stop doing the destructive habit, you will not succeed. You must ﬁnd something that is extremely pleasant to do instead. When one of my overweight friends whom I coached ﬁnally admitted that she and her husband were drinking too much every night after work, she wasn’t able to eliminate the habit until they came up with other fun activities to substitute for their nightcaps (hint: let’s just say it involved more calorie expenditure). She and her husband have both lost substantial weight from just that simple substitute in behaviors.

WHAT’S IT GOING TO BE LIKE WHEN THESE WERE THE GOOD OLD DAYS? Think of a list of easy, stress relieving good-for-you activities. These can be as simple as taking a walk, getting into nature, listening to calming music, or having game night with the family. They might include reading a joke book, calling a supportive family member, or sharing time with friends. These do not need to be time-demanding activities but should be included every day in your schedule. Add more active things to do, not because you have to but because you want to. Try to laugh, joke, sing, dance, or ﬁnd pleasurable activities for at least an hour a day. Keep it positive and mentally and physically active. If you are doing something more passive, like television or movies, choose uplifting and humorous or silly topics. Avoid the depressing— search out comedy, joy, giggling, friends, and spontaneity.

When picking good-for-you music, be selective. I was a child in the 1960s. Everybody always thinks the 60s was about people doing drugs and that the music was a consequence of that. There’s this idea that Jimi Hendrix and “Puff the Magic Dragon” came out of heavy inappropriate drug use. In reality, what people don’t realize is that it was the other way around. Folks did the drugs because the music was so bad. If you don’t believe me, we could test this. Take a bunch of laboratory scientists and expose them to 60s music for 18 hours straight and see if they don’t start drinking hydrochloric acid right from the beakers.

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I’m a big believer in a daily regimen of at least 15 minutes of what I call “nonactive moments.” Perhaps this could be prayer, meditation, or something that you would otherwise feel is indulgent time. For me, it’s time at the beach just watching the waves. Increase your “me” time away from energy- and mood-sucking activities. Practice a habit of quiet moments, whether it is sitting on your porch and listening to the birds sing before you begin your day, or listening to some calming music while sitting in a dimmed room, or soaking in a warm bath before bed. This simple daily activity will not only lower your blood pressure; it will lower your stress level and improve your coping skills. Defend that time daily, and don’t let anyone, particularly yourself, steal it away from you. The way that you cope with life is critical to your weight. Back in 1990, the University of California and Kaiser Permanente showed that obese women who confronted problems directly were much more likely to lose weight and keep it off permanently.6 Ninety percent of the formerly obese women who successfully lost the weight used that coping mechanism, whereas only 10 percent of those who gained the weight back did so! That’s a remarkable statistic. In fact, if you take away nothing else from this chapter, understand that the way you choose to cope with life’s challenges will determine your weight. This fact is more important than what you eat or how you exercise.

A brand-new speech therapist was working on cognitive tasks with a patient of mine to determine whether the patient had good coping skills. The dear old lady had macular degeneration in one eye and glaucoma in the other. The therapist quizzed her with a theoretical scenario to find out how well she could problem solve. She said to the patient, “You drive your car to Wal-Mart and get out, realizing that you’ve just locked your keys in your car. What would you do?” The patient responded, “I’d say, thank God. I’m blind and I shouldn’t be driving.”

SHE WAS SO MATERIALISTIC, SHE WENT OFF THE SHALLOW END Another way to decrease negative emotions is to give up materialistic attitudes. The pressure to acquire the trappings of status tends to increase stress. Besides, more things cause more aggravation, more bills, more ﬁghts, and more work. Ask yourself, “What can I give up that might be

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stressing me and making my life less fun? ” Then start searching for nonmaterialistic friends and have heart-to-heart talks with your family about what your real monetary goals need to be. Consider moving to a less fancy neighborhood if you have the opportunity to move. Even if you can afford the luxuries and a high-end neighborhood, what unwritten messages are being transmitted to you and your family? Find places that “ﬁt” your personality; whether they ﬁt your ﬁscal abilities should be secondary. I truly believe that materialism is rotting the American soul and leads to a great deal of unnecessary stress, anxiety, and depression.

THE BEST THINGS IN LIFE ARE FREE—OR AT LEAST LESS THAN $1.99 You’ll notice throughout the book that I emphasize frugal ways to accomplish weight-loss goals. That is a reﬂection of my personality. It is unnecessary to spend large quantities of money to be healthy. The most precious gift that you can give yourself, the gift of excellent health, should not be expensive.

And there’s nothing wrong with a modest lifestyle, most of the time. I read about a famous director who named all three of his kids after the locations where they were conceived. I think one was named Houston and another, something like London. Obviously, he traveled a lot. I wanted to do that with my own kid, but Motel-6 Rotenberg just didn’t have the right ring to it.

Another way to decrease negative emotions is to encourage your own positive health behaviors with what I term “beneﬁcial self-reward.” There is a difference between materialism and self-reward. When you pamper and love yourself with positive behaviors, it is not decadent or hedonistic. During your weight-loss journey, when things are going right, like you slip into those jeans that haven’t ﬁt since forever, it’s time for self-reward. No, I’m not talking about the trip to Dunkin’ Donuts. But I am talking about the 30-minute bubble bath, the drive to the lake to go ﬁshing, or the afternoon off to be utterly indulgent with your time. Ask your partner for a luxurious massage, or drive an extra couple miles to that really nice park for a walk or bike ride under the trees. Better yet, plan to meet a friend there to join you. These types of rewards are best

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when they don’t involve excess calories or monetary expenditures. Find behaviors that are truly rewarding and that will not result in additional stress on your waistline or your wallet. WHEN OUT IN THE COLD, LET YOUR NUCLEAR FAMILY GENERATE HEAT Remember that University of California study that I mentioned earlier about those study subjects who lost weight permanently versus those who gained it back? The women who permanently lost the weight were much more likely to lean on social support than those who gained it back.7 Find connectedness with people who are helpful to you and give you proper encouragement. At the same time, move emotionally away from those who generate negativity. Search out a positive community to surround yourself with, and constantly gauge if this community continues to be positive and inspire you. Avoid those who give unwelcome advice and criticism. Find people who will listen in a nonjudgmental manner, and use a support group if you ﬁnd it helpful. Not everyone in your social circle will support your endeavor as you think they should. Sometimes family members get comfortable with a certain familiar lifestyle or partner, and they may be threatened by your attempts to change your habits. Friends can quickly become jealous. They may be intentionally or accidentally undermining your success. Sometimes it’s just a lack of education and understanding (such as a well-meaning but misguided “Let’s go out for ice cream to celebrate the 10 pounds you just lost.”). Often the family member or lifelong friend may have the same old self-defeating habits that you are trying to change. You may need to do gentle re-education with them to encourage behaviors that are useful to you. Don’t get defensive if they are being well-meaning but stupid. However, if repeated education on your part doesn’t change their behavior, you need to ﬁnd someone else (or just rely on yourself) to continue your progress. You can even look online for support groups that will help you feel less alone in your journey.

Under the category of “people with good intentions doing stupid things” would have to be the people who planned the annual fundraiser at our local zoo. It was a big evening barbecue. They called it the Zoo-b-q.

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Laugh Yourself Thin They should have called it the “Let’s Celebrate Animals by Eating Them Night.” I’m glad Habitat for Humanity isn’t doing anything similar: “This weekend, we’re having our annual cannibalism social!”

Approach social occasions (especially with food) with a positive, joyful approach and concentrate on receiving pleasure from your dining companions. Enjoy the small moments of life. Take the time to notice not just the smell of the ﬂowers but the smile of a co-worker, the hug of a child or lover, the sound of new music. Concentrate more on enjoying these little pleasures, working them into a part of your daily life. Find new ways to recommit to your lover or spouse. Be there more fully in your attention, and truly listen. Be creative in your signs of affection, and act like you did when you were ﬁrst dating. Be on your best behavior, and don’t expect anything back (but don’t be surprised if your new activities get a very positive response). Spend more time really listening to your signiﬁcant other and your family members; take special time out for a friend that you haven’t made enough time for. A MIND IS LIKE A PARACHUTE. IT WORKS BEST WHEN OPEN—OR WHEN FALLING FROM A PLANE Don’t hesitate to ask yourself daily, “What is my passion? What is my purpose, and what gives meaning to my life?” Answer carefully, always keeping an open mind. A happy life is driven by meaning and purpose. The best, easiest stress-reducing activity that also lowers blood pressure and improves daily coping skills is physical touch. This includes hugs and cuddling. A fun little study done by the University of North Carolina and the University of Pittsburgh showed that women who hugged and touched their partners most frequently had the lowest blood pressures and the highest oxytocin levels.8 The hormone oxytocin is thought to be involved in trust, relationships, sexuality, bonding, and maternal behaviors. It is believed to decrease anxiety. There has been research to demonstrate the health beneﬁts from physical contact and the need to hug and touch others, from the time we are born until the time we are aged and dying. Yet our modern world scorns physicality, leaving it for only a bedroom activity or the interaction between parent and child. Adults have inadvertently sexualized touching and hugging, even when it is meant platonically. Unfortunately, because of abuses by

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the perverted few, the rest of us are forced to abandon physical signs of appreciation with most of the people we interact with on a daily basis. In the proper and acceptable setting, put physical touch back on your “to do” list. As a physician, I sit at the bedside and touch my patients on the arm or hold their hand just to connect with them and make certain they understand that I care. (With the use of high-tech equipment, doctors have almost eliminated the need to touch patients. Some of us have gotten lazy and have forgotten that medicine is still as much an art as a science.) Healing touch does matter. I do hug my patients and their families often, and they appreciate and ask for it.

There is one precaution I have about doctors touching patients. It seems some don’t bother to wash up between patients, transmitting diseases. I wipe my stethoscope between each patient I examine. What’s amazing is that most doctors don’t. In fact, a study was done a few years ago that found that the typical physician cleans his stethoscope once a month, say about every 300–400 patients. So why does he bother to wash his hands? Next time a physician comes at you with a stethoscope, remember to yell, “Have you washed that? Where’s that thing been?” Just make sure you are pointing at his stethoscope and not any lower.

If you truly ﬁnd that you cannot increase your hug factor with family or other situations, then by all means get yourself a huggable pet from the animal shelter. Do a good deed and save an animal from destruction, and watch that animal save you, as well.

My husband offered to get me a pet; he wanted to know which animal I liked. I suggested an elephant. That way there would be more than one gray and wrinkled creature around the house.

Overweight people feel less huggable because of the stigma society attaches to fatness. Heavy people feel less desirable and less acceptable to others, resulting in less physical interactions, both sexually and

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nonsexually. If you believe that this may be a problem for you, avoiding the issue is not going to help. Talk about this with your signiﬁcant other or make honest, frequent attempts to correct your unwanted habit with others. Often we are our own worst enemy and undermine our own mental health. Everyone needs to feel wanted and loved, and physical touch is one of the most immediate ways to express this. I’M FOUNDER OF THE ORGANIZATION DOCTORS WITHOUT BOUNDARIES Another very important way to bring more positive emotion into your life is to give more of yourself to others, but not in a stressful way. Make a positive difference through volunteering, giving, and showing compassion. Donating time and money is not only emotionally rewarding, it’s been shown to increase immune function! Practice random and deliberate acts of kindness. Put yourself in situations that allow you to see the life of those who are less fortunate or who are struggling. There are always those who have less. It makes it easier to feel grateful for what you have, rather than dwelling on what you are lacking or have lost. WHY DON’T WE DO FUN RAISERS? When we are concentrating on the needs of others, we are less full of ourselves and our own problems. Then our personal fulﬁllment soars. I believe that’s why there are so many problems with wealthy celebrities, particularly the young, hedonistic types. They haven’t learned that the more you try to feed your own emotional needs (particularly with materialistic objects), the hungrier you become. Self-obsession, hedonism, and materialism inevitably lead to self-loathing. This often results in depression, anxiety, and, for many, addictions to food and other things. When you are tending to the needs of the less fortunate, you have the opportunity to build empathy. There is a strong relationship between empathy and one’s level of happiness. When you feel for others, your own positivity rises. Lessen negative emotions with gratefulness, including gratitude for food. Whether you use words prior to eating, such as saying grace, or just pause in the realization that you are lucky to have food, this act brings joy. We are blessed to live in a land of plenty, but don’t forget the hundreds of millions who don’t. Gratitude should become a practice for you, if it isn’t now, for the health that you do have and for the ability to make it even better. In my family, we practice a ritual of gratitude

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by getting together weekly and reciting the special things that we are grateful for at that moment, including our freedoms, our friends, and our community. REMEMBER, THE FAMILY THAT LAUGHS TOGETHER IS LESS LIKELY TO KILL EACH OTHER When stressed and overwhelmed by work, family, or life, remind yourself of the big picture. Keep proper perspective on the small stuff and the little bumps in the road that we too easily enlarge. A sense of humor is especially important here. People who are able to laugh at the smaller annoyances of life cope better in general.

In terms of my own family life, I have to admit that I’m not your typical mom. I’ve never been someone who fits neatly into the traditional mothering role. So when my son was younger, I used to teach him nursery rhymes that were a little different, imbued with my own odd sense of humor. For example, “The queen of hearts made some tarts. She ate them all and got the farts!” Which was great fun, that is, until the preschool principal called me. And then I had to pretend I’d never heard that rhyme before.

I believe in what I call the “art of contentment.” Much of daily stress is self-induced by dissatisfaction with ourselves or others. Expect less, look at the positive side of life, and don’t be so hard on other people and yourself. But, at the same time, work toward steady improvement. You don’t need to be a perfectionist, but also don’t settle for mediocrity. NEWSPAPER HEADLINE: MODERATES DEMAND TO BE HEARD, AT LEAST A LITTLE BIT Eliminate negative thinking. Be constantly aware of how your cognition is framed, in positive approaches or with a sarcastic, negative, pessimistic, undertone. Optimistic, positive thinking attracts success in all areas of life. Our society tends to focus on the negative, cynical, and sarcastic. Note that the news emphasizes the violent, the angry, the ugly, and the unusual—that’s what makes it news. Learn to tune out that emphasis, and embrace the beautiful, the compassionate, and

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the positive. Guard your brain from assaults by those who dwell on the darker, pessimistic side of life, and guard your own emotions to keep from dwelling on this. Being positive-minded in your thinking is not improper or unrealistic any more than dwelling on the negative, the violent, and the miserable is proper (even if it has become “normal” in our society).

THAT NEW TRAVEL AGENCY NAMED “JUST DON’T GO THERE” Concentrate on losing weight for the joy of feeling and looking better, rather than because of the fear of illness or the fear of being lonely. Toss guilt, fear, and shame (the three most common emotions in dieting) out the window, and embrace joy, compassion, and contentment as part of your new attitude about weight loss. Learn to accept and like yourself as you are right now. Understand that you are not perfect and are a “work in progress.” We all are. Do not become defeated by lapses in judgment while you are on your weight-loss journey. Don’t go there. If you learn to like yourself right now, even with imperfections, this will lead to greater happiness and better follow-through with weight-loss behaviors. Eliminate self-criticism. Overweight people contribute to their negative emotions by being very harsh on themselves. In the business world, it has been demonstrated that an uplifting management style is a much more effective way to change behavior permanently than a negative one. Concentrate on positive feedback when things are going right, and leave it at that. Successful permanent weight loss occurs through laughter and happiness. Develop joy through positive physical and social activity. Happy people are busy, unself-conscious, productive, fulﬁlled, and realistic in setting goals. Accept mistakes. Forge close, loving relationships, and focus on the positive. Then watch how easy it is to slim down forever. WHAT YOU SHOULD REMEMBER FROM THIS CHAPTER • You will lose weight permanently with happiness and laughter. • Stress, negative emotions, and mistaken thinking are leading causes of obesity • Concentrate on mental and physical health, and the weight loss will follow.

Turn Your Head and Laugh • The fatter you are, the more likely that you are depressed. • To get thin, believe that eating is pleasurable and exercise is invigorating. • There are several keys to happiness, and they impact weight loss. • To decrease stress and anxiety, eliminate unfulﬁlling work and boredom. • Increase pleasure with music, dance, ﬁtness, and nature. • You are no good to those you love if you use self-destructive coping mechanisms. • Search out comedy, joy, giggling, friends, and spontaneity. • Use daily nonactive moments away from energy and mood-sucking activities. • The way you choose to cope with life’s challenges will determine your weight. • Decrease negative emotions by giving up materialistic attitudes. • Encourage your own positive health behaviors with beneﬁcial selfreward. • Those who lose weight permanently lean on good social support. • The easiest stress-reducing activity: hugs, touches, and cuddling. • Give more of yourself to others, and practice gratefulness. • Be positive-minded in your thinking; guard against pessimists and self-criticism.

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TWO I’m Allergic to Food, It Makes Me Swell: Thought and Mind for Success

I’m a big believer in integrating delight, fun, and happiness into everyday life. We humans underutilize our natural abilities to enjoy life. I bragged to my husband one day, “I have an organ whose only purpose is pleasure and you don’t.” He retorted, “True, but at least I have two organs for thought.”

This book is about lifestyle change; it’s not about a “diet.” Good food choices and increased activity feel positive and are not restrictive. When you follow the ideas of the book, you will say to yourself about your new habits, “I choose this lifestyle because of the wonderful way it makes me feel.” There is no guilt, nor are there any absolute restrictions or commands. You will behave in a certain way because you are positively motivated to do so. Nobody will watch over you, because you will learn to motivate yourself. That’s how permanent weight loss is achieved. As a physician, I see myself as an advocate for my patients. I don’t command or even cajole; I only advise. In this book, I can give you advice, but the ultimate responsibility for your health and habit choices is your own. Once you make positive new habits your own, you will achieve a new level of health, happiness, and easy weight loss that is truly enjoyable, for a lifetime.

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A BALANCED DIET IS NOT SNACK CRACKERS IN ONE HAND AND AN ORANGE SODA IN THE OTHER I work with a nurse who is a 40-year-old single mom of two teenage boys. Her kids are the center of her universe, and she proudly recites their latest perfect report cards and amazing athletic achievements every chance she gets. She has more energy than anyone I know. In fact, recently I asked her, “Linda, are you taking anything that makes you hyper?” She shook her head, laughed, and replied that people ask her that all the time. “I’m high on life!” she exclaimed. Then she showed me a photo of herself from ﬁve years ago. I didn’t recognize the person in that picture. That woman was 80 pounds heavier and looked absolutely miserable. Linda told me about how, when she was fat, her mom used to call her lazy because she had so little energy. Finally, her sluggishness got to her, and she was determined to be a healthier person and a better role model for her sons. She walks every day, drinks green tea, limits her sweets, and eats a balanced diet. Now, she has boundless energy and an amazing positive attitude about life. What an inspiration she is to her two boys, teaching them that they can reach any goal with patience, optimism, and perseverance. She’s so happy and healthy, why wouldn’t she want to feel like this the rest of her life? Linda is African American. When she was 80 pounds overweight, not only did her obesity put her at risk for heart disease, but her misery and sluggishness put her at risk for a stroke. Yes, the Centers for Disease Control published a study in 2000 showing that depression is an independent risk factor for strokes, and that risk is signiﬁcantly higher in blacks than whites.1 Linda’s lifestyle changes are self-propagating. She feels better mentally and physically, and she carries that old photo of her miserable former self to remind her of how far she has come.

LIFE’S A JOURNEY, NOT A RACE Weight loss and maintenance are lifestyle management issues. You aren’t going to keep the weight off if you don’t practice a lifestyle that includes healthy eating and activity, as well as stress reduction. Attitude adjustment is crucial for permanent weight loss. Those who are still thinking in the back of their minds, “When I get to my goal weight, I can go back to my old eating and exercise behaviors” won’t succeed. Don’t even try the ideas in this book if that’s your mindset. You have to accept that this

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new pattern of eating, exercising, and living is just the way it is, forever, and it’s going to be terriﬁc for you. Daily exercise works because it decreases stress, anxiety, and depression. People who exercise as part of a weight-loss plan feel better physically and mentally and are more likely to reach their goals. And, since the goal should be to enjoy the journey as much as the destination, I can’t emphasize this habit enough. People say to me, “I wish I were thinner, but I don’t have time to exercise and eat right, even though I know I should.” Do you like feeling tired and stressed and fat and out of shape? If not, then you have time to exercise and eat better because, in the long run, you haven’t much time for anything else.

Exercise would be much more acceptable to the masses if we saw more regular people exercising on television, not just the elite athletes. In fact, the Olympics ought to go back to being just amateurs only. And let’s make it so all the contestants have to be naked because that’s the way it was originally. Think of what that would do for the TV ratings! Of course, then the Olympic rings wouldn’t be the only things interlocking.

Throughout the book I avoid using the word “diet” as much as possible because that word implies short-term and restrictive behavior. When talking about intake of calories, I prefer to use the term “food choices.” This implies active, positive, lifelong behavior. The truth is, most traditional diets do work for weight loss, but only for a little while. And none has been proven to be superior to the others. That’s because they all do basically the same thing; all diets make us think about what we stick in our mouths. But traditional diets fail eventually because we stop thinking about what we put in our mouths. The only way to modify the input permanently is to ingrain the new eating habits. But the bigger reason that traditional diets fail is that we hate restrictions and commands. When a human feels forced to do a behavior but doesn’t learn to enjoy it, eventually the behavior stops.

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MY SON PRACTICES RANDOM ACTS OF GROOMING Most weight-loss books are traditional diet books because they concentrate on the “diet component,” that is, the food part of the equation for weight loss. Yes, food choices are important, but they’re only a third of the formula. The biggest component of successful weight loss is the mind (behavior), not the food component. And just as big a component as food intake is the activity. An overemphasis on what to put in the mouth misses the truth about permanent and successful weight loss. So now you understand my mentality: “dieting” is not the goal. Rather, the goal is learning permanent good habits for a lifetime. The great news is that you don’t need any willpower for this kind of weight loss, unless you need willpower to brush your teeth! When you were a kid, someone had to remind you to practice hygiene habits. As an adult, nobody forces you to brush your teeth. You do it because you realize that it makes you feel better. Good food choices and proper exercise really will make you feel wonderful. If you follow the advice in this book, you will seek out good habits voluntarily.

THE DISHWASHER DIET: USE THE HOT WAX SETTING (THE FOOD SLIDES RIGHT OFF) I put an emphasis on semantics. Saying “food choices” is so much better than the word “dieting,” which is very negative. Dieting implies a constant battle of restriction, denial, and restraint, rather than positive choices. The joy of choices makes a world of difference in people’s ability to stick to a healthy program and takes away the damaging effects of occasional liberties. One doesn’t feel punished or bad for making a different food choice, whereas failing to follow a restriction is something that obliges one to feel upset or angry. Strangely, restricted diets for weight loss are tremendously popular. Each diet has strict rules about what you cannot eat or drink. Many restrict even when you can eat or limits items at certain stages. Many people respond well to lots of restrictions and rules in the short run but feel deprived and fail in the long run. Very few people stick to those plans for years, and certainly far fewer stay on them for a lifetime. Your job is to learn to make wise choices for yourself, where nothing is completely off limits and nothing is periodically restricted. Surprisingly, it’s not that difficult, and it works better for physical and emotional good health. We become more vested in our own health when we understand and make

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our own decisions. I encourage you to be educated and unafraid of this freedom.

Speaking of being unafraid of freedoms, a friend of mine started dating again after a long marriage and a nasty divorce. Her kids are grown and gone. The guy that she’s dating just got divorced after 30 years of marriage. Over lunch recently, she told me, “Safe sex used to mean ‘use a condom,’ but now it’s ‘oh, good, we didn’t break a hip!’ ”

It’s been shown in the weight-loss literature that when you set up a bunch of strict rules of how, when, or what to eat, the perception is that when you break a rule (which happens inevitably), a tendency to bingeovereat occurs. This is what researchers Janet Polivy and C. Peter Herman, from the University of Toronto, call the “what-the-hell effect.”2 Banishing foods from a person’s diet usually results in increased cravings for that food. Never think of any food as forbidden; then it will never be coveted in an unhealthy or excessive way. Eating without guilt is the goal. Good habits are not stressful and demoralizing; they are uplifting and invigorating. Drop the “do I have to do this the rest of my life” thinking. It’s self-defeating. Nope, you don’t have to do anything. But healthy weight-loss behaviors, done right, mean you’ll want to do them the rest of your life. They’re fun.

THE DANCE INSTRUCTOR WAS SO FAT, HE COULD ONLY TEACH THE CHA Our bodies are built for physical activity, as much as they are built for breathing. To say “I hate exercise” is like saying “I hate breathing”; it just doesn’t make any sense. (We’ll talk more about this point in Chapter 11.) Exercise, done right, builds endurance and self-esteem and lowers stress; it makes you feel mentally and physically better. Duke University did a study that demonstrated a relationship between increasing exercise and lowering stress.3 Overweight individuals were put in a regular exercise program. After six months, the participants in the exercise groups not only had improved heart function and blood

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pressure but also became less stressed when put into an emotionally challenging situation. They dealt with the everyday stresses of life better than those who didn’t regularly exercise. Walk every day before work, and you will be able to handle both the difficult commute and your annoying coworkers! When you exercise, think about the positive changes your body is going through. Recognize the improvements that you see and feel on the outside, and envision the improvements that are happening on the inside. Note that the blood vessels are opening, the muscles are building up, the fat is truly melting away every time you move. Your brain is growing clearer and sharper. The hormones are happily signaling youthful messages to your private parts (ah, what a vivid imagination you have—keep going with that thought . . .) Even though you need to visualize those improvements that you can’t see, they are just as important as what you can see.

I HAVE NO CONTROL, I LOST MY REMOTE People who have chronically dieted with restriction often feel they cannot trust themselves around food. The attitude is “why should I trust myself, when I’ve failed to lose weight so many times before?” The ability to trust yourself to eat what you want, when you want, and how much you want is extremely basic. You must have this belief to be successful at permanent weight loss. Abandon the battleground in your head. What do you love to eat? Self-trust leads to self-respect. How can you respect yourself if you don’t even let yourself enjoy your meals? What if you ate only food that was tasty and pleasurable? Do you do that now? Chances are that if you are overweight, not only do you deprive yourself of your favorite foods, but you might not even remember what they are. Spend time relearning and rediscovering what foods you truly love to eat, both those that are nutritionally packed and otherwise. Try new tastes, new combinations, new textures, and new spices. Don’t be afraid to experiment; explore and enjoy. Learn to love food and eating again and you will learn to respect your body and yourself. People who chronically diet have increased feelings of failure, lowered self-esteem, and social anxiety. Dieting makes you feel lousy about yourself. When you constantly “cheat” on a restriction diet, you lower your self-esteem. This leads to anxiety and depression, which lead to obesity. It’s a vicious cycle that is rampant in our society.

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I have a good friend who is very overweight and swings from one fad diet to the next. Two years ago, she went on an all-fish diet and lost 60 pounds, then gained it all back, plus 20 more. Usually fish is one of the better foods for weight loss, when eaten in moderation, except for swordfish, which is high in mercury. It should be eaten only rarely. But the good news is that, when cooking swordfish, you don’t have to check the temperature—it tells you what it is.

A SIGHT FOR BLIND EYES Remember to treat yourself with kind and gentle words. Think and believe that you have the right to be fed and nourished, body and soul. This means avoiding disparaging remarks from the person who is most likely to dish them out—yourself. How often, honestly, do you look in the mirror or at your reﬂection in a window and self-criticize? Most overweight people do it all day long, often not even realizing it. Focus on the person you are and the inner strengths that you have. Pick speciﬁc character traits or accomplishments that have made you proud. Move away from self-damaging mental scripts that many people run over and over in their heads. The ﬁrst step is becoming aware that you do it. The next step is replacing the script with words that nurture. The third step is repetitive practice and devotion to positive thought. Interestingly, although the mental script is entirely your secret thoughts, I guarantee that if you convert those mental comments from constant negatives to positives, others will notice your improved attitude. People who think positively about themselves (without being grandiose) are extremely attractive to others. Those whose internal thoughts are negative and critical subtly drive others away.

It’s amazing how much your spirit and emotions can be detected by other people, and sometimes in the most unusual ways. A woman who lives by me advertises that she is a spirit photographer. She says that she can take photos of the colors of your natural aura for you, your kids, and even your pets. The more money you have, I guess, the greener your aura.

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Weight loss and maintenance are an ongoing process, so don’t think in terms of “mistakes.” When either eating or activity isn’t pleasurable, take the time to ponder why and learn from that, without guilt or selfrecrimination. Even binging one time won’t destroy a body. Learn and move on, but lose the habit of chronically binging and restricting. Eat smaller amounts of yummy food without the emotional chains that drive people to feel deprived. Realize that most people who lose more than 20 pounds do it successfully over a period of 6 to 24 months. Quick, permanent weight loss does not happen, and it is dangerous and damaging to the body to attempt it.

THERE’S NO ACCOUNTING FOR WAIST Some people are internally driven, that is, they use their own thoughts and emotions to assess and motivate themselves. But many people are externally motivated. They need others to tell them their accomplishments, tasks, and self-worth and to encourage motivation. This is an important point: those who are externally driven are more likely to be overweight, since so many cues to eat surround us in our modern existence. If you are externally driven, you may undermine your ability to lose weight by blaming others for your own behavior. You may say that you can’t lose weight because “my husband likes to eat out a lot” or “I have to keep junk food in the house for the kids.” Nobody forces you to put food in your mouth, and nobody forces you to sit on the couch at night except yourself. (However, if people are tying you to the couch and force-feeding you potato chips, I suggest you put this book down and call 911.)

DEFINITION OF LAZY: WHEN YOU THINK “A NEW EXERCISE” MEANS MASTURBATING WITH YOUR LEFT HAND You will not reach permanent normal weight until you take responsibility for your own actions or inactions. The buck stops with you now. If you are externally motivated, you will need to outline speciﬁc steps, measure outcomes, and set up your own external cues to succeed. In later chapters, I’ll talk about how to do this, but you should be aware that you need a major revision of your environment for your new lifestyle

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habits. This may include putting more emphasis on limiting exposure to the not-so-good-for-you foods and being selective about your exposure to friends and family who do or don’t support your efforts. This may also include things like placing obvious cues to exercise, such as the stationary bike in front of the television. Take steps to put yourself back in the driver’s seat of your health. The more control you have, the more likely you will get to your goal. And note that research has shown that people who exercise regularly while losing weight feel more in control of the process and are more likely to lose the weight permanently.

Beware, there are exceptions to the rule that exercise makes you feel more in control. Golf is not an exercise that breeds that feeling. What is it with golfers and those little head covers they put on their drivers? They’re thinking, “It protects my club so it won’t get scratched.” Then they take the cover off, whack a hard ball as fiercely as possible, hit a really bad shot, wrap the club around a tree . . . then put the head cover back on.

Why is control so important in weight loss? It’s because not every person who succeeds does it the same way. This book is a description of the best proven techniques that lead to sustained weight loss. However, no program is “one size ﬁts all.” Take what works for you and make it your own. To keep weight off permanently, you should individualize the ideas from this book to ﬁt your own style so that you can maintain your success through the years. Persistence is the key. Keep trying different ideas from this book, until you ﬁnd the best ﬁt for you and your lifestyle. Those who succeed keep trying different approaches until they ﬁnd the methods that work for them. Then they stick to those methods. THE THIN-YOUR-WALLET DIET Many people are under the impression that they can lose weight only in a special program, whether it is a diet center or a costly food plan. Interestingly, the research shows that the majority of long-term losers of major amounts of weight have traditionally done it on their own,

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outside a special weight-loss program.4 I believe this is because people who learn to take their signals from their internal environment and are self-motivated will do better. They accomplish this without the structure of a specialized weigh-in program or using diet-program foods and supplements.

There are so many dietary supplements that don’t work. People don’t realize there’s no government regulation for checking the effectiveness of the claims of any type of nutritional supplement. People out there are selling supplements that are supposed to boost memory and cognitive function by “increasing blood flow to your brain.” The funny thing about that claim is the real medical research shows that the better your brain is functioning, the less blood flow it requires. Psst, want to be Einstein? I’ll sell you something better than a supplement. I’ll sell you a tourniquet to put around your neck.

Some people initially lose weight with a structured program, such as Nutrisystem, Jenny Craig, or Weight Watchers, but then most design their own maintenance program for the long term, for the years afterward. Very few people who lose weight and keep it off stay in a structured weight-loss program for years. Occasionally, people who were in such a program return to it when they notice their weight creeping up. There is no relationship between the cost of a weight-loss program and its long-term success. Realize that there is a difference between a structured weight-loss program and groups that offer only social support and encouragement. A study published in 2009 in the journal Evidence-Based Nursing found that structured diet groups sometimes worsened participants’ feelings of low self-esteem, negative feelings, and self-blame.5 However, the National Weight Control Registry found that groups that offer positive social support are very useful to successful big-time weight losers in both the short and the long term. Stop blaming your body parts. I hope you aren’t thinking, “If it weren’t for my big belly, I’d be happier.” That’s silly. Realize that you are more than your weight. Do not base your self-esteem on a number on a scale.

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HE WHO HESITATES—IS LATE Don’t procrastinate on happiness or on making changes. Having goals is important, but, if you delay your happiness until you reach your goal, you’ve missed the point of life. Concentrate on your happiness along the way and the journey will be more enjoyable. If you postpone happiness until you reach your goal, it is likely you will never reach it or that you’ll still be miserable when you get there. Life is a balance. Denying oneself pleasure in the present so as to live a pure life mentally and physically is demoralizing. The best solution is to seek physical, intellectual, and emotional pleasures that are not harmful at work and in personal relationships, as well as in eating and exercise. Find physical pleasures that you can do now that are positively rewarding. It is difficult for many overweight people to accept that they eat too many calories. Most obese people want to blame slow metabolism, hormones, or increasing age. If you are overweight, you are eating too much for your body and its present activity level. There is no way to get around that fact. You will never succeed in permanent weight loss until you are willing to accept the fact that you are ingesting too many calories for your body at this point in time.

YOU LOOK LIKE YOU BELONG IN HOT AND SOUR SOUP One of the most common reasons that people take in too many calories is emotional eating. Dr. Edward Abramson, author of the book Emotional Eating, describes anxiety, depression, boredom, loneliness, and anger as the major emotional triggers. He says that emotional eating usually takes the form of spontaneous snacks, not planned meals, since the calories ingested are in response to immediate emotional distress. Often these snacks are eaten after a regular lunch or dinner, when the person has recently eaten and is clearly not truly hungry. If you ﬁnd that you frequently eat when you are not hungry or overstuff yourself, you may need to ask yourself if you are eating to satisfy a deeper spiritual need. Men do not report emotional eating as much as women. This may be because they do less of it or because they just don’t recognize that their emotions are tied to their eating. Boredom, the biggest cause of emotional eating, is probably one of the biggest triggers for male overeating. Yet men do not see boredom as a root cause of excess calories. Boredom

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comes with fewer physical signs than other emotions and gets missed as an emotion. FRANKENSTEIN WAS LEVEL-HEADED How do you avoid emotional eating? If you ﬁnd yourself reaching for food and you aren’t truly hungry, identify the emotion. At home, perhaps you need to go out and garden, sit by the ﬁre with a cup of herb tea, take a walk, call a friend or family member, write something inspirational, read, or clear your mind. Would meditation or music help? How about just deep breathing and relaxation? Maybe you need heavier breathing and some great sex?

When you “phone a friend” for comfort, just remember to eventually hang up. I have a relative who calls frequently and never stops to take a breath. They’ve invented a pedometer to count the number of steps you take in a day, but there’s no wordometer to measure words spoken in a day. Can you imagine how many husbands would buy that for their wives? Husband (ears bleeding, checks device): “Honey, you’re at you’re 10,000 word limit, now shut up!” I could make millions on that invention.

Meditation, which we talk about in a later chapter, allows you to be more aware of your physical and emotional states and satisﬁes needs other than hunger. It tunes you into those needs and makes you less inclined to indulge in emotional eating. Emotional eating is a response to poorly understood agitation of the mind. Becoming aware of your inner states decreases that muddle. How to deal with anger? If you are angry, decide if it’s serving a purpose. Do you need to be angry? How can you defuse the anger? Would relaxation and meditation work, or do you need to confront the focus of your anger? Would writing down your feelings help, or would exercising help you to blow off steam? Should you go for a walk and calm down? Do you need to read about anger management or even take a course on it? Anxiety can feel like “butterﬂies” in the stomach. Some people feel those butterﬂies and try to feed them, mistaking the feeling for hunger.

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If you are chronically anxious, you may subconsciously feed your butterﬂies, rather than deal with your anxiety. (Chronic anxiety disorder is the most common undiagnosed and untreated psychiatric illness.) You should identify what makes you anxious and ﬁnd ways to reduce the anxiety either by seeking treatment or by dealing with the source. Or you should practice reducing anxiety through breathing exercises or meditation. Then you will succeed in avoiding this common cause of overeating.

There’s no doubt that modern life leads to a lot of difficult emotions and stressful situations. Did you ever wonder about Rapunzel’s reaction to being saved if she were a modern woman? She’s locked up in a tower, away from kids, boss, stress, and traffic. Hey, it sounds pretty good to me. Modern Rapunzel: “Go away! I don’t want to be rescued. And get off my freaking hair!”

Are you lonely? Get on line and ﬁnd someone decent to chat with. Join a class or a support group, or arrange to teach a skill at your local community center. Sign up for a hobby club, exercise class, or the racquetball league. Volunteer at a school, hospital, nursing home, or pet shelter. Make yourself useful to others and they will reward you 10 times over. What if you are bored? If you ﬁnd yourself rummaging in the cabinets for food and you are not hungry, you are very likely bored. Go for a bike ride, call a friend, visit a neighbor, do crafts, grab a fun book, or watch the educational channel on television. If you are bored at work, ask for more challenging assignments or learn new skills. Do something that stimulates your mind and your heart. MEET MY FRIEND, THE INCREDIBLE SULK Are you depressed? If seriously depressed, seek professional help. If more mildly depressed, the best treatment is daily moderate aerobic exercise. A walking program works as well as medications, and the research is pretty consistent on that point.6 Exercise is mood-enhancing, so you’ll treat your mind and body in one fell swoop. Call people who make you laugh and write to people you love. Seek out friends and helpful support.

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Take a mental health day from work and responsibilities, but not to sit home and brood. Instead, do something positive and uplifting with your day off. Go to the park and ride the swings. Walk in nature. Play, laugh, sing, and force yourself to get out of your depressed comfort zone. Recognize that your mood is down and make a deliberate effort to change it with positive activity. Read about depression on university Web sites and ways to recognize if it’s serious enough to warrant professional intervention. Depression causes most people (normal weight and overweight individuals) to eat more, but people trying to lose weight who are depressed overeat the most calories.

I believe in communing with nature to lift the spirits. But here in Florida, the nature often comes to me. I’ve had snakes in my closets and a wolf spider that was bigger than a tarantula in my baking pans. I’ve had large frogs come up from my sewer akin to a biblical plague. The nickname of Florida is “The Sunshine State,” but the motto should be “What the hell is that in my commode?”

If you think you are emotional eating, do the following: 1. When you are about to eat, ask yourself, “Am I truly hungry? ” If yes, go ahead and eat. 2. If not, think about why you feel the need to eat; pin down the emotional triggers. 3. When you have determined the underlying cause, act on the triggers, and ignore the urge to eat. Find another constructive outlet that isn’t taking in calories. Remind yourself that you are in control of your behavior and that you have the capacity to break old habits, no matter how ingrained. 4. “Groove” the habit by practicing steps 1–3 each time you are about to eat until the process becomes automatic. Your goal is to eat only out of hunger.

EAT, DRINK, AND BE BURIED If you avoid dealing with what is bothering you or use escapism as your form of coping with difficult problems, you are more likely to overeat and gain weight. People with escapist and avoidance tendencies also

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tend to excessive drinking as well as other addictive behaviors. Oversleeping, excess television watching, and similar behaviors are often used to numb emotions when someone is unwilling to confront problems.

Recently, a news program announced that researchers are very close to producing human babies without men’s help. Soon, women will have no purpose for men, they claimed. That’s not true. Women need to have men—who else would we have to blame?

Some people use food like an addiction. Food becomes another destructive way to soothe the hurting soul. Dr. Mark Gold at the University of Florida has stated that he believes hedonistic overeating is an addictive disease and needs to be treated the same as other addictions.7 His research shows that, in obese people, beef broth does nothing for brain chemicals, but Kobe beef lights up functional brain scans as if an addictive drug were being given. Food causes dopamine release like sex does. Receptors light up in PET brain scans as they do in cocaine and alcohol abusers. When overeaters are shown a photo of the Golden Arches, their brain brightens like a ﬁreworks display at Disney World. Interestingly, the portion of the brain devoted to the sensations of texture, taste, and feel of the mouth and tongue is also enlarged in overeaters, thereby reinforcing the sensual pleasures of food. In Chapter 9, you’ll see why this isn’t a bad thing.

Addiction is one of the greatest scourges of humanity. I don’t understand the push by some people to make illicit drugs legal. What’s next— forcing the drug cartels to dispose of their old cocaine by using it as bricks on their enemies? Then the coke will have to have a stamped “best if snorted by” date.

If you think you are suffering emotionally, get help. People with real psychological problems that need treatment lost only half the weight of those without emotional problems in the same weight-loss study. Don’t focus just on your weight. You need mental and physical strength and healing to achieve your weight loss goals.

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Laugh Yourself Thin Addictions are a serious problem in my patient population. Still, as a physician, I have a problem with the euphemism “substance abuse.” I’m fairly certain that chocolate and peanut butter are both substances. And I will admit I’ve occasionally used them for the euphoric mood they produce, not because I was hungry. I’ve even used them together. Does that make me a multiple substance abuser? Someday you’ll find me in a dark alley whispering, “Ghirardelli dark and Jif creamy, oh God, I need it quick.”

Emotional eating is not always a negative. Sometimes we are feeling emotions that we don’t want to admit, even to ourselves. If you are reaching for food and aren’t hungry, use that behavior to analyze what is bothering you. Let it become a positive signal, as if you have an early warning system for your emotions. Then act on them before they overwhelm you or lead you into crisis. JEWISH AND CATHOLIC GUILT IS SIMILAR, EXCEPT CATHOLICS HAVE ORIGINAL SIN AND JEWS HAVE EXTRA CRISPY There are a lot of mind games that people play with themselves that undermine their success. Teach yourself that food isn’t the enemy, and neither is your waist or the scale. Learn that weight loss shouldn’t be painful and that pleasure in food and activity is safe and encouraged. Eliminate guilt and enjoy physical indulgences and you will actually eliminate “yo-yo” dieting. There are a lot of myths in weight loss that aren’t substantiated by the health research. Here are the myths and the truths: Myth: I’m fat because of my genes. Fact: Yes, some people certainly gain weight more easily than others, but our present obesity epidemic has nothing to do with a sudden appearance of fat genes in our DNA. Look at the old photos or videos of slim people from the 1970s and earlier. These people have your genes. Get them back. Myth: I was fat as a kid, so I’ll be fat my whole life. Fact: It’s harder to lose weight the longer you have it, but that’s probably due to lifelong behaviors that become more ingrained over time. You can always change behavior. (Interestingly, according

I’m Allergic to Food, It Makes Me Swell to a 2005 article in the American Journal of Clinical Nutrition, it’s also easier to stay thin the longer you’ve been thin. This is true even if you were very obese when you were younger.) Myth: There’s a 95 percent failure rate for diets, so why bother to try? Fact: That oft-quoted statistic comes from the toughest cases at university centers and also from measuring each attempt at a shortterm restrictive diet. We already know those don’t work. Duh! Myth: I’m fat because I have character ﬂaws and no willpower. Fact: You are overweight because you have learned lousy behaviors that aren’t any fun, lowering your self-esteem and increasing guilt. These behaviors have nothing to do with character ﬂaws or willpower and can be changed with simple behavioral intervention.

IF WE COMBINE THANKSGIVING AND PASSOVER, WE CAN HAVE THE NEW HOLIDAY OF “LEFTOVER” Myth: I can lose weight only if I have a target date to be thin. Fact: Many people target speciﬁc life events or holidays in their weightloss goals, for example, “I want to lose 25 pounds by Christmas” or “I want to ﬁt into a size 6 wedding dress.” This is outrageous and self-defeating behavior. If your mindset is to “be good” just until you can ﬁt into those special clothes on that special day, then you will face only frustration afterwards. You must think long term. Your target date is everyday and no day; it’s the rest of your life. If you can’t get your head around that idea because of a lifetime of crash dieting, please work on it. Accept this important point, and you will eventually enjoy lifelong normal weight success. Ignore it, and you commit yourself to a lifetime of yo-yo dieting and unhappiness.

The wedding day is still the most common target date for crash diets. But due to changes in society, weddings are less common than they used to be. On the other hand, things are looking up for the funeral industry, as baby boomers are dying in droves. In fact, wedding planners are now doing funeral arrangements so they can stay afloat. This is a quote from an article in my local paper, given by a funeral director: “Other than the fatality, what’s the difference between a wedding and a funeral?” Well, in one case, you’re less likely to have kids afterwards.

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People who successfully maintain long-term weight loss monitor themselves constantly. As soon as they notice a slight weight gain, they have an action plan to reverse the trend. This is a normal part of the process, not a failure.

Myth: I can’t quit smoking because then I’ll gain weight. Fact:

If you dispose of addictive behaviors, you gain control over your life. And the more you practice healthy habits, the more likely you are to lose weight permanently.

I have patients who insist on smoking while wearing oxygen. I’ve been thinking of opening Doctor R’s Institute of Patient Rocketry. This reminds me of an 89-year-old patient of mine who explained that she started smoking as a child when her mother forced cigarettes on her. Up in the mountains, they thought it got rid of intestinal worms. The lady is still smoking 80 years later. I said to her, “Isn’t it funny that worms are smarter than people? They know to leave when tobacco is around.”

Myth: I can’t have a baby and lose the weight afterwards. Fact: Most women who are successful long-term losers do it. You can, too. Myth: I’m fat because I love food. Fact: Food and love are four-letter words, and sometimes we treat them like that. Most overweight people actually have many negative emotions tied into food, like guilt, fear, and anger. Loving food isn’t evil. It’s not foul-mouthed or even wrong. It’s okay to love food. We’re born with the capacity to suckle the breast; that ﬁrst food we encounter is comforting. So don’t be hard on yourself if you truly love food. It’s normal.

IF WORDS DIDN’T MATTER, THEN ALL LOOSE WOULD BE BREAKING HELL Once again, notice the semantics that I use. This is a “journey,” not a “battle” against obesity. Don’t downplay the importance of the phrases

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playing in your head. Think about how differently you feel when you say to yourself that you are in a “ﬁght” rather than a “learning experience” about your weight. Reframe the words and thoughts that you use, to yourself and to others, when thinking about eating, exercise, and your approach to weight loss. You are not “avoiding” certain foods; rather, you are “choosing” more of this food or less of that food. When things don’t go quite right, it’s another “learning opportunity,” not a “failure.” AND ON THE EIGHTH DAY, GOD MADE CHOCOLATE Remember, no matter how bad life is, it can always be better with chocolate. Unless, of course, you are severely allergic to chocolate; then it will be over.

