Eat Less or Eat Different?

A tad over-simplified, but the basic message is spot-on.

Unfortunately, despite his enthusiasm, this approach will not provide a full answer for all people who are wanting to improve their weight health. There are some people who could follow these recommendations and still find that they have a level of hunger that prompts a food intake amount that does not allow for achieving their weight goals.

Many of the basic concepts he reviews, though, are important parts of the individualized journey of self-exploration that is crucial to long-term success.

If chronically feeling hungry didn’t matter, then, yes, it wouldn’t matter what calories you ate less of – if you ate less enough, you would lose weight. Going chronically hungry is not a tolerable or enjoyable way to live one’s life, so telling someone to eat less, without a strategy that avoids extra hunger, … misses … the … point … entirely.

Let’s just say it about hunger – 2

  • focus on hunger/satiety rather than some judgement about what should be the “normal” way to eat
  • the confusion of what is “usual” (a simple fact) with what is “normal” (a judgement)
  • carbohydrate load strain is simply about being metabolically non-alike
  • Metabolic diversity – laying claim to acknowledgement and respect

Continued from previous post …

Of course, I just had to post a comment to her, and her reply also deserves attention:

“Well, Dea, we could start by refusing to use the dominant discourse which insists we name the kind of eating (which I do) that provides satiety and eliminates hunger as “low carb” or “high fat”. Those are simply socially constructed categories that force people to think of eating for satiety as some WEIRD or anti-social or (OMG) UNHEALTHY way to eat. It’s “low” or “high” because the so-called authorities (corrupted by corporate influences, etc) SAY IT IS LOW OR HIGH. Crazy making, pure and simple. I’m done playing that stupid game of pretense–my lived experiences inform my choices now, not some “authorities” who don’t give an instant’s thought to my well being. They can’t. They can only spout whatever the “authorities” spout. There’s no relationship to whether it’s helpful for people or not. ARGH.”

This is exactly the kind of direction I’ve been trying to express in much of my writing on this blog, especially the recent 3 post series on Satiety Focused Weight Health. In fact, that is the reason for developing this blog in the first place. Hence the blog title “it’s the satiety” – that is, my view that a key missing ingredient to unlocking the weight control conundrum is to use a focus on satiety as both the essential process and a goal.

I have put my heart and soul into promoting a shift from focusing on “which diet” to focusing on the process of resolving struggles with hunger – which can only be done on an individual-by-individual basis using a trial and error approach to finding what they experience as worthwhile. The target – “weight heath with food peace”.  An individual “lived experience” exploration of hunger/satiety responses to carbohydrates in different amounts and forms is one of the key things to consider within that framework.

Still, we need some language to use when discussing this process of coming to understand one’s own responses to carbs. Whether you wind up eating “low” amounts of carbs or “high” amounts of carbs is not at all the point. The point is, are you having a carbohydrate load that is within your current ability to handle without strain or damage. Are you under carbohydrate load strain or not?

I also have to mention here that some people have clearly reported the “lived experience” that they can feel unwell when consuming carbs at (how shall we call it, we still need to use commonly understood terms to communicate) a “low” intake at various levels below about 100 grams per day.

If neither of these states apply to you, the amount of carbs you are having is just fine for you – and “high” or “low” become not judgement issues, but just matter in terms of practical issues, like finding recipes and exchanging practical ideas with each other.

There is a subtle difference between using “low” or “high” as relative terms that relate to some implied normal and using “low” or “high” as merely descriptive quantitative terms that relate to some factual usual.  “Usual” does not have to include any judgement value of desirable or “normal”. I am short, in that my height is factually below the usual height for women in my country. It is not customary in our society to regard “usual” height as implying a “normal” height, which would make me a deviant. Much confusion arises from mixing up what is “usual” with what is “normal”.

“Metabolic diversity” is the name of the game. I insist that my metabolic individuality be acknowledged and respected. I eat the amount of carbs that is “just right” for me. It is “low” compared to the usual intake. On the other hand, it is not “low” at all compared to any normal level, because there is no “normal carbohydrate intake” to be deviant from.

Related articles

Let’s just say it about hunger – 1

Re-blogged from Hopeful and Free. Saying it like it really is about her experiences with hunger. She has more to say on this topic in other posts and in the comments section. I’m an instant fan.