Good self-esteem is needed when weight loss begins and is often propagated by losing weight. Don’t live for the day when you lose the amount of weight that you want; start living and enjoying today. People who deprive themselves of pleasurable food often get into a habit of depriving themselves of other joyful things like dancing, riding a horse, or even taking a vacation. How emotionally damaging is that?

Not every vacation is full of fun and joy. The last cruise I went on, the economy was at its worst. For many people on board, they were looking at a lifetime of investments and retirement savings suddenly gone. Everyone was so depressed that at the muster station, the crew was teaching people how to take their life jackets off.

Be careful with focusing on negative body image; this can lead to selfcriticism and unhappiness. Overweight people often delay socializing or having enjoyable experiences, like going to their high school reunion, waiting until they have their idealized body. Take steps to say and believe that you have a positive body image now and always. Have those

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special experiences now, as that will lead to more happiness, which leads to more success in weight loss. Buy the clothes that make you feel beautiful and handsome now, not when you are a size whatever smaller. Enjoy them; this will bring you closer to thinness and to mental and physical health. Misery, self-deprivation, and neglect certainly won’t. Take the time to make yourself look your best now, every day. Do what you can now to improve your self-image, both inside and out. Don’t wait until some nebulous future time. Chinese fortune cookie: “Over every mountain there is a path although it may not be seen from the valley.” You may feel like you are looking upward at a very steep mountain to reach your weight-loss goals. If so, redirect your view. Start looking at the lovely foothills right in front of you. Then you can enjoy the path along the way. WHAT YOU SHOULD REMEMBER FROM THIS CHAPTER • Good food choices and activity are desirable and not restrictive. • Attitude adjustment is crucial for permanent weight loss. • Saying “food choices” instead of “diet” implies active, positive behavior. • Traditional diets fail because we hate restrictions and commands. • Healthy behaviors done right are fun. You’ll want to do them the rest of your life. • There is a direct correlation between increasing exercise and lowering stress. • When you love food and eating again, you learn to respect your body and self. • Traditional dieting makes you feel lousy; eat without guilt. • Treat yourself with kind and gentle words. • Weight loss is an ongoing process, there are no mistakes. Learn and move on. • If you are externally motivated, you are more likely to be overweight • Individualize the ideas here to ﬁt your own style, and be persistent. • Most big-time weight losers lose weight on their own, outside a structured program. • Your self-esteem isn’t a number on a scale. Don’t procrastinate on happiness. • Anxiety, depression, boredom, loneliness, and anger are major eating triggers.

I’m Allergic to Food, It Makes Me Swell • Escapism and addictions are destructive forms of coping and lead to overeating. • Address the myths and mind games of weight loss. The truth will make you thin. • Use upbeat words and positive body image and thoughts, right from the beginning. • People who deprive themselves of pleasurable food deprive themselves of other joyful things. Live and enjoy today.

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THREE Tossing Your Cookies: Food Behavior That Works People who are fat have fat kids. We know that. The argument is whether that is the effect of nurture (environment) or of nature (genes). Since fat families also tend to have fat pets, I’m betting it is more nurture rather than genetic predisposition. Unless, of course, you are related to your pets. If you have been blaming your obesity on your lousy genes, it’s only going to make your ancestors feel bad, and it’s not going to help you get healthy and skinnier. Leave Aunt Tillie out of this. However, if Aunt Tillie was the one who taught you to always eat dinner at 8 p.m. and never to leave the table until you clean your plate and that exercise is only for athletes, then Tillie is in the doghouse after all.

MY BIRTHDAY SUIT IS TIGHT I ﬁrmly believe that it doesn’t matter how much a person exercises or how little he or she eats if there isn’t change in the fundamental underlying behaviors that result in weight problems. Short-term successes will be lost every time. Those behaviors are the result of habits, as well as expectations and assumptions about food, eating, weight, and activity. Most of these behaviors are formulated in childhood, reinforced in adulthood, and carried onward for a lifetime. Permanent weight loss occurs when we examine and change our actions. In this chapter, we discuss proven successful food behaviors. In the next chapter, we talk about bestknown behaviors for activity.

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Laugh Yourself Thin If you are not certain which actual foods are the best for your body, don’t worry; we’ll discuss that in the “good food choices” section of the book. However, I can give you a few hints here. If you buy most of your foods at Nutrition Whorehouse, you’ve got a problem. If you frequently visit restaurants with names such as Seat’s Up Bar & Grill, Crème de la Phlegm, or the Poached Roach, you definitely need help. And don’t be afraid to get educated if your favorite diner has a sign outside that says, “Try our rib-eye steak, our black-eyed peas, and our blue-eyed waitress.”

A great resource for anyone aiming for permanent thinness is the National Weight Control Registry.1 The brainchild of two researchers at Brown Medical School and the University of Colorado Health Sciences Center, it collects stories of successful weight losers and analyzes their behavior. What makes their research important is the size and permanence of the weight loss among the participants. Registry members, so far, have lost an average of 66 pounds and kept it off for more than ﬁve years. About half the participants lost weight without any outside help or formal program. Almost all modiﬁed their food intake, and 94 percent increased their activity (most of them still walk, exercising about an hour a day). The majority eat breakfast regularly, get on a scale weekly, and watch less than an hour and a half of television a day. These people changed their behaviors and continue to follow their new practices, years after they originally lost weight. They developed permanently good habits and eliminated their bad ones. That’s the way to get thin and stay thin forever.

You can call bad habits anything you want, but they are still bad behaviors that lead to rotten outcomes for your health. Not that long ago, Minnesota passed a law that banned smoking in public places, except for actors on a stage. Some bars got the wise idea to set up stages and began calling their patrons “actors” to get around the ban. One establishment said the patrons were performing The Tobacco Monologues. Gee, I’d hate to think where they were puffing from. “Oh, look, smoke rings!”

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IF WE LIVE EVERY DAY AS IF IT IS OUR LAST, THE LAST ONE COMES QUICKER I can’t emphasize enough how important it is to examine the habits that drive your behavior. Eating and exercise behaviors are mostly habits. These habits keep us fat or thin. The nice thing about habits is that once the good ones are learned, they can be maintained for a lifetime. They deﬁnitely get easier over time, as they become completely ingrained. You may feel a bit overwhelmed or defeated by previous attempts at weight loss. But if you truly follow the advice in this book, someday you will be thin permanently and without effort.

That’s the thing about following advice. You have to choose wisely whose sage advice you follow. I remember once being told, “Whatever doesn’t kill you makes you older.” I’m still not certain how useful that was. Perhaps a more relevant quote here is what FDR said: “The only thing we have to fear is fear itself—and cupcakes—cupcakes are evil.” Look, okay, just follow my advice.

Thin people may not have a naturally higher metabolism than those who are fatter. But they may be more active on a daily basis and stop eating when they are no longer hungry. They may naturally practice all the behaviors of successful permanent weight losers; they just never got fat to begin with. Thus, next time you think about someone who is thin and has never had a weight problem, realize that the person may have a metabolism just like yours but a behavior pattern that is different. Understanding this message will change your life. THIS DIET NOT FIT FOR HUMAN CONSUMPTION Many of us were raised at a time when families ate together. If you are a boomer like me, you probably ate with your parents, at least for dinner, most nights. The entire family got together around the table and laughed at one another. Then we ate lots of overcooked vegetables, fatty chicken, meats, and lard-laden breads. And don’t forget the tons of mashed potatoes and syrupy-sweet desserts. Ah, ignorance was bliss! In my family, as in most families at that time, dinner was at a speciﬁc time. You didn’t eat beforehand, or you might “ruin your dinner.” You

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also ate what everybody else ate (and you didn’t complain if you knew what was good for you). You cleaned your plate of whatever was served to you or you would not get dessert. Take a moment to think about each one of those eating behaviors and the dangerous assumptions that go along with them.

CPR—IT’S WHAT’S FOR DINNER Dinner was the biggest meal of the day. It was usually served fairly late, when everybody was ﬁnally home. That makes sense on a social level. One of the complaints of the present-day family is that no one has time to talk and families now rarely eat together more than one night a week. People should talk, and they should eat together. But saving most of your calories to be eaten shortly before bed is not good for you because it may cause indigestion and reﬂux. In fact, eating ﬁrst thing in the morning and making your breakfast and lunch your biggest meals is safer and may burn more fuel, although that last point is still far from proven.

Even though I’ve painted a picture of perfect familial togetherness, nothing could be further from the truth in my family. I was convinced I was adopted. You see, I really wanted to be. My brother, sister, and I couldn’t be more different. Sometimes I think I nearly drowned in my family’s gene pool. Which reminds me of a sign on a liquor store that I saw recently: “We treat you like family.” I hope it’s not like my family, because then if you bought a bottle at that store, it would have already been open with only a few drops left.

Eating before dinner was a crime in my family. If you had a piece of fruit or drank a glass of tomato juice before you sat down for the meal, you would eat less, a lot less. Mom and Grandmother would get mad because they had worked so hard to cook the food. (They were both overweight, by the way). Now we know that if you eat or drink certain low-calorie foods just before sitting down to your meal, you will signiﬁcantly reduce how much you feel like eating. (We’ll discuss which foods are scientiﬁcally proven to be helpful and why in Chapter 6.) When you are trying to cut back on calories, that hunger suppression effect is a big plus.

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THE PRUNE DOESN’T FALL FAR FROM THE TREE You may have been taught to eat what was served to you, when it was served to you, whether you liked it or not. There is a certain convenience to that for the cook. But learning to eat what everybody else is eating can be dangerous, especially if that becomes an ingrained habit. You go to parties and eat, even if you are not hungry, because everyone around you is eating. You eat pizza and drink beer at the Super Bowl party because you think you are supposed to. You go out for lunch with coworkers and start eating the bread when your boss grabs a piece and proceed to keep right on eating through dessert because Sandra from Marketing ordered the cheesecake. You wouldn’t want her to have to eat her dessert all alone.

It’s like we’re all giant starfish. In order to eat, the starfish must throw up its entire stomach. The stomach then grabs lunch by surrounding it and the organ and meal then return inside the animal to digest. Imagine if humans did that—the cafeteria line at work could get very entertaining. That’s one way to clean your plate.

One of the most dangerous behaviors that many of us were taught as children was the command to “clean your plate.” Often we are told that leaving food on a plate is considered rude. A popular phrase when I was young was “Finish that food, children are starving in China.” Sometimes my friends’ parents told them that children were starving in Africa. I never did understand why if my friends or I overate, that would help those malnourished kids on another continent.

LEFTOVERS GALORE—WASN’T THAT THE NAME OF AN OLD STRIPPER? My husband claims that the “clean your plate” command resulted from the Depression-era households that couldn’t afford to waste food and couldn’t even store leftovers properly. If you didn’t eat the food that was in front of you, it would spoil. So eat now, or be hungry later. Perhaps that was true then. But, even when I was a kid, we had Tupperware and refrigerators.

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I HEARD THAT PARENTING GETS EASIER WHEN YOU DIE The end of the meal for most children comes complete (they hope) with a dessert. But often that dessert is only for the “good” child who eats everything he is served prior to the sweet. “If you ﬁnish your broccoli, I’ll give you chocolate pudding” seems like a great parenting idea until you think about the underlying message. That unspoken message is “If you overeat from those calories still on your plate, I’ll let you eat even more unnecessary calories as a reward.” Most of us who have struggled with a weight issue have learned to eat beyond when we are hungry. Cultures that are thinner don’t do that. Bradley Willcox, MD, of the University of Hawaii, has published extensive research on Japanese longevity, weight, and health habits and compared them to those of the Western world.2 The people of Okinawa are some of the healthiest, longest-lived, and least overweight people on the planet. Traditionally, they practice the concept of hara hachi bu, which means “eat until you are 80 percent full.” Never eat until stuffed or bursting, they tell their kids. The French, it is claimed, learn to gauge their internal signals for when they are satiated (no longer hungry). It is acceptable to stop eating, even if everyone around you continues to gobble down the brie, baguettes, and wine. There is now good evidence to show that people who are overweight no longer check their signals for hunger, according to Dr. Walter Willett, professor of epidemiology and nutrition at the Harvard School of Public Health.

ON A SCALE OF ONE TO TEENAGER, HOW HUNGRY ARE YOU? It is a rare person who is born without the signal to stop eating when full. Most babies come with those signals hard-wired in at birth. Honestly, I have never read one medical report about a baby who ate until her stomach burst. As infants, we cry when we are hungry and we stop feeding when we have had enough. Even the baby who eats a little too much learns to vomit it up. My son was an expert in projectile vomiting—he could hit the opposite kitchen wall so well that I considered taping up bright red targets. Eventually, even he learned to judge when his stomach couldn’t handle any more; the embarrassment and discomfort of vomiting teaches us to stop eating before we get to that point. Those signals to stop eating when satiated come from our stomachs and our brains via stretch receptors, nerve signals, and hormones.

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The exact process behind satiation is still unclear. However, scientists have isolated the mosquito feeding regulation gene. Eliminate it and the bugs suck blood until they literally explode. That would be one way to solve the mosquito problem. I suppose the insect rights people might put up a fight about that. If so, we delete the gene in them too, and then they eat until they explode.

Beyond the age of ﬁve and for the rest of our lives, we humans turn to external cues (our environment) to tell us when and how much to eat. We learn to ignore our stretch receptors in our stomach that tell us to stop before we have had a second helping of turkey on Thanksgiving. We become oblivious to our hormonal levels that tell us our calorie intake is already sufficient and there is no need for dessert at that fancy anniversary meal. It may even become routine to eat until stuffed, instead of 80 percent full because that is what we were taught as children. Eventually, those extra daily and routine unnecessary calories add up. We start to fatten. People eat for all sorts of reasons, hunger being just one of them. Getting back to eating because you are hungry and stopping when you are full will go a long way toward your goal of permanent weight loss. I NEVER MET A CALORIE I DIDN’T LIKE Stress, emotions, and habits cause people to take in too many calories. According to Dr. Brian Wansink, the head of Cornell University’s Food Laboratory, it is very common for people to begin to eat even when they are not hungry. Some people tend to eat when they come home from work or school. Many of us eat at scheduled times for our meals or snacks, whether we are hungry or not. At work it becomes automatic to head to the break room for that bagel or donut mid-morning and to return mid-afternoon for the vending machines. At home, before bed, or in front of the television, you reach for the chips or crackers. It’s a habit you’ve had for years. You are probably feeling fatigue or boredom more than hunger, but it’s just the way you’ve always done things. We all have times when we eat on autopilot. My circadian rhythm is such that by early evening I might still be awake but not genuinely conscious. After 8.30 p.m., I make an excellent

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paperweight. This is one of my traditional food-rummaging times. It is for a lot of people. For many of us, it’s those automatic behaviors that drive our weight problems. It seems so simple to say, “Well, then, I’ll just start eating when I’m hungry and stop when I’m not.” The difficulty lies in the fact that we may not even know when we are hungry anymore or remember how to tell when we truly need to eat. If you aren’t hungry at dinnertime, then why eat? Many overweight people have forgotten the internal signals that tell them whether or not they are truly hungry. It sounds almost ridiculous, but medical research supports this fact. (See Chapter 5 for details.) BEER, PIZZA, AND CHOCOLATE, THE UNHOLY TRINITY Slow down when you eat. The body takes its time deciding when it is full. There is quite a delay between the time the hormonal signals travel from our stomach and small intestine through the bloodstream to the receptors in our brain. It can be 15 to 20 minutes from when our stomach starts yelling, “Help, I can’t take anymore, close the chute!” to when our brain gets the message to tell the hands to stop shoveling food into the mouth. If you are shoveling rapidly with lots of high-calorie foods, like pizza or cake, you can do a lot of excess calorie damage before your sluggish system reports, “All full, sir, and ready for shut down.” In the days before beer, pizza, and chocolate, our system had that delay because foods tended to come in lower-calorie packages. Our ancestors were often hungry from famine and the food they ate was not calorie-dense. They were eating things like vegetables and ﬁsh. There wasn’t a strong need to tell the mouth to shut down due to overfeeding. Evolution hasn’t created the mechanism to clamp the mouth quickly enough to stop the entire box of chocolate chip cookies from heading down the hatch. We have to use our brains, habits, and behaviors to limit overfeeding until evolution works out the chocolate cookie gene (temporary name of gene: BigButtB52). Slowing down the meal creates time for the hormonal signals to get to the brain and for us to consciously feel full. Do what the French are famous for—practice the art of drawn-out conversation. We modern, rushed types no longer know how to eat luxuriously. (Doctors are the worst. We get in the habit of eating quickly during our frantic medical training and then never slow down. Come visit the doctors’ dining room at a busy hospital sometime for bizarre entertainment. The food goes down so fast, the forks look like they are training for NASCAR.)

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MY KID ACTS LIKE HE’S USING HIS SKULL AS A PLANTER My adolescent son is naturally thin because he is a very slow eater. In addition, he has been taught to eat only on his own schedule, when hungry, and to stop when full. He takes between 30 and 60 minutes to eat a meal. The average American meal is over in less than 10 minutes. We had a real problem when he was in elementary school, as the school scheduled only 15 minutes for lunch. What a horrible habit to teach young, impressionable children! Here, kids, gobble your food quickly. This is the modern American way, is it not?

Deepak Chopra once said that we need to get quiet and listen to our bodies. Unfortunately, most people can’t hear their bodies over the scream of a Krispy Kreme donut.

Eat a plate of salad or fruit or vegetables ﬁrst or a thin soup. These foods are less calorie-dense and take longer to eat, so they will slow you down. You have to chew vegetables a lot more before swallowing; you have to sip your soup (no slurping, don’t pick up that bowl, young man, watch your manners). We will discuss using soups, fruits, and salads as a method to lessen caloric intake in Chapter 5, but suffice it to say that this simple approach can make a big difference in successful weight loss.

THE MISS-YOUR-MOUTH DIET One research study at the University of Rhode Island had a group of women eat as much as they wanted at two different meals.3 The only difference was that at the ﬁrst meal the group was instructed to eat very quickly, using large utensils. The second time, the group was instructed to use small utensils, to take small bites, to put the utensil down between each bite, and to chew each bite at least 20 or 30 times. The ﬁrst time, the group took only 9 minutes to eat the meal; the second time, the group took 29 minutes. But what’s really special is that at the second meal, the group members ate 10 percent fewer calories for the meal and stated that they felt fuller when they were ﬁnished! Think about that! If you are a fast eater, just by eating slower, you could feel completely satisﬁed and lose up to 24 pounds a year! No starvation; in fact, you’ll feel more satiated. No effort; just slow down your eating. Relax; it’s that simple.

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Laugh Yourself Thin I have a T-shirt from a vacation that says, “I’m on island time.” Eat like you are on island time. Better yet, eat like you are on contractor time; it’s even slower.

It really is the case that people in Western societies are eating more calories than they used to. It sneaks up on us in ways we don’t know. According to USDA food data, the average American eats 300 calories more in an average day than he did several decades ago. Since it takes only about 3,500 excess calories to add a pound of fat to the hips, belly, or buttocks, that’s less than two weeks of overeating. It doesn’t take many months of routine excess calories before the pants get too tight to button. There are a host of simple tricks that can keep you from overeating. Most of them cut the number of calories you eat in a painless manner. I recommend incorporating as many of them into your life as you can. THE OBESITY EPIDEMIC—LONG LIFT THE FORK! I mentioned one of the simplest but most effective and painless methods to lesson caloric intake just a moment ago. That is the method of using smaller plates, cups, and utensils. This technique seems so simple that only an idiot would fall for it. Yet, in study after study, people who are very smart and even those who are professionally trained food preparers managed to be fooled by different-size or -shape food containers.4 Our eyes do tell our stomachs how much to eat, and anyone who has ever been a fan of optical illusions knows that we can fool our eyes quite easily. I ﬁrst noticed this myself many years ago, when we ran out of big forks around the house and I had to resort to little salad forks for a while. Suddenly, I observed, I wasn’t eating as much. Yes, food behavior studies do bear this out. We all eat less with smaller forks.

If you really want to slow down eating to permit time to lessen the hunger pangs, eat with a utensil you don’t know how to use, like chopsticks. Better yet, eat with only one chopstick. If nothing else, I guarantee it will keep your eating partners entertained. A word of caution: my husband finally switched to smaller forks recently. Not only has he lost weight, but he’s gotten much more colorful clothing as a result. He spends more time feeding his shirts

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than his mouth, which has made him smaller but his shirts bigger. They like my cooking, apparently.

Smaller plates and tall, thin glasses also do the trick. Over the past 50 years, the plate industry has caught on to our rapidly increasing appetites. It has obliged us by creating larger and larger dinner plates. It is the case that the salad plate of today is almost as large as the dinner plate of our grandmother’s china set. What do most people do when presented with a large plate? Fill it up, of course! Brian Wansink, MD, of Cornell University, one of the nation’s most famous food researchers, has published extensively on this subject. If you switch to seven-inch plates for dinner (instead of the common nine-inch plates), you may reduce your caloric intake without even feeling it. Have you ever been to a fancy restaurant where they scribble edible designs all around the edges of your dish? That’s just a form of optical illusion to make the portion size appear larger (and your bill appears more reasonable). Using tall, thin glasses when you drink a calorie-laden liquid will reduce how much you drink. Even bartenders fall for that old optical illusion. Take away those short fat mugs for your beer or cola. Better yet, drink water or unsweetened green tea.

I’LL HAVE THE CAROTID FRIES Deliberate eating behaviors are especially useful when confronted with food challenges, particularly those times when we are tempted to overeat. Restaurants are a great place to practice new behaviors related to what we eat and how much. It is very easy to order calorie-dense foods but even easier to order too much. Restaurants have moved toward bigger portions because society demands it and they need to compete. It is important to order carefully to prevent the presentation of too many calories in front of your eyes and mouth. Order two appetizers only, or split an entree. Note that most people tend to overeat when eating in restaurants. Figure out what will work for you ahead of time before ordering, and stick to it routinely. It would be easier on us if the restaurants were forced to label their food items more truthfully. Instead of calling the ﬁve-eggs/ham/bacon/ hash-browns/toast/pancakes platter the “Home Run” or something similar, shouldn’t the breakfast place have to call it “The Coronary”?

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Laugh Yourself Thin My kid always provides entertainment when we eat out. Once we went to a fondue place. The establishment had a choice of cheese, chocolate, or beef fondue. My son told the waiter he didn’t want that last one, since the idea of dipping your food into liquid beef wasn’t very appealing to him. And last time we took him out to a fancy restaurant, he mentioned something he learned in biology class: that a cockroach and a two-pound lobster are essentially the same thing since they’re in the same family. I told him that’s not quite correct because, in a restaurant, you expect to pay a lot for the two-pound lobster, but the cockroach you get for free.

TO TIP A COW, DO YOU USE 15 PERCENT? Restaurant eating, in general, is fattening. The sight of other people eating around you and the photos of scrumptious, high-calorie food on the restaurant menus tends to cause people to order and eat much highercalorie meals than they would consume at home. I talked to a woman recently who had weight-loss surgery and stopped eating out every night with her family. An interesting consequence is that her husband and son, who used to accompany her out every night, also stopped eating in restaurants nightly. They felt guilty about leaving her home by herself at dinnertime. All three of them have now lost substantial amounts of weight even though only one of them went through the weight-loss surgery! PEOPLE WITHOUT BORDERS Buffets are a special problem. They are attractive to the overeater, and you will often see the morbidly obese gravitate to the all-you-can-eat restaurants. I’m surprised they don’t have seating sections divided into one-, two-, or three-chair customers. It is better to avoid buffets, as the temptation to “get your money’s worth” at the expense of your waistline is very great. If you must eat at a buffet restaurant, always ﬁll your ﬁrst plate with large helpings of salad or vegetables, and then proceed to eat them slowly before going back for more. (Or you can do what I did last night and eat at a really dreadful buffet restaurant. No one at our table wanted to go back for seconds, ever. Not the best weight-loss plan, but perhaps the All-You-Can-Eat-Stinky-Lousy-Food Restaurant has its place in the weight-loss armamentarium.)

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HOW TO ATTRACT A MAN—HIDE IN THE BUSHES AND MAKE A SOUND LIKE A CHEESESTEAK We eat more in groups than alone. This is as true in the lunchroom at work and at the Friday night card party at a neighbor’s house as in a traditional restaurant. Just being aware that you are in a challenging situation is more than half the battle. Allow yourself the festive enjoyment of the social moment without the baggage of excess calories. Concentrate on your internal signals of hunger and satiety (see Chapter 5 on hunger for speciﬁcs). Ignore the external signals of other peoples’ hunger and eating patterns and you will accomplish a true defense against social overeating. Americans love to eat and socialize. According to psychologists, we are the most group-joining society on earth. Perhaps it’s because we are so transient in our lifestyles. Since we are constantly moving, we feel the need to build minisocieties in social groups and organizations wherever we happen to put down temporary roots. A recent phenomenon is the Red Hat Ladies, a group of older women who dress up in badly matched clothing and take Jenny Joseph’s poem to “spend my pension on brandy” wickedly to heart. Feeling left out, my husband thinks that men need their own group of self-embarrassment and compromised couture. He’s starting the Men with Shorts and Black Socks Society.

I often refer my patients to support groups; however, that social phenomenon has gotten completely out of hand. Look in the community section of the local newspaper; there’s a support group for everything. Last week I saw a meeting announcement for People without Tonsils.

Get out of the habit of obligatory eating when at other people’s houses or when at support groups, social events, or holiday celebrations. No matter what your cousin or best friend cooked up, slaving all day in the kitchen, it’s your health that is the priority. Take tastes of the food without taking whole portions, and compliment the host or hostess, then stop when no longer hungry. Preemptively strike: if you know certain situations present an overeating challenge, don’t go there extremely hungry. Before parties, weddings, or festive dinners, eat soup or salad before leaving the house so that you’ll be less likely to overindulge. Then distract yourself from the food with the real reason you are there—for conversation, dancing, and

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socializing. Keep away from the dessert and food tables, and don’t be afraid to tell the wait staff “no” to offerings for certain courses or hors d’oeuvres. Save yourself for the really special stuff, and skip the rest.

One of my favorite memories of a religious holiday food celebration gone weird involves what happened at a relative’s house a few years back. I’m at the table for the Passover Seder, sitting next to an older gent I don’t know, and someone mentions that I’m a doctor. Instantly, this old man spreads out his napkin, pulls out a pen, and—I kid you not—starts drawing the shape of his prostate at the dinner table. At least he didn’t try to sculpt it from a matzo ball! I don’t even remember the guy’s name, and he’s demonstrating for me exactly where his nodule is that his urologist just biopsied. Luckily, he did that part on the napkin, too, and didn’t expect me to stick a finger up his thingamajig Still, that’s too much information, especially before dessert. Needless to say, I ate less than usual that night.

I REGRET THAT I HAVE ONLY ONE BITE TO GIVE TO MY CUPCAKE A major reason that restaurants and social situations cause overeating is that there is an accessible variety of food. Dr. Wansink claims that the average American is faced with a food-related thought or image hundreds of times a day.5 The more exposure to food in thought or image, the more likely you are to eat. Accessibility of food is a major cause of weight gain. It’s so easy to ﬁnd food everywhere we are, so make it less accessible to yourself. If you tend to go to the vending machines, don’t keep change and small bills handy. If you snack on junk food at work, avoid the break room. If you tend to impulsively stop at the convenience store near your house, take a different route home. If you tend to grab the ﬁrst thing you see handy in the pantry and fridge, then make the nonnutritional food less easy to grab (or get rid of it completely). It is true that if you buy it, it will get eaten. Eat only in the kitchen, and otherwise stay out of there as much as you can. The sights, sounds, and smells of the kitchen will make you feel hungry even when you are not. Your subconscious will trick you into believing you are hungry through those environmental triggers, so stay away until you are truly hungry.

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IF YOUR FOOD IS CALLING, STAY OUT OF EARSHOT A research study by dietitians back in 2002 looked at which personality proﬁles are more likely to be obese. What they found is that people who get hungry at the sight of food are more likely to get fat and stay fat. That’s because people who are highly suggestible when exposed to food are more likely to grab calories and overeat more than their body requires. Thus, design your day and your activities so that you don’t see food. This seems like a “duh” comment, but you would be surprised how easy it is to get in the habit of unnecessarily exposing yourself to food. Do you stop on the way to work or back at the convenience store for a cup of coffee or the newspaper? Do you ﬁnd that you often impulsively pick up other edible items while in line, even if you weren’t hungry when you walked in? Does the sight of a familiar fast-food restaurant make you pull into the drive-through, even when you don’t feel that hungry? Do you watch a lot of television with food commercials that make you get up and raid the refrigerator? Do you work or live in an environment where there are constant visual triggers for food? Do you tend to foodshop and buy more than you intended, and eat as soon as you get home (or in the car on the way home)?

Fast-food restaurants use enchanting ads, huge mouth-watering posters, and catchy slogans to get you in their doors. Then they feed you high-calorie, nonnutritious, preservative-laden nastiness. But if God had a restaurant, his slogan would be “We didn’t invent the chicken sandwich, just the chicken.”

A BREAKFAST PLACE, THE HOUSE OF SEVEN BAGELS Spend a few days this week just noting how often you are exposed to the sights of food and whether any of it makes you hungry. Think about when you eat as it relates to your exposure to the sights (and possibly smells) of food. Then start to think about what you can do to modify your environment or your daily activities to reduce the barrage of visual (and other sensory) triggers to which you are exposed. Can you get someone else to food-shop for you? Perhaps you can trade off the laundry or other chores if food shopping is a trigger. Can you drive a different route to work or school to avoid the bagel shop or the fast-food restaurants that have become a habit? Can you put away the candy dish at work and the

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box of donuts that sits on the counter in the kitchen? Can you brew your coffee at home before work to avoid the convenience store line? Can you record your favorite television shows and zip through the mouthwatering food commercials?

It dawned on me that women like to food-shop because it’s just a modern version of the cave woman art of hunting-gathering. I imagine that, back then, the women came out of their caves in the morning and went scrounging around in the dirt looking for turnips on sale at WalGrub. Personally, I can’t stand supermarkets and make my husband do all the food shopping. Modern food stores are so big, with endless selections, that I get overwhelmed. For instance, there’s so much variety in women’s sanitary products that it can get awfully confusing. Usually my husband’s pretty good at getting the right stuff, but, last time, he accidentally got me panty liners with breaded wings.

NO NERVE CELLS WERE HARMED IN THE MAKING OF THIS THOUGHT On the other hand, don’t get in the habit of keeping the cupboard bare. Place nutritious foods in the house so that you don’t come home to an empty fridge or pantry. This eliminates the tendency to starve and then binge-eat or run out to the fast-food emporium. Plan ahead what you’ll eat for meals. Simply planning and keeping nutritious, low-calorie foods available to grab, heat, and eat will eliminate excess calories by the hundreds. A little bit of thought goes a long way. Do this regularly, week after week, and you will see a remarkable lowering of both your weight and your stress level. You’ve probably heard the advice not to food-shop when you are hungry. This is good advice. People who shop when hungry buy highercalorie foods than those who are not hungry. Always stick to the shopping list. Interestingly, people who are overweight are less likely to use a shopping list at all. Lincoln University did a study back in the 1980s that showed that if you teach an overweight person to plan meals and foodshop on the basis of shopping lists, the obese person can lose up to 10 pounds in three months.6 Some of the participants in the study reduced the number of impulse purchases (which are usually high-calorie and low-nutrition) and excess calories by almost half.

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THE CEREAL KILLER DIET One way to deal with less-nutritious and higher-calorie fare is to make it a challenge to eat. The more hassle it is to eat, the less we eat. Indeed, put a lid on a container and it will decrease how much and how often we eat. This has been demonstrated in medical study after study. Food stores know this. Close the see-through top on a freezer case in the mini-mart and sales of ice cream plummet. Just the act of having to open the case (even when the treat is staring right at us) decreases how many people reach for ice cream! Make your home “food environment” less friendly and convenient. Better yet, eat less accessible food. If all you ate were crabs in the shell and ﬁsh you had to catch yourself, you would get skinny fast. At least make your high-calorie-density foods more effort to obtain. Convenience food and frozen ready-to-eat meals are a danger to the waistline. Overweight people tend to keep a greater variety of junk foods around their houses than normal-weight people. We know that variety encourages overeating. Decrease the assortment of junk food around the house and you will decrease the temptation to eat the stuff too often. Keep one type of sweet and one type of cracker or chips around, and get rid of the rest. Eliminate the multiple assortments of sugary, processed breakfast cereals in the pantry. At the same time, increase the diversity of fruits, vegetables, and good-for-you foods. Avoid routinely going to places that might offer you a tempting variety of the nasty stuff.

The food industry has done a great job of creating all sorts of innovative ideas and combinations. One night, I was eating this new type of “all natural” sausage for dinner. But it was kind of a strange food item, chicken sausage in pork casings. I imagine the chicken parts were in there talking to each other: “You know Bill, this just doesn’t feel right.”

WHATEVER YOU DO, DON’T LOOK IN THE GRAVY Portion size is going up. Not just in restaurants, but at home. Foods packaged for home use may appear to be for one or two people but often contain many more portions. Nowhere is this more evident than in the soft drink industry, where the traditional eight-ounce portion has become almost nonexistent. This is true, however, throughout the spectrum of the food industry. The creation of the “family pack” may have

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seemed a good idea to the busy family, but it has resulted in grave risk. Nutrition research repeatedly shows that if you give people a large container of food and ask them to help themselves to a portion size, that portion will be much larger than if they had started with a smaller original container.7 Those crazy but fun researchers at Cornell University did a study of unsuspecting moviegoers in which the patrons were offered free popcorn in medium or large buckets.8 Yes, those who had the larger buckets ate more during the ﬁlm, 45 percent more. But the real catch was that some of the participants got 14-day-old stale popcorn that tasted horrible. The moviegoers still ate a third more if they were given the larger bucket, even though the food was downright unpalatable! In other words, don’t serve yourself out of huge family-sized cereal boxes, and don’t eat out of the one-pound packages of chips. You will eat a lot more than you need. Don’t serve food family style, passing the giant bowl of mashed potatoes. People around the table will take a much bigger glop than they otherwise would have taken. This is a big problem on cruises. Not only can you eat anytime, as much as you want, but the buffet lines have enormous platters of delectable delights. By the end of our last cruise, my husband had eaten so much that he claimed he would be thinking outside the pants. The truth is, most men would beneﬁt from thinking outside their pants. Just as you don’t want to serve yourself from huge bowls of food, don’t eat directly out of the package of chips, cookies, or pretzels, ever. Always take the portion you want and place it on a small plate ﬁrst; never dip back into the package. An easy alternative is to divide up snack food into small portions as soon as it is bought. Or buy the individually wrapped limited portions of junk food. Even ice cream now comes in very small individual packages, for a reasonably sized snack.

That concept reminds me of an idea I had recently for new ways to make energy. My local county is building a small methane plant that captures the gases given off by the local landfill and converts them into usable electricity to power thousands of homes. I’m thinking we broaden that idea to attach hoses to people to power their cars. Suddenly lactose intolerance becomes wildly popular. People drive up to the gas station, but not for petroleum; they want ice cream: “Give me three scoops. I’m going on a long trip.”

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Get in the habit of serving yourself smaller portion sizes than you are currently doing, at every meal and snack. Automatically cut out at least a ﬁfth to a third of your usual portion. The bigger the serving, the automatically larger amount that people eat, ignoring their own internal signals that they are no longer hungry. If you are overweight, there is no getting around the fact that you are eating too many calories for your body and ignoring your internal signals. FAVORITE CHINESE RESTAURANT, THE KA-CHING SUPER BUFFET Leave empties on the table as a reminder of what you drank and the remainders of what you ate. In a restaurant, don’t let the waitress clean your table of dishes or beer bottles until you’ve completed the meal. This will encourage you to eat and drink less, as it reminds you of what you’ve already had. Studies have shown people will eat and drink less if they have the debris of the meal still in front of them. Interestingly, people tend to eat more of food that they think should taste good, even if it isn’t any better than usual. So, if the restaurant is fancy or the food has an elaborate label attached to it (e.g., “mélange of passion fruit, kiwi, and star fruit” rather than “fruit salad”), people will eat more of it. Be aware of this tendency, and be more attuned than ever to your own internal signals of fullness. MISERY LOVES COMPANY, BUT SO DOES LAUGHTER Social eating may make you automatically eat more when others are around, but heavy people who are self-conscious will sometimes eat less around others. If you are one of those, then make plans to eat more meals with others. Pick eating partners who will help you eat less by their own behavior if you have a choice in this. Obese people tend to pick other corpulent people to eat with, which encourages overeating. That’s why fat couples get fatter together and have fat kids. Being overweight is contagious because of the behaviors that we encourage in those around us. We surround ourselves with people who reinforce our social tendencies, including overfeeding and lack of exercise. Therefore, if you want to lose weight, you need to start choosing to spend more time with people with healthier attitudes and waistlines. But be careful—not all thin types are healthy. I don’t know anyone who really enjoys being surrounded by skinny, crack-addicted smokers, unless you are an addiction

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counselor being paid by the hour. Hang out in places that encourage healthier behaviors. Meet a friend by the lake or in the park for a walk after work, rather than at the usual happy-hour bar or restaurant.

GOT BRAINS? There are many diet and weight-loss books on the market. There are many fads and many programs. People who lose weight but then gain it back later are more likely to have been in a structured diet program or on a fad diet or a fasting diet. They are also more likely to restrict whole categories of foods and to eat more fat and sugar in their diets. They are unlikely to exercise regularly. Finally, people who gain the weight back are less likely to eat fruits and vegetables but more likely to have used diet pills or hypnosis to initially lose the weight. Don’t do what they do.

I went to a business program recently where I met a local hypnotist planning to open her own weight-loss practice. She told me that her experience consisted of a one-week seminar and trying out her techniques on a few family members. She had no health care background. So if you hire a hypnotist, beware when she says, “Look at this swinging watch—you are getting very poor.”

It bothers me when I see the number of ridiculous fad diets that have come and gone and the number of desperate people who have been victims of these ideas. Fad diets are never based in good scientiﬁc or medical knowledge. I’m surprised some shyster hasn’t published the Eye Color Diet (“If one eye is a different color than the other, eat the blue-eye diet until noon and the brown-eye diet until bedtime.”). I’d like to try out the Phrenology Diet on some of those fad-diet authors. That way I can whack each one of them on the head and tell them it’s for their own good: “Look, a new lump. Now you can eat broccoli on Wednesdays!” The recommended behaviors described here are the best-known methods that work permanently. They ask a lot of the reader. A person who wants to lose weight forever must change the behaviors that led to the weight gain in the ﬁrst place. There is no instant solution that will last. Use the suggestions here to enact healthy behaviors that work, permanently, for your lifetime.

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WE’RE THE BEST EVOLUTION COULD DO Finally, I must apologize to Aunt Tillie. She was the one we wanted to blame for the genes and the habits that got us here in the ﬁrst place. When it comes to being overweight, our genetic predispositions do matter, a little bit. Heredity is involved in taste preferences for food and for psychological coping responses, although often these are learned, as well. Genes also account for how well or how poorly we process our foods (for example, diabetics don’t process sugars as well as others). It is said that genetics account for about 30 percent of our risk for obesity. The other 70 percent is the environment and our own behavior toward it. We can’t change our heredity. We can change our environment and how we react to it. It’s time to stop blaming Aunt Tillie and those who gave us our genes or taught us the behaviors we ﬁrst learned in childhood. It’s time to grow up and take responsibility for our own destiny. Grab hold of new behaviors, and hang onto them for your new thin, healthy life! WHAT YOU SHOULD REMEMBER FROM THIS CHAPTER • Overweight people eat too many calories daily, even when not hungry. • Obesity is caused by behavior, although genes play a role. • Everyone has the capacity to analyze his or her own behaviors and change them. • Habits formed from childhood admonitions like “clean your plate” should be re-examined. • Instead of eating until stuffed, eat until 80 percent full. • Don’t eat automatically, out of obligation, or because you are fatigued. • Slow down your eating, and use smaller forks, plates, and glasses. • Restaurant eating is fattening; be prepared with a plan. • Surround yourself with people who encourage good eating and exercise habits. • Avoid food exposures that encourage overeating. • Stock the pantry and fridge with healthy foods, and cut out the variety of junk. • Use a list when food shopping to cut down on high-calorie impulse purchases. • Make junk food hard to get. • Avoid family-size containers and overgenerous portions. • Be aware of your food behaviors, and you will be successful.

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FOUR Laugh Your Butt Off: Activity Behavior That Works

I’m really glad that the tourist industry is designing more ways to stay physically active while on vacation. But not all the ideas are so well thought out. I was on a cruise ship with an ice rink. Let’s take an instance where people normally fall down and hurt themselves and then take away normal ground stability. I’m surprised there wasn’t a sign that said, “This activity sponsored by Earth, Wind & Lawyer.”

As mentioned previously, overeating is only half the story of obesity. The other (often ignored) half is just as important. That’s the activity side of the equation. Overweight people do not get enough activity for the amount of calories that they take in. There’s no way around that fact and essentially no exceptions. If you are always very active, you won’t be overweight.

THE VOCABULARY GAME SHOW, BROUGHT TO YOU IN HI-DEFINITION The television set is a contributor to our obesity epidemic. We love our reality shows, soaps, and game shows. TV is fattening for multiple reasons: we snack more in front of the television and are more sedentary,

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and the commercials remind us about food (suggestibility). There is a strong relationship between the number of hours of television watched and childhood obesity. Johns Hopkins doctors demonstrated in the 1990s that the more hours of TV watched, the fatter the kid.

Strangely, video gaming hasn’t been found to have the same relationship. Perhaps it’s the fact that the games don’t suggest that you eat food, and your hands are busy doing things other than feeding your mouth. My son is working on the design of an action video game, but I told him it couldn’t have any sex or violence in it—Grand Theft Stroller.

BOREDOM COMES TO THOSE WHO WAIT Watching television usually is done in your own home. But even homebodies who don’t own televisions are more likely to be fat. Stay-at-home work (whether or not you are a parent) is very fattening. Those who work in their house are more likely to be obese. This is because they have unlimited access to food, and the job requirement often includes shopping, cooking, and cleaning up (an increased regular exposure to food). Also, stay-at-home workers report that their jobs are more boring and that they don’t get as much positive feedback as those out in the regular work world. People who work at home have less varied social interaction and less pressure to dress up for the job. This leads to lower self-esteem. The psychology research backs this up.

The whole concept of self-image and self-esteem is a bit of a minefield. But there is pretty good evidence, as we’ve discussed earlier in this book, that people with low self-esteem are more likely to be overweight. A local Hispanic nonprofit holds an annual Miss Latina contest, complete with a scholarship for the winner. According to the organizer, the contest is supposed to “provide self-esteem for young ladies,” apparently as long as those ladies’ self-esteem looks good in a bikini. What you never see is a Miss Jewish American contest with gorgeous Jewish women in bikinis. I’ve always wondered why that is. I guess our selfesteem looks better in a deli.

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It isn’t just workers from home who get into self-esteem problems. Gee, even doctors can suffer from ego issues, as well. The American College of Physician Executives sent a letter asking me to join. It came from their president, a woman whose name was followed with, “M.D. M.M.M. F.A.C.R. C.P.E. F.A.C.P.E.” I threw it away. Personally, I’m seriously suspicious of anyone who feels the need to put 17 letters after her name. Perhaps she is having a bit of a self-esteem issue. Or maybe she’s discovered that people will treat her with more respect with all those extra letters. So I’m going to try it. You may now call me Melanie Rotenberg, MD XYZ PDQ *€ §»¥. I’m thinking of changing my name to an unpronounceable symbol (looks like sunset over a beach with the Greek letter theta with two slashes through it). This loosely means “I’d rather be walking the beach than parallel parking.” You must now refer to me only as “the physician formerly known as Dr. R.” I’ve come up with new categories of trailing letters that you might want to give your own physicians: MD JRK, MD STU PID, and MD PUTZ. I believe many of our physicians in the medical community deserve more letters, so please be generous.

But let’s get back to the subject at hand, self-esteem and work. I’m not suggesting that you have to get a job outside the home to lose weight, but you need to be aware of a tendency to suppress your self-esteem if you spend lots of time at home. This is true for men and women. In addition, people who work at home just don’t need to move as much to do their daily responsibilities, so they are more sedentary. I’ve been at home with my kid, and it certainly didn’t seem like I was getting less exercise than when I worked outside the home, but, overall, it was. Getting out, socializing, and interacting with others does increase conﬁdence and self-esteem. It also increases physical activity. Finally, interacting with others, especially with those less fortunate and people from all walks of life, takes the focus off one’s own problems and helps to increase one’s feeling of gratefulness. If you work at home, you need to concentrate on ﬁnding time to exercise outside the house and also to interact with people separate from your own small social circle. Increase your volunteer or social connections, or join clubs and exercise groups, or develop hobbies that will bring you into conversation with more than the usual suspects.

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THE GERBIL IN YOUR SHORTS DIET Believe it or not, putting a small rodent in your pants is effective as a weight-loss technique. If you aren’t really hungry but ﬁnd yourself heading toward the pantry out of habit or emotion, use distraction or substitute behaviors. Build an armamentarium of things to do when you feel the urge to grab food out of habit or emotional reasons. For example, put on music, dance, go for a walk, grab a fun book, talk to the kid or spouse, call a friend, give yourself a list of happy and fulﬁlling behaviors to do that are easy. This is one of the most common methods employed by those who have permanently conquered obesity. The Karolinska Institute in Stockholm, Sweden, and the researchers at the National Weight Control Registry both found that cognitive approaches to permanent weight loss do work.1 If putting a gerbil in your shorts will make you forget you are hungry (and the gerbil doesn’t mind), consider the action. I’ve always told my headache patients that I’d be glad to stomp on their feet to help them forget their headaches. It works every time. Okay, perhaps stomping on the feet isn’t pleasurable or fulﬁlling, at least to the recipient of the stomp. This brings me to the next effective behavioral method for successful, permanent weight loss: associate pleasure with good health habits. Every time you do something positive for your body and mind, link it in behavior with something pleasurable. When you come home from work and climb on the treadmill or take a walk around the block instead of heading for the bag of chips or dialing for pizza, then make certain that you associate this behavior with positive feelings. Listen to your favorite music while exercising, follow (or substitute for) your exercise with great sex, or call your best friend to share a joke every time you work out. You will quickly link pleasure with your increased activity.

My friend went to have a gynecological procedure done. The physician told her not to engage in any extracurricular activities until her follow-up appointment. So she did have sex but skipped her bowling night.