Of course, I just had to post a comment to her, and her reply also deserves attention:

Note: the rest of this post is just not appearing in proper formatted form. I have tried repeatedly to fix this and no go. Unfortunately, I have to break up this post.  Please see the next post for the continuation of this topic. Thanks for your patience.

First, solve the hunger.

Stepping Stones

Stepping Stones (Photo credit: Rich Jacques)

Satiety-Focused Weight Health

A walk through …

This is not specific advice to be used without consultation with your personal doctor. This is presented for the purposes of discussion.

This is “the middle part”, which belongs within a larger context of each person’s unique health and medical situation, their resources and circumstances, and their goals, preferences and values.

For example, if you have any problems involving foods, such as digestive issues, gallbladder problems, food allergies, celiac disease, etc., these must be taken into consideration. Be aware that sometimes these only become newly apparent when eating patterns change. If you have, or suspect you may have, an eating disorder or food addiction, please seek personal knowledgable professional care.

The short version -

It’s all about:

  • finding what things may be pushing up your appetite
  • finding what things you can do to get the most satiety (fullness, sense of satisfaction of appetite) from the food you eat
  • during this learning time, understanding that eating to appetite (without over-eating) and having regular meals is fundamental to the process.

First, solve the hunger. Then, consider the weight goals.

For many people, it would go something like this:

  1. Be hopeful – the landscape of weight care has changed dramatically and will change more. Further, substantial health gains often do not require substantial weight loss. “Food peace” is a worthwhile goal in itself.
  2. Help, support and de-burden  – Help from your doctor plays a vital role before and during. Support from people who have made the same changes can make all the difference. Realize that change is work. Find ways to lessen other demands and burdens. Get help with understanding your physical and emotional responses.
  3. Cultivate satiety – the core strategy is to evaluate every aspect of your lifestyle, your health, and your circumstances for all means available to favor satiety and to lessen the things that promote a higher hunger drive. Keep looking, adjusting and learning over time. Nothing replaces this. There are countless factors that affect your appetite/satiety balance. Some are easier to do something about than others.
  4. The three critical “leverage points” that are most useful for most people are – stopping trying to go hungry as a means to weight control, avoiding high insulin levels and blood sugar swings by adjusting your intake of carbohydrates, and learning to recognise and avoid trigger foods. These can be make-or-break keys.
  5. Stop disrupting your appetite/satiety control system. Treating it as a war is not productive. It is now clearly established that using willpower to override the signals from this complex system (going hungry on calorie restricted diets) is not of substantial lasting benefit to most people. This leaves us with the only other option – finding ways to influence and work with the appetite/satiety control system.
  6. Consider the roles of sugar/carbohydrate craving, swings in blood sugar and high insulin levels - From the start, find out whether you are among the approximately two-thirds of the population who have a tendency towards metabolic syndrome – which is expressed as some degree of limitation in how much carbohydrates their body can handle without harm or metabolic strain. Planning your eating style starts with considering your metabolic responses.
  7. Notice the things that interfere with implementing your plans – such as time stress, emotional responses, lack of support, depression, fatigue, pain, insomnia, and many other possible extra burdens or interfering factors. As much as you can, address these. You may need help (e.g. doctor, counsellor, support group). Sometimes a change brings out symptoms of some other health problem.
  8. You may need an extra intervention. Recognize that not everybody can get to the point where their appetite/satiety control system is working in a way that allows them to reach their weight control targets  After implementing satiety-friendly strategies as much as possible, you may need to consider a “second level” intervention. Nutritional ketosis is under-recognized as a useful option to lessen hunger during weight loss. Some people benefit from making use of a soft calorie target. Although not of net benefit for most overweight people, some people prefer a calorie-restricted diet or a meal-replacement medical program and do well with it long term. A “third level” of possible interventions would be obesity management medications and obesity management surgery.
  9. Every one is different. Theories and research will only take you so far – trial and error plays an essential role. Remember that some aspects of how you respond to any given change/intervention will not be obvious. Work with your doctor. Do follow-up lab tests when indicated. Don’t take your response for granted – test, don’t guess, how your blood sugar and lipids (cholesterol and triglycerides) are doing. Once you have as much information as possible, only you can decide what you find worthwhile.

Expanding on this …

1/9  Be hopeful – Using today’s insights, you may have a much easier time with weight loss and weight control than you imagine. Still, we don’t have as many insights and tools as we need, so some people still find it difficult to lose much weight. Even without substantial weight loss, you still likely can greatly improve your sense of well-being, your enjoyment of your life and your health. By maintaining your health (including not sacrificing your health or your enjoyment of life for your weight goal) as much as possible, you will be in a better position to benefit from new developments as they come along. By exploring ways to lessen appetite drive and promote satiety, you may find relief from cravings, struggles with hunger and battles with weight control – this can be very worthwhile even without a return to target weight.

2/9  Help, support and de-burden - See your doctor to gain more insight into your health situation and to consider different options from the viewpoint of your unique situation. Some changes you might want to make may bring up the need for various lab tests before or during the initial stages. You may need review of any medications. You may need to make plans for close follow-up and rapid adjustment of medications if you are undertaking substantial changes to your food intake – especially if you plan to reduce your intake of carbohydrate foods (sugars and starches).

If you make major changes to your eating pattern, you will need some input from your doctor to help you fully assess how that has worked out for you. Some people have unusual and unexpected responses to health choices that may be wonderful choices for many other people. Don’t take your own unique response for granted – be sure to get follow-up evaluations or lab testing done as needed.

3/9  Cultivate satiety - Evaluate every aspect of your health, lifestyle and circumstances for all means available to favour improved functioning of your appetite/satiety control system. It is a big mistake to focus only on diet and activity. For example, one of the biggest barriers is that most people are far more willing to make changes to their food choices than they are to face their need for sleep. You may need to work closely with your doctor to find your way, as pain, insomnia, depression, fatigue, certain medications and many other medical factors may influence your appetite balance.

As you make changes to address the above goals as much as possible, monitor your response by paying attention to how much you feel a need to eat and how your body composition is responding. If you find over time that the amount of food you need to eat to avoid being hungry is not allowing you to reach your weight health goals, re-evaluate whether you are doing all that you reasonably can to support the function of your appetite/satiety control system. Remember to think about sleep, stress and whether your eating and sleeping patterns are consistent day by day – your body functions best on a regular circadian rhythm.

There are countless things that can affect appetite balance and you can expect more research findings to come. Of the things you identify that are, or may be, disrupting your appetite balance, some may be difficult to change and some may be things you can’t change at all. That places more importance on the things that you are able to change.

4/9  There are three critical “leverage points” that can have a make-it-or-break-it impact:

  1. calorie restrictive dieting and all related behaviours
  2. your metabolic response to sugar and starch intake
  3. food cravings and food addiction

5/9  Stop disrupting – Stop messing with your body’s weight control system – stop restricting calories, skipping or delaying meals, going hungry, dis-ordered eating and using stimulants such as stress and caffeine to delay meals. If any of these strategies were useful, we would not be in the situation we are now. As a general strategy, losing weight by going hungry has failed miserably and has probably caused a lot of harm along the way. Stop being at war with your appetite system and learn to work with it.

Learn to honestly recognize restrict/rebound eating patterns as the dead-ends that they are. The most common restrict/rebound eating pattern is skipping or restricting food intake in the early day, followed by over-compensation in the later day. The same pattern may be played out as restriction on week-days followed by overcompensation (rebound of appetite drive) on week-ends.  It also show up as weeks/months of strict calorie restriction followed by over-compensation due to an appetite on over-drive. I think that this restrict/rebound pattern is a major contributor to the current obesity epidemic. The things that indicate when a pattern like this is dysfunctional include – cravings and unwanted over focus on food, intake of food in types and amounts that are unintended and regretted, and over-compensation in the calories consumed in the appetite rebound phase.

Many people find that cravings and later-day over-eating fade away when they learn to eat in ways that promote stable blood sugar, avoid high insulin levels and avoid triggering stress hormones. Of course, eating disorders and addictions are complex disorders that require much more than a simplistic approach. If you have active addictions and eating disorders, your appetite/satiety control system will not have a chance to work properly. If you find that you are having great difficulty controlling your intake of sweets or starchy foods, it is important to know that full abstinence from these is a strategy that many people have chosen. Such an eating pattern can be healthy, enjoyable and very effective for relief from cravings and disruptive eating. An eating plan can be high or low volume according to need.