CHESS IS A FUN SPORT WHEN PLAYED WITH LOADED GUNS How can you make activity something enjoyable? I’ve always scratched my head when chess and other sedentary activities are broadcast on the

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sports channels. But what if you took one of those staid activities and livened it up a bit? This is one of the keys to permanent successful lifestyle change. The reason that regular exercise behaviors extinguish (go away) is that most people don’t associate exercise with something fun or positive. Okay, loaded guns might be fun, but they’re not very positive. My son and I used to play a game we called “toaster chess” where the pieces, once captured, were ﬂung far and away about the room. This brought a whole new level of physical exertion to a generally sedentary game. If activity is just another chore or responsibility, it will be ignored. If you list physical activity on your “to do” list, it will be an item to be avoided. Rather than make it a “to do” item, make it a “want to do” item by always designing the physical activity to be fun and pleasurable. In the same way, you should associate all positive health behaviors with pleasure, joy, and laughter.

They held the national rock-paper-scissors championship. The winner got $5,000. I hope he also got a life.

The more you link positive health behaviors with pleasurable things, the more you will succeed in changing your life and slimming down. When you decide to eat the lower-calorie menu item, when you leave food on your plate because you feel “80 percent full” instead of completely stuffed, when you park on the opposite side of the parking lot at Wal-Mart instead of in the closest space, make certain that you immediately link that behavior to something that is emotionally pleasurable to you. For me, that might be something as simple as imagining myself in a pair of new skinny jeans that turns heads or playing my favorite music in my car when I get back from the store. Make certain you select thoughts and behaviors that are truly pleasurable for you. Avoid anything that might inadvertently make you anxious. Go for real rewards in thoughts and behaviors, and you will succeed in turning good health habits into lifetime habits. Don’t just tell yourself, “I’m not going to do that bad habit anymore.” Create an acceptable and pleasurable substitute. It must become “I will do this instead of that.” If you remove behaviors and foods that are pleasurable to you (for example, “I won’t eat chocolate donuts for breakfast anymore”), your new behavior (no chocolate donuts) will not win out in the long run. In that example, all you did was take away something that gives you pleasure without substituting another pleasurable

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behavior. It doesn’t have to be the same type of behavior; you don’t have to substitute one food for another. It is very difficult to ﬁnd a food that gives as much immediate short-term pleasure to a carbohydrate addict as a chocolate donut. So, instead of trying to ﬁnd a healthier alternative food that gives the same pleasure rush as the donut, ﬁnd another acceptable behavior that can get those brain chemicals dinging on the pleasure centers. ALL WORK AND NO PLAY MAKES ME BEHAVE THIS WAY Let’s say that you usually grab a chocolate donut and a ﬂavored latte at the coffee house next to your office on the way to work during the week, since this gives you the jolt of sugar and caffeine you need to face the work day. What could be an equally pleasurable substitute to get you in a good mood for work but cause less damage to your long-term slimmer goals? How about listening to comedy routines in your car on the way in to work, but only on the days that you eat a piece of fruit and a handful of nuts with your home-made coffee on the way in? It has to be a good switch to something that leaves you feeling truly uplifted and happy, not just less guilty, or the new behavior will not last. Immediately link pleasure with good habits. Don’t promise yourself something down the road for good behavior now. And don’t focus on the negatives, the punishments for “bad behaviors.” Life is too short to constantly berate yourself for your slip-ups. Be gentle with yourself, and focus on the positives. You will be much more successful.

Perfectionism is a dangerous game. Let go of any notion that you can’t make mistakes. Imperfection is what makes us human. No matter how much progress we personally make or society makes, we will still get things wrong. In science, we make assumptions that turn out to be way off base. I find it humorous how much archaeologists try to conclude about ancient civilizations from little bits of cloth or shards of broken pottery. I worry that 20,000 years from now, archaeologists will find that the only remnants of our present-day society are plastic pink lawn flamingos. They will then conclude that we were a primitive people that worshipped a bird god.

It’s not like physicians are much better. I don’t know why people are always suing doctors. Hey, we admit we’re not very good. That’s why

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we call what we do “practice.” Doesn’t that imply something, like that we haven’t gotten it right yet? One hundred years ago, doctors routinely prescribed cocaine. It was supposed to be good for you. Not that long ago, back in the early 1990s, a physician at the Harvard Medical School published a “landmark” study that referred to exercise as unconventional or alternative medicine.2 Ah, yes. It is an alternative—an alternative to disability, ill health, and lots of visits to the pharmacy. Activity is a mood-enhancer in and of itself. If you tend to eat when you are stressed or at certain times of the day, work in fun exercise as your habit to be done during those stressful times. If you ﬁnd that you automatically eat after work, meet a good friend at the basketball court or yoga class on a regular basis at that time of day. An added bonus is that exercise is appetite-suppressing, so when you do eat dinner, you will eat less. Don’t avoid socializing; instead, do the opposite, since that also is a mood enhancer. But change how you socialize, by making it more active. Do fun, physical activities instead of going out to dinner or to the mall shopping. Play volleyball or tennis or go hit golf balls on the range. Invite a friend to go horseback or bike riding. Take a walk in the park with your lover or even your spouse. Just don’t arrange to meet both in the park at the same time. You’ll be sprinting instead of walking.

My friend wanted to get more active, so she bought a large sailboat, only she doesn’t know how to sail. Luckily, our river is really shallow. By the third time out, marine rescue knew her on a first-name basis. I suggested she innovate for the local tourist trade and offer submarine sailboat tours. Call it “20,000 Millimeters under the Sea.”

PUSH UP OR SHUT UP Here’s the next big take-home point: exercise is the single biggest factor in losing weight and keeping it off forever. Those who do it regularly remain slim, with no more yo-yo dieting. This is according to data obtained through the National Weight Control Registry. Even the Mayo Clinic lists 30 to 60 minutes of daily exercise as its number one recommendation for permanent weight loss. Your mission is to ﬁnd activities that you love and to do them regularly, and never stop. Later on in this book we discuss speciﬁc exercises that are most effective for permanent weight

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loss. The key, though, is to do something enjoyable just about every day, forever. Increase your activity at the office, not just during your free time. Work more motion into your work day. Chuck, a tall, skinny physical therapist who sees some of my patients, mentioned that he once meticulously counted the number of paces he took in a typical work day at the hospital. When he added them all up, he ﬁgured out that he walks an average of three to ﬁve miles a day during his work hours! I walk close to that number during my work day but also put in an additional three to four miles daily during my morning walk with my husband. No, I don’t feel tired; I feel invigorated. In fact, I become antsy and frustrated if I don’t get my usual physical activity at work or home. Chuck mentioned that he could retire soon but is hesitant to do so because he fears he would get out of shape and become disabled without all that work activity to keep him moving.

MY WORKPLACE IS AN EQUAL OPPORTUNITY ANNOYER Another friend of mine, Joan, a physician, mentioned to me that she recently worked in a clinic for several weeks. Her entire day consisted of walking no more than 10 feet between her desk and a couple of examination rooms. Joan was used to walking the gargantuan hallways of our hospital, normally putting on the kind of mileage that Chuck and I walk. Suddenly, her enforced “desk job” caused her to feel sluggish. And in a matter of weeks she gained more than a bit of weight without changing anything else in her life. Needless to say, Joan was thrilled to be back to the busy halls of our hospital after her stint in the clinic. She quickly lost the “desk job” weight. How much can work and programmed daily activity help you to lose weight or maintain a thin shape? Chuck has one more story that reﬂects how an active job can allow weight loss. Back when he was in his 20s, he quit his regular day job to work on a ski patrol at one of the famous Rocky Mountain ski resorts. Chuck noticed that he was eating all the time, much more than when he was back East. Finally, being the scientiﬁc mind that he is, Chuck bothered to count the number of calories he consumed on a typical day while on patrol. Turned out he was eating an average of 10,000 calories a day just to maintain his slim physique and to prevent becoming emaciated! That’s roughly ﬁve times what the average person eats. If Chuck had eaten only 9,000 calories a day, he would have been losing about eight pounds a month.

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Now I’m not saying that you need to quit your desk job and become a ski bum. However, there is something to be said for gradually working more and more regular activity into your life, night and day. We’ll discuss the ways you can do that in more speciﬁcs in Part III, the metabolism and exercise section of this book. I STILL HAVE THREE HOURS AND FIFTY NINE MINUTES Erectile dysfunction drugs say in their commercials, “Ask your doctor if you are healthy enough for sexual activity.” I know what most physicians are thinking when they are asked that question: “How would I know? I work 100-hour weeks. I don’t get any, either.” How do you know if you are healthy enough for sex? The truth is, it depends on who you are with and what you are planning to do. It is a known medical fact that a patient is much less likely to have a cardiac complication during sex if he is with his wife than if he’s having illicit sex. (Presumably the excitement of being with another woman is more taxing on the heart.) I guess in worst-case scenarios, I can just say to my patient, “I’m not certain. Grab your wife and let’s see. . . .”

IF TIME IS INFINITE, WHY IS THERE NEVER ENOUGH OF IT? If you have it, put exercise equipment where it will be used. As you do with good-for-you foods, you need to make activity more accessible and user friendly. Equipment should not be in the dank basement or in a claustrophobic spare room or used as a clothes hanger. The treadmill or elliptical needs to be parked front and center in your bedroom, living room, or family room in front of the television or set up with a place to put your music, books, and magazines. Make the equipment part of your daily living situation, appealing and easy to use. Make it as easy as the remote control and the television and as comfortable as the couch. Then, make the time to use it. If your health is important to you, you will ﬁnd the time.

One leading professional golfer claimed that his stretching and exercise program was so successful that he got taller. He claims he got so

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Interestingly, it doesn’t take more time to exercise if you attach it to something else that you are already doing regularly. I’ve seen treadmills placed in front of computer work stations. We’ll discuss the NEAT studies in Chapter 11, the exercise chapter. Those were done by researchers at the Mayo Clinic who studied ﬁdgeting and its relationship to weightloss. Suffice it to say that humans were meant for constant activity, not sitting at a desk or a couch. Obviously you can’t run and type at the same time, but if you are not using your treadmill now and you are on your computer for more than 15 minutes a day, start thinking about the easy calories you can burn while cruising the Internet or answering e-mail. While you’re ambulating at an easy pace, mindless movement adds up to a svelte ﬁgure. If you don’t have the equipment, join a gym or a walking group. Many overweight people admit that they avoid socializing and external activities because of their body size. Does obesity keep you from doing the things that you like to do? Do you ﬁnd yourself refusing to join others because you fear how you look or how short of breath you would become during an activity? How can you get back to doing those things now? How can you plan to do more of what you want to do in the future? Move your life from the “should do” back to the “want to do.” Start slowly, but challenge yourself to ﬁnd new ways to be active.

I’m thinking about taking up skydiving. I saw on television that there’s a safer contraption that gives the sensation of jumping out of a plane without all that height. It’s a giant fan underneath, and it blows upwards; it’s supposed to be great exercise. All one has to do is step off of a platform and float. But what happens if I fly too close to the fan? I’m worried that the next thing I know, I’m Chinese-made dog food.

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THE GRASS IS ALWAYS GREENER, UNTIL I TAKE CARE OF IT Once you begin the weight-loss journey, never let yourself gain back more than 5 or 10 pounds or let your clothes get more than a little tight. Constantly self-monitor so that you nip weight gains in the bud. Put that favorite pair of jeans on frequently enough to monitor yourself, or get on the scale weekly, if that’s your technique for self-monitoring. Whatever it is, have a routine for catching weight gain early, and stick to it, always. However, if you do start to put on more than a few pounds, don’t look at it as a failure of your system; see it as an opportunity to try new foods, exercise equipment, or activities. Try new recipes; go for a bike ride instead of your daily walk. Sell the riding mower and get one of those environmentally friendly push mowers. Turn every challenge into an opportunity. Always, always keep positive. Keep laughing, keep smiling.

I went on a river-rafting trip. When I signed up for it, they told me that they went out, rain or shine. But if there’s lightning, they give you your money back—or they give you an urn.

I FEEL SO FAT, EVEN MY CONTACTS DON’T FIT I strongly believe in using clothing for self-monitoring. Buy new clothes when you get down a size and give away the large ones right away. Don’t keep them around or you are giving yourself permission to gain the weight back. If you start putting on weight, it’s a lot harder to get dressed in the morning if you really don’t have a larger-size pair of pants to put on. Thus, you have a built-in system to catch problems quickly. If you keep elastic-waist pants and stretchy or bigger-sized clothes around, you give yourself the opportunity to grow wide without having to take action. Yes, everyone needs objective feedback with weight control, so if you don’t like the clothing idea, at least weigh yourself weekly. Any more often and changes in water weight might drag you down emotionally. Much less often (such as monthly), and you can gain a lot of weight without realizing it. Scales can be misleading and really aren’t a great measure of successful, healthy weight loss, particularly when you are starting out. The

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reason is that healthy weight loss is really “adipose loss” (fat cells). When you eliminate calories, eat well, hydrate yourself properly, and increase activity, you might very well gain weight, but it’s good weight. It’s the lean muscle weight that will serve you well in the long run. If you follow my advice, you are likely to get thinner but heavier at ﬁrst before you lose actual weight! We’ll discuss why this is the case in Part III, on metabolism and exercise. For now, understand that if you are following good health behaviors, the scale may just upset you. That’s why I recommend using clothing as your feedback mechanism. Pick your pants as carefully as you do your friends. Then enjoy them as they grow loose on you (your pants, not your friends). Let them be your guide if the scale is too anxiety-producing. When you listen to your pants, avoid scrubs or elastic drawstring pants, as they do lie. Avoid baggy clothes that allow you to hide your ﬁgure to yourself and to others. Those are the clothes that will let you expand your size without notice. Insist on wearing a ﬁtted waistband on most days. Dress nicely to impress yourself, your lover, and your friends. Baggy clothing is often a sign of someone who is hiding from the world. Stop hiding, and dive right in.

The men’s sensitivity final exam: You are presented with the inevitable question from your significant other. She asks you, “Does this make me look fat?” Please choose the correct answer: (a) No, darling, you look wonderful; (b) No, but it does make my eyes thicken; (c) Excuse me while I go TASER myself; (d) What do you say we go get ice cream?

BEHIND EVERY GREAT MAN IS A GREAT WOMAN’S BEHIND During your weight-loss journey, reward yourself regularly for keeping a healthy lifestyle but not necessarily for losing 10 pounds. I know people who’ve gone out for hot fudge sundaes when they get to a certain goal weight. Do you hear that obnoxious buzzer sound? Yikes, wrong approach. Reward yourself for not slipping back into old, unhealthy habits. Make it nonfood rewards, like a night out at the movies, a soaking bubble bath, a couples massage, a new special piece of clothing or perfume or a new piece of sports equipment. You should plan to do something that makes you feel special, sexy, and powerful. Disconnect that old habit of starvation and deprivation followed by overindulgence.

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Do not be afraid of your inherent sexiness. Use it as a positive motivator of behavior. As you trim down, don’t hesitate to grab your butt, thighs, belly, and other slimmer, toned, and trim areas and note even the subtle improvements in a very positive way. (Avoid doing that in public, and don’t offer your parts to your signiﬁcant other for inspection without checking for privacy!) Remember that you will trim parts before you trim numbers on the scale, so use those ﬁrmer parts as a reinforcement technique to keep on track with your new behaviors. Remember that funny movie Freaky Friday, with Jamie Leigh Curtis? When she suddenly ﬁnds her mind in the body of her teen-age daughter (played by Lindsay Lohan), she grabs her new rear and declares, “That’s deﬁnitely not mine!” Turn that comment around and make it your positive mantra: “This is deﬁnitely mine!” Not every attempt at turning up the heat will be a success. I decided to try wearing thong underwear because, you know, it’s supposed to be sexy. I spent my whole life trying not to give myself a wedgie when I pull up my undies. Suddenly I have butt floss. Would someone please tell me what’s sexy about that?

A positive attitude will keep a positive lifestyle on track. Ask yourself what makes life meaningful and enjoyable and fulﬁlling for you now. Spend more time with family and friends who are good to you and supportive and do things that make you smile. Go places that you love to go or want to visit. Plan activities that you love to do or always dreamed of doing. Don’t put them off; can you make them a “now” rather than a “someday” part of your life? The more positives you instill in your life now, the more successful you will be with those seemingly tougher goals, including permanent weight loss. Success and joy breed success, joy, and health. Constantly challenge yourself to ﬁnd new ways toward happiness and fun. Avoid depression and sluggishness with music, dance, and walking in nature. Use prayer and meditation. Allow worthy causes to ﬁll you up. Build emotional strength, and work those habits into everyday life. WHAT DO THEY READ IN THE BATHROOM AT THE LIBRARY OF CONGRESS? There’s another behavior that should be part of your weight loss lifestyle. It’s keeping a food and activity log. It’s a good idea to do a food/

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drink and activity/exercise log for at least one to two weeks. Some people stick to their logs permanently. Many formerly obese people use this technique, either forever or when their weight creeps back up. A recent study by Victor Stevens, Ph.D., at the Kaiser Permanente Center for Health Research, showed that people in a weight-loss study who wrote in their logs daily lost twice as much weight as those who kept their logs one day of the week or less.3 Be honest, and mark all exercise and everything that you eat and drink. No one else has to see it unless you want them to. It’s not meant to be fascinating reading or to be published in the Congressional Record. However, use it to carefully evaluate your intake and how many minutes of nonroutine activity you accomplish.

And speaking of nonroutine activity: my son attended an archery camp. I had some concerns about the instructor when he said, “Okay, archers, everyone gather in a circle.”

For many people, the act of logging changes their behavior. People avoid bad habits when they make a written record. If this is the case, you may need to continue the log indeﬁnitely, either to pinpoint problem behaviors or to encourage yourself to move toward healthier ones. If you ﬁnd that the act of writing down your food, drink, and exercise is changing what you do, that in itself is an important clue. This gets back to the idea that most of our eating and exercise choices should be in the front of our awareness, not mindless afterthoughts. Once we do that, it becomes much easier to reach our goals for normalizing our weight. Perhaps the most important reason for this log is that people tend to distort their memory of their behaviors. Often, when I ask patients about their nutrition or exercise and activity level, they are very inaccurate, even for recent events. When I ask them to focus on speciﬁc examples or include family or spouses in the conversation, I frequently get a very different scenario. Take away your reliance on memory and the emotional underpinnings that you might attach to your behavior, and jot it down. Then periodically go back and review this log. Are you really working increased activity into your daily habits? Are you including more of the good foods and eliminating the frequency and amounts of the not-sogood foods? Can you see a pattern to behaviors that needs attention? Do you ﬁnd that you are making real strides in a healthier lifestyle? Be objective; don’t be overly critical. Be constructive and honest. You are

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your best friend and biggest supporter when it comes to weight loss. Use the logs to help yourself into your new permanently thin body. IT LOWERS YOUR BLOOD PRESSURE, BUT SO DOES A KNIFE THROUGH THE HEART Set speciﬁc goals that are attainable, and track them so that you monitor whether you are reaching them. Don’t set unrealistic goals. Don’t state, “I’m going to exercise one hour a day starting today” if you’ve never exercised regularly in your life. Start at 10 to 20 minutes every day or 30 to 40 minutes three days a week. Start gently and slowly. Be kind to yourself. Then track your progress. Gradually work up to more activity as you tolerate it. If you do it correctly, you’ll ﬁnd you are looking forward to the activity and want to expand your time exercising. You’ll ﬁnd you like the way it makes you feel and look. Read Chapter 11 on exercise and activity for more speciﬁcs. No matter how out of shape you are feeling right now, I guarantee you that there are people who have come back from worse. Every once in a while, I am asked to see someone for rehabilitation in the intensive care unit. I always want to say to those patients, “Drop and give me zero!”

On the other extreme, my favorite event on sports television is the world’s-strongest-man competition. That’s where incredibly overmuscled men hold up buildings and carry cars and such. I watch it with this morbid fascination, waiting to see if one of the contestant’s arms will rip off, right out of its socket. I’m sure they don’t show everything on TV, like the announcer shouting, “Gentlemen, check your scrotum; next up, the gonad drop, followed by the longest entrails competition.”

You don’t need to become the world’s strongest person. And you don’t need to get in perfect shape anytime soon. Aim for multiple small, new habits. Each new positive routine encourages more changes as you see great results. Each habit gradually added in will result in permanent success. Don’t ask yourself to perform an overnight complete overhaul. Pick one or two small changes that are easy to enact at ﬁrst, and, as they become ingrained and habitual, add one or two more. This will ensure life-long results. This chapter gives you the activities and behaviors for permanent weight loss. Remember to laugh, sing, dance, and enjoy every moment.

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WHAT YOU SHOULD REMEMBER FROM THIS CHAPTER • • • • • • • • • • • • • • • • •

If you are always active, you won’t be overweight. The more hours of television watched, the fatter the kid. Stay-at-home workers tend to be fatter. Improving self-esteem improves weight loss. Distraction is a technique commonly used by those who used to be obese. Associate pleasure with good health habits, and immediately link them; don’t wait. Avoid perfectionism, and aim for being positive in your health behaviors most of the time. Activity is a mood-enhancer in and of itself. Exercise is the single biggest factor in losing weight and keeping it off forever. Make your exercise equipment accessible, appealing, and easy to use. You may get thinner but heavier at ﬁrst, before you lose weight. Use clothing as a feedback mechanism to monitor your progress; it’s better than the scale. Do not be afraid of your inherent sexiness. Find things that make life meaningful and enjoyable and fulﬁlling for you now. Keep a food/drink and activity/exercise log, at least at ﬁrst. Each habit gradually added in will result in permanent success. Laugh, sing, dance, and enjoy every moment.

FIVE I’m on the Duct Tape Diet: Handling Hunger

Some female spiders are so hungry that they eat their mates. Very aggressive fishing spiders sometimes eat their intended mates before actually mating, a definite disadvantage in the Darwinian Olympics. Scientists blame the lady spider herself for being genetically too assertive. But maybe it isn’t her fault; maybe he just didn’t take out the garbage again.

Hunger is normal; it’s part of being human. People who are overweight, unfortunately, have come to think of hunger as the enemy. It’s not the enemy, and “ﬁghting hunger” isn’t a battle. Satiety (pronounced “say-tie-et-tea”) is the medical term for the opposite of hunger, for feeling full. As I mentioned earlier, it takes the body about 20 minutes to register fullness after you have taken in enough calories. Thus, if you are eating quickly, you might overeat. This is an important concept. If we understand how our body registers hunger and satiety, we can meet its needs without overeating. We can feel happy, satisﬁed, and well cared for and become thin. No need for deprivation, ever. Dr. Barbara Rolls of Penn State estimates that obese people begin eating due to hunger only 20 percent of the time and ﬁnish eating a meal due to internal signals of satiety less than 40 percent of the time. If you are overweight, it is very likely that you eat beyond when your internal

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signals should have told you to stop. Relearning your body’s own signals may be the most important step you ever take to permanent thinness. The nice thing about this approach to weight loss is that self-deprivation and starvation aren’t necessary. So you don’t think that you are a person who judges how much to eat by your eyes, rather than your stomach? Cornell’s Dr. Brian Wansink performed an extremely clever research study on multiple groups of average adults.1 He rigged up soup bowls on a table to reﬁll automatically by hidden hoses under the table. The test subjects were then told to eat until full. The adults who had the specially rigged soup bowls ate 75 percent more than those who had normal soup bowls! Both groups claimed they felt the same amount of satiety at the end of the meal. Thus, Dr. Wansink was able to demonstrate that most people, even those who aren’t fat, decide to stop eating not when their body tells them to but when the plate or bowl is empty.

I like reading Dr. Wansink’s research, he always seems like he’s having a lot of fun in his lab. I never had that much fun when I was a medical researcher. Of course, it might have been because I spent my time sitting in a walk-in refrigerator injecting tiny bits of DNA into maggot butts (really, that’s what I did). I used to go home at night and dream about wriggling maggots. Recently I heard about a research study that was done to determine if penis size truly is related to foot size. Now that sounds like fun medical research. I hope it was a female scientist doing the study: “Okay, gentlemen, put your feet and your organs up on the counter and let’s get you measured!”

OPEN SKULL, INSERT THOUGHT All right, let’s get back to the subject of hunger and satiety. Think about how you end a meal. Do you ﬁnish eating when your plate is empty or at the end of a TV show? Become aware of feelings of fullness while you are still eating, even at the beginning of the meal, and ask yourself frequently, “Am I full?” You might be surprised how often your response will be “yes” earlier than it would have been if you had not made the conscious effort to decide. In fact, you should start noticing that you will eat less at almost every meal.

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People who are externally driven by signals to eat are more likely to be overweight. I strongly feel that this process can be relearned, however, and that, once a person realizes that this is a problem, he can retrain himself to pay attention only to his internal signals—it takes time and real effort, but it’s worth it. THE SOUTH BITCH DIET: ANY DIET MAKES ME BITCHY Many obese people don’t even remember what it feels like to be truly hungry and are disconnected from their inner physical feelings. The person who chronically diets becomes used to eating or starving himself according to outside, externally imposed rules. The dieter will say to himself, “I can’t have food for two more hours no matter how much I want to eat.” Eventually, the person becomes dissociated from hunger signals and starts to forget what it feels like to be hungry until he is ravenous. Hunger sensations include a growling or pain in the stomach and feelings of lightheadedness or faintness. You may have difficulty concentrating, be irritable, or get a headache. Spend time refamiliarizing yourself with your own body signals. Be open to the idea that you need to relearn those signals you knew when you were very young. Pay active attention at every meal, at every snack, to stomach fullness, your comfort level, your emotional state. Deliberately ignore external signals like time of day, portion sizes, plate size, and other people’s eating expectations (or your own expectations). Remind yourself to avoid eating out of boredom, fatigue, or emotional causes. IF GOD WANTED US TO DIET, WE WOULDN’T HAVE MOUTHS It is also important for you to understand the sensation of being uncomfortably stuffed, of being overﬁlled. People who chronically starve and then binge often don’t even know what it feels like to be full without being overstuffed. Become aware of when you feel satisﬁed without feeling overly full. Then stop. If you habitually clean your plate, start intentionally leaving food on the plate, even if it’s just a smidgen at ﬁrst. Get out of the habit of eating until nothing is left. However, when you are truly hungry, eat until the last morsel is gone from the plate. Give yourself choices, and monitor your inner physical state constantly. Ask yourself, “Am I really hungry, or am I thirsty, and, if I’m thirsty, would plain water do, or am I really craving caffeine, sugar, or salt (like

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in a sports drink?).” Substitute herb teas to relax and get a ﬂavored decaffeinated tea at night or chamomile, which naturally relaxes without the calories. This is also a good way to ﬁnish off a meal with a treat that isn’t calorie-rich (substitute it for dessert). Vary your ﬂavors, and go shopping in the natural food aisles for some fun variety.

Talk to your stomach, and wait for it to answer on fullness level. Just remember, when in a restaurant, always use a low tone of voice when talking out loud to your stomach, and try very hard to act like you are speaking on your cell phone if you are sitting alone. Otherwise, your next meal may be psychiatric hospital food.

Consider yourself successful when you stop eating earlier than you used to—because you no longer attend to the external signals and are back to listening to your body. Once you have relearned the sensations of hunger and satiety and feel pretty certain you can regularly monitor yourself, you will want to keep your hunger level within a certain range. It is best for your mental and physical state to never allow yourself to be very hungry or very full. Culturally, Americans are more prone to eat “until stuffed” than other people in the world. It is not uncommon for us to eat until we are suffering physical signs of reﬂux or regurgitation, like belching or coughing at the end of a meal.

THE GARBAGE MAN COMETH AND THE GARBAGE MAN TAKETH AWAY Fidget during meals, take breaks if you need to while eating to give yourself time for the food to register with your brain, and then decide if you’ve had enough. Two-thirds of the way through your usual meal, get up and move around. Make a phone call; open your e-mail. Throw in a load of laundry, or take out the garbage. Then come back and decide if you are still hungry. Chronically ﬁdgety people are thinner than those who don’t move constantly. It isn’t just because of the increased basal metabolic rate from constant movement. I suspect it may have to do with their inability to sit still during a meal, giving their bodies time to register “full.”

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In my household, I’m The Laundress. That’s my name and my job. I’m convinced that, as soon as I finish the laundry and go to work, our clothes run around the house until they get sweaty and then they hurl themselves into my hamper. I get home and there’s laundry to do again! One of these days, I’ll arrive home early and catch my husband’s underwear running on the treadmill.

Eat until mostly full, not stuffed, and get in that habit. You don’t have to starve, but there is nothing inherently wrong with practicing feeling a little hungry. Societally, we’ve grown to accept that hunger is a bad thing and to believe that we need to appease it immediately. Rethink your thinking about this; then do what is comfortable for you. But don’t let hunger impair your ability to function or worsen your mood. THE PACIFIST’S GUIDE TO FIGHTING FAT Perhaps the biggest myth in weight loss is that certain food groups, such as fats or sweets, protein or carbohydrates, are to be avoided. When a person feels deprived, he or she is less likely to be successful in losing weight permanently. Diets don’t stick. That’s why I differ from “diet doctors” in refusing to ban high-calorie foods or entire food groups. However, there is no doubt that some foods will make it easier for you to feel full on fewer calories. My recommendation is to become familiar with those foods and habitually to eat them at the beginning of every meal. I introduce the various choices here and expand the discussion in Chapter 6. In the next chapter, I delve into the details of the “four great choices.” These foods are the most important food choices you can make at the beginning of every meal. Pick a whole fruit, a salad, a thin soup, or a tomato juice drink, like V8. Each one of these, for reasons explained in Chapter 6, is nutritional and will signiﬁcantly decrease your desire for calories. You will feel full after every meal and eat a whole lot less. You can drop weight without starving yourself. How awesome is that? In addition, there are other helpful foods that truly do allow you to feel full on fewer calories. Whole grains are more ﬁlling than processed grains. I eat whole cooked oatmeal for breakfast but never processed cereals. The difference in satiation is amazing.

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THE FARTMAN’S DIET: FEEL FULL AND FRIEND-FREE ALL DAY Along those same lines, ﬁber in vegetables slows the processing of food and the emptying of your stomach, so you feel full longer. Eating foods that are high in ﬁber is a great way to feel full without taking in a lot of calories. But watch out—one of the techniques that the diet bars and diet drinks try to do is ﬁll you up with ﬁber that is poorly absorbed. As a result, many people do feel full but later are gassy and miserable. It is best to eat vegetables rather than diet bars or drinks. You are looking for permanent techniques that are good for your body, not short-term diet solutions.

The propane company near me advertised a clearance sale. Heck, my husband does that. When he has extra gas, he clears the room.

Good nutritional foods, like vegetables, satiate you and make you feel full, but foods lacking in nutrition make you hungrier through several mechanisms. Good foods ameliorate the desire for nutrients you might be missing. Yes—and this is common—you can be extremely overweight and still be malnourished! Junk food lacks nutrition and won’t stop a malnourished body from searching for minerals or vitamins that it is missing. I believe that’s why some people become foodobsessed despite being extremely obese and chronically overeating. Strangely, it’s well documented that people who are malnourished will eat the wrong things (even nonfood objects like paint, paper, and paste) in a compulsive search for the nutrients their body is missing. In my own clinical experience with thousands of overweight patients, I have found many who had severe protein, vitamin, and mineral deﬁciencies. Their malnutrition explains why they came to me: serious wounds, infections, neurological problems, or broken bones caused by osteoporosis. Once they started eating more nutritionally sound diets, they lost their compulsive hunger and lost weight! They felt better, and they healed.

TASTES LIKE DIABETES In addition, foods and drinks that are high in processed sugars (highfructose corn syrup, which is used in soft drinks and many prepared

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foods) or highly processed grains (most breads, crackers, and snack foods) send your blood sugar spiraling quickly upwards, sending you into a sugar-induced stupor followed by a crash and the rebound munchies two hours later. That’s why some people claim they are always hungry; the typical American diet produces chronic hunger. Sugarpacked foods aren’t the only thing that can send you on a calorie roller coaster. Caffeine overuse does the same thing. Unfortunately, the predominant caffeine drinks now used are high-calorie sodas and energy drinks, ﬂavored coffees, and prepackaged teas. These are discussed further in Chapter 8. Finally, on the subject of how proper nutrition for your body can make you eat less: if you are allergic or sensitive to certain foods, those foods may wreak havoc with your system and promote overeating. For instance, although whole wheat is promoted by most nutritionists as healthy eating, it’s horrible for those who suffer celiac disease. Celiac patients have an intolerance to wheat and other grains containing a type of protein called gluten. This protein creates damage and inﬂammation throughout the body, as well as chronic fatigue. Exhaustion leads to overeating in an effort to give oneself a burst of energy to counter feelings of sluggishness. It’s a vicious cycle because those grains actually produce malabsorption syndrome and malnutrition in those who are susceptible.

When I go visit my friends, I like to bring a gift. In the old days, I used to bring a bottle of wine, but a lot of people are alcoholics in recovery. So then I was giving candy. But I found that so many of my friends are diabetics. Then I was stuck bringing a nice loaf of bread. But seems like everybody has a gluten intolerance. So now I just give something that everyone needs—health insurance.

COVER YOUR FOOD WITH INGREDIENTS THAT SUPPRESS YOUR APPETITE—CINNAMON IS SAID TO DO THAT—EVEN BETTER, TRY SUPER-GLUE A lot is written about the best combinations of foods to eat to promote a feeling of fullness. Some authors maintain that a meal with a lot of fat and protein increases satiety by reducing the speed of stomach emptying. Fats and proteins take longer for the body to process, so, theoretically, you get to “full” faster. This is thought to contribute to the

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short-term successes of those who follow an Atkins-type diet. The longterm research, however, doesn’t support the idea that people lose more weight on this type of diet.2 And certainly the cardiologists and the kidney doctors cringe because of the long-term damage that a high-fat and high-protein diet does to the body. Finally, there are those experts who claim that constantly eating fatty foods actually suppresses the usual satiation response, resulting in an increase in caloric intake. Some authors insist that meals should include a certain percentage of protein, carbohydrates, and fat to promote satiation. Complex carbohydrates, such as fruits and vegetables, are water-containing and so help with satiation because they are higher in volume. The stomach registers fullness not just according to the calories and the composition of the food (e.g., fats) but also by its volume. I’m not convinced, however, that those diet bars and foods that are supposedly “balanced” with the proper percentages of fats, protein, and carbohydrates are that useful. They are still missing the water content in the food itself and, as mentioned earlier, may not have easily absorbable nutrients, as do plain whole fruits and vegetables. The closer the food is to the soil, the less processed it is, the better it is for you. (Or, as my husband likes to say, the closer you eat to the ground, the shorter you are.)

I LOVE NUTS—THAT’S WHY I MARRIED ONE Nuts are a great food to suppress the appetite. Eat a handful at the beginning of a meal, or 20 minutes before you plan to eat, or as a fast snack. You will eat less later on. The problem is that most people don’t just eat a handful; they eat a canfull. Nuts are packed with nutrition and calories—so a handful is 6, not 60. Avocados and foods rich in unsaturated fats (like olive oil) can also curb hunger pangs. There’s research that shows that foods like these break down in the small intestine to form appetite-suppressing chemicals.3 Nuts are actually a high-calorie-dense food, that is, they pack a lot of calories in a little itty-bitty package. That’s why you have to go easy on them, despite their nutritional value. Eating low-calorie dense foods routinely will make losing weight much easier because you can eat your ﬁll, without ever having to feel starved or deprived. This is an approach that will work permanently to help you keep the weight off even after you have completed your weight loss and that is crucial to long-term success. Complex ﬁber-containing fruits and vegetables give you the most satiation for the number of calories of any type of food. Eating an

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apple or a snack bag of carrots helps immensely and is great for your body. Increasing soups, stews, fruits, ﬁsh, casseroles, vegetables, and natural ﬁbers cuts calories and increases satiety. A glass of water by itself doesn’t help reduce your appetite unless you are truly thirsty instead of hungry. But water, when mixed in with other foods, is very helpful, especially when it is warm and part of the dish being served. Water mixed in with a food increases satiation and lowers the calorie density of what you are eating. On the other hand, foods that are dry and sugary or full of fat or alcohol increase calorie content and intake.

Recently, I saw a cooking show chef make a concoction of deep-fried hamburger between two donuts. She’s going into the restaurant business, I hope in partnership with Cardiologists R Us.

THE WORLD ISN’T FLAT, IT’S FLUFFY As Dr. Barbara Rolls wrote in her excellent book Volumetrics, taking in water is the most common way to increase satiation without increasing calories. In addition, an often overlooked way to increase fullness without adding calories is to mix air in with your food. Air-ﬁlled foods, like dry popcorn and smoothies, work to improve satiety with relatively few calories. (Blenders mix lots of air into the liquid.) The air in the food or drink fools your stomach into thinking you ate more than you did. That’s why the rice-cake industry was born. Rice cakes are good for an occasional munch but don’t help in the nutrition department. Smoothies, often higher in calories, are also much higher in powerful nutrients. Do what’s best for your body. Your body will thank you for it. As I’ve already mentioned, if you slow the rate at which the stomach empties its contents into the small intestine, food will ﬁll you up faster and you will eat fewer calories. Gastric emptying is inﬂuenced not only by the composition of the food but also by such things as whether you have eaten solids or liquids. Liquids empty quicker since there is no grinding to be done to process them. A soda or an alcoholic drink is loaded with calories and will go right on through. It won’t ﬁll you up, but it will pack on the calories. But liquids that have a more complex composition (like a soup that has a protein base such as a beef or chicken broth or milk) will dump slower. Add a little solid meat or vegetables,

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and you’ve got a soup or stew. The additional sensory stimulation of multiple complex ﬂavors and aromas and the act of chewing will increase satiety much more than a plain drink will.

Here’s a caution, though. People can become overzealous in their desire to eat nutritious foods. One of my son’s friends is a third-generation strict vegetarian. His mom feeds him salads, pureed as smoothies, for lunch. I tried them once—eeeehhh, yuck! The boy is very tiny as a result. He’s so small that I have to tell my kid, “Aaron, check the sofa seat cushions—George’s mom just called, and he’s missing again.”

Interestingly, warm foods and drinks may stick around in the stomach longer than cold foods and drinks. Cold foods and liquids have been shown in some studies to stimulate thermoreceptors in the stomach to empty the meal early. I’ve been postulating that Asians may traditionally be thinner than Westerners because there is a strong cultural bias against eating cold foods and drink—perhaps they just ﬁll up faster on less food because it’s warm. Americans and other Westerners who insist on cold food and drink with meals are more likely to empty their stomachs prematurely and eat more food at each meal. Warm food makes the stomach muscles relax and retain the food, thus giving people a feeling of being fuller on fewer calories. That may be only one of the reasons that hot oatmeal ﬁlls up the tummy with far fewer calories than a cold bowl of cereal (besides, it’s a whole-grain product). Finally, there is a little bit of research that shows capsaicin (the chemical that makes hot peppers taste hot) may decrease appetite, but the thermal heat produced in the stomach may have more to do with it than the peppers.4 THAT GREAT ITALIAN, DR. PLACEBO DOMINGO There are other ways to feel fuller during or after a meal that don’t involve food choices. The most common techniques are medications to suppress the appetite or surgery to restrict the stomach. We discuss surgery a little later and medications in the next section. There are less frequently used approaches that don’t involve the expense and danger of surgery or pharmaceuticals. Unfortunately, we don’t know if they work. One of the most fun concepts is the idea of Professor Luigi Ambrosio, lead researcher on a study at Italy’s National Research Council.5

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He’s testing a powder pill made up of cellulose called hydrogel. After it’s swallowed, the hydrogel turns into a large glob of indigestible jelly in the stomach. It gives a sense of early satiety. You need to swallow the hydrogel pill at the beginning of every meal, and long-term studies for safety aren’t completed. The concept is really very similar to the gastric banding idea, without the mess of surgery. There’s not enough information yet to know if it’s cheaper or safer in the long run or if it’s truly effective. Also, we don’t know how your digestive system or your house plumbing will hold up to a three-times-a-day gel poop. Dr. Luigi isn’t saying. TAKE TWO PLACEBOS AND CALL ME IN THE MORNING I have to tell you right away: I’ve never prescribed a medication specifically for weight loss. I don’t like the concept of diet drugs because that’s exactly what they are, medications to promote a temporary condition, a diet. They are never intended to be permanent and therefore don’t help a person learn long-term solutions to overeating and underexercising. Also, medications have side effects and can be dangerous. On the other hand, obesity is very dangerous, too. So, with that in mind, I review some of the commonly used drugs here. RED HERRING PHARMACEUTICALS—OUR PRODUCTS HAVE BEEN CONFIRMED IN CLINICAL TRIALS TO REDUCE SWELLING OF THE WALLET Phentermine was a popular diet pill for a while in the 1990s. It gives modest help to control hunger and is relatively well tolerated. Still, it can cause heart palpitations, high blood pressure, nervousness, and an upset gastrointestinal system. That’s a lot of complaints for a modest eight-pound weight loss over six months, and it’s really not intended to be used for more than three months. I don’t want you to think I hate pharmaceuticals. That’s just not true. I prescribe other types of drugs every day for my patients and take some medicines myself. My allergies get to me a lot. I get sneezy and itchy. Then I take medicine and become hungry and sleepy and dopey from the side effects. And, since I’m already doc, I’m practically the whole damn crew of seven dwarfs, all at once!

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Another weight-loss drug that has held a lot of promise but that hasn’t really delivered is sibutramine, also known as Meridia, Reductil, or Sibutrex.6 It was designed to be an antidepressant but failed miserably. However, during the drug trials, subjects were noted to complain of anorexia (feeling like they would rather not eat). Thus was born a new diet drug. According to the British Medical Journal,7 you will lose about 7 to 10 pounds more than if you took a placebo, but you stay on the medication continuously for half a year. Its main side effect is heart rate increase. Another, more successful antidepressant, ﬂuoxetine (best known as Prozac or Sarafem), is thought to produce weight loss of between 2 and 20 pounds if you take it for six months.8 The problem is that this drug has a lot more side effects, including nervousness, sweating, tremors, nausea, vomiting, fatigue, insomnia, and diarrhea. Oh, and let’s not forget one of my favorite ignored side effects of this drug class, sexual disinterest. With all those delightful symptoms, I’d choose the placebo section.

Speaking of sexual side effects, I’ve always wondered what the emergency room does with all those guys who take Viagra, Levitra, or Cialis and end up with that infamous side effect, the four- hour erection that won’t go down. Are the nurses in the back room playing ring toss? And, on that note, the average dose for Viagra used for erectile dysfunction is 25 milligrams. But that same exact drug is used for a lung condition called pulmonary hypertension at much higher doses, around 60 milligrams.9 It turns out that’s convenient in Florida, where I live. On sunny days, the patients can double as beach umbrellas.

TV ANNOUNCER: SIDE EFFECTS MAY OCCUR, INCLUDING BLOATING OR RASH, AND YOUR HEAD MAY FALL OFF. LUCKILY, YOU WON’T COMPLAIN Orlistat (Xenical, or Alli, as it’s sold over the counter) is a drug that doesn’t have all the neurological or cardiac side effects of the medications mentioned earlier. The reason for that is that it isn’t really absorbed

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into the body and so has limited effects on organ systems outside the gastrointestinal system. It will help you lose about one extra pound a month. It blocks fat absorption, and the result is that fat gets ﬂushed through your intestines, resulting in diarrhea, ﬂatulence (farting), bloating, pain, oily stools, and regurgitation.10 Oh, and if that weren’t enough, there’s always the very popular bowel incontinence and anal leakage. I know I want to worry about that when I go to parties.

Which reminds me of the rumor that I heard: that the drug companies are also working on a diet drug that combines that appetite-reducing hormone leptin and the stool softener FiberCon to produce a medicine called Lepricon. You do realize that gold is not the only thing you’re gonna find in that pot.

So now you know how I feel about diet drugs. They are only for shortterm use and generally are more trouble than they are worth. None of these are “happy pills” for dieting. They are not adding to your pleasure or joy, and the weight loss that results is very minimal. Finally, most research shows that you will gain the weight back as soon as you go off the medication if you haven’t developed other ways to deal with overeating and underexercising. Personally, I don’t see the point to using them.

NEW SURGERY: IT’S MORE EFFECTIVE THAN STOMACH STAPLING; WE STAPLE YOUR ASS SHUT. GUARANTEED YOU WON’T WANT TO EAT Bariatric (obesity) surgery is becoming acceptable as a successful alternative to lifestyle changes, particularly for those who are very overweight. These surgeries still have a 1 percent or more one-year mortality (death rate) and a high complication rate (such as wounds and neurological problems as a result of malnutrition). A proper diet and regular exercise are much safer and have no mortality, if done correctly. Lifestyle changes will make you healthier, permanently. If you can change your habits and forgo the risk of surgery and all the complications that go with it, obviously you are much better off.

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ROCK, PAPER, CIRCUMCISION And surgical complications are no joke. Except here. My friend told me the true story of her first husband’s vasectomy. They used to tell you to shave the area before you showed up that day. So he shaved his entire area, all the way to his knees. Then for some reason, he decided to apply cologne. Suddenly, she heard screams and found her husband bent over the toilet splashing water on himself. Stifling a laugh, she blurted out, “Oh, hon, wasn’t the dog just drinking out of that?” The funny thing is, the whole point of shaving before surgery was to make the process more hygienic. After the procedure, he was given a prescription for a support, in case he had a lot of swelling. He took it to the medical supply company, and they asked him what size he needed: small, medium, or large. Wouldn’t you know it, every guy asks for extra large. But, in this case, he was probably a little swollen.

DOCTOR PERFORMS SURGERY BY TEXT MESSAGE—IT’S CUTTING-EDGE TECHNOLOGY One of the most common types of bariatric surgery is the gastric bypass, officially called the Roux-en-Y, which is a procedure that bypasses most of the stomach and the ﬁrst portion of the small intestine. It causes food to be absorbed and processed differently. It reduces the size of the stomach by more than 90 percent. A normal stomach can hold more than 1,000 milliliters of volume, whereas the bypassed stomach may only hold as little as 15 milliliters of food. So the patient feels full very easily after only a little bit of food. Eventually, the small intestine connected to the bypassed stomach will stretch to hold more food; that’s why bypass patients don’t lose weight forever. This surgery creates signiﬁcant nutritional deﬁciencies because the stomach and small intestine, which is mostly bypassed as well, are where many nutrients are absorbed. Bypass patients often ﬁght lifelong nutritional deﬁciencies of calcium, iron, B12, thiamine, and vitamin A. They may also have protein malnutrition from eating less protein than they should after the surgery. The gastric band (lap band) procedure places a band around the top portion of the stomach that restricts how much a person can eat and causes a person to feel full earlier. Nutritional malabsorption is less of

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a problem. However, the weight loss may not be as extensive, quick, or permanent. Obesity and diabetes are less likely to be cured, but the complication rate of this surgery, both short and long term, is lower than for other forms of weight-loss surgery. The sleeve gastrectomy, another type of surgery, reduces the size of the stomach by as much as 80 percent. It can require a second surgery and often comes with permanent complications.