You can’t learn how to work on friendly terms with your body weight control system while at the same time poking it with a stick. Many people who have had long term struggles with their weight have not gone a day in decades without an appetite/satiety system that is chronically disrupted due to chronic or cyclic calorie restriction or meal skipping/skimping.

6/9  Consider the roles of sugar/carbohydrate craving, swings in blood sugar and high insulin levels - From the start, find out whether your metabolism is able to handle high carbohydrate meals without straining to cope. That is, whether the amount and/or rate of glucose coming into you body after eating a high carbohydrate meal is handled well by your body in your current state of health. Is your appetite being driven by swings in blood sugar?  This often shows as hunger a few hours after having a meal that would have seemed substantial enough to last until the next meal time.

Are you showing signs of metabolic syndrome and insulin resistance? Is your fasting blood glucose above normal?  Does your blood glucose go up above normal after meals? Do you have type 2 diabetes or pre-diabetes?  High insulin levels that occur from insulin resistance promote fat storage.  A tendency to gain weight around the middle is one of the hallmarks of metabolic syndrome.

All of these things affect the appetite/satiety control system.  Any of these effects can be so strong that weight control can, in some people, be very difficult without addressing them. If any of these conditions apply to you, you will likely find it much easier to improve your well-being and your health by adjusting your carbohydrate intake to within the amount that your metabolism can effectively handle. Carbohydrate load is more than just the total amount of carbohydrate in a meal or day. Carbohydrates that are quickly absorbed cause more strain on your metabolism and more tendency for ups and downs in blood sugar that the types of carbohydrate foods that are very slowly digested. Some people may find excellent improvement in their health from changing the types of carbohydrate foods they eat, without cutting down on the actual amount of carbs they are eating.  Some people can take steps to improve their insulin resistance and thus, if they are still making insulin, improve their ability to handle carbohydrates.

If you are not showing signs of difficulty handling high carb meals, you may do well on a lower fat, higher carbohydrate eating plan, provided that this focuses on low glycemic index foods (for example, with most carbs coming from foods with a glycemic index of 50 or lower). Some people do best focusing on a high volume of low-calorie-density foods.

7/9  Notice the things that interfere – In addition to the comments above, keep in mind that initiating changes in your life can bring out emotional reactions, sometimes in very unexpected ways. It can also bring out emotional responses in those around you. We all have blind spots when it comes to understanding ourselves. Friends, family and support groups can be invaluable. Sometimes getting professional help is needed.

8/9  You may need an extra intervention – Recognize that not everybody can get to the point where their appetite/satiety control system is working well enough that they can achieve reasonable weight control goals without sustained hunger or cravings. If it seems that you really are doing what you can and you feel you need some additional strategy, it is time to consider adding a “second level” intervention.

Nutritional ketosis is under-recognized as a useful option to lessen hunger during weight loss. Being in nutritional ketosis helps most people (not all) with appetite control.  This does not depend on whether or not you have any difficulties with handling carbohydrates or whether you would otherwise would be considering a low carb lifestyle. This is also called being on a “ketogenic diet”. Ketogenic diets are receiving quite a bit of research attention now as they can be remarkably effective for epilepsy and it may turn out that they are useful for a variety of medical conditions. Some people report that their energy and sense of well-being is improved when they maintain themselves in a state of nutritional ketosis (which is very different from ketoacidosis!).