There are a lot of different names for surgeries, and it gets confusing, even for physicians. I had a patient who had a diagnosis on his chart of “failed sex change operation.” I wasn’t sure what that meant. so I did an Internet search for that phrase “failed sex change operation.” All I got was an ad for Valentino’s Pepperoni.

The complication rates from bariatric surgeries range from less than 1 percent mortality to as high as 14 percent for other types of complications (e.g., nonhealing wounds). This is more common in the old-style “open” surgeries,” where a traditional scalpel incision is made, than with laparoscopic procedures (the bigger the incision, the more risk of complications).

INTERNAL GPS DEVICES: “ TURN RIGHT AT THE APPENDIX” There are many different ways surgeons get to your internal organs. The old-fashioned way was by an open surgical incision. Frequently now, surgeons are using laparoscopic tubes placed through tiny holes to get at organs. The next phase is “incisionless” surgery, where instruments are snaked through catheters into natural oriﬁces.

They aren’t doing incisionless surgery yet for bariatric surgery, but I have read about gallbladders coming out through vaginas (those two organs are nowhere near each other). I’m not certain of the advantage of that procedure, except that you can return to the beach in your bikini the next day. I’m waiting to hear about the testicular cancer biopsy being done through the ears. This is the major reason that

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I’ve seen ﬁrst-hand the short and long-term complications suffered by patients who have had bariatric surgery. Often the patient does not follow up permanently with the surgeon and does not follow the longterm recommendations for proper nutrition. This problem will only get worse as more of these surgeries are done. Even after surgery, you still have to take care of your body, change your eating and exercise habits, and develop nutritional awareness. Bariatric surgery is only one step in the process of successful weight loss, even if you do choose that route. TAKE SURGERY SERIOUSLY—DON’T GET LASIK OR A BOOB JOB AT THE MALL—OR YOU MIGHT BE LEFT WITH CINNAMON BUNS FOR BRAINS Long-term studies of bariatric surgery patients reveal that, 10 years after the procedure, there were no improvements in blood pressure, despite the weight loss.11 In other words, the long-term consequences of surgery may be weight loss but not better health. So, at least when it comes to improving cardiovascular health, surgery has not been proved to help. There is research to show that diabetes can be reversed in the short term, but the long-term studies aren’t convincing. Unfortunately, the complications of the surgery itself may negate any health beneﬁts. The success of any of the surgeries that create smaller stomachs is dependent on the patient learning different eating and lifestyle habits. If a patient grazes constantly on high-calorie foods and never exercises, he or she will defeat the effectiveness of the surgery. This is a common cause of surgical failure. For the very obese, unless you have extensive psychological and nutritional counseling and commit to lifestyle changes, including regular exercise, you will not lose weight permanently, even with surgery. Most of the research on these surgeries does not follow the patients for years afterwards to examine the long-term successes and complications. This is where the real problems come in, so keep that in mind. SEX AND OTHER EXERCISE Exercise (including sex) decreases hunger temporarily but increases hunger later. There’s a lot of controversy as to whether the net gain is

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beneﬁcial to weight loss. Since I’m a big believer in sex (and other forms of exercise), I strongly recommend it. However, you might ﬁnd that you need to plan the timing of your exercise to get the most appetite suppression. Sexercising and other activities might just work best before bedtime, at least to decrease hunger and the evening munchies. “SQUARES”: A GYM FOR MIDDLE-AGED MEN IN SHORTS AND DARK SOCKS A lovely little study done at the School of Sport and Exercise Sciences at Loughborough University in the United Kingdom in 2007 found that ghrelin, a hormone essential for appetite regulation, is signiﬁcantly altered for up to nine hours after one hour of vigorous exercise.12 (They used running, not sex, in the study, probably because it’s easier to control calorie expenditure.) Unfortunately, the test subjects felt less hungry only for three hours afterwards, not for the full nine hours, and the researchers used only young men. In fact, in most studies that have looked at exercise and appetite suppression, the researchers have either found no change in the intake of food after exercise (65 percent of the time) or a modest increase (19 percent of the studies). It is fascinating that some of the research shows that appetite suppression by exercise works better for men than women but that it depends on the exercise (high intensity or low).13 Men respond better to high intensity, women better to low, uh, maybe. Depends on which research you read and which scientist you talk to. Oh, and if you had any health problems, were obese, more than 25 years of age, or drank alcohol, you weren’t in these studies. As usual, the research doesn’t necessarily tell us much about the real world. HARDLY DAVIDSON As an exercise doctor, this is one of my pet peeves. Research on activity is usually done on the young, fit, and perfectly healthy. But the people who most benefit from exercise are those who aren’t in the best shape. Our society doesn’t encourage getting fit, either. Remember when a biker was someone on a bicycle? Now, it’s someone on a $25,000 Harley. Come to think of it, bikers used to look young and cool, like James Dean. Now a lot of them look older, fat, and suburban, more like Jimmy Dean.

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I’VE EXERCISED MY SELF-RESTRAINT, AND NOW I CAN’T GET OUT Generally, studies on eating patterns after exercise have found that the increase in calories taken in, even in those few studies where people ate more in the exercise group, was less than the calories that they expended by exercising. Thus, the increased noshing did not cancel out the beneﬁts of the burn of exercise. And note: a person continues to burn calories at a higher rate for up to 24 hours after vigorous exercise. No one seemed to be calculating for the higher metabolic rates produced by daily exercise; they just looked at the caloric work done during the one activity hour. Personally, I think there may be both a reasoning and a math problem here.

THE SUMO AND YOU DIET What is known is that people who decrease the amount of exercise that is normal for them don’t decrease the amount they eat and thus fatten quickly! Also, people who skip meals make up most of the calories in the next 24 hours, but people don’t make up all the calories that they expend while exercising. Thus, starving doesn’t help you lose weight, but exercising regularly does. We’ll discuss the speciﬁcs in Part III. Ultimately, you need to be aware of your own body. Most people do experience appetite suppression after exercising, but it depends on the type of exercise and the timing. You need to listen to your body. It’s talking to you.

WHAT YOU SHOULD REMEMBER FROM THIS CHAPTER • Relearn your body’s own signals for permanent thinness. • People who are overweight are more likely to use external signals for eating. • Eat when hungry, and never wait until you’re starving. • Stop eating before you’re stuffed. Eat until pretty full, not very full. • Don’t restrict food groups, but realize that some foods are more ﬁlling than others. • The “four great choices” plus whole grains and ﬁber-rich foods increase satiation. • Nutrition-loaded foods are more satisfying than those that contain empty calories.

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• Foods high in sugar or caffeine or that create sensitivities cause overfeeding. • Eating foods closer to Mother Nature results in better health and increases satiation. • Water- or air-containing foods or a handful of nuts will help you feel full. • Thin liquids like soft drinks or alcohol will not register as calories as well as solid food or complex liquids like smoothies or soups. • Warm food and drink may ﬁll the tummy better than cold substances. • Diet drugs help you lose a pound a month, are for short-term use, and have side effects. • Weight-loss surgery has complications and may not have beneﬁts. You still have to exercise regularly and learn better eating habits for the surgery to work. • Exercise decreases and then increases hunger, but the calories eaten later do not make up for the calories burned off by exercise, so you have a net loss.

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PART II Input—Food and Drink

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SIX Eat Right, Die Anyway: What Are Good Foods?

One of the problems here where I live is that, until recently, you could call yourself a nutritionist and not have any real training at all. Florida is a place where they practice the separation of state and knowledge.

Understanding nutrition is important for everybody—if you understand the content of what you put in your mouth, you are less likely to eat junk. We can do the same with the nasty food industry that was done to the cigarette industry: the death stick manufacturers lost many of their potential customers when teenagers became educated to the 300 toxins inhaled in every cigarette. If we can do the same with nutrition, people will be less inclined to indulge in the toxins from the food industry and will instead eat the quality foods that the industry does produce. I’ve already mentioned the three basic parts of food that give us fuel: carbohydrates, proteins, and fats. All the energy of our body, the fuel that allows us to move and build our body parts and carry out our physiologic activities, comes from these substances. It’s important to understand that the use of the word “energy” in nutrition and food descriptions is not always a good thing. The other word for energy is “calories.” Humorously, some in the food industry like to label things

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high in calories as “energy foods,” implying that they’ll give you a boost of energy. In reality, they’ll give you a boost to your hip size.

MY FAVORITE DELI HAS AN AWESOME DESSERT CALLED KILLER CAKE—NOW WITH 90 PERCENT MORE LAWSUITS! When eaten, carbohydrates are broken down the quickest and fats the slowest. Carbohydrates are broken down into sugars, proteins into amino acids, and fats into fatty acids and glycerol. Complex carbohydrates (like whole grains, beans, and vegetables) take longer to break down and so don’t give the sugar rush into the bloodstream that simpler sugars do. Carbohydrates that are processed (such as white bread, sweets, or pretzels) are stripped of their nutrition and ﬁber. These types of foods may often have vitamins and minerals put back in by the food companies, but it’s not clear that those vitamins and minerals are absorbed and used as well as those from the unreﬁned versions. There has been a deluge of data showing that a diet high in simple and reﬁned carbohydrates results in obesity and diabetes. Proteins are the building blocks of your body parts and also make up the enzymes for body functions. Proteins and enzymes are made up of various amino acids, about half of which your body can produce on its own. The other half must be eaten in your food. If you are on a very restricted diet, you may be missing some of these amino acids and will be malnourished.

DANGER, HAZARDOUS WAIST Fats in your diet are very important. Animal fats tend to be saturated and are not as good for you as other types. (The type of saturation refers to a type of chemical bond.) Saturated fats lead to heart disease. In general, plant-derived fats are mono- or polyunsaturated fats and are healthier. If the fat is a solid at room temperature, it’s not a great choice. However, liquid vegetable fats (and ﬁsh oils) can have a very positive impact on the body. Dietary fats are intensely full of energy (that’s why you don’t need a lot of them in quantity) and are extremely useful for physiologic processes like hormonal regulation and immune function. Take in too much or too little fat, and you will be asexual and prone to infection or cancer. When you eat too much carbohydrate, protein, or fat, you make more fat (adipose tissue), as that is the way the body

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stores excess energy. Understand this: any overindulgence in calories, whether it comes from fried bacon (protein and fat) or snack crackers (carbohydrate) will be processed into the spare tire around your belly or cellulite in your thighs.

Manatees eat 16 hours a day and feed exclusively on plants that are like lettuce. They weigh up to 3,500 pounds. Imagine how much they would weigh if they ate fried chicken.

Calories are the way that we measure quantities of energy. The more calorie-containing a food, the more fuel you get. Eat too much fuel, and your body stores it for later use. It’s an exquisite system that was designed at a time when humans suffered long periods of drought and famine. When there was relative plenty, people ate as much as possible to store fuel for the lean times. Evolution hasn’t caught up with the appearance of the convenience store. Even in developing countries, obesity is becoming a bigger health threat than starvation and famine.

IF MASS CAN NEITHER BE CREATED NOR DESTROYED, WHY AM I ALWAYS ON A DIET? Please don’t aim to be perfect with your approach to nutrition. The goal should be to be healthy and eat healthy most of the time. Realize that it’s okay to eat nonnutritious foods on occasion. My deﬁnition of healthy eating is to eat food that is good for you and to have a good relationship with what you eat. Talk nice to your dinner, and don’t forget to apologize to the pork. As mentioned in Chapter 2, I don’t believe in restricting food groups or timing food choices to stages. There are no proven long-term weight loss beneﬁts to such diets as Atkins, South Beach, or Ornish beyond their causing a person to become conscious of the amount and type of foods that are eaten. Research studies have not shown that one type of restricted diet is much more successful for weight loss than any other, when you are looking at more than a month or two at a time.1 Indeed, there is a lot of concern that eliminating food groups is detrimental to your health and unsustainable in the long run.

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IF I EAT EVERYTHING, SOME OF IT HAS TO BE GOOD FOR ME So what is a healthy diet? It seems that a straightforward question like that ought to have a straightforward answer. The problem is that nutrition research is much more complicated than health workers have been willing to admit. Suffice it to say that the traditional food pyramid that we were taught in elementary school has fallen out of favor. It is no longer believed that a diet based on grains is as safe as a diet based mostly on fruits and vegetables. Meats, dairy, grains, oils, and sweets are to be eaten in smaller amounts. Fish might be okay to eat in large quantities, but it’s not clear whether it is safe to eat lots of shellﬁsh.

People really love shellfish, whether it’s shrimp, scallops, or mussels. Supposedly, oysters are an aphrodisiac. Personally, I think they taste like a bad head cold.

The more you know about nutrition, the more you realize that eating “nasty” foods is true deprivation. Your body thrives on fruits, vegetables, and low-salt, low-sugar, and low-fat foods. When you serve it anything else, your body lets you know that you have deprived it of what it really needs. Listen to your body. If you feel tired after a meal, it wasn’t the right food, or you ate too much. Food, like exercise, should make you feel energized, not sleepy. Older studies examining Eastern cultures where people are thinner than Americans ﬁnd that rural Asians tend to eat more calories than people in the United States, yet the Asians are thinner. Why is that? Dr. Dean Ornish, the proponent of a very low-fat diet, said it’s because thin Chinese eat less fat. He didn’t mention that, per capita, they also have fewer televisions, cars, and convenience stores than Americans. Presumably, a thin, rural Asian has to walk to get places, buy food, and work his farm. There’s a good chance he might exercise more than the typical American. The Chinese farm worker probably eats more fresh fruits and vegetables grown in his own backyard.

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FAMOUS HEALTHY DEAD PEOPLE: EUELL GIBBONS IS STILL DEAD, DR. ATKINS IS STILL DEAD—HELL, GENERALISSIMO FRANCISCO FRANCO IS STILL DEAD On the other hand, Dr. Robert Atkins thought that as long as we ate lots of fat and protein we’d burn more calories processing those types of foods than if we ate carbohydrates. Thus, he reasoned, we could eat more calories of some types of foods than others. Dr. Atkins was probably correct that too many processed carbohydrates are not good for the body, but he missed the point about the natural carbohydrates, like fruits, vegetables, beans, and legumes, which are extremely important to the health of our bodies. His theories also alarmed many in the health care community because of his emphasis on eating saturated fats and animal products. There’s no epidemiological research to show that eating large amounts of saturated fats and animal products is safe for the long term; there’s lots to show that it is dangerous. What good is losing weight if your diet causes you to end up in the cardiac intensive care unit or on dialysis?

THE ELVIS DIET: EAT ANYTHING YOU WANT, YOU’LL PROBABLY DIE ON THE TOILET ANYWAY As far as I’m concerned, a person should be able to eat any food he or she has the desire to eat, but the person might want to restrict how much of it he or she eats. Most weight-loss programs concentrate on the “what” of food—-which foods you can and cannot eat. They don’t place enough emphasis on the behavior of eating (limiting amounts) or moving your body to burn fuel. That’s the failure of diet plans. The vast majority of dieters fail because they have a mindset that all that matters to weight loss is the type of food. There’s the myth. Dr. Ornish (the low-fat guru) and Dr. Atkins (the low-carb guru) both stated in their bestsellers that their diets are based on the way humans evolved to eat. Dr. Ornish says that people used to eat mostly fruits, vegetables, and grains but not meat. Dr. Atkins wrote that people used to eat mostly veggies, ﬁsh, poultry, and meat but not grains. The truth is, they both may have been correct; it depends on the ancient human you ask. Go ahead, ask one. In the very cold northern climates, historically humans didn’t have a lot of vegetables growing out of the permafrost. They subsisted on ﬁsh and whale blubber. In the tropics, people found wild fruit and green

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leafy things to eat. One thing we do know is that cavemen weren’t eating goose liver spread or potato chips.

The Tutankhamun (“King Tut”) display came to a nearby museum. It had a viscera coffin, which held mummified preserved internal organs. It even contained the young Pharaoh’s preserved last meal of noodles— Tutan-Ramen.

There is a lot of controversy about what constitutes a nutritionally sound modern diet. One of the reasons is that it is hard to run experiments in which humans eat only limited types of food for months or years on end, unless it’s my son. If anyone ever wants to do an experiment on a person subsisting on pizza and chicken ﬁngers for more than a decade, I have a ready-made volunteer. I’M ON THE HELLO CARB DIET Widespread carefully controlled experiments on large numbers of people eating only certain food items have not been done. Our conclusions on nutrition come from epidemiological research of populations. This means that we look at what large groups of people tend to eat, look at their overall health, and try to draw conclusions from this. Of course, we can make the wrong conclusions, since we often assume that the diet had something to do with the health outcome, whereas in fact it may not have. We medical types think we know that the Mediterranean diet is healthier because the people of that area of the world who eat a lot of fresh fruit and vegetables, olive oil, lean meats, and limited processed grains seem to do better. There are even theories about why this is, related to protective naturally occurring chemicals in the oils and plants ingested, but we don’t have hard scientiﬁc evidence in humans to back it up. THAT NEW NUTRITIONIST UP THE STREET, DR. BURYME Some of the reasons for the controversy in nutrition advice has to do with the agenda and point of view of the adviser. This helps explain why there are such dramatic differences among nutritionists, physicians,

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and other health care workers when it comes to dietary advice. For instance, according to a 2007 article in the Journal of the American College of Clinical Nutrition, although a high-fat diet may actually promote faster weight loss initially, it contributes to an increase of C-reactive protein, a well-known marker for inﬂammation and cardiovascular risk. If you are a cardiologist, this matters more than the rate of weight loss. If you are someone like me, who sees a lot of people disabled by stroke and heart disease, it matters a lot. If you are one of those pseudo-“nutritionists” working in a storefront weight-loss clinic and all you care about is the quick result, you might advise someone to be on a high-fat diet; you are not worrying about being around when your patient has a stroke or heart attack. Interestingly, the hard scientiﬁc evidence about nutrition in people is really pretty lousy. That’s because nutrition is incredibly complicated and foods are made up of thousands of various chemicals. That doesn’t give us permission to throw our best guesses out the window. I will say that the jury is far from done deliberating on the ideal type of diet to follow. Since I have to make some decisions today that are based on questionable and incomplete data, I do recommend that people who are seeking sound weight loss eat lots of fruit and vegetables and limit excessive salt, fat, and sugar. I believe in limiting processed grains, also. This advice comes from my personal experience as a physician and the best synthesis of the medical data. It seems to work for people all along the health spectrum and for all ages, from the elderly to young children.

And, speaking of kids, I don’t understand why people name their children after food. You just can’t take that person seriously. Take the name Candy, for instance. What are parents thinking when they name their kid Candy? What if Adam and Eve’s kids were named Candy and Cain? People wouldn’t have read the rest of the Bible! I know a couple of Candys who have important administrative positions, but you can’t help but doubt their abilities. You might as well name your kid Flapjack. Announcer’s voice, “And the winner of the Nobel Peace Prize—Flapjack Jones.”

And speaking of ﬂapjacks and other pancakes, I think more data will emerge that show that processed grains (and perhaps most grains)

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are not as healthy as the traditional or updated food pyramid leads us to believe. Many modern versions of wheat, corn, and rice cultivated for mass consumption are not nutrition-packed and may cause dangerous allergies. The priority in a healthy diet is to eat nutrition-packed foods. In the same vein, I believe that choosing foods on the basis of the glycemic index misses the point. The glycemic index is the measurement of blood sugar after a food is ingested. Often foods that are high on the glycemic index are low in nutritional content, but not always. I’m annoyed by authors who decry such wonderful foods as bananas, sweet potatoes, carrots, and peas for being too high on the glycemic index; they are all packed with important nutrients and have a place in a nutritionally sound diet. One of the problems with the glycemic index is that more recent research has shown it is not very accurate.2 The measurement varies by as much as 20 percent, depending on the type of blood drawn, the numbers of repetitions of the draw, and whether and when the subject ate food or drank any alcohol previously. On the other hand, for those with diabetes or who have gestational diabetes, a low-glycemic-index diet has been shown to help avoid the use of insulin.3 It may help diabetics avoid progression of cardiac disease, as well. But, the relationship between diet and disease was found to be the same as if the person were on a high-ﬁber and whole-grain diet. Finally, there is some meta-analysis data ( pooled research from multiple studies) to show that a low-glycemic-index diet can help diabetics avoid other diseases, such as breast cancer and gallbladder disease. That makes sense —if you are a diabetic who eats foods that spike your blood sugar, your body may not be able to defend itself against illness. The bottom line: avoid processed grains, and you’ll do better. ANCIENT CHINESE SAYING: MAY THE WIND BE AT YOUR CRACK Many people believe (wrongly) that healthy food is boring or unpalatable. The traditional Asian and Mediterranean diets are not unpalatable by any means, and they are both considered healthy. Ever been to a Thai restaurant? The food is spicy, not bland. How about a real authentic Italian place? There’s a spot near me that Tony Bennett (born Anthony Dominick Benedetto) would eat at every time he came to town. Supposedly, he claimed it reminded him of food like Momma used to make. It’s real Mediterranean fare. The food at that restaurant isn’t anything like Americanized Italian places, and it’s not boring

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or unpalatable. It doesn’t go heavy on the pasta and bread, instead emphasizing vegetables, olive oils, and spices. MY NEW VEGETARIAN COOKBOOK, STOP AND EAT THE ROSES I’ve noticed that a lot of Americans (and, unfortunately, some American restaurants) seem to think that health food consists of plain tofu and steamed vegetables, which, I will admit, are boring. But, luckily, there is a lot more variety to healthy and nutritional food items than that. In fact, I’ve found that food unencumbered by the intense ﬂavors of salt, fat, and sugar is much more interesting, as the more subtle and varied underlying tastes aren’t drowned out. The palate gets a better workout and has more fun. You will, too. Sometimes people use the phrase “Eat like a cave man” since we have evolved to eat the foods our ancient ancestors ate, not modern processed and packaged foods. I say, “Screw that; instead, eat like a cave woman.” While Cave Man was out doing macho things, like clubbing the heads of poor, helpless, little mammals, Cave Woman was scrounging around in the dirt for berries, vegetables, nuts, and tubers. Cave Woman had a healthier and more varied diet and less fur between her teeth. And note: neither one was baking sweet rolls. THE FLATULENCE DIET—LOSE WEIGHT AND FRIENDS I have heard the complaint that healthier foods can be harder to digest. That’s part of the beauty of a good diet— our bodies have to work to digest it. The slower digestion results in slower emptying of the stomach; thus, it ﬁlls faster during a meal, and you eat less. Also, the slower digestion of a meal results in lower spikes in blood sugar and insulin, which we know is healthier, as well. Make your stomach and intestines work—that’s what we pay them to do!

Along those lines, I get complaints that healthy foods result in gas. Flatulence is a favorite topic of mine. We didn’t spend a lot of time talking about it in medical school, but we should have. In fact, given the interest that the average patient has in avoiding gas, you’d think there would

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be at least a semester spent on this topic. Two courses that should have appeared on our transcripts at graduation: “Farts and Belches 101”and “Write Indecipherably, Like a Doctor.” I would also have liked a course called “Screaming Effectively at Insurance Executives.” That one I would have passed with flying colors.

I EAT ONLY FREE-RANGE TOFU Back to farting and belching: when a person starts eating foods his body is not used to, it will sometimes ﬁght back and complain. Fruits, vegetables, beans, and legumes are healthy and high in ﬁber. They are important to a balanced diet and to losing weight permanently. But they can create gas. That is why it is important to introduce high-ﬁber foods into the diet gradually, particularly if you are noticing that your family and friends have started to choose seating on the other side of the house at dinner time. Use Beano, a digestion aid that works for beans and other foods, including cruciferous vegetables (broccoli and cauliﬂower). It may even help with soy products, tofu, lentils, and hummus, some of my favorite gas-producing foods. Beans can be soaked before cooking to reduce their gas-producing effects (throw the soak water away). THE FOUR GREAT CHOICES: MEMORIZE THESE. THERE’S A TEST AT THE END! There is a very simple way to decrease the number of calories you eat every day and not even feel it. I call it “the four great choices.” Before each meal, eat or drink one of the following: a glass of V8 or tomato juice, a whole fruit, a bowl of thin soup, or a salad. It is such an important concept, and it really works, so it is worth repeating and elaborating. There is signiﬁcant research to show that this is one of the simplest ways to eliminate calories painlessly. The reason is that each one of those foods has been demonstrated to suppress the appetite and make a person feel full more quickly. If you pick one of those four choices before each of your meals every day, you will likely trim enough calories from your diet to lose weight painlessly without feeling hungry or like you are “dieting.” And each one of these choices is very healthy and packed with nutrition. Add in a daily walking or other moderate

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exercise program that you enjoy, and you will have signiﬁcant permanent weight loss without pain, starvation, or feelings of self-neglect. I like that. You should, too. Tomato juice, unlike other fruit juices ( yes, tomato is technically a fruit) is low in calories and is a great suppressor of appetite, without the sugar high and rebound that other fruit juices give. One eight-ounce glass of tomato juice or V8 (low-salt preferably) has about 50 calories and likely will cause you to eat hundreds of calories less. They are also packed in serving sizes that are convenient for work and travel. Bring a six-pack to work with you, and keep them in your desk or in your car. As if calorie-losing isn’t a good enough reason to drink them, tomatobased juices are rich in nutrients and lycopene, a natural chemical thought to be associated with health beneﬁts ranging from eyesight improvement to cancer prevention. Interestingly, the research seems to point to the fact that lycopene in tomato products works for cancer prevention but not when taken in pill form.4 Again, all the more reason to choose healthy foods and drinks.

COLLEGE STUDENT’S BUMPER STICKER: PAID THE TUITION—NOTHING LEFT FOR MY NUTRITION If you would prefer a fruit other than tomato, you must eat it whole, not in juice form, to get the calorie-decreasing beneﬁt. This is a good one to do ﬁrst thing in the morning, at breakfast, before your oatmeal, eggs, or low-fat cheese or meats. The reason orange, apple, and grapefruit juice won’t work but the whole fruit will has to do with the body’s ability to process the pulp and ﬁber of the whole fruit. Whole fruit takes a lot longer to get broken down in the stomach. Fruit juice is so full of available natural sugar that, when dumped into the stomach, it slides immediately into the intestine and the blood, creating a sugar rush (and lower blood sugar and the rebound hunger later). There’s a reason that, even today, in an emergency, health care workers and diabetics still use orange juice to get low blood sugar up quickly. Orange juice is one of the fastest ways to give yourself a sugar high. Skip that traditional glass of OJ with your breakfast. However, when an orange is eaten whole, and especially when it is paired with a protein like tofu, eggs, meat, or cheese, you won’t get that kind of rush. Vary your fruit so that you don’t get bored, and grab the best fruit in season to keep your wallet and your stomach happy. This will work with pears, bananas, apples, or any other whole fruit.

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And speaking of breakfast: humans find spirituality anywhere, particularly Floridians. I was in Clearwater a number of years ago, and there was a church set up in a car dealership’s parking lot. The Virgin Mary’s image had appeared on an oil stain on one of the big glass windows of that business. People came from miles around to pray to the Virgin and to donate money, of course. The other morning, I found Richard Nixon’s image on my French toast. It was a religious experience. I wonder how much my old breakfast will sell for on eBay?

If it’s cold or if you just can’t bring yourself to do the fruit thing, soup is a great alternative as a starter for meals. It’s best to use a thin soup, not creamed or thickened, since they tend to be calorie or fatladen. To suppress the appetite, use chicken rice, vegetable, or tomato soup or just a plain broth. Have a cup before sitting down to your meal; you will notice a difference in how much you want to eat of everything that follows. There is research to prove that the protein and vegetables combined with the ﬂuids and broth in soups trigger the satiation signals early in the meal.

I used to be a vegetarian, which is a difficult thing in the South, where they throw ham in everything, including the vegetables and even the dessert. Yes, last week I went to a party where they served ham apple pie (I’m not kidding). When you go to a restaurant, you never see ham soup on the menu because every soup is ham soup, including the vegetable soup. There’s ham in the damn chicken soup. Last time I was in a restaurant eating French onion soup, it dawned on me that there’s no polite way to eat all that stringy, half-melted cheese on the top. Is it more correct to wrap it around your fingers or your eating partner? I realized that Spider Man’s secret to web-slinging was probably French onion soup.

IS CHICKEN SALAD FULLY DEVELOPED EGG SALAD? Finally, my old stand-by is still one of the best. I love a salad before or instead of my meal. You don’t even have to make it very big, if it’s just

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the ﬁrst course, but make certain you eat it all before you eat anything else. The salad takes work for you to chew and for your stomach to grind up, giving your body time to decrease its hunger signals. Also, the volume in salad, particularly of the greens, helps the stretch receptors in the stomach to work with fewer total calories in a meal. It’s very important that your salad be based on dark green lettuce and not be covered with a calorie-laden dressing or snuggled up to a mound of mayonnaise-based creatures like potato or pasta salads. I’m astounded how often I see overweight people eating “salad,” which they think will help them lose weight and which they’ve drowned in a high-calorie dressing or that’s accompanied by some god-awful mushy lump that was once identiﬁed as a food item. I’ve always found those mayo-laden dishes to be true misnomers. In my mind, a salad should be something fresh, crunchy, and good for you. If it can’t sit in your garden for the afternoon without spoiling, it shouldn’t be called “salad.”

Tuna Fish Haiku I Live in a Can Some Day I’ll Be a Sandwich I Hate Mayonnaise.

FAVORITE VEGETARIAN RESTAURANT—THE INTERNATIONAL HOUSE OF SPINACH I have a wealth of salad hints to make a vegetable-based diet more appealing. Variety and quality do matter. I’ve found that when I talk to people about how much they hate salad, it often has to do with the fact that they have one simple recipe for it and have never varied it in 40 years. I, too, was scared by a head of iceberg lettuce as a child. If you are still using iceberg lettuce and light-colored mass-market tomatoes as the basis to your salad, then go ahead and hate it, since that type of salad deserves to be hated! Iceberg lettuce has almost no taste or nutrition. Go for the dark greens, and experiment with the variety you can ﬁnd in the supermarket or at the produce stand. I’m a big spinach and baby leaf lettuce fan, but I love to experiment. Use bagged, prewashed lettuce to speed up the process and those lovely little sweet grape tomatoes to avoid chopping.

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MAD COW DISEASE HAS A VEGETARIAN EQUIVALENT—DISTRAUGHT ARTICHOKE DISEASE If your life is stressful and harried, use pre-cut items like broccoli and cauliﬂower. Throw on baby carrots, shelled edamame, nuts, raisins, cranberries, and sliced mandarin oranges or grapes to limit cutting time and increase the interest of the salad. Leave the skins on the cucumbers; it increases nutrition and ﬁber and simpliﬁes preparation. Chop green beans into one- to two-inch lengths, and cut up fruit like pears or peaches to throw in. Add seeds, beans, or chickpeas on top. To be different, don’t even bother with dressing; top with salsa, green Tabasco sauce, slices of sweet banana peppers or jalapeño peppers, hummus, or guacamole. These will decrease the calories and increase the nutrition and vary the ﬂavors. Always use the freshest ingredients and bright colors to attract the eye, nose, and mouth. Avoid high-calorie toppings like croutons and fried noodles or high-fat or high-sugar dressings. Experiment with dressings that you’ll look forward to using (we’ve found some that I even mail-order, they are so special, healthy, and low-calorie).

THE WASTE-REDUCING DIET Use fruit and vegetable life extenders like special bags or drawer inserts to decrease your waste and costs. Wash everything carefully to decrease pesticides, particularly in the nonorganics. You can wash away about 80 percent of the pesticides remaining on produce with good technique if you can’t afford organics. Products from produce markets and roadside stands can be quick to prepare and much fresher and cheaper than those in the supermarkets. Look for in-season produce and local supplies for the best taste and cost. Learn how to pick the best produce by asking questions of knowledgeable people, be they family, friends, or the produce guy, so you get the best taste for your money. Experiment with new fruits and vegetables that you’ve never had before and with new ways to serve them. (My friend told me he doesn’t like anchovies on his pizza because he doesn’t like the leaves. Hello, friend, let me introduce you to Mr. Artichoke.) Experiment with steaming, roasting, and stir-frying, and use lots of different healthy sauces, dips, mixes, and seasonings to give your veggies acceptable ﬂavor for you. Search the Internet for new ways to prepare them and for new ﬂavors to add; don’t accept boring as part of

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the vegetable mantra. And, by the way, frozen vegetables are almost as good as fresh, in terms of the nutrition, if you don’t have access to fresh. Good eating doesn’t have to be complicated. If you just want a steamed plate of a simple vegetable instead of salad before your meal (or something raw and crunchy), that’s ﬁne. Just avoid the butter, salt, and not-so-good toppings that will negate the positive choice that you’ve made. I HAD A PATIENT AT THE NURSING HOME WHO SWALLOWED HIS DENTURES WHOLE; NOW HE DOESN’T HAVE TO CHEW Finally, if you are not “good” at eating whole fruits and vegetables, at least drink them in the form of vegetable and tomato juices or smoothies. My son, the kid who eats only a few foods, avoids malnutrition with twice-a-day smoothies full of mixtures of frozen fruit.

Watermelons are called that because they are round and full of water. Humans are round and full of water, so why aren’t we called watermelons?

Many people do not realize how important fruit is to skin, immunesystem, and bowel function. I often hear women in particular tell me how they avoid fruit, thinking it is high in calories, when it is not. Fruit is very high in important nutrients, antioxidants, and natural protective chemicals. I’m very irritated with the many diet books that tell readers to cut out all fruit for a certain phase of the diet or altogether. There is no good medical research to prove that cutting out whole fruit from a normal diet is ever healthy; the more types and colors of fruit, the better. Try to vary the colors of the fruits, since the colors are a hint to the types of phytochemicals (natural plant substances) they contain, and presumably the more types, the better. If you aren’t a fruit lover, ﬁnd some way to make yourself love them. Freeze the fruit and eat it as dessert, plain as a substitute for ice cream or mixed with a small amount of low-fat sour cream. Add fruit to cereals or plain yogurt, or top it with a little bit of granola.

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IT WAS THREE BELOW ZERO IN MONTANA TODAY—THEY KEEP THEIR MEAT IN THE FREEZER WHILE IT’S STILL ALIVE Perhaps the most important point in all of this is to automatically cut portions at each meal for the processed starches and meat (or poultry) dish and to increase the portions of vegetables and fruit that you are eating. If your dish is at least half full with vegetables and fruit, then you are well on your way to a healthier, slimmer waistline.

The exception to the rule about limiting your entrée size is when you eat fish. You shouldn’t eat more than about a deck-of-cards-size amount of meat, pork, or poultry. But the research has not shown that we need to limit how much fish we eat. Certainly, bears don’t do that. When I was up in Alaska, I saw a salmon hatchery. When salmon swim upstream, they make huge leaps into the air, sometimes right into a grizzly bear’s mouth. I bet the salmon feel pretty stupid when they do that. Their last thoughts: “Hey, I guess I should have paid more attention in school.”

EAT ONLY ONE FOOD, BE IT SUGAR APPLES OR SUGAR GLIDERS There is an ongoing debate raging about what is better for weight loss, eating a monotonous diet or eating a variety of foods. To me, there is an easy answer: it depends on how long you want to lose the weight. If you need a short-term ﬁx, the monotonous diet is the way to go; that’s why there are so many of those one-food (cabbage) or one-category (protein) diets. In the short term, life is simpler if all you are eating is soy bars or soy beans. However, in the long run, your body is healthier with the diet that is varied. And the restricted diets inevitably fail in the long run; people almost always gain the weight right back when they loosen their restrictions. That dieter has not learned permanent life lessons. If you believe that your life will be simpler and less stressed and you’ll eat fewer calories on a restricted diet, then perhaps that will work for you in the short term, but it won’t help you in the big picture. Everyone must learn to eat a varied diet with moderation; eventually, you will be exposed to real food situations and will have to learn to eat in the real world.

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My cousin claims he keeps thin by eating a monotonous diet. Like one day he had only a bagel and six cups of coffee. I would eat less on that diet because I wouldn’t be able to stop vibrating long enough to open the refrigerator.

THE PASSION OF THE RICE DIET Some people are comfortable only with limited familiar foods. My son eats the same foods every day and likes it. He despises anything else. His response to new foods is, “Okay, if you force me to.” But if you are like most people and crave variety and adventure during your meals, a restricted diet is equivalent to deprivation. A varied diet comes with precautions, as more variety tempts most people to increase calories consumed. That’s why buffet restaurants are so damaging to the person trying to practice moderation in calorie intake. By all means, if you are feeling deprived, please aim for variety in your food consumption, and never restrict yourself in types of food. Be honest with yourself about whether the increased variety is helping you move toward your goals. You will need to watch your fuel consumption with a little more enthusiasm, but, in the long term, you will be more successful and healthier. Limiting what you eat of the good-for-you foods will result in malnutrition. It will also result in boredom, and where is the joy in that? A true caution: Dr. Rena Wing, a professor at Brown University and the creator of the National Weight Control Registry, notes that most long-term losers of large amounts of weight do tend to eat an unvaried diet, more restricted than the diets of people who recently lost weight. They found from their own personal experimentation what works for them and the limited diet keeps their weight from ballooning back upward. My concern with that approach is the extent of malnutrition that I see in the obese and the previously obese. Our bodies don’t make certain amino acids necessary for enzymatic processes and rebuilding tissue (like muscle and skin), and we need to get certain vitamins and minerals from our food that we can’t generate ourselves. The best approach is to give yourself unlimited variety of the good food choices but to limit your opportunities for eating the not-so-good food choices. In other words, spend your time at the produce stands and the fruit section of the supermarket, and don’t even head down

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the snack and bakery aisles. Use what you now know to your advantage, and modify your behavior accordingly. That way you will be successful, and healthy, without feeling deprived.

Some animals naturally eat only one food. Scientists discovered an undersea worm that feeds exclusively on deceased whale bones at the bottom of the ocean. The give-away to the new discovery was the little sign that said “Eat at Willy’s.”

The reason the monotonous diet plans are so popular for quick weight loss has to do with sensitization. In a monotonous diet, we become desensitized to the interesting taste of most foods and we desire less of them. Essentially, we bore ourselves into weight loss. However, it doesn’t always work for comfort foods and high-calorie sweets. Our taste buds don’t get bored with them. I can personally attest to that. When I was 19, after my freshman year in college, I had the Job of My Dreams: I worked in a hand-made chocolates store. Although I earned only minimum wage, I was allowed to eat any of the store’s products to my heart’s content. For three months, I ate exquisite hand-made chocolates all day, every day, and never got bored with it. I still daydream about that job when I’m having a particularly bad day at the hospital. Really.

SUCCULENT BROCCOLI DONUT I advocate eating lots of variety but smaller amounts of the not-so-good choices. This will lead to more pleasure. When you limit your variety or deprive yourself of the foods that you want, you may ﬁnd that you gorge yourself on the foods that you are permitting (although I doubt anybody pigs out on broccoli donuts). There is only so much enjoyment in eating the entire bag of rice cakes. Don’t get pleasure from engorgement; get it from taste, and texture. Never restrain your food choices; limit only the amounts. I still eat chocolate donuts, just on rare occasions. It’s a special treat then, and fully enjoyed, without any guilt.

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YOU NEVER SEE A SALAD-EATING CONTEST One of the funny things about healthier food is that people make assumptions about it. If you label a food as “healthy,” people will automatically give it a lower score in taste-testing but will tend to eat more of it. They think that they can consume more calories without the guilt. According to the Nutrition Action Newsletter, put out by the Center for Science in the Public Interest, you can eat all you want of whole fruits and vegetables. They are essentially “free foods.” For anything else (even if it’s labeled “healthy”), you have to limit the quantities. Which brings me to my ﬁnal point for the chapter—healthy snacking. If you eat fruit or veggies as a snack, you are free to move about the refrigerator. Stick to the “four great choices” I mentioned earlier as a between-meal snack, such as a can of tomato juice or a cup of instant soup, and you are okay, too. Or bring a bag of baby carrots and salsa to work for munching, or small individual bags of spiced or lightly salted nuts; an ounce of low-fat cheese or a cup of all-natural yogurt is great. Have a bottle of iced green tea if you feel like you need the buzz of caffeine for a boost at work or home. Mild caffeine is certainly a better alternative than a candy bar when you are feeling an energy dip. If you need the oral stimulation of something crunchy, go for the apple or pear or celery sticks (I eat them with hummus dip) instead of the potato chips. Wherever you are, always have good food snacks handy so that you don’t allow yourself to get too hungry and you aren’t tempted by the availability of the not-so-good foods. This makes the vending machines, chips in the pantry, and the donut tray in the break room less inviting. It’s okay to dive into your own personal snack bag when you need it; just make a habit of going there ﬁrst, rather than in the direction of the not-so-good foods. WHAT YOU SHOULD REMEMBER FROM THIS CHAPTER • Understanding nutrition helps you to eat healthier and to lose weight. • Calories are a measure of fuel and come from protein, fats, and carbohydrates. • We need all three types of fuel for our bodies to function properly; don’t restrict any type. • Overindulging in any of the three results in increased fat tissue in the body.

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• Don’t be perfect, but aim to eat food that is mostly good for you, and have a good relationship with what you eat. • You should eat a diet based on fruits and vegetables, less on everything else. • There is so much confusion in nutritional advice because foods are complex. • Healthy food is as tasty as the nasty stuff and makes your body feel better. • High-ﬁber and healthier foods can be harder to digest, for good reason. Increase them slowly, and ﬁnd ways to make eating them comfortable. • Start every meal with one of the “four great choices”: tomato juice, a whole fruit, a cup of thin soup, or a salad. This will decrease hunger and increase nutrition. • There is no excuse for a boring salad or vegetable dish. • You can, and should, eat as much fresh or frozen fruit as you want. • Cut the processed starches and meat/ poultry part of each meal, and ﬁll up more of your plate with produce. • Monotonous (one-food or restricted diets) are popular for quick weight loss because they bore you into weight loss. For most people, they don’t work in the long run, and they are dangerous to health. • Always have healthy snacks at hand so you don’t resort to not-sogood-choices.

SEVEN Put the Muffin Down and Slowly Back Away: What Are Not-So-Good Foods?

You have to watch the food labels carefully. In New York, there’s a food company that sells something that they label as “real vegetarian liver.” Now, I don’t pretend to be a vegetable anatomist, but I’m fairly certain that there aren’t ANY vegetables that grow livers.

Our bodies want good nutrition. Often our bodies will tell us when we are not eating correctly or if we are lacking in a certain important mineral or vitamin. However, we might not know how to correct the problem. Strangely, though, in many cases our bodies might not even give us a hint. As mentioned in chapter 5, it is not uncommon for people, both children and adults, who are nutritionally deprived to eat nonfood items like paper or paint chips in the subconscious search for the nutrient their bodies are missing. Don’t send your body down the wrong path looking for poor food substitutes because you haven’t fed it the right foods. I believe a well-balanced nutritionally sound diet will help you avoid many cravings for junk foods, not just paint chips. If you judiciously spend your calories on proper food, your spouse won’t need to restrain you from a late-night run to Dairy Queen or ﬁnd you chowing down on the morning paper.

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Listen to your body; it will often give you clues to nasty food and drink. If you are nauseous or have an upset stomach after eating something, that’s an important hint. Perhaps the food was bad, as in old and stinky, or perhaps it wasn’t meant to be ingested by you. Your body will feel better when it eats food that energizes it. THAT WHICH DOESN’T KILL YOU MAKES YOU WISH YOU WERE DEAD It seems that animals know what to do when they are not feeling well, when they eat something that doesn’t agree with them. First of all, they learn to avoid eating it again. Scientists have done rat studies that show that if you give a rat a food that makes it sick to its stomach, it will never eat that food again. Why don’t people learn that? We’ll keep eating the junk because somehow we’ve learned to ignore those signals. But they are there; you can become more attuned to them.

Animals are pre-programmed with cures for bad food that results in an upset stomach. People, unfortunately, are clueless. Dogs know to eat grass if their stomach gets upset. Why don’t humans do stuff like that? If we’re the top of the evolutionary ladder, we should inherently know these simple cures. Wouldn’t it be cool if a guy is at work and he says to his buddy, “Man, my stomach is upset from this hangover. Hey, Joe, watch my monitor for a second. I’ve got to go outside and eat some grass”? Even NASA ought to get in on stuff like that. Space crews should take a patch of sod with them on every mission. Hey, space dude, don’t forget the fork—and a putter.

In general, the simpler the ingredient label, the better, as the food is less likely to have chemicals you don’t want. However, if the list looks like “fat, sugar, salt,” that food item probably isn’t good for you, either. (The label is required by law to rank ingredients in order, with the main ingredient ﬁrst and the rest in descending order according to quantity.)

I was eating salad with low-cal dressing, and I made the mistake of reading the label. It had a list of ingredients too numerous to count, the last one being titanium dioxide. Which means, I guess, if I eat enough of it, I’ll have buns of steel.

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Fats have gotten a bad rap. I think it has to do with the word. People have come to believe that you get fat by eating fat. The truth is you get fat by eating too much and not moving. Fats are not the only culprit, but they’ve certainly taken their hits by health professionals and the media. Don’t eliminate fats, but choose them wisely and you can leave your fat buttocks behind. THAT NEW BREAKFAST FOOD, PIGS IN AN ARTERY Trans fats are mostly a modern invention. They are found in food naturally only in trace amounts, but they are found in restaurants, ice creams, puddings, prepared foods, and baked goods in larger amounts. There has been evidence to show that trans fats promote cardiovascular disease and are not known to be beneﬁcial to the body. Avoid them. Many of us are more familiar with saturated fats. That’s what my grandmother and mom used to cook with when I was growing up. They used butter, lard, and animal fat liberally. I never knew my grandfather; he keeled over of a massive heart attack in middle age. I suspect it was at least partially because of his diet. WHY WAS POPEYE’S GIRLFRIEND NAMED OLIVE OIL—WAS IT BECAUSE SHE WAS EXTRA VIRGIN? The good fats are believed to be the ones that are less saturated and are made from nonanimal fats. That means you should cook with olive or vegetable oil or use products made from them. Margarine got labeled as “evil” for a while, but that was before they started making margarine out of canola oil (a vegetable oil). One of the concerns that nutritionists have had is that people try to avoid all fats and end up substituting more simple carbohydrates for their calories. The result is that they make themselves fatter and sicker. Thus, you need to make certain that you get the good fats. The easiest way to do this is to add canola oil margarine to your bread or to add olive or vegetable oils to your salad (as part of your dressing). Use these oils to sauté vegetables and add them to your recipes. Just don’t re-use cooking oil; that’s when you start to get a breakdown of the chemicals, resulting in those dangerous trans fats. (That’s why you get trans fats in restaurant food—restaurants use the same oil over and over and over again—yuck!) Eat unsalted nuts and seeds, and throw them into your salads. Fish oils are great fats, too, especially from salmon and sardines.

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WHICH IS A BIGGER ISSUE, WINGS-WISE, THE MILLIONS OF AMPUTEE CHICKENS OR ALL THOSE FLYING BUFFALO? One of the things that many people don’t realize about animal fats is that they, too, are mostly a modern invention. Traditionally, when humans hunted wild animals and birds, they didn’t eat a lot of fat. That’s because true game creatures aren’t very fatty. They are not penned up, they have very strong muscles from ﬂying, running, and escaping predators, and they are in much better shape than their modern food-item equivalents. (There’s something strange about modern man making our food as lazy and out of shape as our own damn selves.) To be healthy, trim the fat from your animal diet. Use whole cuts of poultry, pork, or meat, and trim off as much fat as possible. When you use ground meat, select the highest quality (least fat). Prepared foods like hamburgers, hot dogs, and sausage have the animal fat mixed in and will coat your arteries faster.

Did you ever wonder why, when you eat an animal, it gets a different name, like cow becomes beef and pig becomes pork? Deer is suddenly called venison, but chicken is still chicken. It should be called something like shlemiel. “Here, have some grilled shlemiel.”

HUMANS, THE OTHER WHITE MEAT The truth is, it’s best to eliminate meat, particularly red meat, from your diet as much as you can. Studies have shown that you cut your risk of dying from heart disease and cancer by about a third over 10 years just by eliminating most red meat from your diet. And young women who eat a lot of red meat increase their risk of early breast cancer. By the way, the government classiﬁes pork as a red meat, no matter what the advertising tells you. Just as with other foods, the more processed and packaged the meat product, the more likely it will give you trouble. Research has demonstrated a link between eating sausage, bacon, ham, hot dogs, and deli meats and the development of diabetes.1 No study has yet been done to determine whether poultry versions of those (for example, turkey sausage) are any safer.

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There is research that shows that on our planet, cow belching and farting are among the biggest producers of that highly volatile gas, methane (a major cause of global warming). Using that knowledge, I have a new idea that would solve two major international problems at once. The next time there’s a mad-cow outbreak, instead of slaughtering all those innocent bovines, pack them up and send them to the war zone du jour. Then simply use the methane that the cows produce as a new weapon— moooo—BOOM!

The controversy about meat sometimes centers on getting enough protein in our diets. Most people use beef, pork, and poultry to get adequate levels of protein. High-protein diets (for example, Atkins) got a bad reputation because of the concern that they could damage kidneys. We’re not certain that they can in perfectly healthy people, but a highprotein diet deﬁnitely can cause damage in those with kidney problems. Why should that concern you? Because more than 13 percent of Americans now have kidney disease, and the vast majority of them don’t know it! And here’s the real kicker: being overweight is the number one cause of diabetes, and diabetes is the number one cause of kidney disease. So if you are obese, you might not have the healthy kidneys that you think you do. Don’t stress them needlessly. LIVING LARD I’ve got some really good medical research to back me about the relationship between high-protein diets and kidney disease. The Nurses’ Health Study from the Harvard Medical School looked at 1,600 middle-aged women with mild kidney disease.2 Those who ate the most protein faced a risk of losing kidney function that was 350 percent greater than the risk of those who ate the least amount of protein. (If you lose enough kidney function, you end up on dialysis or a transplant waiting list.) The Third National Health and Nutrition Examination Survey, done at Stanford University, looked at both men and women ages 20 to 80, a much broader population. What they found is that those who ate the most protein didn’t necessarily develop more kidney disease, unless they also had hypertension and diabetes.3 Since overweight people are the most likely to have those diseases, it may very well be dangerous to you to eat large amounts of protein.

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Are you still with me? This is where the data get more interesting. When the authors of Harvard’s Nurses’ Study looked at what types of protein were being eaten, they could ﬁnd a correlation only between progressive kidney damage and animal ﬂesh protein, not vegetable or dairy protein.4

Fancy restaurants in our Western culture tend to promote an animal protein diet. Last cruise I went on, the food was so bad I was convinced the dinner entrée was whatever birds happened to land in the ship’s smokestack. I swear our server said, “ Tonight’s special, Cornish puffin.”

Why does protein matter to you? Because people who are cutting calories to lose weight tend to cut calories uniformly, resulting in protein malnutrition. Your body needs as much protein now as it did when you were younger, to build muscle and keep body processes ﬂowing. In fact, chronic dieters (and the elderly) are some of the most proteinmalnourished people in the developed world. If your body doesn’t get enough protein from your food, it resorts to breaking down its own muscles to continue body functions. Thus, if you don’t eat enough protein, you’ll actually cause muscle wasting and weakness, which is the last thing you want! But, unfortunately, an animal-protein diet might promote a three-day-a-week schedule on dialysis. Luckily, there just might be a solution. THE CHICKEN WAS ON SALE; I GOT IT IN THE NATURAL CAUSES SECTION Make the effort to substitute beans, nuts, seeds, soy nuts, tofu, and nonanimal protein sources as often as you can for your meats and poultry dishes (again, watch the nuts on quantity, since they are calorie-dense). Put a small amount of the meat, pork, or poultry on top of a bed of lettuce or a crunchy salad, and add fruit or melon to the platter. There’s your whole meal—it’s as fast and simple as that. (Note, there’s no need for white rice or potato, bread or starch.) You’ll be completely full, without any effort, and no starving later. Or, use small amounts of dairy, in the low-fat version, such as cottage cheese, hard cheeses, yogurt, or milk, instead of eating animal ﬂesh. Just watch out for the fruit yogurts, which

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can have up to ﬁve teaspoons of added sugar in each cup or added chemical sugar substitutes. Get the plain or natural versions, and add your own fresh or frozen fruit—it’ll taste much better that way.

I wish nutrition labels were easier to understand. Shouldn’t food labeling be simpler, such as “Nutrition Facts: none” or “Nutrition Facts: don’t eat this”? Why do we have to be registered dietitians to understand them? It’s really very simple: just don’t eat any food with a mattress tag on it.

Sugar is another area that’s gotten a bad reputation. Our bodies naturally crave sugar and are programmed to want and eat it, even if we can’t taste it! A study published by Duke University in 2008 looked at mice that had been genetically altered to be unable to taste or smell sweets.5 Yet, when those mice were given real sugar water, their brains responded with a burst of the neurotransmitter dopamine, the same chemical that is released in the brains of addicts when they get their favorite drug. When presented with an artiﬁcial sweetener, sucralose, in the water, the mice’s brains didn’t respond. This means that the brain centers that are involved in reward and pleasure respond to both calories and sugar separately, whether the sugar is tasted or not. What’s interesting about the study is that the normal animals that could taste the sucralose artiﬁcial sweetener also had a brain surge of chemicals in their pleasure centers of their brains, even without the calories. Both types of animals wanted more of the sugar-type taste (when they could taste it) and wanted the calories (when their bodies had time to register the calories). This has many implications, the most obvious of which is that sugar taste (real or artiﬁcial) may drive people to want to eat or drink more calories. It may explain why drinking diet sodas and eating artiﬁcial sweeteners does not result in weight loss. 1774 WAS THE FIRST CONTINENTAL CONGRESS, FOLLOWED BY THE FIRST CONTINENTAL BREAKFAST There’s been a lot of bad press about high-fructose corn syrup, which is just a combination of fructose and glucose, made from corn starch. Fructose and glucose are two normal sugars that naturally occur. The combination, as far as we know, is not any more dangerous than table

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sugar. But it is a problem because it is sugar, and we eat too much of it. Since 1970, Americans have increased their intake of all caloriecontaining sweeteners by almost 50 percent. But because high-fructose corn syrup is cheaper to produce than regular sugar, the food industry has been using it more and more; the use has more than quintupled in the past 30 years. And those food companies have noticed that we like the taste. Foods from health cereals to spaghetti sauces to breads to salad dressings have it. Even foods like crackers and baked beans have it. I ﬁnd this hard to believe, but the per capita consumption of sugary soft drinks is around 50 gallons a year! (Since I don’t drink any, someone out there is practically ﬂoating away on a liquidy sugar high on my ration.) What’s scary about that is the highly positive correlation between the consumption of processed food and drink sweeteners and the obesity epidemic.

A study by drug manufacturers of a new diabetes medicine has been stopped a year early because too many people were dying. Apparently the sugar pills really were full of sugar.

The natural sweet taste in fruits and vegetables is also made up of fructose and glucose, but in lower levels than in processed foods, and is thought to be acceptable. According to the research on diabetes and nutrition, there doesn’t appear to be the same problem with whole produce with spikes of blood sugar or a higher risk of developing chronic illness that there is with processed foods or even fruit juice. Harvard’s Nurses’ Health Study looked at exactly that question in an article published recently in the journal Diabetes Care.6 The study followed more than 70,000 women over 18 years and noted that those women who ate higher quantities of whole fruits and vegetables were less likely to get diabetes. Those who drank fruit juice were more likely to get it. BETTER THAN DEEP-FRIED COTTON CANDY I talk to patients all the time about improving their diet by eating more fruits and vegetables, particularly fruits, because we all like sweet tastes. I’m astounded by how little whole fruit people actually eat, instead substituting fruit juices or canned, syrupy fruit for the real thing, the whole

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product. The syrupy canned product is more likely to have additives and preservatives and is not as safe to eat as a simple whole fruit. You like sweets? So do I. Get them naturally, and your body will thank you, for a lifetime.

All right, I’m willing to admit it; “natural” does not necessarily mean that something is good for you. The black plague is all natural, and so are cobra venom and pond muck—mmmm, want some?

I eat frozen fruit frequently, pretty much daily, since I make my son’s smoothies from frozen fruit. I usually sneak some of the fruit, popping the pieces directly in my mouth while I’m preparing the smoothies. It gives the same yummy brain chemical rush as any other sweet dessert, without the guilt. Buy big bags of your favorite fruits already frozen, and prepare bowls whenever you want. A cup of frozen blueberries has about 80 calories and is a to-die-for delight. Peel bananas and throw them in bags in the freezer, then microwave them brieﬂy and munch on down. It’s so much cheaper and healthier than any other dessert, and you can eat it all day long! Fantasizing about eating three scoops of rich ice cream? Eat a huge bowl of frozen blueberries, strawberries, and cut-up bananas. Top it with a little bit of chocolate syrup and chopped nuts, and you have the best-tasting sundae on the planet. (Better yet, drizzle the chocolate syrup on your signiﬁcant other and eat the fruit off him or her. Just give a warning before you do it. Oh, and don’t use frozen fruit or you’ll be facing shriveled, unhappy parts and an unhappier partner.)

Medical researchers have explored the headache that you get from ice cream, better known as “ brain freeze.” It turns out that it runs in families; if your parents suffer from it, you are likely to get it, as well. (Which brings up the delicate subject of genetic counseling.) There is another term for brain freeze; it’s called video games. As in when my son’s mouth is going at 100 miles an hour: “ Here kid, have this video game controller.” Ta daa, instant brain freeze.

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Dried fruit isn’t as good as whole fresh or frozen fruit because you are missing the water, which is what’s so helpful. Eat grapes instead of raisins, plums instead of prunes, and give the kids cut-up cantaloupe instead of fruit roll-ups. Sugar is everywhere, and it’s something that we naturally crave. Eat it with gusto, just the way nature gave it to us, in the purest form. Enjoy!

SUGAR-ENCRUSTED BLACK HOLES AND OTHER INTERSTELLAR TEMPTATIONS Sugar really is everywhere, even in places you don’t expect it. According to the National Radio Astronomy Observatory, an eight-atom sugar molecule has been found in an interstellar gas cloud near the center of our celestial Milky Way. The Mars confectionery company may have been onto something when it named its candy bar the Milky Way.

USE IT WITH A GRAIN OF SALT Salt has been highly valued for thousands of years. It was the ﬁrst preservative, improving humanity’s ability to store food for the future. It has been a major cause of international trade and bloody wars. Salt is a food delight, and our bodies crave and need it, in small doses. But it is deﬁnitively associated with high blood pressure and cardiac disease, the number one killer in Western society. The simplest way to eliminate excess salt from the diet is to limit restaurant food and processed, prepared, and canned food. When you use canned and prepared foods, choose the low-salt variety. Realize that not all saltytasting foods are high in salt; they might just have a coating of salt on the outside (for instance, popcorn). Also understand that some highsalt content foods don’t taste salty (like cottage cheese) since the salt is buried inside. It behooves you to take a quick read of the sodium content on the labels. Everyone should cut back, even if you don’t have hypertension or heart disease. There’s now evidence that the high salt content of a Western diet may result in diseases ranging from osteoporosis (brittle bones) to stomach cancer and, yes, even diabetes. The best alternative to salting foods is to use other spices, peppers, lemon, or lime. Take the salt shaker off the table and out of your life. As you move your diet toward eating

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more fresh fruits, vegetables, and unprocessed items and less of the nasty stuff, the salt drops away. IT’S GOOD ENOUGH TO DIE FROM Speaking of nasty stuff, MSG (monosodium glutamate) is a “ﬂavor enhancer” found in many products at home and commonly in restaurant food. It works to enhance ﬂavor by screwing with your taste buds and, in some people, with brain chemistry. Personally, my brain chemistry can’t take any more screwing up. I avoid it. Other additives, like artiﬁcial sweeteners such as aspartame, acesulfame potassium, and saccharin, may be linked to cancers. How about artiﬁcial colorings? Many of them, from Blue 2 to Yellow 6, are known to increase cancer risk, but they are still on the shelves in your local supermarket.7 On the other hand, naturally colored foods from plants are cancer protective. Go to my Web site, doctorRcomedy.com, for more information about the latest research on all of this.

Chinese food factories have been caught putting all sorts of nonedible contributions into their products: chemicals, plastics, parts of animals we don’t want to eat. Perhaps they thought that when we name our product Bob Evans, we mean it. As in, “Oh, look, there’s Bob now.” Their motto could be “We stand in each and every one of our products.”

A BUN PAIN REALLY MEANS A PAIN IN THE ASS Whole grains will help you permanently lose weight and lower your risk of heart disease, cancer, and diabetes, but what is a “whole” grain? It’s the seed of a cereal plant like barley, wheat, rye, rice, corn, or oats that hasn’t been pulverized and had the nutritional content removed by processing. When you look for whole-grain products such as bread and cereal, the label “whole” should appear in the ﬁrst (and usually the second) ingredients. Except for oats, which are assumed to be whole grain, most others won’t be, unless it speciﬁcally says otherwise on the ingredients label. Unfortunately, the food industry gets liberal use of that word “whole” on the front of a box or carton and will tell you something is “whole grain” when most of it is not. That’s why turning the box around and reading the true ingredients label is worth the effort.

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The reason whole grains help with weight loss is that they hold water, and processed grains (often called reﬁned grains) do not. Notice that theme again of increased water content in food? When the water is mixed into the food item, you feel full on fewer calories, and you never starve. Traditional breakfast cereals, pizzas, bagels, breads, pastries, cookies, cakes, pies, crackers, chips, and pretzels are usually made from reﬁned grains, and that’s why they have a bigger calorie load and won’t satisfy the appetite. White rice is stripped of its nutrition; brown rice is ﬁber-, vitamin-, and mineral-rich. Unprocessed oatmeal is a whole grain and absorbs a bunch of water, and it’s heavy in the stomach. Eat a big bowl of steaming fresh-cooked old-fashioned oatmeal (about 300 calories in a double serving) and you’ll be full for hours. Eat too many take-out muffins from a typical chain bakery shop (about 600 calories each), and you’ll still be hungry while you’re waggling your tush right into the emergency room.

I LOVE THAT ICE CREAM FLAVOR. WHAT’S IT CALLED, SNAIL TRACKS? Other common foods that can be disagreeable include dairy products. Most of us could tolerate cow’s milk foods when we were young kids, but many people develop lactose intolerance by adulthood. This is the inability to digest the sugar in dairy products. Symptoms include abdominal pain, bloating, gas, and diarrhea. In fact, it’s estimated that there are almost 100 million people in our country with lactose intolerance. Most minorities, including blacks, Hispanics, Native Americans, and Asians, avoid dairy products since lactose intolerance is very common in their populations. As a result, millions of Americans have serious deﬁciencies of protein and calcium. (Seventy-ﬁve percent of the calcium in our diet comes from dairy products.) As mentioned earlier, low-fat dairy products may be one of safest ways to get adequate protein in the diet when you are trying to lose weight, and we know that protein itself suppresses the appetite. This may partially explain why the obesity epidemic is even greater in minorities.

LEM’S FREEZIE 32ND FLAVOR: BULIMIC’S DELIGHT! Funny thing about lactose intolerance: the more you avoid dairy, the worse you make the problem. If you eat a small amount of dairy at each meal (about a cup of milk) or even just once a day, you’ll develop the

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ability to digest the dairy without disagreeable symptoms. You actually train your colonic bacteria to work for their money! All this time, they’ve been thinking that they get a free intestinal ride, but, no, give them some regular activity, and they’ll do it. In addition, eating dairy with other foods during a meal makes it easier to digest. Delayed gastric emptying helps the enzymes to work more efficiently. That’s why that run to the ice cream shop on an empty stomach is vile for many people. (Unless it’s that you had the 2,300-calorie-super-large shake with three days worth of saturated fat. Yes, those do exist.) In addition, some forms of dairy, such as yogurt and hard cheeses, are easier to digest than others. Finally, digestive aids, such as lactase tablets, which contain the enzyme that you’re missing if you can’t digest dairy, or lactose-free products are a good choice, particularly if you’re going to have a bigger amount of dairy. The point is this: if you are skipping dairy entirely, you may be making your road to thinness a harder journey.

Lactose intolerance is normal. For most of history, humans didn’t drink milk or eat dairy products after they were weaned, at about the age of three. Then northern Europeans started making cheese, and adults there developed the ability to digest it. That happened sometime in the past 10,000 years. Some scientists claim that adults’ ability to make lactase, the enzyme that digests milk, is an example of human evolution in progress. That is, unless you believe in intelligent design. And then God just started in northern Europe first. I guess he’s been too busy to get to the rest of us.

While we’re on the subject of protein and food myths, let’s talk about eggs. The poor misunderstood egg. I never really questioned what I had been taught in medical school about the bad effects of cholesterol from the egg yolk, that is, until I met my patient, the “Egg Man.” Mr. Egg Dude was addicted to eggs; he ate them morning, noon, and night. On an average day, he had a six-egg omelet for breakfast, several egg-salad sandwiches for lunch, and up to a dozen hard-boiled eggs for dinner. (As Dave Barry likes to say, I am not making this up.) Yet the man had low total blood cholesterol, was thin, and was in the hospital due to trauma, not because of any heart or medical illness. His mother insisted that I do a thorough medical and blood evaluation because she wanted some

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ammunition to get him to change his eggy ways. Strangely, I couldn’t ﬁnd anything medically wrong with him, and I reluctantly told her that. What we’ve learned since then, from epidemiological studies in Japan and the United States, is that whole eggs are safe for most people.8 There is a slightly increased risk of death if you eat more than an average of one egg a day (sorry, Egg Dude), particularly if you are a diabetic. But what we now know is that it is probably safe to eat up to seven eggs per week, and not just the egg whites. There’s no research to show that eating whole eggs results in a higher risk of stroke or heart attacks. That’s a cholesterol myth. One large egg has as much protein as a cup of yogurt and has fewer than half the calories. Don’t give up on the egg; boil some and pop them in your purse or briefcase as a quick, nutritious snack. Okay, use a lunch box. I don’t want you e-mailing me, complaining about smashed eggs on your tampons, car keys, or legal briefs. ATTACK OF THE KILLER POTATOES Now it’s time for you to think about restaurants and meal planning at home. How do you decide what’s a better choice and what’s a not-sogreat choice? First of all, when going to restaurants, think about portion size. Split an entrée, or order a kid’s meal or sample portion. Run like hell when you see the word “buffet,” unless it’s just the salad bar. Avoid or limit most white foods: fried foods (trans fats) and items that are stuffed, pasta, pizza and other doughs, bread, white potatoes, pastries, breaded foods, white and fried rice, and sour cream and butter sauces. (A plain white baked potato with the skin on is ﬁber-, mineral-, and vitamin-rich. The problem is that few people eat it that way. If you eat your potatoes the way most Americans do, fried or mashed, salted and slathered in sour cream or butter, just say “NO.”) And, when eating out, avoid most cheese products, as they’ll really add on the calories when they aren’t low-fat.

Did you know that French fries were invented in Belgium by the Flemish? I guess Flem fries just didn’t sound appetizing.

Instead, when ordering and at home, use lean meats, poultry, ﬁsh, tofu, and soy products that are boiled, baked, or slow-grilled (lower temperatures). Lower-temperature cooking is thought to be safer; it

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produces fewer toxins in the animal protein. Again, this may have to do with keeping the moisture in the animal ﬂesh, so try not to dry out the meat or poultry when cooking (and it will be more ﬁlling that way). Try to avoid smoked meats and ﬁsh, since the nitrites (or nitrates) haven’t been proven to be safe.

Some Floridians eat smoked alligator. There’s a whole back-swamp technique to catching one of those razor-toothed monsters. We’ve had a number of people from my state distinguish themselves with Darwin awards for their stupidity. Traditional Floridian hunters sometimes use the ancient method involving the car battery, zapping swamp water to get their kill, occasionally while sitting in a metal boat. The alligators peacefully hide in the reeds and exclaim, “Oh, look, bar-b-q for lunch!”

At home or away from your kitchen, look for salsa, marinara, olive oil, lentils, hummus, guacamole, beans, legumes, vegetables, and fruits. Get the noncreamed soups, the plain eggs, and the crunchy salads. Use salsa and hot and sweet peppers for ﬂavorings on potatoes, eggs, or vegetables or as a salad dressing. HORROR-THEMED EATERY’S MENU: LAST VEGETABLE ON THE LEFT, NIGHTMARE ON PASTA, CHILDREN OF THE CORNDOGS, HALLOWIENERS If you do go to a buffet restaurant, I encourage you to do what I do both at the beginning of the meal and between courses. Get up and nonchalantly walk around the restaurant looking at all the really morbidly obese people. Be careful, it can be scary. You will normally ﬁnd a much higher percentage of them at buffet restaurants than at regular restaurants. Scout out what they have on their plates, which are generally piled with high-calorie foods. See what that does to your appetite and your own behavior. I’ve been told by others that it has the same dampening effect on them that it has on me. Which brings me to the dessert table: some empty-calorie junk is obvious, like cookies, cake, and ice cream. But other foods are disguised by the restaurant industry as “good for you.” Realize that bagels, big bowls of pasta, and most wraps, panini, burritos, sandwiches, and pita chips are not full of nutrition but are full of empty calories.

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Even at home, understand that those granola and energy bars that you buy at the convenience store to eat on the run or for breakfast—big buzzer sound—they’re really not so good for you. The advertisers love to produce commercials with buff models on mountain bikes at the edge of cliffs munching on those “health bars” so that you’ll believe you’re eating something more than candy bars dressed up in Halloween costumes.

My version of convenience food is old pizza sauce in the back of the refrigerator that grows its own toppings. “Hey, honey, you like mushrooms, right?”

A funny thing about pizza, pasta, bagels, and dessert items is that they are often a comfort food, brought out in times of strong emotions or stress. Comfort foods don’t have to be bad for you, although they do tend to be high in calories and fat and are often simple carbohydrates. Determine what your comfort foods are and don’t abandon them, but do use them more judiciously. Pick your comfort foods and save them for special times, and always pair them with healthier foods, like a salad before the pizza. Then you will literally be able to have your chocolate cake and eat it, too, without stress, guilt, or undue physical or mental costs. Which brings me to the last point, whether to eat sweets and yummy desserts at all? Of course you should! Just realize that it is my sincere belief that it is better to eat a small amount of the authentic item (regular cookie, real ice cream, or rich high-quality chocolate) than larger amounts of the imitation stuff. Fat-free foods are not necessarily better for you, as they are often high in sugar. Low-sugar foods are often loaded with bad-tasting chemicals. The real thing tastes better and is more satisfying. You’ll end up eating less junk food and feeling better about it in the end. My favorite food, high-quality chocolate, is something I eat often, in small amounts, and completely enjoy. No deprivation necessary, and no binging. Because I know I’ll be eating it again soon. How beautiful is that? WHAT YOU SHOULD REMEMBER FROM THIS CHAPTER • Eat nutritionally and you won’t crave junk food. • Listen to your body; it will tell you if you are eating the nasty stuff.

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• Not all fats are bad for you; vegetable and olive oils are beneﬁcial. • Animal protein leads to a wide range of health problems in the overweight. • Vegetable-based proteins, dairy, and eggs are safer and will get you thinner. • Added sweeteners, either sugar or high-fructose corn syrup, make you fat. • The natural sweetness in whole fruits is safe. • We eat way too much salt for our health; eliminate excess salt by limiting processed, prepared, canned, and restaurant food. • Read the labels and avoid MSG, artiﬁcial sweeteners, and colors. • A true whole-grain diet will get you to slimness and keep you there permanently. • The lactose intolerant can train their bodies to eat dairy again. • Use everything you’ve learned for better restaurant ordering and meal planning. • Eat small amounts of your favorite authentic sweet or comfort food regularly so you don’t feel deprived.

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EIGHT Water Intolerant: The Right Drinks

Occasionally I will debate with other health care workers which organ is the most important one in the body. Personally, I think it’s the colon. It stores stuff and absorbs water. Without it, you’d be dehydrated and incontinent. It’s a maligned organ; you don’t know how much you need it until you lose it. This is unlike the brain, which is totally overrated. We’ve all known people who seem to get along just fine without their brains—they often become bosses.

An important type of intake fuel to think about is not food at all; it is drink. Generally, when people concentrate on losing weight, they concentrate on the goal of limiting what type of food or how much food they will take in. They put little thought into their drink. People who are dieting might switch to a diet cola or change the creamer that they put in their coffee, but they’ll leave it at that. There needs to be a lot more thought into the type of liquid that enters the mouth, all day, every day. Something that I’ve known for years is that calories in liquid form are easier to disguise than those in solid form. The way I ﬁrst became aware of this was through my work in the nursing home population, with people who are too skinny. Often, frail, elderly patients in a nursing home aren’t getting enough calories. They don’t feel well and they don’t want to eat enough, so we ﬁnd ways to “sneak” extra calories into their

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diets. The main way to slip extra calories into the diet of a person who is not very hungry is to give the person high-calorie liquid supplements between meals. Did you know that the body does not register most liquids as extra calories? So when the next meal rolls around, my patient is hungry again and the weight comes back up. Conversely, liquid “secret calories” are often the easiest target to eliminate in a person who is overfed calories. In the person who is overweight, the secret calories may come in the form of colas, sweetened coffees or teas, juice, alcohol, energy drinks, or sports drinks. I’m a strong believer in eliminating all high-calorie beverages from the diet permanently. THE ARSENIC DIET (IT’S GUARANTEED) Over the past two to three decades, sweetened beverages have become a much bigger part of Americans’ daily calorie intake. This is especially problematic among the young and minorities, but it has occurred across the social spectrum, even among those who label themselves as “dieting.” Science has shown that calories in the pure nutritionally empty liquid form are not recognized the same way by the body and therefore result in chronic overfeeding. Barbara Rolls, PhD, a professor of nutrition at Penn State, has done years of research into this.1 Your body does not understand Coke, Sprite, Dr Pepper, and Mountain Dew; since they contain no nutrition, they are not recognized as normal calories. Gatorade, Red Bull, Arizona tea, and Snapple slip right on through your stomach’s natural calorie counter. But the sugar still gets absorbed and converted quickly into adipose tissue, where it snuggles up to your hips, thighs, and waist.

Coca-Cola is used for all sorts of things other than drinking it. In the hospital, we use it to unclog feeding tubes. Mechanics use it to get rid of gunk on engines. I’ve even heard of women trying to give themselves abortions with it. That doesn’t work. The gynecologist: “Well, you’re still pregnant, but you don’t have any rust.”

GROWTH RINGS DON’T GO AWAY According to researchers at Harvard University, it’s not unusual for teenagers to drink between 500 and 1,000 calories a day in sugar-

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containing beverages.2 They see this as a contributor to the obesity epidemic among children. They have also found a strong correlation between consumption of sugar-containing drinks and the development of obesity and diabetes in adults. The scientists at Harvard have gone so far as to declare the need to curb the consumption of soft drinks and other sweetened beverages to ﬁght our national epidemic of obesity (and the resultant diabetes). According to the Harvard School of Public Health, cranberry juice cocktail (something that a lot of people think is good for them) has the most sugar of any beverage type.3 It has a whopping 12 teaspoons of sugar in a 12-ounce beverage. Orange juice and orange soft drinks have slightly fewer, at 10 or 11 teaspoons, and that’s the same as what’s in one 12-ounce can of cola. A sports drink typically has about 5 teaspoons of sugar in that same size beverage. If someone handed you a glass of water and then asked you to carefully spoon in 10 or 12 teaspoons of sugar and then to drink it—well, would you? Of course not; you would think the request was gross, disgusting. But that’s essentially what you are doing every time you down a can of Coke or a glass of fruit juice. Juices range from 150 to 250 calories a cup, except for tomato juice, which has only 40 calories a cup. Colas and other sodas are about 120 to 180 calories for a standard 12-ounce can, but many people now drink the 20-ounce bottle, which has 250 calories in it. Fruit punches and drinks run between 120 and 240 calories for 12 ounces. Sports drinks contain between 90 and about 250 calories. Even a bottle of store-bought iced tea can run up to 135 calories, and a Starbucks Frappuccino runs almost 400 calories! EAT, DRINK, AND BE STERILE My concern is that sugary beverages are often advertised as exciting, sexy, and good for you. That excess sweetener results in diabetes, which in turn results in impotence. There’s nothing sexy about that. Here you think you are doing something healthy for your body, and those ad writers laugh all the way to the bank.

I went to a dermatology lecture where the doctor said that duct tape works to eliminate warts. Diabetes is largely reversible with weight loss; its treatment is the same as for warts. Use duct tape, just in a different place.

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Artiﬁcial sweeteners are not the solution. Harvard has said on its public health Web site that the beverage industry needs to get more responsible and develop attractive sweetened drinks with fewer calories, preferably without zero-calorie sweeteners. However, a lot of health professionals have been counseling people to switch to saccharine, sucralose, aspartame, and the other low-calorie chemicals. I’m not sure that’s a good answer. The reason lies in new evidence suggesting that ingestion of artiﬁcial sweeteners may also create obesity. Purdue University psychologists Drs. Susan Swithers and Terry Davidson found that rats exposed to diet sweeteners are more likely to consume excess calories than those who drink sugar-containing beverages!4 Their saccharine-fed rats gained more weight and put on more fat than those fed a simple sugar. Those fatter rats never cut back in their eating habits later. The researchers believe that the use of artiﬁcial sweeteners causes a break in the body’s ability to regulate intake and metabolism. Since the substances are sweet, the body believes it’s about to get a lot of calories; when it doesn’t, it actually spurs feeding to get those calories it’s anticipating. This would explain why other studies of artiﬁcial sweeteners have not conclusively demonstrated that they help in weight loss.

TRUTH IN LABELING: “CONTAINS UNPALATABLE SUBSTITUTES” But there’s one more concern about artiﬁcial sweeteners: they might slow metabolism. Usually, when the body is exposed to food, the core body temperature rises in anticipation of burning ingested fuel. The Purdue gang found a blunted response in core body temperature in the saccharinefed rats. They didn’t rev up their metabolism when they ate sweet foods like the sugar-fed rats did. It might be that a body used to being fooled by artiﬁcial sweeteners disconnects from the signal of a calorie load and never bothers to burn fuel as it should. If that’s the case, then the sooner you get off of artiﬁcial chemicals, the better. Learn to live with less sweet ﬂavorings in general; that’s how our ancestors lived. Our bodies are not built for this modern deluge.

TAKE CARE OF YOUR PARTS, AND THEY’LL TAKE CARE OF YOU If you are a big cola or soda imbiber, you might initially switch to the diet version and then cut the number of ounces you drink daily. Or, better

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yet, just substitute healthier beverages. One of my favorite substitutes is green, black, or herb tea. Green or black teas have caffeine, unless they have been decaffeinated, so they make a good substitute for caffeine junkies. Herb teas without caffeine are great at night. Don’t add sugar or sweeteners to the tea! Teach yourself to enjoy the ﬂavors without the sweeteners. Make your own green tea, and store it in the refrigerator. Take it to work or school with you in a sport bottle or thermos, rather than grabbing the high-priced vending version. And remember, hot drinks may suppress the appetite more than cold, so make your tea fresh and hot if you can. Green tea is one of my favorite drinks. It’s thought to suppress cancer and arthritis and also the appetite. The University of Chicago has an herb research center that demonstrated that a component of green tea is a powerful appetite suppressant, at least in rats.5 The rats lost up to 40 percent of their body weight when injected with that component.

People think that the Japanese live so long because they drink green tea with antioxidants. But it’s really all the exercise they get running away from Godzilla.

If you are a ﬂavored-water, juice, juice drink, or sports drink person, switch to plain water or seltzer. Add a spritz of juice in various ﬂavors to liven it up. If buying pre-packaged types, look for companies that avoid using extra sweeteners and chemical additives. Now onto another form of beverage, sports drinks. There is never a need for the average person to use sports drinks, despite what the beverage industry says. If you are an aggressive athlete who is in training for more than 60 minutes at a time or if you are outside sweating buckets on a very hot day, these may be the only exceptions. Occasionally, sports drinks might be useful if you are working at high altitudes. If you are exercising and you take in adequate water and eat nutritionally before and afterward, you have no need to use a sports drink. I never have, and I exercise everyday and can teach classes on the art of sweating. Skip the energy drinks, too. They have as much sugar as colas and contain caffeine levels that can be dangerous. I have no clue why anyone would ever use an energy drink. If you are that tired, you need to sleep more and take better care of your body, not use stimulants to force yourself awake.

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COFFEE SHOP—SUMMA CUM LATTE Coffee is another area of secret (and useless) calories. I drink coffee every morning, plain or with a little skim milk. Black coffee is naturally almost zero-calorie, but nobody seems to have plain black coffee anymore. In a specialty coffee, it is the additives, the high-fat milk or cream, the sweeteners, and the ﬂavorings that can add a tremendous number of unnecessary calories. Even if you make the coffee yourself, a simple ﬂavored liquid creamer adds 40 to 50 calories to your beverage. Add a heaped teaspoon of sugar (another 25 calories) and your three cups of coffee a day adds on a whopping 30 pounds of fat to your body in a year!

I’m amazed that people will spend four or five dollars for a cup of espresso or cappuccino, which is essentially coffee with a fancier name. In a recent study, people thought a wine labeled as inexpensive tasted worse than a costlier one, even though it turned out to be the same wine in both bottles. This is known as the Ripple Effect.

Many people have no idea that their daily whipped ﬂavored coffee or latte from their favorite coffee shop adds up to 500 or more calories a day, with none of those calories doing anything beneﬁcial for the body. Plain black coffee with a little skim milk has 450 fewer calories and gives the same caffeine jolt. Talk about avoiding secret calories! Save your money and brew your own; then be judicious with what you add to it.

I’ll never forget an interview that I read. A famous singer was extolling the virtues of coffee enemas. I’m thinking to myself, “You’re supposed to drink it, not stick it up your ass.” Are there different types of coffee enemas, based on the day that you’re having? Does the therapist give you a double espresso when you have a deadline looming? A flavored latte when you’re feeling down? Decaf when you’re stressed? I’m wondering if drive-through colon therapy isn’t too far behind (pun intended). The drive-through attendant: “All right, back it up here!”

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MILK CARTON INGREDIENTS: COW SECRETIONS Milk alone can suppress appetite because it has protein in it and sits in the stomach longer than most other types of beverages. Use only skim milk. Anything more is not worth the excess fat.

Mother cow berating cud-chewing teenage cow: “And don’t bring it up again!”

Except for tomato-based and vegetable juices (which suppress appetite), most juices and juice drinks ought to be avoided if you are trying to eliminate unnecessary calories. There is nothing wrong with fruit in the solid form, but liquid fruit juices are loaded with calories and don’t have the ﬁber to slow down digestion. (Even juices with pulp aren’t going to help you much.) Fruit juice and juice drinks are deﬁnitely unwanted secret calories. WISCONSIN’S OFFICIAL STATE MOTTO IS “FORWARD.” IS THE UNOFFICIAL STATE MOTTO “I CAN’T FEEL MY LIVER”? Finally, let’s discuss alcohol. Alcohol dulls the senses and the sensibility, causing people to ingest more nasty junk food than they would otherwise. In addition, I see many people who are overweight and severely malnourished. Sometimes it’s from alcoholism. A person who imbibes a lot of beer, wine, or hard liquor can take in thousands of empty calories daily, and eventually that will suppress their appetite for nutritional solid foods like vegetables or dairy. Strangely, Wisconsin, “America’s Dairyland,” is also the binge capital of the United States.6 I guess the tourists keep the cows busy making milk. I frequently see heavy alcohol users with thinking and balance problems or chronic wounds and immune deﬁciencies, all from severe malnutrition. Yet they are obese, and they and their families don’t even suspect how malnourished they are. Alcohol should be limited to one or two beverages a day, at the most. Even in the nonalcoholic, cutting back on alcohol is one of the easiest ways to eliminate nonnutritional secret calories.

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I was on a cruise ship in Croatia, and it had a sign over the toilet on how to flush and what not to flush. There was one of those universal symbols of a red circle with a line across it, only it was a drawing of a person tossing a champagne bottle into the commode. You’d have to drink the whole bottle to be that stupid, right?

Professional football player LenDale White learned the hard way how much alcohol can affect body shape. According to an Associated Press article, when White decided his pudgy physique was affecting his performance and that it was time to lose weight, all this NFL player did was cut out tequila. In six months in 2009, he lost more than 35 pounds. He admits he did nothing else to lose the weight but cut out his favorite beverage. By the beginning of the next pro season, he felt he was in the best shape he had been since high school. There are those who insist that daily alcohol intake is important to health since moderate alcohol ingestion decreases the risk of heart disease and diabetes. But that same amount increases your risk of breast and colon cancer. So don’t imbibe purely for your health. MY FRIEND WAS ALWAYS THE DESIGNATED DRINKER It is a good idea to cut back on the amount of alcohol that you ingest when losing weight for a number of reasons. Let me tell you the true story about one person that I coached on weight loss. She is a very smart, talented, middle-aged woman with a history of fatty liver, from obesity. She likes her alcohol after work, especially on those high-stress days. After a particularly bad day, she and a few workmates stopped at the local festive chain restaurant on the way home. She stuck to her calories, limiting the excess junk food her friends scarfed down, but had her usual cognac or two. They then went their separate ways, but she realized that she felt more far gone from the alcohol than usual. On the way home, a very nice policeman, whom she recognized, tapped on her window at a stop light. She rolled down her window. The policeman recognized her and asked if anything was wrong since she had been sitting at the stop light for more than 30 minutes! My friend was drunk on alcohol amounts that in the past wouldn’t have touched her judgment. Luckily, she made her way home safely, with the help of the policeman, but that incident rightfully alarmed her.

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DO TURKEYS DRINK WILD HUMAN? My friend had erred in judging how much alcohol she could safely consume for at least two reasons. One was that she weighed less than she had in the past and so could tolerate less alcohol, as smaller people need less to get drunk. The second reason was that she had her usual beverages on an unusually empty stomach because she had limited her food calories (but not her liquid calories). Thus, the alcohol was absorbed faster. As another friend said after that incident, “You didn’t have your bread to sop up your liquor.” In a way, that statement isn’t far off base. Food in the stomach does slow down the rate of alcohol absorption into the blood.

People fall into one of three categories for the ability to process alcohol. Most people can drink moderate amounts before getting drunk. People who imbibe heavily rev up their enzymes and can process more, until their liver starts to fail. My liver is essentially decorative; I get drunk on nonalcoholic beer. I like to say that my liver is a placeholder waiting for a better organ to come along.

Cut back on the liquor along with the food, and you will be much safer, as will those around you. Finally, and this is a very serious issue medically, obesity can lead to fat in and around the liver, which may change the way the liver processes alcohol (and other toxins and medications) over time, even sometimes leading to permanent liver damage. Thus, simply being overweight can cause a person to stop being able to handle liquor. Being fat is never a benign condition, and it should never be accepted as medically safe. Obesity (without alcoholism) is now one of the biggest causes of cirrhosis, from fatty liver, and of the need for liver transplantation. A good rule of thumb for all beverages, alcoholic or not, is that they should never have more than about 50 to 100 calories in them for an eight-ounce glass. And you should try to limit your total drink calories to no more than 200 calories (for a small woman) to about 300 calories (for a tall man) a day at the most. That helps to limit your intake of those surprise calories that add nothing to your body except fat tissue. Drink water, skim milk, simple tea or coffee, or tomato or vegetable juice products (and watch the salt). There are plenty of opportunities and varieties

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in the supermarkets and the health food stores, so don’t complain to me that you are bored. I don’t want to hear it. I get enough whining from my teenager. WHAT YOU SHOULD REMEMBER FROM THIS CHAPTER • Calories in a liquid form are easier to disguise than those in a solid form. • There is a relationship between ingestion of sweetened drinks and obesity. • Most sweetened beverages have 5 to 10 teaspoons of sugar and 100 to 250 calories. • Artiﬁcial sweeteners may make you fatter. • Substitute healthier choices, like simple coffee, green or herb teas, or water. • Green tea is an appetite suppressant. • Most people never need a sports drink, and nobody should be using energy drinks. • Coffee is best when drunk black or with a minimal amount of skim milk or sugar. • Milk is an appetite suppressant and is healthiest as skim milk. • Fruit juice and juice drinks should be drunk sparingly, if at all. • Vegetable and tomato juices are low-calorie and are an appetite suppressant. • Limit alcohol-containing beverages to no more than two a day. • Even moderate alcohol is not necessarily safe, particularly for the obese. • Limit calories from all drinks to no more than 200 to 300 a day.

NINE Living Extra Large: How Much, When, and How to Eat?

I was rummaging through my friend’s freezer late one night, looking for something to eat, when I discovered a package of frozen free-range turkey meatballs. It dawned on me that giving a farm turkey a free-range lifestyle is a lot like taking a guy on death row and putting him in a fivestar hotel for a few weeks before his execution. Hey, you still come out frozen meatballs.

EAT THIS BOOK If you are a monkey, and I feed you about 20 to 30 percent fewer calories than others in your species are used to getting, you will be skinnier and live longer than normal. And you will be less likely to get diseases of aging like Alzheimer’s, diabetes, cancer, and heart disease. Chronically restricting calories will make you permanently thin and extend life span, at least in animals other than humans. Longevity has been shown to be extended in calorie-restricted creatures from ﬂatworms to rodents to primates. In California, there is a group of individuals who practices severe daily caloric restriction permanently, not to lose weight (they are already very thin people) but to extend their lifespan.

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They are cold all the time, appear listless, and have very little muscle strength and lousy sex lives. In a study done at Washington University of St. Louis, participants on a two-year caloric restriction diet lost plenty of weight (some were overweight), became food obsessed, and lost bone mass.1 But they had much better blood pressure and cholesterol. It’s too early to tell whether humans live longer on fewer calories.

In one scientific study on mice, the low-fat, calorie-restricted mice lived three times longer than those critters on the regular diet. However, when asked, the calorie-restricted mice said it felt like they were living an eternity—in hell, that is.

THE JOY OF DIETING—NONE Pure food-restriction diets don’t work any better than any other types of dieting weight-loss approaches and likely are more harmful in the long term. The reason is that your body’s metabolism will slow down when confronted with far fewer calories. That’s why those Californians who are in their own longevity experiment are cold, listless, and not in the mood. Everyone has a basal metabolic rate. That is the baseline level at which your body’s cellular mechanisms work. It hums along, burning fuel (calories) to build and repair tissue, digest food, make neurons think, and energize your muscles. Hormones released by your brain and glands control your basal metabolic rate. When you are put on a severely restricted diet, your hormonal controls scream “famine” and slow metabolic mechanisms. By doing this, the body can save fuel to be used for only the most necessary bodily functions. When starvation was common, slowing down metabolism worked well for our ancient ancestors; survival was the priority. This still works for the areas of the world where famine remains a problem. However, in cultures where our biggest food worry is a glut, not an undersupply, our inborn famine mechanism undermines our efforts to normalize our weight. We slow down our body processes, burn fewer calories, and reset our basal metabolic rate to a lower level. Then, it takes even more activity above our baseline activity to burn the same amount of fuel (calories).

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SEND ME YOUR TIRED POOR CALORIES, YEARNING TO BE ME I went to a women’s business center class, and I sat next to an enormously fat businesswoman who was selling—you guessed it—weight-loss products. Surprisingly, she hadn’t been too successful, so she wanted to learn how to market on line. I wondered what would be her advertising angle: “Get skinny when you send me all your food.”

Going through cycles of relative starvation and plenty results in a body that is constantly resetting its cellular mechanisms to lower and lower levels of activity. That is why yo-yo dieting wreaks havoc on the system. This makes it even harder to lose weight every new cycle of severely restricted caloric intake. THE TRUTH ABOUT DIET BOOKS IS THAT THEY ALLOW THE AUTHORS TO LIVE OFF THE FAT OF THE LAND Most diet books surreptitiously encourage yo-yo dieting since they have you starve and restrict yourself up front, frequently in “phases.” I just finished reading a weight-loss and exercise book written by a retired lawyer. It was full of really bad health advice. This was just another in a series of self-hurt books.

Dieting “plateaus” occur commonly in those who yo-yo up and down in their weight. When a person restricts her calories a great deal, the body will usually adjust to that new level of calories in/ calories out. The plateau has been reached when the basal metabolic rate has dropped and the same number of calories eaten and expended no longer results in weight loss. Even worse, at that lower metabolic rate, a relatively small increase in calories will result in an even larger amount of weight gain. Thus, those who constantly diet through fasting or severe caloric restriction will eventually complain that they gain weight with almost no increase in calories. At least that’s the theory. It’s a myth that once you hit a plateau, you cannot lose weight beyond it. However, a plateau generally takes an adjustment upward in activity

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to boost metabolism (see Chapters 10 and 11, on metabolism and exercise, for details). Even though I do not think it is wise to tell people what they can and cannot eat (I hate absolute rules), I do think it is helpful to point out how to eliminate the unnecessary intake of calories. Ultimately, a successful weight-loss plan must include thought on how best to spend the daily allotment of calories (intake). The most successful permanent weight-loss regimen restricts the daily intake of calories to between 1,400 and 1,700 calories a day, depending on the size and goals of the individual. On average, 1,400 calories a day will allow most people to lose weight consistently, and 1,700 calories will allow most people to maintain their weight loss permanently. Note that this is a gross generalization, based on a gestalt of the literature. However, the National Weight Control Registry, my favorite place to get long-term data on the really big permanent losers of weight, reported that previously obese people in their study have kept that range as their target intake, forever. In 1998, the University of Pittsburgh looked at some of the early participants in the NWCR and found that women in that study ate about 1,300 calories a day permanently, men closer to 1,700 calories.2 And most kept a low-fat lifestyle, as well (that is, fewer than a quarter of their calories came from fat). Obviously, as mentioned earlier, there are some active or highmetabolism individuals who can lose weight on much higher inputs of daily calories. The research from the 1970s and 1980s in rural China showed that the typical Chinese man ate an average of 3,000 calories a day and still was thin. T. Colin Campbell, PhD, author of The China Study and a professor at Cornell University, felt that the Chinese could eat so much more because they were essentially vegetarians.3 He felt their protein-poor, low-fat diets led to a higher basal metabolism. Essentially, he believes that it takes more work for the body to digest vegetables; therefore, vegetarians are thinner.