Some people benefit from making use of a soft calorie target – for example, as a means to explore “habit eating” versus hunger, as a means to find what eating pattern gives them the most satiety, as a reminder to eat no more than they need, as an indication of how much to eat before stopping to see if a sense of satiety develops while waiting 20 minutes, or as a way to notice when inadequate sleep, stress, meal pattern disruption, etc. have acted to increase their appetite. (“soft” – that is, used for information feed-back, not rigidly enforced)

Although not of lasting benefit for most overweight people, there are some people who prefer a calorie-restricted diet and do well with it long term. If calories are not restricted much below need, a calorie-capped meal plan may serve as a quick way to break away from old habits, break restrict/rebound patterns of eating, end blood sugar swings, provide a focal point for lifestyle changes, and so on. This is listed under “second level” approaches because attempting to impose calorie restriction can completely block the process of finding benefit from a satiety-focused approach, and can cause more harm than good.  Still, some people find that, despite using all the strategies they can to promote satiety and avoid stimulation of excess appetite, they are not able to achieve their weight management goals without paying attention to calories. In this situation, it is vital to keep a very close eye out for any signs of the development of restrict/rebound eating patterns – such as cravings and episodes of excess eating.

There seems to be a role for medical programs that involve meal replacements. For some people, this might meet their needs in a particular way.

Some people find that a high exercise or activity output can play a central role for them in weight loss. The main role of exercise is for physical and emotional health. Research has shown that, for most people, a regular exercise program does not contribute substantially to weight loss. On the other hand, regular exercise does seem to be a tool to help prevent weight gain or regain. Still, some people are able to use a particularly high amount of exercise/activity as a major tool in their weight loss process.

A “third level” of possible interventions would be obesity management medications and obesity management surgery.

9/9  Every one is different – What will be best for you cannot be predicted solely by considering theories and looking at the research. Trial and error plays an essential role.  Recognize that each and every health intervention with each and every person is always a “trial of therapy”.  The outcome is never certain and must be evaluated, not taken for granted. With as much information as possible, evaluate your health responses over time. Keep adjusting your health practices and medical care according to your individual responses and needs, in context with your personal values and choices. Only you can decide what health habits and interventions you find to be worthwhile – that is, that give you enough benefit, balanced against “cost” and risk.

Related article, added Nov 22/12:

hunger” on www.hopefulandfree.wordpress.com  LINK

Weight control – a new framework takes shape

Stepping Stones

Stepping Stones (Photo credit: Rich Jacques)

Is it Time to Change the Default First Option?

If so, what would that be?

Satiety-Focused Weight Health is a conceptual framework that can be used to organize one’s approach to weight control, in the aftermath of the era of reliance on calorie restricted dieting.

I think that as of now we have the knowledge and interventions to make satiety-focused weight health preferable as the default first option to consider for the majority of those whose health is being affected by excess body fat and/or by fat within the abdomen (including, that is, people within the normal weight range who are “metabolically obese”).

First solve the hunger – then consider the weight.

The core conceptual shift – Calorie restriction can block weight control success.  For many people, the path to their weight control goals requires fully letting go of calorie restrictive diets and behaviors, at least for a period of time.

The line of thinking goes like this:

  • If you want to reduce the amount of food energy eaten (relative to energy requirements), there are only two options. You can try to work with or influence the functioning of the appetite/satiety system so that it signals for less food, or
  • you can try to impose your will power over your response to the appetite control system – that is, refrain from eating despite hunger – also known as calorie restriction.
  • Research has confirmed that calorie restricted dieting, although useful for some, is not a productive strategy over the long term for most people. Imposing control has not delivered on its theoretical promise.
  • This leaves us with the strategy of looking for ways to reduce the hunger drive and/or improve the satiety value that comes from the amount of calories consumed. This is now the available path. Since the only other path is to impose calorie restriction, a person’s best hope is to use all available and personally-acceptable means to achieve this – to the degree that this is practical and sustainable.
  • With a person’s best weight control asset recognized to be the best understanding and balanced functioning of their innate appetite/satiety control system, all things that interfere with that are counter-productive. A person can’t learn to understand and work with their appetite/satiety control system while at the same time acting in ways that disrupt or provoke that system – such as skipping or skimping meals, using caffeine or stress hormones to suppress appetite or refraining from eating when hungry.

“Solving” the hunger is not possible while the focus is on immediate weight loss.

Satiety-focused strategies have come from behind to emerge as a powerful set of tools. We now have enough knowledge base to make a satiety-focused approach to weight health a successful approach for many people. When it is not enough on its own, the next step is to consider moving on to level 2 and level 3 interventions, while still valuing the central importance of avoiding excess hunger and optimizing satiety.