Now remember, vegetarians are going to be thinner only if they actually eat vegetables. My husband tried being a vegetarian for a month, but he gave up meat and ate brownies instead. He gained 10 pounds.

I like Dr. Campbell; he’s a really passionate, smart scientist. Unfortunately, his book completely ignores the fact that almost all rural Chinese in the 1980s walked or road a bike, and very few had cars, cable

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television, or desk jobs. I bet that kept them burning fuel, too. (I’d hate to think that Dr. Campbell spent so much time thinking about vegetables that he started to imagine that his subjects were as active as vegetables. His book is a brilliant compilation of some very important research, but he completely missed a big issue in weight loss— exercise. This gets back to my point about the problem with nutrition and obesity research. Everybody has his own very different agenda, background, and point of view, which then skews his interpretation of the data.) IF YOU SPOUT OFF THE TOP OF YOUR HEAD, SHOULDN’T YOU GET A MOUTH FULL OF HAIR? Still, being the physician and past science researcher that I am, I feel compelled to consult the research, rather than spouting off the top of my head (like a lot of diet book authors do). The studies tell us that a body can lose, by calorie elimination alone, between a half-pound and one and a half pounds a week without triggering metabolic slowdown. (Any more than that and you defeat yourself.) Eliminating about 300 calories a day won’t be noticeable to you, using the techniques we’ve already discussed in this book. If you add into the calculation resetting your basal metabolic rate slightly upwards (what you’ll learn about in the next two chapters), you can easily lose at least three pounds of fat a month, without any deprivation or feeling like you are on a diet. In a year, that’s 36 pounds without any pain! If you are able to reset your metabolism higher, with a more concerted effort, you might be able to lose even more than that, possibly up to 72 pounds in a year. Go away, fatty butt, hips, and belly, all gone permanently. No more plateaus and no more yo-yo dieting, ever. And you’ll still have an enjoyable sex life, unlike those poor starving fools in California.

That’s assuming you have a sex life. When I was in medical training, the doctors were forced to work 80 to 100 hours a week. I’d come home completely exhausted. When my husband would indicate he was in the mood for a romp, I’d tell him the only feel he was getting was necrophilia.

Unfortunately, counting calories is not a lot of fun, and most people are unwilling to do it for very long. In addition, subjects in studies,

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including the experts, are usually very far off in their estimates of their calorie intake! In a New England Journal of Medicine article from the early 1990s, 10 overweight people were asked to estimate their calorie intake. They were off by about 50 percent, estimating that they were eating about 1,000 calories a day when they were actually eating 2,000 calories. That’s a remarkable difference. In fact, overweight people tend to be more inaccurate in estimating calories than normal-weight individuals. This may be due to denial, or a lack of practice, or the fact that obese people eat more calories, so their margin of error is greater. However, even professionals, like dietitians, are usually off by around 20 percent, about the same amount that normal weight people misestimate.

Calorie counting isn’t difficult, but if you need help, there’s lots of ways to get it on line. For instance, wolfromalpha.com allows you to get the answer instantly to the question “How many calories are in a cubic light year of ice cream? ” You can even specify if your cubic light year is made up of Breyer’s French vanilla or Healthy Choice pralines and caramel.

As I just mentioned, overweight people generally eat more than normal-weight individuals, but that depends on metabolism. If you have the genetic predisposition for a very slow metabolism, have done a lot of yo-yo dieting, don’t ever exercise, or take medications that keep it slowed, you may not need to eat more than a normal weight person to get heavy. It really doesn’t matter if you eat only what a normal-weight person eats; what matters is what is the right amount for you. See Chapters 10 and11 for ways to speed up your metabolic rate and burn more calories. I’M NOT FAT, I’M GRAVITATIONALLY ENHANCED Perhaps one of the most common ways to chronically overindulge in calories is to assume that you can eat as much as you did when you were younger. Unfortunately, most bodies don’t work that way. If you continue to eat the same portions for meals that you did when you were in your 20s when you hit middle age, you will gradually and continuously put on pounds. Most people do not lessen their intake

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enough as they age, and this causes middle-age spread. As the body ages, it has less lean muscle mass and tends not to move as much. When was the last time you rode your bike, walked to work, played tennis, or jogged a few miles? Maybe you used to do that when you were younger, but you are very likely more sedentary now. Interestingly, spontaneous movements (ﬁdgeting) decrease as we age. So, between the reductions in our planned exercise and unplanned movements, we get less activity. This results in reduced caloric needs. Meal portions need to go down or activity must go up so that the intake and output equalize.

There’s been a new theory floating around that viruses cause obesity. It just reinforces the denial syndrome and lack of responsibility that many people have toward their health. It’s so much easier to blame a virus than one’s own habits. “Oh, great, it wasn’t the triple cheeseburger with supersized fries I’ve been eating for lunch every day for the past three years; that’s a relief.” I love those people suing the fastfood franchises over their obesity because they don’t know how to shut their mouths and walk out the door. What’s next, suing the Centers for Disease Control for not curing my “fat virus”?

Remember to carefully assess portion sizes. As discussed earlier in the book, from restaurants to supermarkets to bulk food clubs, product packaging and labels often mislead consumers on calorie content. Even nutrition experts will underestimate calorie consumption because of misleading labeling. You have to be vigilant. Watch out for oversized servings, packages, and platters. We eat the amount we are given and assume the portion size is the package size. (We’ll drink a 12- or 20-ounce bottle of Coke and assume both are one portion.) Divide packages, think about how much is the right amount to eat before starting, and then remove the rest before you begin.

And, speaking of bulk food clubs, there was a recent Harvard University economics study that found that people sometimes spend excessively when they go to wholesale stores. The reason is that consumers

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purchase stuff in bulk that they don’t really need. Somewhere in America, right now, a husband is explaining to his wife why he needed to buy the 100-quantity package of puppy butt corks.

Something to think about when choosing portion control: larger meals make you want to eat more later on, particularly if you focus on foods that put you on a sugar high-low roller coaster. If your body eats a lot at one meal, it is more likely to want excess calories at the next meal. Binging begets binging. PEOPLE TELL ME I MUST EAT LIKE A BIRD. RIGHT—LIKE A CONDOR So am I telling you to count calories for the rest of your life? No, because I don’t do it, and I don’t know anyone who does it permanently. But many former fatties do count calories when their weight trends upward. It’s a good idea to get educated and to train yourself to guess how much a food item is in calories and then check the ingredients label or go online to look it up (search the words “calorie count”). Make a game of it; if you are within 10 percent, give yourself a little gold star sticker. The better you get at it, the more educated and accurate you will become about portion control. And that’s the whole point, isn’t it? You might be surprised to ﬁnd what the food industry calls one portion. For instance, the whole-wheat Triscuit cracker is a relatively good snack, according to the Nutrition Action Newsletter (published by the Center for Science in the Public Interest). However, some versions of the Triscuit have as much as 120 calories in six crackers, which is a very small portion. I know I never stop at six crackers when I have a box in front of me. MY COOKING IS PRETTY BAD. YESTERDAY I ASKED MY HUSBAND IF HE WANTED HIS EGGS SCRAMBLED OR TOSSED Now that we’ve discussed how much to eat, we need to know when to eat our calories and how often. Entire treatises have been written on those subjects. Is skipping breakfast bad for you? Yes, it probably is. According to the European Journal of Clinical Nutrition, breakfast

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skipping is seen in fatter people, both adolescents and adults.4 In fact, of those who used to be heavy and permanently lost the weight, only 4 percent (four!) skip breakfast now. If you eat breakfast, you are less likely to binge on lousy, high-calorie food later. Besides, breakfast is your fuel to get your brain going. I hate working with people who left their brains at home.

I was thinking about buying an old historic house and renovating it, then opening an inn. But I don’t like to cook, so it can’t be a Bed & Breakfast. Maybe it could be a way station for hypochondriacs, a Bed & Examination. I’ll call it “Up Yours.”

Are 2, 3, or 17 meals a day better? Dr. David Jenkins, in a study published in the New England Journal of Medicine, had two groups of people eat the same food every day. One group ate 3 meals a day, while the other group ate the same food but broken up into 17 meals a day. Interestingly, the “nibblers” had lower cholesterol, cortisol (a stress hormone), and insulin levels. Supposedly, that’s because constant feeding drove those levels down. In my opinion, I suspect the nibblers were much less stressed, resulting in those numbers. Since they were in the kitchen constantly to prepare and eat their 17 meals, they probably never went to work, did laundry, diapered the kids or mowed the lawn. Voila, no stress! This eating pattern has real possibilities if you don’t want to accomplish anything in life or earn a living; I’m not convinced it’s realistic for the real world. LIFE IS A BOWL OF CHERRIES — OVERPRICED I do suggest eating more frequently than usual but consuming smaller amounts at each feeding. Never let yourself get terribly hungry; that way, you are less likely to gulp down more calories than your body requires. Nibblers who eat all day everyday feel fuller than those who eat only three meals a day, even when given the same number of calories. Snack frequently, but always on such things as fruit, veggie sticks with low-cal dip, nuts, or low-fat cheese. These things won’t give you the sugar rush, followed by the low later. I personally eat all day long, at least every three hours; it keeps me from getting cranky. And you really don’t want to see me cranky.

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Fruit roll-ups are so popular among kids that it seems there ought to be an adult equivalent: Carnivores’ quick snacks, new Cow by the Hoof.

Some thin people are an exception to the “eat frequently” rule. They do better if they eat only two meals a day and have no problem skipping meals. What I do know is that most people will not eat with contemplation and proper meal preparation if they have let themselves get too hungry. Making decisions about proper “good-for-you” foods and proper amounts are best made when one isn’t starving. Dr. Ancel Keys found, in a famous study done years ago, that people who chronically fasted and felt very hungry tended to then binge-overeat and become food-obsessed.5 Interestingly, when I worked on an adolescent eating disorders ward, the anorexics and bulimics loved to talk about cooking and the recipes that they would make for others. Then they would skip meals and starve themselves. I’m not a big fan of meal skipping; however, there has been some research showing that people who routinely fast will lose weight. People who skip eating for an entire day will make up some, but not all, the skipped calories the next day. When fasting on a regular basis, such as every other day, most people will end up eating fewer calories overall. I can’t concentrate when I’m hungry, and I don’t think most people function well when extremely hungry, so, if you are like most people, you are better off losing weight and keeping it off by eating small meals regularly. If you are the exception and don’t mind skipping meals, you might succeed with less frequent feedings. The key is to remain functional and pleasant to be around, without binging later; most people can’t do that when they are chronically severely hungry.

A new movie is coming out for the self-starvation passive-aggressive types, Gandhi vs. Predator. The plot: Gandhi eats nothing, Predator eats Gandhi.

You are better off if you don’t go more than ﬁve hours without eating during the day, because it reduces the risk you’ll overeat at the next meal. Snacking is not linked to obesity, but what you snack on

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is. If you snack on fresh whole fruits or veggies, low-fat cheeses, a cup of soup, unprocessed low-fat meats, all-natural yogurts, a handful of nuts, or tomato juice, you will be ﬁne. If your snacks are cold pizza, pretzels, chips, bagels, donuts, or half a can of nuts and 20 ounces of juice or cola, you will likely become (or stay) obese.

People are always talking about how vending machines are causing obesity in schools and the workplace. I have a solution: vending machines should be rigged up with a camera that measures waist circumference before it dispenses the treat. If you’re fat, you get your money back but no snack. Suddenly, in break rooms all over America, you hear, “Hey, Dave, come over here, stand in front of this machine.” If the camera needs a fish-eye lens to see both sides of your body, you’ll hear a machine voice say, “Access denied.”

Bedtime snacks are the exception to frequent eating. Often we eat just before bed out of habit. Or we are afraid to go to bed hungry. Do not be afraid of hunger at night. There are still at least a billion people on this planet who are forced to fall asleep hungry (we have not cured poverty). Don’t go to bed if you are ravenous and starving; you’ll not sleep well and may wake up with a headache in the morning. Obviously, then, you need to feed yourself. However, in general, stop eating at least three hours before bedtime; then don’t eat again until the morning. If you have twinges that are distracting prior to bed, try some chamomile tea, which often suppresses the urge for food. Avoid any caffeinated beverages, and don’t add sugar to your drink. RECENT STUDY FINDS THAT CHOCOLATE HAS A 100 PERCENT FATALITY RATE—EVENTUALLY There is no research to prove that avoiding bedtime snacks will make you lose weight. However, I strongly feel that most people who eat at night don’t eat because they are hungry. Mental fatigue, stress, and sleep deprivation often lead to eating to decrease physical and mental discomfort. We try to get the bump of pleasure from the food when what we really need is rest and mental comfort. If you check your hunger level before eating every time, you will know whether it is appropriate to eat before bed.

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Fatigue is what drives us to eat at night. A recent study found that one ounce of dark chocolate will help improve chronic fatigue syndrome almost as much as being chased by a very large lion. So, both must be good for you, right?

Unless you are a diabetic or are prone to morning headaches from a lack of food, overnight fasting will serve you well. There is some data to show that short courses of fasting, even for 12 to 14 hours or so (a typical overnight fast), may be beneﬁcial physiologically. I don’t think there is enough data to say this for certain, but it probably wouldn’t hurt. It is best to fast when you are asleep since you have higher demands for fuel during the day to operate your working brain and muscles. If you are a habitual nighttime snacker, gradually try to cut back your evening snack, or switch to lower-calorie foods that are not processed carbohydrates. Then, cut out the snack altogether and see how you do. It may take some getting used to, but it can be a very important technique. This is the time when your body will switch to breaking down some of your adipose tissue and liver fat, which is a good thing. Overnight fasting may avert and ameliorate fatty deposits and clean your liver. SOME MEN WEAR A ROLEX. MY HUSBAND WEARS A ROLAIDS I can’t leave the discussion of nighttime snacking without mentioning gastroesophageal reﬂux disease (GERD). Overweight (and pregnant) people suffer from GERD more than anyone else. When stomach or bile acids backwash up into your food pipe (the esophagus), they cause irritation, including heartburn, difficulty swallowing, asthma, and coughing. Everyone can have this happen on occasion, but when this happens more than twice a week, it’s given the name of GERD. The funny thing about reﬂux disease is that the symptoms can make the sufferer eat more food, trying to alleviate the symptoms. It’s another one of those vicious cycles. GERD is more common in smokers, alcohol and caffeine imbibers, and those who eat a lot of foods like citrus, chocolate, tomatoes, fried foods, mints, hot spices, garlic, and onions. It probably occurs in those with a high-salt diet, too. However, if you have a big belly, then your

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abdomen is pushing your stomach contents back up toward your mouth, and that’s the major reason for reﬂux disease. So you need to eat smaller meals and quit before bedtime since lying down will also push the foods and acids back up the wrong way. When you eat, your stomach makes lots of acid for digestion; when you are fasting, there’s very little acid to go up into the esophagus. That’s why I recommend you quit eating at least three hours before you lie down. SAVOR EVERY BITE, AND YOU WILL NEED TO BITE LESS Finally, we need to discuss how to eat. Weight loss is made easiest when food is pleasurable. There is no better way to truly enjoy eating than to meditate on it. Meditation encourages focusing completely on the experience of eating, including the sights, sounds, smell, texture, and taste of food. By creating a sensory experience and feeling the response of the body to eating, you will relearn pleasure during mealtime. At the end of a meal, you should feel refreshed, rather than sleepy, bloated, and guilty.

We don’t realize how important it is to give food the right texture. Funny thing about health care: we do some pretty barbaric things, like ordering pureed food for our patients. We routinely force the patient to eat blenderized meatloaf and then wonder why he is losing weight. People don’t like to eat mashed-up animal, unless it’s haggis, the national dish of Scotland. (For further fun, I suggest you read Robert Burns’s 1787 poem “Address to a Haggis.” And you thought I was the only one who wrote poems about my food.) I liked haggis, until I found out that it’s a combination of sheep’s heart, lung, and liver, along with mutton fat, oatmeal, and spices simmered in the animal’s stomach for a few hours. That recipe put a damper on my appetite.

DON’T JUST DO SOMETHING — STAND THERE When you live in the present, rather than thinking about what’s happened in the past or worrying about the future, you fully enjoy your life. Be in the present, and enjoy the sensuality of food. If you don’t think sensuality and sexuality are part of eating, rent the movie Tampopo, my favorite ﬁlm about food (input) and sex (activity).

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Thoughtful eating means really concentrating on the pleasurable experience of the food. To me, gratitude is part of the pleasure. I feel very blessed and lucky to be one of the fortunate ones who do not have to go to sleep hungry due to poverty. Mindful eating increases the enjoyment and decreases the need for food. May I suggest some truly revolutionary ideas in eating behavior: while ingesting your next few meals, turn off the television and put down the newspaper. Ignore the computer screen. Eat the food slowly, savoring it, and think about the smells, tastes, and textures. You will eat less and be more satisﬁed. Don’t eat until engorged. Once a day, if you need it, complete the meal with a small bite of a favorite sweet, savored slowly and completely. Enjoy how you feel at the end of the meal: healthy, happy, and joyous. THE POWER OF NOW WHAT? I recommend taking a class or retreat to learn meditative techniques. An alternative is to obtain audio programs on meditation from your local library or bookstore. Just don’t practice the exercises while driving, especially those that require keeping the eyes closed. I went on a meditation retreat a number of years ago. At meal time, for the entire week, hundreds of adult campers came into the dining room and sat down, waiting quietly for their food. When it was placed on the table, everyone began to eat slowly, contemplating the food in silence, chewing thoughtfully. The food was completely vegan, yet no one complained about the taste or quality (except my son, over in the kids’ camp). No one overate, either. People spent the meal quietly together, enjoying the peacefulness and gratefulness of having food. I had never experienced anything like it. IS IT POSSIBLE TO RAP THE OOMPA LOOMPA SONG? I don’t always get to enjoy my meals in peace. I’ve got this neighbor’s kid who insists on practicing the trombone in the evening, badly, at his house, with all the windows open. He is truly awful. Why can’t his parents insist that he go out in the garage and close all the doors—and leave the engine running? I have another neighbor’s kid, who comes home from high school every day and practices on his bass guitar for two or three hours so loudly it actually makes my house vibrate. I finally went over the other day and asked him if the name of his band was Crack the Paint.

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When you eat thoughtfully, you decrease automatic feeding while increasing connectedness and joy. If you improve your environment, both internal and external, you’ll improve your joy and health. Meditation decreases blood pressure and curbs stress and negative thinking. It eliminates impulsive eating behavior that results in overeating and a loss of control. You become alert to signs of hunger and satiation. You are attuned to when you have had enough. You shut off the eating process earlier than otherwise because you are aware of the sensation of fullness much sooner. MEDITATION—DON’T GIVE IT A THOUGHT I use meditation techniques in such disparate situations as when dealing with challenging people at work, sitting in rush-hour traffic, allowing myself to fully enjoy a walk through the woods, or intensely enjoying a small piece of chocolate. Meditation is not distancing oneself from the world but becoming much more connected and aware of the world and one’s own interaction with it. I’m not less emotional (dispassionate or withdrawn, as some believe occurs with meditation) but am able to feel more in control and to participate in my world. But I am less buffeted by the negative effects of the world. I become more of a participant and also more of an observer at the same time. There’s less boredom and more joy. It’s very healing. Use it.

I wrote an essay in which I said that I sometimes resort to meditation to stay calm around difficult patients and families. But my son thought it said “medication.” He read it and said, “Gee, Mom, you shouldn’t tell people you need to take drugs to deal with your patients.”

THE OFFICE SUPPLY COMPANY ADVERTISED IT HAD THE “EASY” BUTTON. WHAT I REALLY NEED IS THE MUTE BUTTON Food research has clearly demonstrated a strong relationship between eating environments and how much is eaten.6 You probably don’t realize this, but when you go into a chain restaurant, the management has designed the setting according to what they want you to eat and how long they hope you will stay. When you eat, the environment should be relaxed and fun, not high-stress, loud, or bright. Research

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has shown that people instinctively eat faster (and therefore are prone to eat more) in a bright and noisy environment. That’s why fast-food places look and sound the way they do.

Nurses’ stations are very noisy places: lots of activity, buzzers, talking, and alarms ringing. Our local hospital’s administrators got the genius idea of putting a noise meter at each nurses’ station to discourage noise so that the patients can rest easier. Guess what happens if we surpass the acceptable noise level? Yep, a piercing alarm sounds! This explains why a hospital administrator has never won the Nobel Prize in medicine.

Unlike fast-food joints, romantic high-priced restaurants are softly lit. In a quieter, calmer place, like Chez Expensive, you are more likely to linger over your food and order more alcohol. So, at work or home, hold the alcohol and calm the lights and noise. Add some calming, pleasant background music. When you slow down and linger over your food, you tend to ﬁll up on less of it. WHAT YOU SHOULD REMEMBER FROM THIS CHAPTER • Severe caloric restriction results in a slower metabolism and isn’t much fun. • Yo-yo dieting results in slowing your basal metabolic rate and is selfdefeating. • The average American who loses weight eats 1,400 to 1,700 calories daily. • You can eat a lot more and lose weight if you speed up your metabolism. • You can lose two to six pounds of fat a month without slowing your metabolism or expending much effort. • Using the techniques in this book, you should never feel like you are dieting. • Counting calories isn’t necessary, but learning calorie content will help you make good food choices and not-so-good choices. • Eat less than when you were younger, and always pay attention to portions.

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• Don’t skip breakfast, and eat frequent small meals all day long. Stop after dinner. • Snacking isn’t related to obesity, but what you snack on is. • Nighttime snacking is related to fatigue, not hunger, and leads to reﬂux disease. • There is no better way to truly enjoy eating than to meditate on it. • Turn down the lights and noise, play soft music, and eat mindfully, and you will eat less. • Improve your internal and external environment and you will improve your joy and health.

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PART III Output—Metabolism and Activity

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TEN That Which Doesn’t Kill You Makes You Fatter: Increasing Metabolism

I saw an ad for a weight-loss patch, so I looked into it for one of my patients. It turns out that the patch works well because it goes over the mouth. There’s fine print on it that says, “Do not open until Christmas.”

Practically every diet book, plan, and product on the market promises quick weight loss. But that isn’t the kind of weight loss that you want; it’s only water weight, not fat tissue. That’s why quick-weightloss programs aren’t sustainable and are unsuccessful. You can dehydrate your body only so much, and eventually you will reabsorb that water back into your tissues. The next time you see a promise of quick weight loss in any type of diet plan or product, run like heck in the other direction. That program or supplement won’t help you in the long term, and it could very well hurt you. Slow, sustained, and permanent weight loss is what you should want because that’s the type of weight loss that results in adipose tissue loss. Permanent, healthy weight loss involves shrinking fat tissue and occurs through slowing calorie intake and increasing metabolic rate. If you try to lose weight too quickly, you will damage yourself by losing muscle mass (that’s the stuff you want to keep) or causing electrolytes, such as sodium or potassium, to be imbalanced.

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CUT-YOUR-LEG-OFF DIET PLAN—YEP, THAT WORKS, TOO When you lose weight the correct way, you will thin out your fat cells and bulk up your muscle cells. If you weren’t very active before and you start an exercise program, you may even gain weight initially because of those bigger muscle cells—that’s great! Eventually, those healthy, well-hydrated muscle cells will tackle your adipose tissue and trim it away. If you do it right, you may not even lose much weight on a scale at ﬁrst, but you will lose inches in your fatty areas. In the long run, the slower approach will make healthy progress toward the goal of permanent weight loss. I DON’T KNOW THE DIFFERENCE BETWEEN A CARBOHYDRATE AND A HYDROCARBON, BUT I THINK THEY BOTH GIVE ME GAS There has been a lot of attention paid to low-carbohydrate diets. They provide false success quickly because when you eliminate carbohydrates from your diet, you also eliminate the water weight that is associated with the storage of those carbohydrates. Those molecules are turned into glycogen in your muscles and are paired with three times their weight in water molecules. So, when you eliminate that glycogen, you eliminate the water weight. But as soon as you go back to eating carbohydrates, the water weight returns. The research has shown that a low-carbohydrate diet doesn’t lead to any more permanent weight loss than any other restricted diet.1 Some other types of diet plans concentrate on having you cut out salt (not a bad thing to do) or MSG or preservatives or just hype you up on lots of caffeine, a diuretic. In any case, it’s false weight loss since you aren’t losing the fat weight. If you try to exercise too much with too little intake of calories or eliminate too much water by those methods mentioned earlier, you can damage your body. Your system will start to break down its own muscles or stop functioning properly. People get ill and die in the singleminded pursuit of dieting. Please don’t do that. There are plenty of healthy ways to speed up your metabolism and make weight loss fun and a positive experience. THAT DRESS DOESN’T MAKE YOU LOOK FAT, BUT NASA IS PLANNING A FLYBY OF YOU NEXT YEAR I’ve noticed that many overweight people get bogged down in their genetics. They spend too much time worrying about their family history

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of thick thighs and not enough time contemplating how to move those thighs. Yes, twin studies and adoption studies show that people are more likely to have a metabolic rate that is similar to those of their biologic parents than one like their adoptive parents’. So your quick or slow metabolism is somewhat determined by genes. However, this can be modiﬁed by nurture, by what you do to speed up your metabolism. Heredity is not destiny.

Speaking of genetics, I’ve been wondering what my kid would have been like if, instead of marrying the guy with the doctorate in molecular biology, I had married the first guy who proposed to me, the mechanic who lives in a trailer park. I guess instead of having Geek Boy 2000, I would have had a waffle iron.

You can control your own metabolism, and you have a lot of power in this regard. We’ve discussed a little bit in earlier chapters about how metabolism is affected by such things as starvation and eating cycles and also perhaps by ingested chemicals like artiﬁcial sweeteners. In addition, metabolism is affected by exercise, sedentary activities (like television watching), temperature, foods, hormones, medicines, and muscle and adipose tissue. By now, you are probably getting the idea that exercise is the predominant way to increase your metabolism. I go into speciﬁcs in the next chapter, but suffice it to say that the more that you move your body, the more you can increase your metabolism—to a limit. A WATCH DOG YOU WEAR ON YOUR WRIST The funny thing about activity is that our bodies expend a great deal of energy doing things that we don’t think of as exercise. And the nice thing about that is that we really can increase our metabolism without doing a true workout. Most of our daily basal metabolism, the energy used to expend the calories we ingest, is used for maintenance events. In other words, our body burns a lot of our fuel just maintaining itself. If you add on a little bit of extra activity all day long, you can burn quite a bit more fuel without any pain or feeling like you are working out. The hardest part is removing the mindset of inactivity and creating a permanent mindset of increased regular activity.

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And it doesn’t take much of an increase in activity to start making a difference. There’s this cute neighbor of mine, a very, very old lady who walks an ancient dog down the street every day, one of those tiny miniature Yorkies. The dog has no teeth, and the woman purees the dog’s food so it can eat. (We nicknamed the pooch “Killer.”) Both walk extremely slowly. I wonder what she’s going to do when that dog finally passes away. She’s not exactly spry enough to keep up with a puppy. I envision her at the pet store: “Do you have anything that’s already dead?”

You’ve probably heard or read about the advice to park your car further away from your destination or to take the stairs on a regular basis, rather than the elevator. Yes, these do increase activity in little bits (plus, you can test whether you are developing improved exercise tolerance). But what about those hours that we spend in sedentary activities, like when we’re tied to our computer desk, reading chair, or couch? Amazingly, research on ﬁdgety and quiet kids reveals a tremendous difference in the energy people expend in a typical day. NEAT, or non-exercise activity thermogenesis, is the energy that a person expends in activities not usually thought of as exercise. This is the fuel that you burn every day when you are standing up and holding your posture while talking to a friend or ﬁdgeting in your chair during a boring television show or lecture. Some people move a lot more than others every day; they are more ﬁdgety. Those people, it turns out, may have an advantage in metabolism.

We solved our problem with the annoyance factor with my son on long car rides. When he gets really fidgety, we just make him get out and run alongside the car. That way he gets his exercise.

Research has looked at both children and adults and their NEAT expenditures and has found that those who ﬁdget more (measured by motion sensitive devices) lose weight or prevent weight gain more easily, even when deliberately overfed. So now the question you need to ask yourself is: how do I learn to ﬁdget more, all day every day?

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DO “GOOD” CHILDREN GROW UP TO BE FAT ADULTS? Interestingly, as schools and work sites have moved more people to desk activities, people formally or surreptitiously get evaluated on how much or little they ﬁdget. “Good” kids in the traditional classroom setting are rewarded if they sit still. That’s one reason my son was sent to a Montessori preschool. Dr. Maria Montessori believed that children should move and use their kinesthetic learning (movement learning) actively in the classroom. As a doctor, parent, and homeschool mom, I believe that children should move, all day, every day, and not sit still for the best learning and health. Movement itself fosters learning and thinking for most people, at any age. This has even been demonstrated in research on the frail, demented nursing home population; those who keep moving are the ones who keep thinking much longer and better.

I MET AN ENGINEER WHO WORKED FOR A COMPANY THAT BUILDS TIME MACHINES. SHE QUIT WHEN HER BOSS TOLD HER TO HAVE THE DESIGN ON HIS DESK YESTERDAY But what about movement in the adult population? Do you ﬁnd your life encourages you to take the “stone statue” approach and not to ﬁdget? At work, are you stuck in a cubicle, slaving to meet a deadline? Do you ﬁnd yourself tied to a seat much of the day? If so, it behooves you to consciously make more movement decisions—that is, to relearn to ﬁdget. Remember what I said earlier? Kids naturally have more spontaneous nonpurposeful movements than adults. It’s time to get ants in your pants again! Take frequent breaks from your chair, and take walks on your breaks. Form a “walk and talk” group before or after work or school. Find ways to move more in place. Huh? Move more in place? Yep, that’s the next phase of raising your NEAT. Dr. Jim Levine at the Mayo Clinic (up in Minnesota, where they ﬁdget to stay warm) has found that people who are naturally thin gyrate their bodies and wiggle their toes a lot more than those who are obese.2 In fact, fat people in his studies sit a lot more than thin people—by about two and a half hours a day! Dr. Levine strapped specially designed underwear to his subjects, complete with motion and position sensor monitors, to determine how much people ﬁdget. He found that fat people instinctively move less than people who are naturally thin. Indeed, even after the fat people lost weight, they

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continued to move less than naturally thin people. (So now you know why television watching is directly related to obesity. Studies show that the more you watch, the less you move and the more you weigh.) This might explain why formerly obese Americans eat almost half the number of calories daily that thin rural Asians eat. I believe those Chinese farmers move more all day, every day, although I haven’t strapped any special underwear to them to prove it. (If you remember the Cornell scientist Dr. Campbell from The China Study, he asserted that eating vegetables makes you burn more calories and implied that perhaps you might even move more! I have yet to ﬁnd any research to show that veggies make you wiggle, but it’s an interesting idea.) Eat more beans. It isn’t just the gas that might propel you forward.

The great thing about being a scientist is that, if you play your cards right, you can get people to do all sorts of ridiculous things in the name of science. I’ve been meaning to call Dr. Levine and ask him where he got his special gyroscope-equipped underwear. Think of the uses! But it’s not just those literally smarty-pants geeks in ivory towers who can do great experiments in the name of progress. True story: one of my friends has a husband who is a contractor by trade, but his dream was to become a scientist. Shortly after they had their last baby, her physician gave her a free box of sample condoms. She took it home and threw it in a drawer and forgot about it. Unfortunately, her hubby didn’t. He had a peculiar interest in trying a novel experiment, his curiosity having been piqued by an article about a concept the Chinese are using—biogas. They are converting methane from sewage into useful energy. Mr. Science Wanna-Be decided to measure the amount of methane the trap produces in his house. Picture this—my friend driving up to her suburban home with a minivan full of kids, only to find fully inflated condoms attached to her roof, flying in the wind, in full regalia.

By the way, the last time I saw a photograph of Dr. Levine, the Mayo Clinic researcher, he was cruising the Web on his computer while walking gently on his treadmill. That’s right, his treadmill. He doesn’t even have a seat in front of his computer in his office! And, yes, that geek researcher is one skinny dude.

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We’ll discuss exercise programs in the next chapter. There’s good evidence to show that you increase your metabolism for up to 24 hours after a moderate to strenuous exercise session. Suffice it to say, for now, start bouncing your legs while you read, run around the couch while watching Two and a Half Men reruns, and nail a mini-bicycle-pedal device under your desk at work.

I RECENTLY WENT TO FREEZE-YOUR-BUTT-OFF, NORTH DAKOTA. THAT’S A PLACE WHERE THEY PRACTICE FULL FRONTAL FRIGIDITY While I was contemplating Dr. Levine’s work in the frigid climate of Minnesota, I stumbled upon an article about colder science: fun-loving researchers at the University of Maastricht, in the Netherlands. Back in 2002, those guys managed to recruit a group of young men to spend multiple sessions of 60 hours each sitting in a cold room, with a rectal thermometer strapped to them, forced to do prescribed activities and eat only a limited amount of food.3 What those scientists found was that basal metabolism increases in a colder environment due to increased movements during sleeping and increased energy used to process the food after eating. When they ﬁnally let the young men eat as much as they wanted, they ate more in the cold rooms rather than the room-temperature settings, mostly making up for the increased fuel they’d burned. Interestingly, in both the warmer and the colder rooms, the young men overate their calories, probably out of physical distress and boredom! I’m sure the study subjects were thinking to themselves, “I knew I should have read the ﬁne print on the consent form more closely. I missed the part about the thermometer . . .”

METEOROLOGISTS PLAY WEATHERSTRIPPING POKER Perhaps lowering the temperature while you sleep may kick up your metabolism a bit, although you are likely to eat more the next day. But don’t do anything uncomfortable; it’s not worth suffering in freezing temperatures for the few extra calories that you might burn. If you make the ambient temperature cold enough, shivering will help burn off some calories too, but that’s about as much fun as giving yourself a fever (which also increases metabolism).

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YOU CAN HAVE ALL THE M&M’S YOU WANT, BUT THEY’RE LETTUCE FLAVORED Do you remember that I said vegetables may help you to burn more calories? That’s called the thermic effect of food. Legumes, fruits, and vegetables have a lot of cellulose and ﬁber in them. These are things that the body can’t easily digest, so it burns more fuel just to break down your meal. It’s claimed that celery is so hard to digest that your body burns more calories to break it down than the food has in it. Protein is also hard to digest and takes a lot of energy to break down, once in the stomach. Fats are easiest to digest and cause the least amount of thermic energy to be expended. Thermic energy accounts for a signiﬁcant amount of your daily fuel burned, your output.

We usually lump mushrooms into the vegetable category, but, technically, they are fungi. But a mushroom is a good fungus, full of nutrition and fiber. I was watching a science program on TV, and I learned something cool: mushrooms breathe oxygen, just like people. (If you remember from biology class, green plants breathe in carbon dioxide and breathe out oxygen.) I realize some of my relatives are a lot like mushrooms: they’re round and white, grow bigger every day, don’t do very much, and sit in waste, and breathe oxygen.

What’s fascinating is that the type of food isn’t the only thing that is responsible for how much fuel you burn when you eat. There’s now evidence that your health determines how many calories you expend to break down your food—the more ﬁt you are, the more your body burns fuel to process the same exact lunch. Your level of ﬁtness might account for up to 40 percent of the thermic energy expended. This is an amazing ﬁnding and helps explain why fat and unﬁt people gain weight at a faster rate than people who are in shape. No, it’s not all in your head; if you are a couch potato, that bag of chips you’re eating will stick to your butt more than to Mr. Super Jock’s. You may have suspected it, but now you know the truth: your own adipose tissue is working against you. The good news is that you can destroy the fat cells that are working against you with exercise (and perhaps with regular doses of vitamin C, which seem to increase thermogenesis in sedentary folks).4

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This increases metabolism chronically, and as you lose adipose tissue, your metabolism may very well continue to speed up—ﬁnally, a positive cycle leading in the right direction! And, as this same great group of researchers at the University of Colorado at Boulder demonstrated, when you get in shape, the adrenaline stimulation from exercise makes you burn more calories than if you were fat-laden, too. Food and exercise both cause you to burn, baby, burn—and you burn more when you lose those fat cells.

When you burn energy, you generate a lot of heat. That’s why exercise makes you warm up and sweat. Sweating is your body’s mechanism for dissipating heat. This fact makes me wonder whether that whole story about the Land of Oz might just have been a fantasy. Look, even if the Wicked Witch of the West never exercised, why didn’t she just melt on a high-humidity day? Really, if the Munchkins had thought about it, they didn’t need Dorothy. They only needed a decent humidifier.

I’ve found myself wondering if caffeine, which also stimulates the production of adrenaline, can itself increase metabolism. Unfortunately, although caffeine does increase heart rate and acts as a stimulant in the short run, it doesn’t seem to do much for increasing metabolism in the long run. When caffeine is ingested by athletes, it actually decreases the use of glycogen stores from the muscles initially and then ramps up its use later. That does allow athletes to exercise for longer amounts before they fatigue and so might be useful if you are training for the Olympics. For the rest of us, its use should be limited to minimal amounts in the morning as a wake-up call. THE GROUNDHOG DAY DIET—SLEEP FOR SIX MONTHS, THEN EAT UNTIL YOU SEE YOUR SHADOW Per the National Sleep Foundation’s Sleep in America Poll, 81 percent of the general population drinks caffeinated beverages daily, an average of three servings a day. And that’s not even addressing the caffeine that’s now present in so many nonbeverage food items that are on the grocery store shelf, like energy bars, coffee-ﬂavored yogurt, and chocolate snacks. Why does this matter to a fat nation? Because caffeine ingestion seriously impairs sleep, and a lack of sleep makes you fat.

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My son’s school library has one couch that’s always occupied by sleeping students. They fight to get it on their breaks between classes. I think it ought to be reserved through a reward system, like what businesses do for special parking spaces. A sign above it should say, “This couch reserved for Jane DoGooder, student of the month.” Annually the dean announces, “And the winner of the Golden Cot award is. . . . ”

Americans are the most sleep-deprived people on earth and also the fattest. Columbia University presented research in 2004 showing a statistical relationship between the number of hours of sleep daily and the risk for obesity.5 Those who get less than four hours of sleep a night have a 73 percent greater risk of being severely overweight. Anyone who gets less than seven hours of sleep a night is at increased risk for becoming overweight, and there is a strong inverse relationship— the less sleep you get a night, the fatter you will become. Do you think you are the only one not getting enough sleep? Americans report an overall decrease in sleep by about two hours a night in just the last four decades. The theory is that sleep deprivation increases ghrelin and decreases leptin, two hormones thought to have a signiﬁcant role in appetite and weight regulation. Hormones are just chemical messengers in the body that help various organs and tissues communicate; they regulate body functions. Ghrelin, which means “growth” and is released by the stomach, stimulates the appetite. Leptin, a hormone that is released during sleep, is suppressed when laboratory rats or humans are sleep deprived. Those lab subjects then become hungry and overeat calories. Interestingly, the tired human subjects in particular crave sweets, starches, and salty snacks. I AM WOMAN. I AM INVINCIBLE. I AM TIRED It’s believed that a lack of sleep directly contributes to making the body less sensitive to a much more famous hormone, insulin. That’s the chemical messenger that is instrumental in sugar management. In fact, if you take normal, nonobese healthy people and force them to get only four hours of sleep a night for about a week, you can induce a prediabetic metabolic state in them; essentially, the tissues stop listen-

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ing to insulin. If your muscles and organs no longer “hear” the insulin your pancreas is putting out, eventually you develop diabetes. Importantly, there’s new research to show that fat cells may also release hormones that make muscle cells deaf. (Picture those adipose cells stuffing cotton in the ears of the muscle cells. The cells become like an old married couple: “I can’t hear you, I don’t wanna talk to you. Leave me alone, I’m having a bad day.”) Unfortunately, that bad day can translate into a lifetime of pills and injections, not to mention amputation and blindness. A study at Washington University in St. Louis bred fruit ﬂies to be insomniacs. The resultant ﬂies show symptoms of chronic sleep deprivation.6 The fruit ﬂies sleep only an hour a day, as opposed to the normal 12 hours, and as a result have poor memory, fall over a lot, and are fat. (Since I read that article, I’ve been envisioning some frustrated, underpaid researcher sitting in a lonely lab trying to measure an obese, staggering, stupid fruit ﬂy on a teeny-tiny scale . . . and you think your job sucks.)There are easy things that you can do to improve your sleep. Proper rest is important not just to lose weight but to improve your immune system. There are no short cuts. Get enough sleep, at least seven hours a night. As a pain physician, I strongly believe that chronic pain diseases like ﬁbromyalgia are directly related to too little and poor-quality sleep. I see a lot of chronic pain syndromes in overweight patients. If you are having difficulty falling asleep or staying asleep, you might need to improve your “sleep hygiene.” That’s the environment that you rest in and where you prepare yourself to rest. It’s more important than you realize. Don’t watch television or stare at computer screens before bedtime; the light from the monitors causes insomnia. Don’t read or listen to stories that are too exciting or frightening before bed; it’s better to listen to quiet music to calm the brain. Sleep on a good bed in a dark room.

The topic of proper sleep environment reminds me of the time my husband and I went shopping for new furniture for our guest room. The salesman said, “We have some very comfortable day beds.” My husband retorted, “We don’t want that. It’s for my mother-in-law. Do you have anything in a bed of nails? ”

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Avoid alcohol before bedtime. It will make you fall asleep, but during the night you’ll wake up more easily, and your deep sleep will decrease. As mentioned earlier, avoid caffeine and chocolate in the late afternoon or evening. Avoid taking medications late that may stimulate you to stay awake, like theophylline, Prozac, or Ritalin. Sleeping pills do the same thing as alcohol; they may get you to sleep more quickly but not improve the quality of your sleep. Nicotine is a stimulant, too. Do I need to tell you again? Please quit using tobacco, and never smoke close to bedtime.

I was having insomnia, so my doctor suggested I try a certain herb tea. I checked the ingredients; it has chamomile, ginger, and catnip. It works great, but I find myself spending hours scratching the couch and batting the cord on my window shade for no reason.

For many people, exercising right before bed produces too much adrenaline to fall asleep, so plan your vigorous activity for earlier in the day. Daily aerobic exercise of at least 35 to 45 minutes will improve the quality of your sleep. I ﬁnd that when I walk every day for about threequarters of an hour, I sleep better, but for shorter amounts of time, closer to seven hours than eight. The end result is that I don’t use up any more free time between my exercise and my sleep. So there, now you truly have no excuse not to exercise. Don’t tell me that you don’t have time! Finally, on the subject of sleep, I need to mention sleep apnea. That’s the syndrome that results in a lack of oxygen from not breathing properly during sleep. Often overweight people don’t sleep well and they don’t know why, when the reason is that they aren’t getting enough oxygen to their brains. Obese people have a much higher rate of sleep apnea than the general population. There is now research to show that if you snore (a common sign of sleep apnea) or have known sleep apnea, losing just 10 percent of your body weight may cure you of the condition.7 Putting more emphasis on your rest may be one of the most useful things you do to improve your health and one of the most effective steps toward permanent thinness. Don’t underestimate how important it is to sleep well.

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CUSTOMER SERVICE SLOGAN: I’M SORRY, THERE’S NOTHING LESS WE CAN DO Stress itself is a major producer of hormones, particularly cortisol, known as the predominant stress hormone. It’s thought that chronic ongoing stress causes your body to produce too high levels of that hormone and results in abdominal obesity and damage to the body’s normal metabolism. There’s a theory gaining popularity that, as cortisol levels rise, a person seeks highly palatable, calorically dense foods (e.g., junk foods and processed carbohydrates) to relieve the stress he or she feels. It’s thought that junk foods that are eaten when stressed may work on the same neurological mechanisms as narcotics to relieve suffering.

Speaking of stress, wouldn’t it be great if businesses had to be named after the personalities of their owners, such as Real Bastard Pools or You-Want-It-When Dry Cleaning? A sign on the door says, “Our motto: service with a grimace.” When you get their voice mail, you hear the message: “Press 3 if you want to scream in frustration. Press 4 if you’re ready to commit suicide.”

WHAT DID CAVEMEN HAVE AS COMFORT FOOD, SABER-TOOTH POPPERS? Our brains have what is called “endogenous opioids,” that is, we make our own narcotics in our brain to relieve physical and mental pain. When junk foods continuously make us feel better in our chronically stressed state, we develop compulsive overeating. Unfortunately, this condition leads to dysregulation of our appetite hormones, like leptin, and our sugar-regulating hormone, insulin. Junk food gives us happy brains in the short run, but, in the long run, it’s a disaster. Interestingly, there are some researchers who believe that chronic food restriction in this situation actually backﬁres and leads to worsening stress and perpetuates the cycle. If you are in that cycle, this book should help you break out of it. CAUTION: I’VE GOT PMS, AND I KNOW HOW TO USE IT Now I have to discuss female hormones. Women have a higher rate of obesity than men, and it may have to do with our unique, pesky

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chemical messengers. Fluctuations in hormone levels during the menstrual cycle can lead to overindulging in calories; this is extremely common. What’s interesting is that even basal metabolic rate changes throughout the cycle. I mentioned at the beginning of this book that I developed a serious weight problem with my pregnancy. This is one of the most common times for women to gain weight, and often they stay heavy afterward, particularly if they have more pregnancies in quick succession.

I have an idea for a new type of wall clock. It doesn’t tell time or even the moon phases or the ocean tides. It’s an estrogen clock. Get one for every woman in your life or for that special person who is tied to her. The clock runs on a four-week cycle. At what would be the noon position, it says, “Oh, crap.” At three o’clock, it says, “All better now.” At the six o’clock position on the dial, it says simply, “Getting close.” And at nine o’clock, it declares, “Just leave chocolate and tiptoe quietly out of the room.”

CHURCH SIGN: HE IS RISEN, BUT SHE IS BLOATED Women often have to deal with hormone-related mood swings that can contribute to weight gain. Sometimes this is seen in postpartum depression. Later on in life, women are at greater risk to gain weight during menopause, as well. After menopause, the lack of female hormones is thought to cause a shift of adipose tissue from the rear end and thighs to the abdomen. This results in a more metabolically active, dangerous type of fat and may lead to a higher rate of medical complications for women in later life.

A research study by a psychologist says that men also suffer from postpartum depression, and that it’s due to changes in family structure, economic pressures, and a lack of sleep after the baby is born. He claims that women don’t get depressed for those reasons. The only reason we get depressed, he says, is that women are hormonal. I tried to contact that psychologist to discuss his findings, but his wife answered the phone. She said she had a bad case of PMS and her husband was tied to the couch, and he would have to call me back later.

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Finally, while I’m on the subject of hormones, I must mention the thyroid. It’s the most common organ to be maligned when people gain weight, but it’s rarely the underlying cause. There is no doubt that when a person develops an underactive thyroid gland, he or she is more likely to gain weight. But, the vast majority of overweight people in the United States have normal levels of thyroid hormone. If you notice you are suddenly and inexplicably adding a lot of weight to your frame, have dry skin and hair and constipation, and are getting dull in the head, you should have your thyroid hormone levels checked. This is an easy blood test, and low thyroid hormone is easy to treat. It would be nice if obesity could be solved with a small daily pill, but for most of us, being overweight is not a simple glandular problem. The reason that the thyroid gland is often suspected or talked about in this ﬁeld is that it is one of the primary organs that regulates our metabolism. When we have too little thyroid hormone, our metabolism slows down, and our bodies burn less fuel per day. However, taking extra thyroid hormone is extremely dangerous if the thyroid is functioning normally. Too much hormone can lead to heart rhythm abnormalities.

A 90-YEAR-OLD MAN’S CHART SAID HE’S ALLERGIC TO VIAGRA. I WANTED TO ASK HIM, “IS THAT A HIVE OR ARE YOU JUST HAPPY TO SEE ME?” It is important to be aware, though, that many medications prescribed to us for other medical issues can affect the metabolism, often negatively. The most common medicines to do that are the group of heart drugs called beta blockers. These medicines are also prescribed for a number of other maladies, including migraine prevention and tremors. Many psychiatric drugs can cause a slowing of metabolism and subsequent weight gain, although it’s not clear from the literature whether this reflects true metabolic changes or results from an effect on appetite. Narcotic pain medications also may slow metabolism, causing weight gain, but the effect is usually minor. If you are on a prescription that you suspect may be leading to weight gain, please talk to your doctor about it, as many medicines do stimulate the appetite or cause ﬂuid retention, even if they aren’t slowing your metabolism.

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Not only is it important to get the right medication, but it must be taken the right way. Recently, the nurse screwed up giving my patient the two shots I ordered. He got the right medicine, just in the wrong place: the flu shot in the forehead, the Botox in the butt. Okay, he won’t get the flu, but now the man has no crack.

MY HUSBAND PLAYED HIGH SCHOOL FOOTBALL. NO, NOT QUARTERBACK, NOT RECEIVER—HE PLAYED LEFT OUT I’ve skirted the issue, but I haven’t confronted it directly. Now we must discuss one of the clearest ways to increase your basal metabolism: get more muscle. Obviously, everyone has some muscle, but if you are signiﬁcantly overweight, you may not realize how little you have since your lean muscle tissue is now padded or inﬁltrated with fat. When you were younger or skinnier, you might have noticed your muscles— they were round, ﬁrm, and well delineated. You see them on television, in ﬁtness infomercials, and in movies, rippling on the stars. Once in a while, you see them bulging on our national sports heroes, even those who aren’t steroid-built. Most of our daily calories are burned up every day on activities like breathing, churning our intestines, thinking, maintaining core body temperature, and repairing damaged tissue. But our muscles use a lot of calories every day to keep warm and to move our skeleton for our activities of daily living. Even when resting, muscles burn a lot of calories, particularly compared to adipose tissue. Fat is relatively inert; it sits there and jiggles and puts out hormones to wave at passing cells, but it doesn’t burn much fuel. Belly fat in particular is thought to use those chemical signals to slow the body’s metabolic rate. On the other hand, muscle is too busy to sit around and talk; it burns fuel to keep the body upright and warm. I’ve read that each pound of fat burns about 2 calories a day and each pound of muscle burns anywhere from 6 calories to 60 calories a day (once again, that value varies widely and depends on which nerd scientist you believe). Thus, just a ﬁve-pound conversion from adipose tissue to muscle might be enough to help you lose substantial weight over a year’s time. That’s why the exercise chapter, coming up next, will help you raise your metabolism by burning fuel through aerobic exercise and increasing your basal metabolic rate by losing fat and gaining solid muscle.

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TEENAGE BOYS AND THEIR EATING HABITS, OTHERWISE KNOWN AS THE 17-YEAR-OLD LOCUSTS The average American loses almost seven pounds of lean muscle mass for each decade of life. That lean muscle is replaced with much more than seven pounds of fat tissue. That’s why you gain weight over the decades and may not realize how much muscle that you have lost. Much of that muscle loss, I believe, results from inactivity, not the “normal” processes of aging. This creates an enormous downward shift in metabolism as we age. According to the literature, the basal metabolism rate of the average person slows by up to 20 percent for every 10 years of life. Thus, a 45-year-old man may burn only half the calories daily that he did when he was 20, especially if he is now sedentary. So when you think to yourself, “All I have to do is look at that piece of cake and I get fat, but when I was a teenager, I could eat the entire cake,” you aren’t far off the mark. It doesn’t have to be that way, and you have the capacity to change it. Even the Mayo Clinic Web site for patients claims that aging causes a slowing of metabolism, and you just have to accept it.8 I disagree. Don’t accept it—just get moving.

And movement is important, all across the age continuum. According to a New England Journal of Medicine article, a study of 75- to 85year-olds’ sexual activity revealed that about one-third admitted to participating in oral sex, one-third couldn’t remember, and the rest recalled an embarrassing denture incident.

The funny thing about the Mayo Clinic is that its own endocrinology department recently published research showing that most agingrelated changes in muscle result from inactivity, not true aging.9 The number of mitochondria, the individual powerhouses of cells, declines only in inactive muscle but can be increased if the subject exercises. This was demonstrated by an elegant study done more than a decade ago in the United Kingdom, at the University of Newcastle upon Tyne.10 The researchers compared muscle function in young and old, in sedentary and in active people, and were able to conclude that in those older folks who stayed active, the metabolic markers for “aging muscle” were absent. Build those muscles, maintain them, and make them work for you, even when you are resting, by burning off your fuel. And then you can have your cake and eat it, too!

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I’VE GOT A MIND LIKE A STEEL SIEVE Ahhh, well, I can’t leave the subject of moving up metabolism without discussing one of my favorite activities—thinking. What about thinking and burning calories? Our three-pound brains are a constant energy drain, buzzing through huge amounts of blood sugar and using 25 percent of our daily calories, on average. (Kind of reminds me of the United States, which has only 2 percent of the world’s population but uses 25 percent of its energy.) So, do intense thinkers use more calories than stupid people or chronic TV watchers? Was Einstein thin in later life because he was busy writing keynote addresses and meeting with heads of state and wasn’t sitting home watching The Honeymooners?

My husband likes to play private investigator in our house. The other night, he asked my son if he could remember exactly when he first noticed that his brain was missing.

Well, it turns out that deep thought might just burn more than a few calories. According to reports, television watching uses as little as 5 calories an hour, but doing the crossword puzzle burns up to 90 calories during that same time. If you eliminated much of your passive thinking time, you might stave off Alzheimer’s disease, become more interesting to your friends, and help yourself ﬁt into a slimmer wardrobe. Keep this idea in mind. As Winnie the Pooh likes to say, “Think, think, think.” THINGS THAT COME OUT, BUT NOT OVER DINNER I’m fascinated by what lengths people will go to for weight loss. The conquest of the scale can come at tremendous cost. In medical school, I worked in an adolescent eating disorders unit of a hospital. There, girls and young women were hospitalized after they had starved or purged themselves to lose weight. Purging consists of forced vomiting or using diuretics or laxatives. All are dangerous, of course, and sometimes result in death or brain damage. It has been written that the famous court battle centering around Terri Schiavo (the longest rightto-die case in U.S. history) began with her dangerous bulimia in pursuit of permanent thinness.11 It is thought her dieting behavior resulted

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in electrolyte imbalance, heart attack, and subsequent severe brain damage. Her husband and parents then spent more than a decade ﬁghting in court over her feeding tube. There’s more than a little irony that those around her spent the rest of her life battling over her intake of nutrition. I HAD A PATIENT WHO PUT DULCOLAX IN HIS EARS TO TREAT WAX. IT’S AMAZING WHAT A GOOD LAXATIVE CAN DO We must discuss another type of purging—colonics. If you are a celebrity or are from California, it’s called that. Everywhere else, we still call it an enema. Truly, a colonic is just a method to ﬂush the colon, which is an organ that is the end part of our intestine. The large intestine’s only responsibilities are storage of our already-processed poop and absorption of water. So, like any enema, a colonic is just a form of purging of waste and water, which will quickly build right back up anyway. It is neither a useful or safe form of weight loss and has no place in a healthy regimen. Despite what the colon therapists and some weirdo writers on the Net would have you read, there are no “toxins” that are drawn out by a colonic, except the toxins of an overstuffed wallet. DON’T WORRY, NO REAL BREASTS WERE USED IN THE MAKING OF THAT BODY Before the Academy Awards, there was a show on television about the beauty secrets of the rich and famous. It demonstrated how they put cucumber slices on their eyes to decrease puffiness and rub coffee grounds on their thighs to decrease cellulite. I have this image of starlets rummaging through their neighbors’ compost piles in the middle of the night yelling, “Isn’t there anything here to put on my ass?”

Sweating off the pounds is another popular and dangerous pastime for those who desire quick weight loss. Boxers do it before weighing in for the big ﬁght. Stars do it before the Academy Awards. It isn’t safe. Our bodies are meant to be at least 70 percent water. Losing weight rapidly through sweat evaporation that results in multiple pounds lost means danger. It indicates that, somewhere in the system, the metabolism is going haywire. Enzymes stop functioning, sodium gets too concentrated, the muscles and the brain seize up.

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Sweat lodges fascinate me. They are very popular in a community just south of where I live. Even some physicians have them in their backyard, for spiritual communion. They’ve become a New Age phenomenon, mimics of Native American rituals. I’ve never quite understood the desire to force oneself to dehydrate to the point of hallucinating in order to have a spiritual moment. It seems like God wouldn’t want us to go to all that trouble. If you’d like to teeter on the brink of brain injury, it’s less trouble to just slip a plastic bag over your head, but remember to pull it off before you kill yourself. If you don’t, there’s a chance you’ll get to heaven and find out that God is the check-out person in the great grocery store in the sky. His first words to you are, “Paper, plastic, or brimstone? ”

Finally, let’s discuss the future of metabolism. The Imperial College in London, along with help from the Nestle Company (yep, that Nestle, the one that makes candy), has developed probiotics that may improve metabolism and weight loss.12 Probiotics are good bacteria that live in our gut and help with digestion, among other things. This group of researchers is looking into developing bacterial strains that break down our food more efficiently or change the way fat is absorbed. I suppose their idea is that we’ll absorb fewer calories, even if we overeat chocolate bars. Need I say more? WHAT YOU SHOULD REMEMBER FROM THIS CHAPTER • Quick weight loss is just water weight and can be very damaging. • Metabolism is determined to some degree by heredity but more by things you can control. • Small amounts of activity done all day long add up to big effects on metabolism. • Cold environments spur the body to burn more calories and increase metabolism. • The more difficult a food is to digest, the more calories you burn. • The more ﬁt you are, the more fuel you burn to digest your food and to exercise. • The less sleep you get a night, the fatter you become. • A lack of sleep may directly lead to diabetes, as well.

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• To get good rest, you may need to improve your sleep hygiene. • Stress itself produces hormones that damage the body’s normal metabolism. • Female hormones affect metabolic rate, weight gain, and fat distribution. • Thyroid gland problems can cause weight gain but isn’t the issue for most people. • Medications can affect the metabolism or cause weight gain for other reasons. • Even when resting, muscles burn a lot of calories, much more than fat. • Age-related slowing of metabolism is a result of inactivity, not true aging. • Intense thinking burns a lot more calories than passive intellectual activities. • Purging behaviors don’t work and are very dangerous. • Someday we might be able to let bacteria in our gut speed our metabolism.

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ELEVEN Dinosaurs Refused to Exercise and Look What Happened to Them: The Right Activity

My husband had a 300-plus-pound friend who used to play racquetball with him. The guy drove a subcompact vehicle that probably weighed less than he did. He would apologize while trying to extract his body from behind the wheel: “Excuse me while I take my car off.”

The only way to lose weight is to burn up more energy than we take in. Exercise is the easiest and healthiest way to do that. I am astounded, when I read diet books, including some of the most popular books, at how few pages are devoted to the behavior of moving our bodies through space. Both Dr. Atkins and Dr. Ornish were cardiologists when they wrote their bestseller diet books, and both devoted fewer than 10 pages to a conversation about exercise and behavioral approaches to losing weight and keeping it off. However, both devoted more than half their books to recipes for their eating plans! This is akin to trying to empty a bathtub by letting less water run into it but never removing the stopper from the drain. I like the analogy of the bathtub. I think it is a useful one when it comes to thinking about calories and exercise approaches in weight loss and weight maintenance. Your body is the water in the bathtub. If you want there to be less water in the tub, you should try to slow the amount coming out of the faucet. That’s your food and drink that goes into your

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mouth. But, in addition, you had better unclog the hairball in the drain. The hairball is a sedentary lifestyle. Most traditional diet plans and weight-loss centers place almost all their emphasis on food and calories. They concentrate on the spigot. They ignore the hairball. WELCOME TO LEMMINGS LEAP FAT FARM—WHEN WE SAY “JUMP,” WE MEAN IT! I’m going to give it to you straight: it is nearly impossible to lose weight and keep it off long term without a daily exercise regimen, permanently. Yes, there are people who do it, and you may know them, but they are a very small minority of the successful normal weight individuals of the world. And, besides, just because they are normal weight doesn’t mean they are healthy. My approach to weight loss is to do it for the sake of health, not just for the great-looking ﬁgure. The great-looking body is a wonderful side effect. Exercise is not optional. Is brushing your teeth optional? If you went two or three days without brushing your teeth, you would have green, slimy teeth. That’s gross. Think of what is going on inside your body when you don’t move it for two or three days, or longer. You get green, slimy insides. (That’s ﬁguratively speaking, of course; the truth is, we are all the same on the inside—mushy and red, except for the parts that are mushy and brown.) WILD HAMSTERS CAN RUN 10 MILES A DAY, BUT WHERE DO THEY GET THE BALL? One hundred years ago, most people led very active lifestyles out of necessity. The vast majority of the world’s population lived on farms. They exercised the equivalent of jogging up to 7 to 10 miles a day. Our bodies have evolved to want and need that much activity; we are not that far removed biologically from our animal brethren. When we are inactive, our bodies break down rapidly, both physically and emotionally. At least three-quarters of those who lose any weight permanently do so by exercising regularly at least three days a week for the rest of their lives. Walking is by far the most common exercise, and many do it daily to lose the weight and keep it off forever.

Walking is one of the safest and most effective regular exercises. I recommend regular walks in nature parks to improve mood and overall

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health. Not far from my house is a beautiful setting that is an ancient sinkhole more than 120 feet deep. It is a state park in an area called Alachua, which is Native American for “Hey, where’s Grandma?”

The research shows that up to 90 to 95 percent of those who’ve lost more than 30 pounds and kept it off still exercise three to seven times a week, forever. That’s according to a Kaiser Permanente study from the early 1990s and also, more recently, from the National Weight Control Registry’s (NWCR) data. For those who’ve lost signiﬁcant weight permanently, then started to gain weight back, almost all use an increase in exercise as their primary method to get their weight back down. It is crucial to get active, stay active, and increase activity when needed. That’s what works for those who’ve tried everything and succeeded. DOES A FAT BALLERINA WEAR A THREE-THREE? The simplest exercise program is to walk daily, and, interestingly, that’s where the research is the most deﬁnitive on exercise and weight loss. Individuals who participated in studies that had people walk daily lost weight. The longer the research study went on, the more weight lost.1 No other exercise has been shown to be as useful. Don’t want a complicated exercise prescription? Walk at least 30 to 40 minutes every day more than you have been up until now. According to the NWCR, the most common type of exercise by those who lost signiﬁcant amounts of weight and kept it off was walking. This was followed in popularity (distantly) by bicycling, aerobic exercise classes, and weight lifting. Those who stop exercising at the end of a “diet” are more likely to gain all their weight back than are those who continue to exercise regularly, no matter what else they do with their food intake. Find the activities that you love, whether it’s walking, kayaking, or dancing; then do them every day and never stop. THE MOST SERIOUS SIDE EFFECT OF REGULAR EXERCISE—LAUNDRY As implied, the ideal exercise for permanent weight loss is aerobic exercise, like walking. The deﬁnition of aerobic exercise is any repetitive

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motion that moves your major muscle groups in a rhythmic manner to increase your heart rate. Walking, swimming, bicycling, jogging, using elliptical machines, and step aerobics all fall into this category. When you do this type of exercise, you are increasing your endurance for more exercise, even of a different type, because you are training your heart, lungs, and muscles to work more efficiently. That’s why this type of exercise is the most important for long-term health. And aerobic exercise is what gets your metabolic rate up, not only while you are doing it but for up to 24 hours after you’ve ﬁnished. That’s why the recommendation of daily aerobic exercise matters to weight loss. Want to keep your body’s metabolism constantly revved, even while you are asleep or sitting at your desk? Move it aerobically for at least 30 to 40 minutes every day. Daily exercise places you in a higher metabolic category, burning more fuel throughout the day. OUR METABOLIC PROGRAM: ULTRA-CANNIBALISM. YOU RUN UNTIL WE CATCH YOU Purdue University and the University of Vermont looked at their crosscountry teams and other highly trained runners and compared them to sedentary students. What they found is that those who were endurance athletes had a higher basal metabolic rate. But what’s really interesting is that each pound of muscle burned more calories in the trained athletes, even when the researchers controlled for the amount of lean muscle in the two groups! Thus, it isn’t just building muscle that’s important; it’s the aerobic exercising of the body that matters, too, if you want to get the biggest possible increase in metabolic rate.

I’ve been wondering why most of the great marathoners come from Africa. I think I’ve figured it out: it’s a different lifestyle there. They are all lean muscle, they eat right, and they are constantly on the move. When a marathoner comes here to compete, he risks his career ending when someone hands him a remote control. Suddenly he can’t get farther than the minibar.

As we mentioned in the previous chapter, you need to have solid lean muscle along with endurance training. Your increased resting muscle constantly burns calories, even days and weeks after you’ve built it.

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Strength or resistance training is how you build lean muscle the fastest. It’s not just for jocks. Don’t worry, increasing muscle by pumping iron won’t make you look like an Olympic weight lifter, but it will make you look sexier. There are many ways to build muscle, and it doesn’t have to be with traditional weights. Resistance training can be done very effectively with exercise bands or tubing. These are small, lightweight, inexpensive devices that have different levels of resistance and are meant speciﬁcally to build strength. The idea is to do a set of strength exercises about two or three times a week, but not daily. The goal should be to repeat each exercise about a dozen times without resting. If you can do a lot more in a row, it’s too easy for you and you won’t build much muscle. If you can’t do a dozen without resting, you are risking damaging your muscles instead of building them. Make sure you use proper form, and don’t do the same exercises every day, as the muscle needs time to build and repair between sessions. Don’t be afraid to ask for advice from someone who is trained on the equipment or is a certiﬁed ﬁtness instructor, especially when you are ﬁrst starting out. I’M WATCHING THAT FAMOUS GOLFER, GUNNA STEPINIT The nice things about the resistance band or tubing method is that it can be done just about anywhere and at anytime (except while driving— deﬁnitely not advised). I’ve taken them with me while traveling. I usually use my tubes in front of the tube, while watching golf or the news. Try them. If little old ladies can do exercise bands in physical therapy after a stroke, you have no excuse. They can be bought at discount department stores or sporting goods store. If you are really cheap, use old underwear (wash ﬁrst) and pull the waistbands out.

A friend of mine said that she was going to get dumbbells to exercise, but she had been too busy to shop. I suggested she start with a 16ounce can of beans in the meantime. That way, if she drops the can on her head, she can put a steak on her eye and have a ready-made meal.

If you aren’t very active, you can build muscle simply from walking, swimming, or other aerobic exercises (like walking in water, one of my favorite exercises to prescribe). I ﬁnd it funny how often doctors will say

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water exercises are not resistance training. Have they ever done a water aerobics class? Think about how much a gallon of water weighs (about 8–9 pounds). Now imagine trying to push through all that water by jogging or using a water aerobics paddle. There’s a lot more resistance than you get holding a light dumbbell out of the water! I like exercises done in the water because you can get a great cardiovascular workout at the same time you are doing resistance training. I’m always encouraging my patients to get in the pool because water supports an overweight body more easily than air and warms and supports arthritic knees and backs. But always exercise with a buddy, or have someone watching you exercise when you are in water. I WENT TO A VERY STRENUOUS STRETCHING CLASS, TYPE-A YOGA Another component of exercise is ﬂexibility. The more ﬂexible you are, the less likely you are to injure yourself. That’s why it’s good to stretch before or after aerobic or strength workouts or to do ﬂexibility training separately (like yoga). A lot of people talk about core strengthening, too. All that means is to concentrate on the muscles in your torso, including your back. I believe core strengthening is particularly important to the overweight population, since it prevents or reduces back pain. HE EXERCISES; HE HAS A THREE-PACK. HE’S SCULPTED LIKE FINE LIVERWURST I should make a point about spot reduction exercises—they don’t work, because the body decides where to break down fat according to its metabolic needs. It may not take the fat from your adipose tissue with extra cellulite in your thighs, no matter how much you want to get rid of those lumpy thighs. If you are someone who gains and loses weight ﬁrst in your belly or chin, that’s where your body will go looking for fuel ﬁrst. But, as you lose fat tissue overall, you will lose those cellulite deposits eventually. Exercising a particular spot will increase the muscle in that area, giving it more deﬁnition and a sexier shape that will be emotionally beneﬁcial when you look in the mirror (and when others look at you). If you ﬁnd that you are in a plateau and cannot lose more weight, it means you need to ramp up or change your exercise activities. Increasing time or intensity will burn additional fat by increasing your metabolism. Adding a second type of exercise or a regular strength program or doing interval training will help by challenging the muscles more.

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Interval training involves high-intensity exercise done in short bouts, interspersed with lower-intensity exercise or rest periods. An example would be alternating walking and sprints. The University of Guelph, in Canada, showed that just two weeks of interval training will help the body to burn more fat tissue than regular moderate exercise.2 However, the study used young, healthy women.

And, speaking of young, healthy women, I saw a lady going down a busy street on inline skates, wearing protective knee and elbow pads, and talking on her cell phone. She was paying absolutely no attention to the cars while she weaved through traffic. No matter how much protective equipment you wear, this behavior won’t keep you healthy for long. It’s a lot like driving a car with dual airbags while wearing a blindfold.

In 2008, the Norwegian University of Science and Technology did a similar interval training study using middle-aged subjects with metabolic syndrome, a common problem in the obese.3 (Metabolic syndrome involves having some or all of the following: abnormal cholesterol or triglycerides, high blood pressure or blood sugar, or a big waist circumference.) They found their subjects burned considerably more fat with interval training than through regular moderate exercise. But don’t start a new exercise program with interval training. Do it once you’ve developed endurance and are in better condition. The intensity of exertion in your exercise is just as important as the time you spend doing it. I’ve had people tell me that they walk their dog everyday for 60 minutes, but when I see them walk, they can barely make it across the room. In their hour of exercise, they get down the street and back! Certainly, swimming at a good clip for three-quarters of an hour is not the same as moving silly putty around a table for 45 minutes. That’s why you need to monitor your intensity and exertion with the talk test. It’s part of what we rehab types call the Borg exertion scale. Don’t worry, it won’t turn you into a Star Trek alien. It’s a subjective rating of how hard you think you are working, in terms of physical stress, effort, and fatigue. What the exertion scale teaches is that you should be able to converse or sing comfortably while exercising for mild to moderate exercise. This is where you want to start an exercise program, if you are not a regular exerciser. Moderate to severe exertion

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should make you feel that you are working hard or very hard and that you will fatigue quickly. This is for the more ﬁt and in-shape or those who are being medically supervised. Leave the harder exertion to those who are experienced in their exercise, because that’s where the trouble usually comes in.

SORE, THE GREEK GOD OF INJURY Any exercise is better than not exercising at all. Start somewhere, anywhere, and don’t give up. Then, as you get more energy, time, or comfort, expand your commitment. The key here is to do something regularly. Start slowly. People who do an intense exercise program are more likely to drop out and more likely to get injured. You never have to get to the “intense” level of exercise. In fact, unless it thrills you to smash racquetballs in a competitive league, you are better off concentrating on moderate exercise as your ultimate goal. You’ll stick to it in the long run, and you won’t get injured. Start with ﬁve minutes a day, if that’s all you can muster, and then go from there. Intense levels of exercise may actually increase fatigue and worsen tension, pain, anxiety, and insomnia. This is the level of exercise that also causes more cardiac complications and sudden death. The weekend warriors who are out of shape but insist on exercising intensely on rare occasions are the ones most likely to end up in the obituary column at a young age.

Some competitive sports are more dangerous than others. Ice hockey is pretty violent. It’s the only sport where there’s an actual penalty for causing an amputation. You have to carry the limb around for two minutes.

People tend to exercise vigorously when starting a new diet, a New Year’s resolution, or a new gym membership. Then they get hurt or sore and become unhappy and give up. Don’t do that. Prevent noncompliance by starting slowly and doing only short bouts of reasonable activities. You don’t need to feel sore afterward to accomplish a good workout. You don’t even need to feel tired. You should feel happy and refreshed, if you did it right.

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INTERNATIONAL SPORT OF ULTIMATE PILLOW FIGHTING— IT CONSISTS OF THREE 2-FEATHER ROUNDS Exercise does not have to be deﬁned narrowly in the traditional sense. Toss aside the notion of tight clothes, health club memberships, and barking ﬁtness instructors, unless that appeals to you. Throw away your “Kvetching and Stretching with Shoshanna” DVDs. Exercise doesn’t have to be burdensome or expensive. It should be fun. When my son was young, we bought a “jumping couch.” It was meant speciﬁcally for my kid and his friends to jump and wrestle on and enjoy during lots of pillow ﬁghts. It was overstuffed and supplied with tons of pillows. Ten years later, the jumping couch is worn and sagging, but no one wants to part with it—too many excellent memories. Many of those memories involve vigorous exercise (all of it G-rated, mind you). But we’ve had fun and laughed until we couldn’t breathe thanks to the jumping couch. I’m a big believer in the ﬁne art of skipping. That’s right, skipping. Why do people think that a person has to stop doing it around the age of six? Try skipping into the mall or around the block like a kid. You won’t be able to stop smiling, and you’ll probably get the neighbors smiling, too. Talk about great exercise! BEWARE OF YOUR DOCTOR’S EXERCISE PRESCRIPTION IF IT SAYS, “RUN DOWN TO THE CORNER AND GET ME A BURGER” Don’t become an exercise slave, thinking that you have to do it, or overdo it, to the point of exercise burnout. Also, don’t get into the “I ate a donut so now I have to jog for 30 minutes to burn it off ” mindset. Then exercise becomes a punishment for what you perceive as guilt-laden dietary indiscretions. Oh, no, you’ve fallen back into diet-hell mentality! Guilt and punishment are detrimental and self-defeating. Always associate exercise with pleasure. It should be a reward in and of itself. So what do I think is the perfect exercise prescription? Ideally, it consists of moderate aerobic activity for 60 minutes every day, plus two to three sessions a week of strength training with ﬂexibility and stretching. Am I telling you to do that starting this week? Heck, no, but understand that’s the ideal to get you permanently slim and to stay that way and to be in the best health of your life. My son thinks that exercise and hygiene work the same way. If you can exercise once a week for 60 minutes or three times a week for 20

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minutes and get the same benefits, then, he assumes, you can do the same with hygiene. In his mind, a shower taken once every three days for 45 minutes must be the same as a daily shower of 15 minutes.

There are some things to focus on after you start your exercise program to ensure it is effective and helping you. Ask yourself, “Do I sleep better, do I have more energy, or do I hurt afterwards? ” A little ache is okay, but real soreness or hurt is unnecessary and a warning sign. I don’t believe in the philosophy of “no pain, no gain.” Be careful of advisers who push that mantra. Ask yourself, “Do I feel more in control, less stressed, and happier after doing this?” or “Do I ﬁnd myself smiling during or afterwards, or am I bitchier?” Don’t be afraid to question “Do I feel better physically, and can I do things now (like climb stairs easily) that I couldn’t do before?” Use these newfound skills to remind yourself why you exercise. Modify your program if you aren’t getting enough positive feedback from your body and your mind. BOTOX IN YOUR ARMPITS STOPS SWEATING, BUT SO DOES BOTOX IN YOUR HEART Daily exercise must be in the mindset of everybody, no exceptions. There are only a few contraindications (that’s the medical term for “reasons not to prescribe it”) to exercise. The biggest contraindication in the overweight population is a dangerous, unstable heart condition. Since I routinely see patients in the hospital just after major heart attacks and open heart surgery, I’m familiar with this situation. Here’s a revelation: even those horribly sick patients get out of bed and exercise within days of when they were admitted to the hospital! If they don’t move, they get sicker. What if sports teams were named after common medical diseases, like the Peoria Psoriasis or the Hyannis Hypertension? They could have numbers on their uniforms like 160/90 or 200/80.

I believe our medical establishment has overblown the necessity of “check with your doctor before beginning an exercise program.” I’ve always been irritated by that statement when I see it in a magazine or hear it on TV. Given the fact that many people wait to see a physician un-

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til they are having a near-death experience (men more than women do this), telling people to “check with their doctor” throws a huge hurdle in front of couch potatoes. Those potatoes are more likely to stay on the couch; it gives them a great excuse to procrastinate. What I’d love to see is blaring television ads and front-page headlines screaming, “Check with your doctor if you want to stay a couch potato.” Believe me, in our modern culture, inactivity kills many more people than exercise. I’VE ALWAYS THOUGHT CLOGGERS REFERRED TO ARTERIES. NOW I FIND OUT IT’S A FORM OF DANCING Okay, here’s the caveat: you should check with your physician before starting a new exercise program in a few simple cases, such as if you have poorly controlled blood pressure or a heart condition, get dizzy with exercise, or have signiﬁcant kidney or liver disease or brittle diabetes. If you are 45 or older and smoke or have high cholesterol or a family history of early heart disease, you should get checked out. If you’ve had joint replacements, just remember to follow the surgeon’s advice on complying with any restrictions on movements. If you have severe osteoporosis, I usually don’t recommend weight lifting. But you should do something that helps the bones to get stronger (that’s why weight-bearing exercises like walking are better). If you are pregnant, have a discussion with your doctor or midwife.

Remember, use some common sense when exercising. There are activities that aren’t safe and aren’t smart. For example, Canadians have never won an Olympic diving competition—ice diving doesn’t have many survivors.

You should also seek medical advice if you are exercising and notice chest pain or pressure, arm pain, jaw or back pain, nausea or unusual sweating, or overwhelming fatigue. In those cases, you need to call 911 or get medical help immediately. Those are all signs of a lack of blood ﬂow to the heart’s arteries and can result in a heart attack or sudden death if ignored. Also, if you ﬁnd that you are wheezing or having more lung symptoms, call your doctor. Finally, if it hurts, stop doing it! If walking on concrete is too tough on the knees, start bicycling or water exercise. Find a form of movement that makes you and your body feel good.

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IF YOUR LIFE IS TOO STRESSFUL TO EXERCISE, THAT’S WHEN YOU NEED IT THE MOST Exercise has been shown in innumerable studies to improve mood by decreasing stress, anxiety, and depression. Exercise is an antidepressant and works as well as or better than prescription medications for mild to moderate depression. And, according to German researchers, daily physical activity makes antidepressant medications work three times as effectively for severe depression.4 It will allow you to make your weight-loss goals because you feel better mentally and physically. Dr John Foreyt, a professor of psychiatry and an authority on obesity at Baylor’s College of Medicine, has said, “I deserve to enjoy exercise regularly.” He encourages walking as a form of relaxation. Researchers at the University of Missouri-Columbia demonstrated that high-intensity exercise decreases anxiety better than moderate or no exercise.5 Interestingly, women, particularly “older” women (up to age 45 in the study) got the most emotional beneﬁts from exercise.

One of my favorite Olympic women’s sports is synchronized swimming. I was watching the competition, and the competitors were in a circle throwing one of their teammates up in the air with their legs, while they were face down in the water. Apparently, you got extra points for throwing one of the gals high up in the air. How much would they have gotten if they shot each other? Hey, what if we could combine sports, synchronized swimming, and skeet shooting: “Okay, pull!”

Exercise releases norepinephrine in the brain, which decreases stress and induces relaxation. The brain also emits endorphins during physical activity. Endorphins are the brain’s natural pain relievers and happy chemicals, and they stimulate the pleasure centers. Exercise also increases a sense of control and self-esteem, which is a huge component of a successful weight-loss program. It’s also been shown that a regular exercise habit helps maintain and improve other healthy habits. Think about it— have you ever seen a jogger smoking? Exercise decreases naturally occurring cytokines, inﬂammatory chemicals, in the joints and in circulation. This probably explains why exercise decreases the risk of heart attack and stroke. These same toxic chemicals have been linked to arthritis, ﬁbromyalgia, and chronic pain. Research on people with painful arthritic knees who were considering

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total knee replacements shows that a regular exercise program can decrease pain sufficiently to avoid surgery. In fact, in overweight middleaged women with disabling knee pain, exercise and a 10- to 15-pound weight loss resulted in large improvements in pain and function. I HEARD A NURSING HOME EXERCISE INSTRUCTOR BEGIN CLASS BY YELLING, “OKAY, EVERYBODY, POP IN YOUR TEETH, STRAP ON YOUR DEPENDS, AND LET’S START!” Physical activity can reverse peripheral arterial disease in the legs and prevent amputations. It can help reverse heart disease by decreasing inﬂammation, blood pressure, and cholesterol. In one study, older people who walked at least 60 blocks a week at a moderate pace lowered their risk of developing atrial ﬁbrillation, a dangerous heart rhythm, by almost half.6 Since atrial ﬁbrillation is a very common cause of stroke, you can see how walking can dramatically lower your risk of stroke (and perhaps Alzheimer’s and other dementias). Walking 10 blocks a day is not very hard to do and should become part of your healthy lifestyle.

It doesn’t take much to walk that far. If you play golf, just get out of your cart. Recently, I was playing on a municipal course near my house and the sign said, “Beware of water moccasins.” As if the alligators weren’t bad enough, now I have to fear the attack shoes.

Exercise has been shown to decrease the risk of multiple cancers, particularly colon cancer. In 1995, the brilliant Walter Willett, MD, chair of nutrition at Harvard, and his group published an article looking at the health of more than 47,000 male health professionals. What they found was an inverse relationship between the amount of activity and the likelihood of developing colon cancer (the more you exercise, the less likely you are to get cancer).7 In addition, they found a separate direct relationship between the amount of abdominal fat and colon cancer risk. Thirty minutes of daily walking is known to decrease breast cancer risk.8 Are you like many women, terriﬁed of breast cancer? Stop thinking that regular mammograms are the only thing you can do to prevent dying of that dread disease. Eat more fruits and vegetables, consume fewer animal products, and get moving. I’m amazed every year that, during Breast Cancer Awareness Month, doctors drone on and on about

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frequent mammograms and breast self-exams, which haven’t been shown to save many lives, particularly in women under 50.9 (In fact, the research is clear that breast self-exams at any age haven’t been shown to do a damn thing to keep you from dying of breast cancer!)10 Yet they forget to mention the great research showing a connection between lifestyle habits and cancer. Get moving so fast that your cancer awareness pink ribbon is ﬂapping in the breeze.

SEXERCISE, ANYONE? I’ve already told you that aerobic exercise will improve sleep and cure insomnia, but did you know that a daily exercise program might help with that other bedroom activity? Yep, regular physical activity helps men avoid impotence and gives you better stamina in the bedroom, not to mention makes you more ﬂexible.

And sex is a form of exercise, for now, anyway. I wonder if researchers will ever figure out which neurotransmitters (brain chemicals) are released during orgasm. Then you could have all the fun without any of the work. Of course, nobody would get any real work done, either. I can just see it: the clerk at the front desk in a hotel greats you with a big smile. You say, “Excuse me, I’d like to check in.” She says, “Sorry, I’m in the afterglow, I just took one of those new orgasm pills. You’ll have to wait maybe, say, half an hour.” Nobody would ever eat; they’d be too busy glowing. Whole segments of society would starve to death, but they’d die happy. Oh, my God, I see the future. All brain research must stop right now! People worry about the secrets of the bomb falling into the wrong hands, but it’s really the secret of the perfect orgasm falling into the wrong hands that spells our eventual doom.

Our greatest fear is not dying; it’s not even getting up in front of an audience and doing stand-up comedy. It’s becoming a burden to those we love. The surest way to become just that burden is to be sedentary. Get fat and stay fat and you will become disabled; eventually you and I might meet in a nursing home (I’ll be the one writing the orders on your care). If you don’t want that, then get going. What are you doing sitting there? Drop the book and march!

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SAYING, “I HATE EXERCISE” IS LIKE SAYING, “I HATE BREATHING” In Oprah Winfrey’s Foreword to Bob Greene’s excellent book The Best Life Diet, she said, “I still work out even though I really hate it.”11 I respect Oprah so much, but I have to admit I was taken aback when I read that. Moving your body through space is like moving your lungs in and out; the body doesn’t do well when you stop it. If you approach exercise as if it’s detestable or drudgery and an obligation, you will never achieve permanent weight loss. If you believe that you “hate exercise,” I suggest you go and seek out people who love it. I’m certain that if you spend time around people who are having fun while burning calories, you will catch their enthusiasm. Start by expanding your deﬁnition. Open your eyes; check the newspaper or online listings for less obvious sites of activity. Get up early for the start of your community’s local fund-raiser 5k race or walk-a-thon. Go to the river and watch the kayakers paddling across at sunrise or sunset. Stop by your skating rink on “cheap skate” night and watch kids of all ages dancing on their wheels or blades. (My friend Cyndi’s dad took up roller skating on his 90th birthday because he wanted to improve his balance. He was still windsurﬁng, too, by the way.) Head to the mall before opening time and watch the chatty mall walkers race around the perimeter. Redeﬁne for yourself what exercise is and what you need to do to achieve a higher metabolism.

There’s an inane sport called chess boxing; it’s popular in Europe. Opponents play four minutes of chess, followed by a round of boxing. I’d like to see more outrageous sports like that. For instance, leaf blower hockey. It’s also real, played in the street with wiffle balls. I think we should make it more challenging. We’ll call it Electric Air Hockey. Put it on ice, with skates. And use electric leaf blowers with extra-long extension cords. ZAP! AAAAH! Now that’s competition. Run your skates across the cords and you won’t care about the penalty box. Television announcer: “Today in electric air hockey, the Chicago Charred take on the Cincinnati Cinders . . . ”

There’s no doubt that overweight people have more negative associations with exercise. People who are not naturally athletic or who were stereotyped as nonathletic as children rebel at the thought of activity.

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Get rid of your old memories of the gym class (and P.E. teacher) from hell and of not getting picked for the team. If you were in the military, you might remember exercise as punishment, taking laps or doing push-ups for infractions. Discard all those associations, all the negative feelings that you have about exercise. They keep you from healthy thinness. People often push back emotionally when others tell them what to do. If you are constantly being told by others, “You should exercise,” then you might dig in your heels and put your own health in jeopardy. In the past, if the only time that you ever exercised was when you were attempting to lose weight and then you didn’t succeed, you may have very negative feelings about exercise. If you starved yourself of calories as part of a diet program, then tried to exercise, you probably felt lousy. The body needs calories, particularly from carbohydrates, to do activities. If you were on a low-carbohydrate diet and then exercised, you felt like crap, even if you were taking in enough calories. My approach is very different. Exercise to feel good. Eat enough calories to feel good. Eat your complex carbohydrates, too. Follow the suggestions in this book and you will feel and look wonderful. Exercise will become something that you look forward to doing. EASY DANCE SCHOOL—WE’LL TEACH YOU THE TEXAS ONE-STEP Think about what will increase your chances of sticking to a program of daily exercise. What do you enjoy? What isn’t costly? What is convenient? Experiment; try different activities. Think outside the traditional exercise box. Start deﬁning yourself as physically active. Most overweight people deﬁne themselves as sedentary. They immediately discount opportunities to play games in the park or to do intramural activities or informal pick-up sports. “No, you go ahead without me,” they say to their coworkers heading out to throw a Frisbee at lunchtime. Obese people get notices for local organized sports, exercise camps, or open pool times at the YMCA and immediately chuck those notices into the trash bin. You might be someone who watches others be active without ever envisioning yourself in those activities. The ﬁrst step is the vision.

I was going to take a belly-dancing class, but my husband didn’t want me to. He said that belly dancers look like bees trying to communicate where the pollen is.

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Learn to set up your exercise environment as a reward activity so that you don’t need extra motivation to want to do it. Set up your time so that you listen to your favorite music, read your favorite types of books, or watch your favorite show only when you are exercising. This instills a sense of fun and reinforces the likelihood that you will look forward to the activity tomorrow. Make your exercise time special, and, if you want, make it so that you exercise with a special friend or your favorite spouse. Unless you have an unstable heart or orthopedic condition (you just broke your leg in three places), there are no excuses! You are never too old to exert yourself. My oldest patient in rehab was 105; she exercised in the gym and went back home again. Don’t tell yourself, “I look awful” or “I’m too self-conscious.” And I don’t want to hear that you have no time—you have time to breathe, don’t you? It’s just as crucial to your health, so stop thinking any other way.

I was on a cruise ship that had a rock-climbing wall. One of the crew members told me that they had a 75-year-old woman get to the top. It’s amazing what you can do with Denture Grip.

If you truly can’t ﬁt exercise in to your schedule, then you need to ask yourself the hard question “What are my priorities in life, and how can I get them on track?” If your health isn’t a priority, then you are screwed up. If you are that time pressured, start by scheduling 10 minute blocks daily. Gradually increase as you see the emotional and physical beneﬁts. If you aren’t getting support from your friends or relatives, surround yourself with those who are supportive. Join groups that encourage your activities, and avoid those that demean your efforts.

Even your sedentary activities should include more stories about an active life. I’m reading a great new book, The Power of Personal Impact, a Skydiver’s Memoir. Chapter 1: “Crater Angels.”

Exercise is not expensive. All it takes is a good pair of walking shoes and a set of old clothes. Heck, you don’t even need that, if you’re on the beach. Just watch which beach you go to without your clothes. I’m not

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paying for your indecent exposure ticket. (Hey, if you get jail time for being naked, where do they grab you to haul you away?) MY DOG ATE MY ELECTRONS People get pretty creative when it comes to making excuses. With the prevalence of computers in schools, you’d think we’d be beyond the “my dog ate my homework” era. But the excuses are still there. It’s the same way with exercise. People will ﬁnd excuses if that’s what they want to ﬁnd. I hear it all the time: “I’m running around all day and exhausted when I get home. That’s enough exercise.” Or, “I stand on my feet all day; that counts for my exercise.” Maybe it’s something, but it’s not enough. If you are overweight, you are taking in more calories than you are expending in your daily activities. Up the burn with increased activity and you will up your basal metabolic rate. What you are doing right now everyday isn’t enough. That’s why you are fat. Don’t try to make it more complicated than that. Don’t even try to pull the excuse about being too tired. I’m not going to fall for that one. Exercise, done correctly, is invigorating and gives you more energy. I have never heard that Lance Armstrong complained that fatigue kept him from a bike ride. What now? It’s too hot/cold/humid/dry/whatever. We always ﬁnd time, energy, and money to do the things that are truly important to us. The excuses fade away when you really want to make a difference in your own life. Now is that time. Just remember, the most important exercise you can do is the one that you are willing to do. WHAT YOU SHOULD REMEMBER FROM THIS CHAPTER • • • • • • • • • •

Few people lose weight permanently without exercising regularly. Our bodies are designed mentally and physically to need exertion. No other exercise is shown to be as useful for weight loss as walking. Stop exercising at the end of a “diet” and you will gain the weight back. Aerobic and strength training both increase metabolism. Aerobic exercise is best done daily, strength training every other day. Flexibility, core strengthening, and interval training all have beneﬁts. Never start an exercise program with intense levels of exertion. Start slowly and gradually build up both time and intensity. Exercise should be fun and make you feel great when you are done.

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• Inactivity kills more people than exercise does. • Physical activity decreases stress, anxiety, and depression. • Exercise decreases pain, prevents cancer and heart disease, and improves sex. • Staying fat and not exercising will lead to disability. • Hang out with people who enjoy activity, and you will love it, too. • Redeﬁne yourself as an active person, and redeﬁne what a fun activity is. • Choose exercise that is inexpensive, enjoyable, and easy to do. • Set up your physical activity so that you feel rewarded when doing it. • Don’t look for excuses. Your health is too important for you to be sedentary.