The value of a satiety-focused approach has been under-recognized in large part because of the pervasiveness of calorie-restrictive dieting and behaviors, which have been adopted by large numbers of the population as ingrained chronic behaviours.  Therefore, it is not possible to evaluate the true usefulness of satiety-focused strategies for an individual unless there has been active, intentional, informed avoidance of calorie restriction in all it’s forms.

This entails a fundamental shift in thinking. Hunger and cravings when trying to eat less are seen, not as an unpleasant nuisance, but as fundamentally disruptive to the process of achieving weight control goals.

Your body intends to be in charge of how much you eat. You have an incredibly  complex, multi-layered and redundant fundamental body management and survival system referred to as the body weight control system, which is expressed through the appetite/satiety control system. We are barely scratching the surface in understanding this system and how it works. (You can find preliminary descriptions of this system and diagrams of our current concepts of how it works – but be advised that these are all early “sketches”, no matter what other impression you might be given.)

It turns out that your hunger drive can be pushed up by many things, some of which you can take control of and change. Your ability to feel adequately fed with the food you’ve eaten is also something that can be influenced by many things other than the energy (calorie) amount of the food itself.

Calorie-restricted dieting, with it’s inherent hunger, has been the default treatment recommendation for weight loss. We now know that this approach, although helpful for some people, in general has been stunningly ineffective. There is also reason to be concerned that it might, in some people, actually be harmful in that it can cause disrupted eating patterns, lowered metabolic rate, (unjustified) feelings of personal failure, distrust of medical/nutritional advice, and so on. (See link below to the previous post on this topic.)

You cannot win a fight with an ancient, extremely complex basic body system that is wrapped into every part of your functioning – it’s better to make nice.

Millions and millions of people had made repeated efforts to control their food intake by using their will-power to over-ride the signals from their body weight control system.  This often results in short-term wins that are tantalizingly misleading. Over the longer term, your body fights back. Research has shown repeatedly that the short term weight losses are a false promise, for most people. Although some people have made this approach work for them, for most people this approach brings poor results after the first weeks or months. The false promise of the weight loss in the first weeks or months has been wrongly interpreted as a valid indicator of how the weight loss could be expected to proceed over time. For most of the people most of the time, it is more realistic to see this initial weight loss phase as a temporary situation that the body will muster its resources to fight against.

Calories control the skirmishes, but satiety ultimately determines the winning or loosing of the game.

Satiety-Focused Weight Health – overview

“Satiety-focused Weight Health” is a conceptual framework on which to build an approach to:

  • supporting each individual’s efforts to attain and maintain a body composition and weight
  • that is most compatible with their long-term health,
  • in the context of their goals, their choices, their individual circumstances and their inherent body tendencies.

General health, individual circumstance, over-all quality of life and individual goals take precedence over total body fat when considering body composition targets.

If reduction in body fat stores is desirable and this is not occurring, interventions are chosen that are designed to facilitate achieving satisfactory satiety and freedom from sustained hunger while undergoing weight loss. Failure to see improvement in body fat levels over time is a valuable feedback from the body that more needs to be done to reduce appetite drive and facilitate satiety. Any attempt to impose a calorie cap will ruin this essential feedback and sabotage progress towards a successful long-term strategy (which will actually be composed of a combination of strategies).

The same model is applied when the goal is stabilisation of weight in the face of a trend to weight gain. This model can also be used when the target goal is “food peace” – that is, relief from chronic struggles with hunger and cravings.

In this model, sustained or excess hunger is regarded as a symptom requiring attention, investigation and problem-solving.  Sustained or excess hunger is also regarded as counter-productive, and something to be responded to by eating.  Therefore, when eating according to one’s appetite, the determination of whether hunger/appetite is excess is made principally by tracking changes in body composition as accurately as possible with today’s limited tools.

Of course, as part of general weight control recommendations coming from agencies and health practitioners, every effort is already being taken to help with hunger as much as possible during weight loss interventions. The shift is in the concept going from (1) the calorie cap being the prime and beneficial intervention, with hunger being addressed secondarily as much as possible within the calorie cap to (2) the achievement of satiety while body energy stores remain stable or intentionally decrease as the prime and beneficial target.

The key to unlock the great potential of this approach is the recognition that calorie restrictive dieting and behaviors can severely undermine or fully block success.

All those involved in the field of weight control have been increasing their focus on appetite and satiety.

The writing has been on the wall now for some time about the failures of the calorie restriction (go hungry) approach. More and more attention has been given to understanding the things that affect body weight control. There has been a lot of research into what things push people’s appetite up (for example, certain medications, sleep deprivation). Research also is aimed at understanding which foods or eating habits or patterns result in the most feelings of satiety for the least amount of calories consumed. For example, when people take in a lot of calories as sugary drinks, their bodies tend to not “notice” those calories fully in terms of how much else they consume afterwards. Obesity management medications and obesity management surgeries are also oriented to helping people feel less hunger (appetite) and more satiety from a given amount of food energy consumed (or consumed and absorbed in the digestive tract).

Experts in obesity management are moving away from the focus on calorie restricted dieting. However, this has not trickled down much yet from the realm of the “obesity experts” to the doctors, nutritionists, nurses and so on that most people see as part of their health care team. And you’ll still see endless books and magazine articles describing diets that are one form or another of calorie restriction (often cleverly disguised).

This major shift within the field of obesity medicine* is reflected in a ground-breaking program released in Canada in 2012. This program is called “The 5As of Obesity Management”. (Links below)  One core of the new approach that this program teaches is the focus on finding ways to reduce excess “drivers” of appetite and identifying and correcting factors that disbalance the appetite/satiety control system. The purpose of developing this program and a set of educational materials is to get this message out to the general community of health care providers and the public. The old days of “give diet sheet first, ask questions later” are gone, or should be.

This program is a remarkable development and I highly recommend that you have a look at the video at the bottom of this post and consider learning more. It is a bold statement that we really are in a new era and it is past time to ditch old ways.

To be continuedFirst, solve the hunger. (Part 3 of this series)

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* obesity medicine is also called “bariatric medicine” – note that’s not the surgeons, who practice bariatric surgery.

Related Resources:

The Canadian Obesity Network developed the tool kit “The 5As of Obesity Management”. This excellent set of resources is presented on their web site on their Resources page, on the tab “5As”   LINK

On the page, click on “View 5As Presentation (pdf)” for much more information than is presented in the video.

The set of resources is sold for a modest fee and is intended for use in clinical offices.

Video introduction to “The 5As of Obesity Management” (5 min.) Highly recommended.  This is a great video to share with your doctor and all members of your health care team.

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Hunger Therapy – Or?

How to Make Low Calorie Apple Breakfast Cut th...

How to Make Low Calorie Apple Breakfast Cut the Apple (Photo credit: admiller)

What is Hunger Therapy?

You know if it is Hunger Therapy by asking yourself this question:

“If I have eaten my meal (and waited some minutes), or am waiting for my next meal time, or have eaten all my “allowed” food for the day, and I’m still hungry – what am I “supposed” to do?”

If the answer is – – “go hungry”  then what you are doing is a form of Hunger Therapy.

I first published this April 9, 2012. I’m posting it now because it is still topical and because this was originally published as a page “Which Way to Weight Loss?”. As a page it is often not noticed by people in the way a post would be. I’ve made some minor editing to provide context and improve readability.

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What is the most promising strategy to try first for most people seeking to reduce high total or belly body fat:

  • calories are controlled by intent – capped at a prescribed level in spite of hunger

OR

  • calorie are controlled by the appetite/satiety control system – the task is to help the appetite/satiety control system function appropriately so that weight can trend towards normal without sustained hunger?

CONTEXT

No-one has a lock on what the best way forward is. I am bringing up some concerns that I feel warrant some consideration.

Many people have spent their long efforts doing their best to support the health and well-being of people who would like to improve their health by loosing weight. Much effort has gone in to pursuing many different approaches to treatment. Given the striking and unexpected absence of substantial long term benefit other than for small numbers of people, a full re-evaluation is warranted. I am with those many who feel that one vitally important aspect of this is to assess and consider the potential harmful effects of not only the occurrence for individuals of sustained hunger as a side-effect of the recommended restricted-calorie eating, but also the potential harms from the very existence of professional advice that it is advisable and desirable and “good behaviour” to engage in sustained hunger for medical benefit.