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Conclusion: I Told You That There Would Be a Quiz at the End! 1. There are several keys to happiness and they: A. all start your tractor B. accidentally fell through the sewer grate C. impact weight loss D. open your cell door 2. Traditional diets fail because we hate: A. everything and everyone because we’re on a freakin’ diet B. pureed Brussels sprouts C. restrictions and commands D. shopping for new clothes 3. When you are trying to lose weight, what’s the most important part of your body? A. your mouth B. your anus C. your brain (Hint: it’s the part that doesn’t have a hole in it, we hope) 4. If you are externally motivated, you are: A. more likely to be overweight B. currently being chased by a mountain lion

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Conclusion C. facing a tax deadline D. frequently perusing naughty Internet sites 5. Although genes play a role, obesity is caused by: A. Aunt Tillie’s holiday dinner get-togethers B. behavior C. participation in the annual hot dog eating challenge D. failing to grow to a height of nine feet 6. Instead of eating until stuffed, eat until: A. the game starts B. you can catch another smoke C. 80 percent full D. the restaurant closes 7. Surround yourself with people who: A. encourage good eating and exercise habits B. prevent you from getting to the buffet line C. steal the food from your plate D. squeal on you whenever you overeat 8. Don’t eat out of: A. your dog’s food bowl B. obligation C. your retirement savings D. your spouse’s navel 9. Relearn your body’s own signals for: A. turning right B. showering more often than once a week C. tiredness (no, that’s not a winged dragon in your coffee) D. permanent thinness

10. The “four great choices”: A. are top sellers at fast-food restaurants B. increase satiation C. are a popular rock band D. decrease gravity with the square of the distance

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11. Eating closer to Mother Nature will result in: A. a quick slap in the face B. the desire to graze in your backyard C. better health and increased satiation D. arms and legs that are as strong as tree trunks 12. Always have healthy snacks at hand so you don’t resort to: A. digging through sofa cushions for old candy corn B. drooling outside bakery dumpsters C. not-so-good food choices D. sampling that green fuzzy stuff at the back of your fridge 13. Listen to your body. It will tell you if you: A. should warn others that you had beans for dinner B. slept the entire night on your left arm C. should increase your life insurance beneﬁt D. are eating junk 14. Read the labels and avoid: A. MSG and artiﬁcial sweeteners and colors B. men in trench coats C. toaster pop quadruple-chocolate hash browns D. that chatty greeter at your local discount market 15. There is a relationship between ingestion of sweetened drinks and: A. emergency roadside stops B. frequency of bee stings C. obesity D. temper tantrums in parents of the very young 16. Milk is an appetite suppressant and is healthiest: A. while still in the cow B. when mixed with high-calorie, ﬂavored syrups C. after three days in the sun D. as skim milk 17. Artiﬁcial sweeteners may make you: A. fatter B. listen to 80s disco music

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Conclusion C. question your reasons for living D. both B and C

18. Nighttime snacking is related to fatigue, not hunger, and leads to: A. nightmares about carnivorous manicotti B. frequent light-bulb replacement C. unexpected dips in the swimming pool D. reﬂux disease 19. Metabolism is determined to some degree by heredity but more by: A. your handheld remote B. alien beings with antennae and bushy ear hair C. your personal aura D. things you can control 20. The less sleep you get at night, the: A. fatter you become B. better you’re known on the Internet C. more bizarre your office presentations D. more attractive those dark rings under your eyes 21. Age-related slowing of metabolism is mostly due to: A. decades of appeasing your crazy family B. global warming C. inactivity, not true aging D. licking too many envelopes 22. Few people lose weight permanently without: A. eating only desert shrubbery B. opting for unnecessary limb amputation C. using a single chopstick as their utensil for all meals D. exercising regularly 23. Our bodies are designed mentally and physically to need: A. heaping dollops of whipped cream B. quarterly vacations to warm, sunny climates C. exertion D. daily exposure to multiple electronic devices

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24. Inactivity kills more people than: A. the local greasy spoon restaurant B. have ever lived C. long-term exposure to elevator music D. exercise does

Go to my Web site, doctorRcomedy.com, for the answer key and for more fun questions related to the book!

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Notes CHAP TER 1 1. Holly Jarrell et al., “Polymorphisms in the serotonin reuptake transporter gene modify the consequences of social status on metabolic health in female rhesus monkeys,” Physiology and Behavior 93 (2008): 807–819. 2. Debra L. Franko et al., “Does adolescent depression predict obesity in black and white young adult women?” Psychological Medicine 35 (2005): 1505–1513. 3. Chiadi U. Onyike et al., “Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey,” American Journal of Epidemiology 158 (2003): 1139–1147. 4. Lynn Haley, “Daily stress and depression linked to weight regain and obesity,” Diabetes, Obesity and Cardiovascular News 3 (2006): 8. 5. Neil E. Rowland and Seymour M. Antelman, “Stress-induced hyperphagia and obesity in rats: A possible model for understanding human obesity,” Science 191 (1976): 310–312. 6. S. Kayman, W. Bruvold, and J. S. Stern, “Maintenance and relapse after weight loss in women: behavioral aspects,” American Journal of Clinical Nutrition 52 (1990): 800–807. 7. Ibid. 8. Kathleen C. Light, Karen M. Grewena, and Janet A. Amicob, “More frequent partner hugs and higher oxytocin levels are linked to lower blood pressure and heart rate in premenopausal women,” Biological Psychology 69 (2005): 5–21.

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CHAP TER 2 1. Bruce S. Jonas and Michael E. Mussolino, “Symptoms of depression as a prospective risk factor for stroke,” Psychosomatic Medicine 62 (2000): 463–471. 2. Todd F. Heatherton, Janet Polivy, and C. Peter Herman, “Dietary restraint: Some current ﬁndings and speculations,” Psychology of Addictive Behaviors 4 (1990): 100–106. 3. K. A. Brownley et al., “Sympathoadrenergic mechanisms in reduced hemodynamic stress responses after exercise,” Medicine and Science in Sports and Exercise 35 (2003): 978–986. 4. Rena R. Wing and Suzanne Phelan, “Science-based solutions to obesity: what are the roles of academia, government, industry, and health care?” American Journal of Clinical Nutrition 82 (2005): 222–225. 5. “People who were obese tried diets but felt they needed ongoing support to empower them to make lifestyle changes,” Evidence-Based Nursing 12 (2009): 92, http://ebn.bmj.com/content/12/3/92.extract. 6. James A. Blumenthal et al., “Effects of exercise training on older patients with major depression,” Archives of Internal Medicine 159 (1999): 2349–2356. 7. Mark Gold, “Addictions and eating disorders,” lecture presented at the U.S. Psychiatric and Mental Health Congress, Orlando, FL, October 11, 2007.

CHAP TER 3 1. Wing and Phelan, “Science-based solutions to obesity.” 2. D. Craig Willcox et al., “Caloric restriction and human longevity: what can we learn from the Okinawans?” Biogerontology 7 (2006): 173–177. 3. Ana M. Andrade, Geoffrey W. Greene, and Kathleen J. Melanson, “Eating slowly led to decreases in energy intake within meals in healthy women,” Journal of Nutrition Education and Behavior 108 (2008): 1186–1191. 4. Brian Wansink, “Environmental factors that increase the food intake and consumption volume of unknowing consumers,” Annual Review of Nutrition 24 (2004): 455–479. 5. Brian Wansink and Jeffery Sobal, “Mindless eating: The 200 daily food decisions we overlook,” Environment and Behavior 39 (2007): 106–123. 6. W. M. Beneke, C. H. Davis, and J. G. Vander Tuig, “Effects of a behavioral weight-loss program food purchases: Instructions to shop with a list,” International Journal of Obesity 12 (1988): 335–342. 7. Wansink, “Environmental factors.” 8. B. Wansink and J. Kim, “Bad popcorn in big buckets: portion size can inﬂuence intake as much as taste,” Journal of Nutrition Education and Behavior 37 (2007): 242–245.

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CHAP TER 4 1. L. Stahre and T. Hallstrom, “A short-term cognitive group treatment program gives substantial weight reduction up to 18 months from the end of treatment. A randomized controlled trial,” Eating and Weight Disorders 10 (2005): 50–58. 2. David M. Eisenberg et al., “Unconventional medicine in the United States—prevalence, costs, and patterns of use,” New England Journal of Medicine 328 (1993): 246–252. 3. Victor J. Stevens et al., “Design and implementation of an interactive Website to support long-term maintenance of weight loss,” Journal of Medical Internet Research 10 (2008): doi:10.2196/jmir.931.

CHAP TER 5 1. Brian Wansink, Mindless Eating: Why We Eat More Than We Think (New York: Bantam Dell, 2007); see the section titled “The Bottomless Soup Bowl,” pp. 47–52. 2. Gary D. Foster et al., “A randomized trial of a low-carbohydrate diet for obesity,” New England Journal of Medicine 348 (2003): 2082–2090. 3. Gary J. Schwartz et al., “The lipid messenger OEA links dietary fat intake to satiety,” Cell Metabolism 8 (2008): 281–288. 4. Mayumi Yoshioka et al., “Effects of red pepper on appetite and energy intake,” British Journal of Nutrition 82 (1999): 115–123. 5. Nicole Martinelli, “Jelly in the belly: A diet pill that expands so you don’t,” Wired.com, June 08, 2007, http://www.wired.com/medtech/health/ news/2007/06/dietpill.html. 6. Paul Crane Arterburn and David Veenstra, “The efficacy and safety of sibutramine for weight loss,” Archives of Internal Medicine 164 (2004): 994–1003. 7. John Wilding, “Science, medicine and the future: obesity treatment,” British Medical Journal 315 (1997): 997–1000. 8. David Goldstein and Janet Potvin, “Long-term weight loss: the effect of pharmacologic agents,” American Journal of Clinical Nutrition 60 (1994): 647–657. 9. S. C. Mathai et al., “Addition of sildenaﬁl to bosentan monotherapy in pulmonary arterial hypertension,” European Respiratory Journal 29 (2007): 469–475. 10. H. Cavaliere, I. Floriano, and G. Medeiros-Neto, “Gastrointestinal sideeffects of orlistat may be prevented by concomitant prescription of natural ﬁbers (psyllium mucilloid),” International Journal of Obesity 25 (2001): 1095–1099. 11. Lars Sjostrom et al., “Life style, diabetes and cardiovascular risk factors 10 years after bariatric surgery,” New England Journal of Medicine 351 (2004): 2683–2693.

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12. D. R. Broom et al., “Exercise-induced suppression of acylated ghrelin in humans,” Journal of Applied Phsyiology 102 (2007): 2165–2171. 13. Marjorie Pomerlean et al., “Effects of exercise intensity on food intake and appetite in women,” American Journal of Clinical Nutrition 80 (2004): 1230–1236.

CHAP TER 6 1. Gary D. Foster et al., “A randomized trial.” 2. B. J. Venn and T. J. Green, “Glycemic index and glycemic load: measurement issues and their effect on diet–disease relationships,” European Journal of Clinical Nutrition 61 (2007): 122–131. 3. Alan W Barclay et al., “Glycemic index, glycemic load, and chronic disease risk—a meta-analysis of observational studies,” American Journal of Clinical Nutrition 87 (2008): 627–637. 4. Edward Giovannucci, “A review of epidemiologic studies of tomatoes, lycopene, and prostate cancer,” Experimental Biology and Medicine 227 (2002): 852–859.

CHAP TER 7 1. M. B. Schulze et al., “Processed meat intake and incidence of Type 2 diabetes in younger and middle-aged women,” Diabetologia 46 (2003): 1465–1473. 2. Eric L. Knight et al., “The impact of protein intake on renal function decline in women with normal renal function or mild renal insufficiency,” Annals of Internal Medicine 138 (2003): 460–467. 3. E. Wrone et al., “Association of dietary protein intake and microalbuminuria in healthy adults: Third National Health and Nutrition Examination Survey,” American Journal of Kidney Diseases 41 (2003): 580–587. 4. Knight et al., “The impact of protein intake.” 5. Ivan de Araujo et al., “Food reward in the absence of taste receptor signaling,” Neuron 57 (2008): 930–941. 6. Lydia A. Bazzano et al., “Intake of fruit, vegetables and fruit juices and risk of diabetes in women,” Diabetes Care 31 (2008): 1311–1317. 7. “Chemical cuisine,” Nutrition Action Health Letter, Center for Science in the Public Interest, May 2008, p. 4, http://www.cspinet.org/nah/05_08/ chem_cuisine.pdf; Morando Soffritti et al., “Life-span exposure to low doses of aspartame beginning during prenatal life increases cancer effects in rats,” Environmental Health Perspectives 115(9) 2007: 1203–1297; M. M. Andreatta et al., “Artiﬁcial sweetener consumption and urinary tract tumors in Cordoba, Argentina,” Preventive Medicine 47 (2008): 136–139; M. R. Weihrauch and V. Diehl, “Artiﬁcial sweeteners—do they bear a carcinogenic risk?” Annals of Oncology 15 (2004): 1460–1465.

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8. Frank B. Hu et al., “A prospective study of egg consumption and risk of cardiovascular disease in men and women,” Journal of the American Medical Association 281 (1999): 1387–1394.

CHAP TER 8 1. Diane M. DellaValle, Liane S. Roe, and Barbara J. Rolls, “Does the consumption of caloric and non-caloric beverages with a meal affect energy intake?” Appetite 44 (2005): 187–193. 2. Y. Claire Wang, Sara N. Bleich, and Steven L. Gortmaker, “Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among U.S. children and adolescents 1988–2004,” Pediatrics 121(2008):1604–1614. 3. For more information, see The Nutrition Source, http://www.hsph.harvard. edu/nutritionsource/healthy-drinks/. 4. Susan E. Swithers and Terry L. Davidson, “A role for sweet taste: Calorie predictive relations in energy regulation in rats,” Behavioral Neuroscience 122 (2008): 161–173. 5. Yung-Hsi Kao, Richard A. Hiipakka, and Shutsung Liao, “Modulation of endocrine systems and food intake by green tea epigallocatechin gallate,” Endocrinology 141 (2000): 980–987. 6. Dirk Johnson, “Some see big problem in Wisconsin drinking,” New York Times, Nov. 16, 2008, page A16.

CHAP TER 9 1. Edward P. Weiss et al., “Lower extremity muscle size and strength and aerobic capacity decrease with caloric restriction but not with exerciseinduced weight loss,” Journal of Applied Physiology 102 (2007): 634–640. 2. S. M. Shick et al., “Persons successful at long term weight loss and maintenance continue to consume a low-energy, low-fat diet,” Journal of the American Dietetic Association 98 (1998): 408–413. 3. T. Colin Campbell and Thomas M. Campbell II., The China Study: The Most Comprehensive Study of Nutrition Ever Conducted and the Startling Implications for Diet, Weight Loss and Long-term Health. Dallas, TX: BenBella Books, 2006. 4. A. Keski-Rahkonen et al., “Breakfast skipping and health-compromising behaviors in adolescents and adults,” European Journal of Clinical Nutrition 57 (2003): 842–853. 5. A wonderful article on this famous World War II study is Leah M. Kalm and Richard D. Semba1, “They starved so that others be better fed: remembering Ancel Keys and the Minnesota Experiment,” Journal of Nutrition 135 (2005): 1347–1352. 6. Wansink, “Environmental Factors.”

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CHAP TER 10 1. Gary D. Foster et al., “A Randomized Trial.” 2. James A. Levine et al., “The role of free-living daily walking in human weight gain and obesity,” Diabetes 57 (2008): 548–554. 3. M. S. Westerterp-Plantenga et al., “Energy metabolism in humans at a lowered ambient temperature,” European Journal of Clinical Nutrition 56 (2002): 288–96. 4. Christopher Bell, Nicole R. Stob, and Douglas R. Seals, “Thermogenic responsiveness to ß-adrenergic stimulation is augmented in exercising versus sedentary adults: Role of oxidative stress,” Journal of Physiology 570 (2006): 629–635. 5. J. E. Gangwisch et al., “Inadequate sleep as a risk factor for obesity: Analyses of the NHANES I,” Sleep 28 (2005): 1289–1296. 6. Laurent Seugnet et al., “Identifying sleep regulatory genes using a Drosophila model of insomnia,” The Journal of Neuroscience 29 (2009): 7148–7157. 7. Kari Johansson et al., “Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: A randomised controlled trial,” British Medical Journal 339 (2009): b4609, http://www.bmj.com/ cgi/content/full/339/dec03_1/b4609. 8. Ian R Lanza and K Sreekumaran Nair, “Muscle mitochondrial changes with aging and exercise,” American Journal of Clinical Nutrition 89 (2009): 467–471. 9. E. J. Brierley et al., “Effects of physical activity and age on mitochondrial function,” QJM: An International Journal of Medicine 89 (1996): 251–258. 10. Francois-Pierre J Martin et al., “Probiotic modulation of symbiotic gut microbial–host metabolic interactions in a humanized microbiome mouse model,” Molecular Systems Biology 4 (2008): 157. 11. Donald Hensrud, “Slow metabolism: Is it to blame for weight gain?” www.mayoclinic.com/health/slow-metabolism/AN000618. 12. William Thompson, “Terri’s Law: The limit of the Florida legislature to decide an individual’s right to die,” New England Journal on Criminal and Civil Conﬁnement 31 (2005): 485–490.

CHAP TER 11 1. Caroline R. Richardson et al., “A meta-analysis of pedometer-based walking interventions and weight loss,” Annals of Family Medicine 6 (2008): 69–77. 2. Jason L. Talanian et al., “Two weeks of high-intensity aerobic interval training increases the capacity for fat oxidation during exercise in women,” Journal of Applied Physiology 102 (2007): 1439–1447.

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3. Arnt Erik Tjønna et al., “Aerobic interval training versus continuous moderate exercise as a treatment for the metabolic syndrome, a pilot study,” Circulation 118 (2008): 346–354. 4. K. Knubben et al., “A randomised, controlled study on the effects of a short-term endurance training programme in patients with major depression,” British Journal of Sports Medicine 41 (2007): 29–33. 5. Richard H. Cox, Tom R. Thomas, and Joseph E. Davis, “Delayed anxiolytic effect associated with an acute bout of aerobic exercise,” Journal of Exercise Physiology 3, no. 4 (October 2000), http://faculty.css.edu/ tboone2/asep/Coxv2.pdf. 6. Dariush Mozaffarian et al., “Physical activity and incidence of atrial ﬁbrillation in older adults,” Circulation 118 (2008): 800–807. 7. Edward Giovannucci et al., “Physical activity, obesity, and risk for colon cancer and adenoma in men,” Annals of Internal Medicine 122, no. 5 (1995): 327–334. 8. C. M. Friedenreich and A. E. Cust, “Physical activity and breast cancer risk: impact of timing, type and dose of activity and population subgroup effects,” British Journal of Sports Medicine 42 (2008): 636–647. 9. Karla Kerlikowske et al., “Efficacy of screening mammography: a metaanalysis,” Journal of the American Medical Association 273 (1995): 149–154. 10. David B. Thomas et al., “Randomized trial of breast self-examination in Shanghai: Final results,” Journal of the National Cancer Institute 94, no. 19 (2002): 1445–1457. 11. Bob Greene, The Best Life Diet (New York: Simon and Schuster, 2006), p. xviii.

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Resources and Further Reading For lots more fun information, go to my Web site, doctorRcomedy .com. The following resources are great further reading. I am indebted to the authors for their ideas, which have been an inspiration to me. They have allowed me to be a better physician to my patients and, I hope, a better adviser to my readers. Mindless Eating by Brian Wansink The Volumetrics books by Barbara Rolls The Best Life Diet by Bob Greene Thin for Life by Anne Fletcher Intuitive Eating by Evelyn Tribole and Elyse Resch Emotional Eating by Edward Abramson Living without Dieting by John Foreyt and G. Ken Goodrick The China Study by T. Colin Campbell and Thomas M. Campbell II

And a special mention goes to the Center for Science in the Public Interest and its very informative Nutrition Action Health Letter. I am a big fan of executive director Michael Jacobson and his efforts to improve the safety and health of the public. Go to www.cspinet.org, and get a real education.

Index Abramson, Edward, 33 Activity log, 79 – 81, 82 Addiction: controlling, 40; as coping mechanism, 43; to food, 18, 37, 72; neurotransmitters and, 131 Adipose tissue. See Fat Adolescent issues, 6, 53, 162, 190 Aerobic exercise: for depression, 35; frequency of, 203; metabolism and, 188, 197 – 200, 212; sleep and, 184, 208 African Americans, 24 Air in foods, 91, 101 Alcohol consumption: before bed, 184; calories from, 91; excessive, 11, 37, 149 – 51, 152; processing, 150 – 51, 164 Alzheimer’s disease, 153, 190 Ambrosio, Luigi, 92 – 93 Anger issues, 7, 33, 34, 40, 42 Animal protein, 130, 139, 141 Anxiety: coping with, 18, 33 – 35, 42, 71; exercise and, 25, 202, 206, 213; oxytocin and, 16; social, 28; stress and, 7 – 8, 14, 21 Appetite suppressants: exercise as, 73, 98 – 100; foods as, 48, 90, 114 – 16, 147, 152, 163; hormones for, 99;

hydrogel pills, 92 – 93; medications as, 92; protein as, 136 Armstrong, Lance, 212 Art of contentment, 19 Artiﬁcial colorings, 135 Artiﬁcial sweeteners, 131 – 32, 135, 141, 145 – 48, 152, 175 Asian diets, 92, 108, 112, 136, 156 – 57, 178 Atkins, Robert, 109, 195 Atkins diet, 90, 107, 109, 129, 195 Atrial ﬁbrillation, 207 Attitude. See Negativity/negative emotions; Positivity/positive thinking Bariatric (obesity) surgery, 95 – 98, 101 Basal metabolic rate. See Metabolism Beano (digestive aid), 114 Bedtime snacks, 163 – 64 Behaviors: changing, 46, 80; “clean your plate” command, 49; family meals, 47 – 48; goal setting, 81; habits and, 45 – 47; obesity and, 65; rewards for, 78 – 79; social conditioning of, 49; weight gain and, 64; weight loss and, 109. See also Addiction; Coping

232

Index

mechanisms; Eating; Exercise; Habits; Laughter; Overeating The Best Life Diet (Greene), 209 Bicycling, 10, 179, 197, 198, 205 Binge eating (binging), 27, 30, 60, 85, 140, 160 – 62 Body image, 41 – 42 Boredom: calories and, 179; emotional eating and, 33 – 35, 42, 51, 68 – 69, 85; meditation and, 167; stress and, 21; taste and, 121 – 22, 152; weight loss and, 5, 8 Borg exertion scale, 201 – 2 Brain factors, 5, 28, 37, 50, 52, 72, 131, 185 Breakfast: energy bars for, 140; foods for, 61, 87, 115, 136; juice with, 115; regularity of, 46, 48; skipping, 160 – 61, 169 Breast cancer, 112, 128, 207 – 8 Breast Cancer Awareness Month, 207 – 8 Breathing exercises, 27, 34 – 35 British Medical Journal, 94 C-reactive protein, 111 Caffeine: from coffee, 148, 152; diets and, 174; from green tea, 123, 146 – 47; sleep and, 181 – 82 Calcium deﬁciency, 96, 136 Calorie intake: aging and, 158 – 59; from alcohol, 91; boredom and, 179; cholesterol levels and, 154; counting, 158 – 60, 168; emotional eating and, 51 – 52; empty calories, 100, 139, 149; energy and, 105 – 7, 123; estimating, 157 – 58; habits and, 51 – 52; high / low-calorie dense foods, 48, 90; liquid calories, 143 – 44; from liquids, 143 – 44, 152; metabolism and, 146, 154 – 58, 173 – 74; reducing, 54 – 55, 114 – 15, 153 – 54, 157, 168; salads and, 117; “secret calories,” 144, 148; with varied diets, 121. See also Diet / dietary choices; Exercise; Food/ food choices Campbell, T. Colin, 156 – 57 Cancer prevention: alcohol and, 150; artiﬁcial sweeteners and, 135; with

exercise, 207–8, 213; fat and, 106; with green tea, 147; with lycopene, 115; obesity and, 5; by restricting calories, 153; salt and, 134; with vegetarian diet, 128 Carbohydrates: complex, 90; energy from, 105 – 6, 123; fat and, 106 – 7; low-carb diets, 174, 210; natural, 109; pleasure from, 72; simple, 127, 140; weight loss and, 87, 90, 164 Cardiovascular disease: alcohol and, 150; eggs and, 137 – 38; exercise and, 205, 213; preventing, 3, 111, 153, 207; risks for, 24, 128, 135, 150; salt and, 134; saturated fats and, 106; trans fats and, 127 Celiac disease, 89 Center for Science in the Public Interest, 123 Centers for Disease Control (CDC), 24 Childhood eating, 6, 49, 50, 53, 162, 190 The China Study (Campbell), 156 Cholesterol levels: calories and, 154; eggs and, 137 – 38; exercise and, 205; lowering, 161, 207; metabolic syndrome and, 201 Chronic anxiety disorder, 35 Cirrhosis, 151 “Clean your plate” command, 49 Clothes, as self-monitoring technique, 77 – 78, 82 Coffee, 148, 152 Cold vs. warm foods, 92 Colon cancer, 150, 207 Colonics, 191 Comfort foods, 122, 140, 141, 163 Complex carbohydrates, 90, 106 Contentment. See Art of contentment Control: exercise and, 206; over habits, 36, 40; over hunger, 93, 160; importance of, 7 – 8, 31, 175, 192; meditation and, 167 Coping mechanisms: for anger, 34; eating as, 4, 36, 43; effectiveness of, 10 – 11, 13, 21; heredity and, 65; improving, 6, 12 – 13; laughter and, 19; self-defeating, 12

Index Dairy products: dietary needs of, 108; lactose intolerance and, 136 – 37, 141; milk, 149; protein from, 130 – 31 Dancing, 10, 12, 21, 41, 57, 70, 79, 81, 82, 197, 209 Davidson, Terry, 146 Department of Agriculture (USDA), 54 Depression: emotional eating and, 33; exercise and, 25; lowering, 3 – 4; stroke risk from, 24; treatment for, 35 – 36; weight gain and, 21 Desserts, 47 – 51, 58, 119, 133, 139 – 40 Diabetes: alcohol and, 150; development of, 128, 129; glycemic index and, 112; insulin and, 112, 113, 161, 182 – 83, 185; natural sugar and, 132; preventing, 153; sleep problems and, 182 – 83, 192; sweetened beverages and, 145 Diabetes Care (journal), 132 Diet /dietary choices: exhilaration with, 9 – 10; fasting as, 64, 155, 162, 164 – 65; health and, 110; hunger and, 85; as lifestyle change, 23; low-carb diets, 174; metabolism and, 154 – 56; negative connotation of, 26 – 27; obesity and, 3 – 4; plateaus, 155 – 56; primate studies and, 4; restricted, 26 – 27, 106 – 7, 120 – 24, 154, 174; selfesteem and, 28, 32; vegetable-based, 117 – 19; weight gain and, 64; “yo-yo” dieting, 38, 155, 157, 168. See also Drinks /drinking; Eating; Food /food choices; Healthy eating; Junk food Diet pills, 93 – 95 Dietary supplements, 32, 144, 173 Digestion: of dairy products, 136 – 37; healthy foods and, 113 – 14, 124, 149, 156, 180, 192; of hydrogel pill, 93; indigestion and, 48; metabolism and, 154; process of, 165, 192 Dopamine release, 37, 131 Dried fruit, 134 Drinks /drinking: energy drinks, 144, 147, 152; fruit juice, 115, 132, 145, 147, 149, 152; green tea, 24, 55, 123, 146 – 47, 152; milk, 149. See also Alcohol consumption; Caffeine

233

Eating: binging, 27, 30, 60, 85, 140, 160 – 62; in childhood, 50 – 51; childhood issues with, 6, 49, 50, 53, 162, 190; as coping mechanism, 4, 36, 43; disorders, 190–91; enjoyment of, 7, 10; fasting, 164; frequency of, 161 – 63; hara hachi bu concept, 50; before meals, 47–48; meditation and, 166 – 67; mindful eating, 165 – 67; “nibblers,” 161; obligatory, 57 – 58; purging and, 190–91, 193; skipping meals, 161, 169; social eating, 63 – 64; speed, 53; stopping, 84, 87; triggers for, 42. See also Breakfast; Calorie intake; Diet / dietary choices; Digestion; Drinks/ drinking; Emotional eating; Food / food choices; Healthy eating; Hunger / hunger triggers; Overeating; Snacking Eggs, 137 – 38 Emotional eating: avoiding, 34 – 35; boredom and, 33 – 35, 42, 51, 68 – 69, 85; calorie intake and, 51 – 52; causes of, 33 – 34; music therapy for, 34, 70, 71; negativity and, 38; treatment for, 36 – 38 Emotional Eating (Abramson), 33 Emotions: anger, 7, 33, 34, 40, 42; boredom, 8, 33 – 34; hugging and, 16 – 18, 21; materialistic attitudes and, 13 – 14, 21; positivity/positive thinking, 4, 21, 29, 78 – 79; as triggers, 33. See also Depression; Happiness; Laughter; Negativity/negative emotions Empty calories, 100, 139, 149 Endogenous opioids, 185 Endorphins, 206 Energy: basal temperature and, 179; from caffeine, 89, 123; calorie intake and, 105 – 7, 123; from dieting, 10; exercise and, 195, 202, 204, 212; fats and, 105 – 6, 123, 180; from food, 105, 140, 179 – 81; laughter and, 24; from protein, 105, 106–7, 115, 123. See also Metabolism Energy drinks, 144, 147, 152 Environmental inﬂuences, 167 – 68, 183, 192

234

Index

Escapist /avoidance tendencies, 36 – 37, 43 European Journal of Clinical Nutrition, 160 – 61 Evidence-Based Nursing (journal), 32 Exercise: activity log, 79 – 81, 82; aerobic, 197–98, 200, 208, 212; anxiety and, 25, 202, 206, 213; appetite and, 98–100, 101; before bed, 184; bicycling, 10, 179, 197, 198, 205; breathing as, 27, 34 – 35; depression and, 35 – 36; effectiveness of, 25, 67, 73 – 75, 82; enjoyment of, 7, 10, 70 – 71, 209 – 10, 212; equipment for, 75 – 76; excuses for, 211–12, 213; frequency of, 204 – 5; intense levels of, 202; interval training, 200 – 201, 212; jogging, 159, 196, 198, 200, 203, 206; necessity of, 195 – 96; resistance training, 199 – 200; self-esteem and, 27, 206, 210; sexercise, 99, 208; for stay-at-home workers, 69; strength training, 199, 203, 212; stress and, 25, 27 – 28, 42, 206 – 7; swimming, 198, 199, 201; walking, 10, 12, 196, 197 – 98; weight loss and, 196 – 97, 210, 212. See also Energy; Metabolism Fad diets, 64 Family time: emotional eating and, 34; enjoyment of, 12, 14, 16 – 19, 47 – 48, 79; meals, 47 – 48 Famine, 52, 107, 154 Fast-food restaurants, 59 – 60, 168 Fasting, 64, 155, 162, 164 – 65 Fat (adipose tissue): artiﬁcial sweeteners and, 146, 152; belly fat, 188, 207; breaking down, 28, 164, 200; dangers of, 5, 45, 63, 186; depression and, 17, 21, 24; from food, 51, 54, 56, 64, 106 – 7, 123; hormones from, 183, 193; hunger and, 59; in liver, 150, 151, 164; myths about, 38 – 40, 87; shrinking, 173, 174, 181, 192, 200 – 201; sleep and, 181 – 82; from sugar, 144; TV and, 67 – 68, 82. See also Metabolism; Weight gain; Weight loss

Fats: in dairy, 119, 123, 130, 136, 148 – 49, 161, 163; energy and, 105 – 6, 123, 180; fat-free foods, 140; good fats, 127, 141; high-fat diets, 109, 111, 118; low-fat diets, 108, 115, 138, 156; from meat, 47, 128; in meat, 128, 138 – 39, 163; satiety and, 89 – 91; saturated, 106, 137; trans fats, 127, 138; types of, 106 – 7, 108, 127 – 28 Female hormones, 185 – 86, 193 Fiber-rich foods, 88, 90 Fibromyalgia, 183, 206 Fidgety people, 86, 176 – 78 Fish oil beneﬁts, 127 Flatulence, 113 – 14 Fluoxetine (diet pill), 94 Food /food choices: air in, 91, 101; cold vs. warm, 92; comfort foods, 122, 140, 141, 163; desserts, 47 – 51, 58, 119, 133, 139 – 40; diet vs., 23 – 25, 42; enjoyment of, 6 – 7, 37; good-foryou foods, 31, 61, 75, 121 – 22, 162; intake modiﬁcation, 46, 101; labeling, 126; leftovers and, 49; log for, 79 – 81, 82; nutrition and, 100 – 101, 123, 125 – 26; portion sizes, 61 – 63, 65, 120, 159 – 60, 168; in restaurants, 138 – 39, 141; satiety and, 89; shopping for, 60, 65; thermic effect of, 180; variety in, 120 – 22; water in, 91, 101, 136; weight gain and, 58, 59; weight loss and, 26, 87. See also Diet / dietary choices; Drinks /drinking; Eating; Healthy eating; Junk food; speciﬁc foods Food pyramid, 108, 112 Foreyt, John, 206 Fructose, 88, 131 – 32, 141 Fruit juice, 115, 132, 145, 147, 149, 152 Fruit nutrition, 115, 119, 124, 132 – 34, 141 Gallbladder disease, 112 Gastric bypass, 96 – 97 Gastric emptiness, 91, 137 Gastroesophageal reﬂux disease (GERD), 164 – 65 Genetics and obesity, 45, 65, 174 – 75

Index Gestational diabetes, 112 Ghrelin hormone, 99, 182 Glucose, 131 – 32 Gluten, 89 Glycemic index, 112 Gold, Mark, 37 Good-for-you foods, 31, 61, 75, 121 – 22, 162 Grains: diet based on, 108, 109; processed, 89, 110 – 12, 136; whole, 87, 92, 100, 106, 112, 135 – 36, 141 Gratitude rituals, 18 – 19, 21 Green tea, 24, 55, 123, 146 – 47, 152 Greene, Bob, 209 Habits: behaviors and, 45 – 47, 71 – 72; breaking bad ones, 72 – 73; calorie intake and, 51 – 52; choices and, 23; control over, 36, 40; social support for, 49, 57, 63 – 64 Happiness: behaviors for, 70, 72, 79, 83, 204; empathy and, 18; endorphins and, 206; hormones and, 28; importance of, 33, 42, 166; junk food and, 185; keys to, 3 – 9, 16, 20 – 21; unhappiness vs., 41 – 42, 202; weigh loss and, 5, 23, 70 Hara hachi bu concept, 50 Healing touch, 16 – 17 Healthy eating: assumptions about, 123; calories and, 114 – 15; digestion and, 113 – 14, 124, 149, 156, 180, 192; enjoyment of, 112 – 13; ﬂatulence and, 113 – 14; nutrition and, 107 – 10; snacks and, 90 – 91, 123, 138, 160 – 61, 163. See also Breakfast; Cancer prevention; Hunger / hunger triggers; Nutrition/nutritional concerns; Protein; Vegetable-based diet Heart disease. See Cardiovascular disease Herman, C. Peter, 27 High-fat diets, 109, 111, 118 High-fructose corn syrup, 88, 131 – 32, 141 High-protein diets, 128 – 29 Hormones: as appetite suppressants, 99; from fat, 183, 193; female,

235

185 – 86, 193; ghrelin, 99, 182; happiness and, 28; insulin, 182 – 83; leptin, 182, 185; metabolism and, 186; oxytocin, 16; stress and, 185; weight gain and, 186, 193 Hugs / hugging, 16 – 18, 21 Hunger/ hunger triggers: control over, 93, 160; exercise and, 98 – 99; fat and, 59; food shopping, 60; frequent eating and, 161 – 63; overeating vs., 59, 85 – 86; satiety vs., 83 – 84, 86, 100; signals of, 85; starvation and, 49, 53, 60, 78, 84 – 85, 154 – 55. See also Starvation Hydrogel pills, 92 – 93 Hypertension, 129, 134 Infant eating, 50 Insomnia, 94, 163 – 64, 183 – 84, 202, 208 Insulin hormone, 112, 113, 161, 182 – 83, 185 Interval training, 200 – 201, 212 Japanese longevity, 50 Jenkins, David, 161 Jogging, 159, 196, 198, 200, 203, 206 Joseph, Jenny, 57 Journal of the American College of Clinical Nutrition, 111 Juices. See Fruit juice; Vegetable juice Junk food: alcohol and, 149; happiness and, 185; limiting, 31, 61, 62, 65, 140; nutrition vs., 105, 108; overeating and, 61, 88, 185, 192; primate studies and, 4; rat studies and, 126; stress and, 185 Kaiser Permanente Center for Health Research, 13, 80, 197 Karolinska Institute, 70 Keys, Ancel, 162 Kidney disease/damage, 90, 128–30, 205 Lactose intolerance, 136 – 37, 141 Lap band procedure, 96 – 97 Laughter: as coping mechanism, 35 – 36; eating and, 10; exercise and, 203; as

236

Index

healthy, 71, 77, 81, 82, 145; stress and, 12, 19; as weight loss key, 3 – 8, 19 – 20 Leptin hormone, 182, 185 Levine, Jim, 177 – 78, 179 Liquid calories, 143 – 44 Longevity experiments, 153 – 54 Low-calorie foods, 48, 90 Low-carbohydrate diets, 174, 210 Low-fat diets, 108, 115, 138, 156 Low-temperature cooking, 138 – 39 Malabsorption syndrome, 89 Malnutrition, 88, 89, 95, 96, 119, 121, 130, 149 Mayo Clinic studies, 76 Meat diet: at breakfast, 115; fats in, 128, 138 – 39, 163; food pyramid and, 108; Mediterranean diet and, 110; reducing, 120, 124, 130; satiety and, 92; traditional, 47; vegetarian diet vs., 109, 128 – 29 Medications, 187, 193 Meditation: for depression, 79; eating and, 166 – 67; emotional eating and, 34 – 35; enjoyment and, 10, 13, 165, 167 Mediterranean diets, 112 – 13 Menstrual cycle hormones, 186 Mental health, 5, 6, 18, 36 Metabolic syndrome, 201 Metabolism: aerobic exercise and, 188, 197 – 200, 212; artiﬁcial sweeteners and, 146; calories and, 146, 154 – 58, 173 – 74; cold temperatures and, 179; control over, 192; of endurance athletes, 198; fat and, 173 – 74, 180 – 81; ﬁdgety people and, 86, 176 – 78; genetics and, 158, 175; hormones and, 186; medication and, 187, 193; muscle mass and, 188 – 89, 198 – 99; probiotics for, 192; thinking and, 190, 193; thyroid gland and, 187; weight gain and, 155, 187. See also Energy; Exercise; Weight loss Milk protein, 149 Mindful eating, 165 – 67 Monosodium glutamate (MSG), 135, 141, 174

Montessori, Maria, 177 Motivation. See Self-motivation Muscle mass/weight, 78, 188–89, 198 – 99 Music therapy: for emotional eating, 34, 70, 71; exercise and, 75, 79, 211; for insomnia, 183; for stress, 10, 12 – 13, 16, 21, 168, 169 National Research Council, 92 – 93 National Sleep Foundation, 181 National Weight Control Registry (NWCR), 32, 46, 70, 73, 121, 156, 197 Natural carbohydrates, 109 Negativity/negative emotions: body image and, 40 – 42; elimination of, 19 – 20; emotional eating and, 38; exercise and, 209 – 10; medical issues, 187; meditation and, 167; in obesity, 3 – 4; self-reward and, 13 – 15, 18, 21, 29, 72; weight loss and, 32 Nestle Company, 192 New England Journal of Medicine, 158, 161 “Nibblers,” 161 Non-exercise activity thermogenesis (NEAT), 76, 176 – 77 Nurses’ Health Study, 129, 130, 132 Nutrisystem (weight loss program), 32 Nutrition Action Newsletter, 123, 160 Nutrition /nutritional concerns, 89; approaches to, 107–10; carbohydrates, 106; controversy over, 110 – 11; energy, 105 – 7; fats, 106, 127; food choices, 100 – 101, 123, 125 – 26; junk food vs., 105, 108; malnutrition vs., 88, 89, 95, 96, 119, 121, 130, 149; proteins, 106; salads and, 87, 117 – 18, 119, 130, 132, 139 – 40; scientiﬁc studies on, 111 – 12; in tomato juice, 115. See also Calorie intake; Fats; Protein Nuts, beneﬁts, 90 – 91, 127, 130 Oats /oatmeal, 135 – 36 Obesity: artiﬁcial sweeteners and, 146; bariatric surgery for, 56, 95 – 98, 101; behaviors and, 65; factors in, 3 – 4, 20; food availability and, 61; genetics and, 45, 65, 174 – 75; health problems

Index from, 5; liver problems with, 151; processed sugar and, 132; sleep apnea and, 184; social eating and, 63 – 64; stress and, 3 – 4, 6, 20; sweetened beverages and, 144 – 46. See also Fat; Overeating; Weight gain Obligatory eating, 57 – 58 Orlistat (diet pill), 94 – 95 Ornish, Dean, 108, 109, 195 Ornish diet, 107, 109, 195 Overeating: allergies and, 89; behaviors, 63, 65; binge eating, 27, 30, 60, 85, 140, 160 – 62; in childhood, 50; depression, 36; exercise and, 67; hunger and, 59, 83, 85 – 86; junk food and, 61, 88, 185, 192; medication for, 93, 95; nutrition and, 89; in restaurants, 55 – 57, 58; slowing, 52 – 54, 57 – 58, 167; triggers, 33, 35 – 37, 43 Oxytocin hormone, 16 Parkinson’s disease, 5 Passion for life, 8, 16 – 18 Peripheral arterial disease, 207 Phentermine (diet pill), 93 Physical activity. See Exercise Physical health. See Exercise; Healthy eating; Nutrition /nutritional concerns Polivy, Janet, 27 Portion sizes, 61 – 63, 65, 120, 159 – 60, 168 Positivity/positive thinking, 4, 21, 29, 78 – 79 Prayer, 13, 79 Probiotics, 192 Processed grains, 89, 110 – 12, 136 Protein: animal, 130, 139, 141; C-reactive protein, 111; deﬁciencies in, 88, 96, 136, 156; digestion of, 180; from eggs, 137 – 38; energy from, 105, 106 – 7, 115, 123; high-protein diets, 90, 109, 128 – 30; intolerance, 89; lowtemperature cooking of, 138 – 39; from milk, 149; satiety and, 89 – 90, 116; vegetable-based, 130, 141; weight loss from, 87 Purging, 190 – 91, 193

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Red Hat Ladies group, 57 Resistance training, 199 – 200 Restaurant eating: fast-food restaurants, 59 – 60, 168; food choices and, 138 – 39, 141; limiting food intake, 63; overeating, 55 – 57, 58 Restricted diets, 26 – 27, 106 – 7, 120 – 24, 154, 174 Rhode, Paula, 7 – 8 Rolls, Barbara, 83, 91, 144 Roux-en-Y gastric surgery, 96 Salads: as appetite suppressant, 53 – 57, 114, 116 – 17, 124; good fats and, 127; nutrition and, 87, 117 – 18, 119, 130, 132, 139 – 40 Salt usage, 134 – 35, 141, 174 Satiety: achieving, 91–92, 116; fats and, 89–91; hunger vs., 83–84, 86, 100; meat and, 92; protein and, 89–90, 116 Saturated fats, 106, 127 Schiavo, Terri, 190 – 91 School of Sport and Exercise Sciences, 99 “Secret calories,” 144, 148 Self-esteem: dieting and, 28, 32; exercise and, 27, 206, 210; improving, 82; low, 39, 68, 69; raising, 41, 42, 82 Self-monitoring techniques, 14 – 15, 40, 77 – 78, 82, 210 – 11 Self-motivation, 30 – 31, 79 Sexercise, 99, 208 Sibutramine (diet pill), 94 Simple carbohydrates, 127, 140 Singing, 10, 12, 36, 81, 82, 201 Skipping meals, 161, 169 Sleep in America Poll, 181 Sleep issues: aerobic exercise and, 184, 208; caffeine, 181 – 82; diabetes and, 182 – 83, 192; insomnia, 94, 163 – 64, 183 – 84, 202, 208; sleep apnea, 184; “sleep hygiene,” 183, 193 Sleeve gastrectomy procedure, 97 Snacking: at bedtime, 163 – 64; healthy choices for, 90 – 91, 123, 138, 160 – 61, 163; hunger and, 85; on junk food, 58; at night, 164; portion sizes, 62 – 63; TV and, 67

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Index

Social support /socializing, 15 – 16, 21, 49, 57, 63 – 64, 73 South Beach diet, 107 Spot reduction exercises, 200 Starvation: with binging, 85; eating slower and, 53; exercise and, 210; guilt over, 49; as habit, 78, 85, 87; metabolism and, 154 – 55, 175; nutrition and, 60, 90, 130, 162; purging and, 190 – 91, 193; sleep and, 163; water and, 136; weight loss and, 84, 100, 115 Step aerobics, 198 Stevens, Victor, 80 Strength training, 199, 203, 212 Stress: anxiety and, 7 – 8, 21; eating and, 51; exercise and, 25, 27 – 28, 42, 206 – 7; hormone levels and, 185; housekeeping, 4; junk food and, 185; laughter and, 4 – 8, 12, 19; music therapy for, 10, 12 – 13, 16, 21, 168, 169; in obesity, 3 – 4, 6, 20; obesity and, 3 – 4, 6, 20; weight loss and, 8 – 9; from work environment, 10 – 11 Stroke, 24, 138 Sugar: artiﬁcial sweeteners and, 131 – 32, 135, 141, 145 – 48, 152, 175; brain processing and, 131; glucose, 131 – 32; high-fructose corn syrup, 88, 131 – 32, 141; processed, 88 – 89; sweetened beverages, 144 – 46 Swimming, 198, 199, 201 Swithers, Susan, 146 Talk test, 201 – 2 Tea. See Green tea Television (TV), 67 – 68, 82 Thermic effect of food, 180 Thinking and metabolism, 190, 193 Third National Health and Nutrition Examination Survey, 129 Thoughtful eating, 165 – 67 Thyroid gland, 187, 193 Tomato juice, 114 – 15 Trans fats, 127, 138

Varied vs. restricted diets, 120 – 22 Vegetable-based diet: beneﬁts of, 88, 117 – 19, 128 – 29, 156, 180; meat diet vs., 109, 128 – 29; metabolism and, 156; protein from, 130, 141; variety in, 113; weight loss and, 120, 123, 124. See also Salads Vegetable juice, 114 – 15, 152 Visual food triggers, 59 – 60 Vitamin C therapy, 180 Volumetrics (Rolls), 91 Walking, 10, 12, 196, 197 – 98 Wansink, Brian, 51, 55, 58, 84 Water in foods, 91, 101, 136 Weight gain: behavior and, 64; depression and, 21; diets and, 64; ﬁdgeting and, 176; foods and, 58, 87; hormones and, 186, 193; metabolism and, 155, 187; monitoring, 40, 77; muscle weight, 78; stress and, 9 Weight loss: behaviors, 109; carbohydrates and, 87, 90; exercise and, 196 – 97, 210, 212; ﬁdgety people and, 86; laughter and, 3 – 8, 19 – 20; myths, 38 – 40, 43, 87; as ongoing process, 30, 40 – 41; passion and, 8, 16 – 18; programs and, 31 – 32, 173; reasons for, 20; rewards for, 78 – 79; starvation tactics and, 100; stress and, 8 – 9; surgery for, 56, 95 – 98, 101. See also Diet /dietary choices; Exercise; Food / food choices Weight Watchers (diet program), 32 “What-the-hell” effect, 27 White, LenDale, 150 Whole grains, 87, 92, 100, 106, 112, 135 – 36, 141 Willcox, Bradley, 50 Willett, Walter, 50, 207 Wilson, Mark, 4 Winfrey, Oprah, 209 Wing, Rena, 121 Work environment, 9, 10 – 11, 177 – 78 “Yo-yo” dieting, 38, 155, 157, 168

About the Authors MELANIE W. ROTENBERG, MD, is a medical school professor and stand-up comedian. She is in private practice in Melbourne, Florida, and holds a volunteer faculty appointment at the University of Central Florida College of Medicine in Orlando. She has counseled thousands of people on weight-loss techniques. MITCH ROTENBERG, PhD, is a research professor and a humor writer. He holds a volunteer faculty appointment in the Department of Biology at the Florida Institute of Technology in Melbourne. Melanie and Mitch live with their son, Aaron, on the beach. For more great comedic health advice and free audio downloads, go to doctorRcomedy.com.

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