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There is a fundamental choice at the core of any eating plan designed for loss of body fat:

  • (1) set a limit on the total daily intake of food energy (calories)
  • (2) do not set a limit on the total daily intake of food energy (calories)

These two options are mutually exclusive.  You can’t have both those choices at the same time.  Either there is a limit set or there is not.  If the limit is “sort-of-set”, there is not actually a limit – as in, “the total calories for the day is to be no more than (for example) 1400 calories  — well, unless you are really, really hungry, then have more to eat if you want”.

This choice could be expressed another way:

  • Option 1: stay below a set limit of total calories for the day, whether you become hungry or not. Calories are capped, and this is the path to success, with hunger being a nuisance side-effect to be ignored or managed.  Weight/fat mass is tracked over time and the calorie cap is adjusted up or down until a calorie level is found that permits weight loss at the desired pace.

or,

  • Option 2: calorie balance is monitored indirectly by following any changes in body weight/fat mass over time. Sustained or excess hunger is regarded as a threat to long-term success and is to be avoided. The path to success is through taking steps to achieve the absence of excess hunger (adequate level of satiety) while eating an amount of calories that permits slow weight loss.

In the first situation, excess hunger is regarded as not of direct importance to the outcome.  In the second situation, excess hunger is considered to directly interfere with long-term successful outcome.

The Theory – In the calorie restriction model, the idea is that as long as the individually-adjusted calorie cap is not exceeded, then loss of body fat will proceed. The idea is that hunger will not itself prevent this loss of body fat, it is just an unpleasant nuisance. It is agreed that hunger can indirectly prevent success, if the person responds to the hunger by eating more than the set limit of food. Hunger can also indirectly interfere with the effectiveness of this approach by leading the person to abandon the treatment plan and/or by discouraging future attempts to follow similar treatment plans. Note that this set of ideas must be based on an assumption that it is safe and smart to ignore and disrupt your body’s basic maintenance and survival signalling system.

Because excess hunger can lead to the person “breaking their diet”, a growing amount of medical attention and research is being paid to the science of hunger/appetite/satiety. It is also understood that the study of hunger/satiety will shed light on the factors that are promoting the current obesity crisis.

For the past many decades, overwhelmingly the common (OK, the standard of care) approach to body fat loss has been to advise or prescribe a set limit on total daily food energy (calorie) intake. This limit may be expressed as a calorie number (for example, 1500 calories per day) or as serving amounts of various foods, which is just a less obvious way of counting calories.

How do you recognize a calorie-restricted approach? Curiously, by the same criteria I have outlined at the top of this page regarding Hunger Therapy.

The mathematics of the approach is so convincing, and it all appears so logical, that it has pretty much been taken as a given that:

  • the benefits were plainly obvious
  • the risk of harm was plainly low
  • the balance of benefit to harm was plainly so great as to not require specific investigation

So, why this long article?  What is the point of this discussion?

There is a shaking, dust and confusion at the very foundation of what has been the standard approach to weight loss. Each of the above three points has come under serious doubt:

  • the long-term effectiveness of limited-calorie dieting seems to be amazingly less than anticipated
  • the long-term safety of limited-calorie dieting has increasingly come under doubt
  • the net benefit versus harm is in doubt and has not been proven scientifically

To be clear, these statements are not limited to limited-calorie dieting, but are true for weight loss diets in general. However, I would contend that the attitude favouring calorie restriction is so pervasive in the culture that any research on over-weight/obesity is going to be studying calorie-restricted eating unless a very concerted effort is expressly made to avoid the ingrained behaviours of calorie restriction in the study population. Therefore, are we actually totally sure what we have in the way of weight-loss/control studies (on obese people, otherwise they don’t count anyway) that are completely free from the contaminating effect of calorie-restricting behaviours. In other words, have pretty much all research studies in the past decades been, in actuality, studies that at least reflect, in some part, the effects of self-imposed and possibly even automatic calorie-restriction (even when that has not been intended or there has even been an attempt to avoid it)?

Under these circumstances, perhaps it would be useful to revisit the core decision as to whether to impose a calorie limit or not.  Or, more to the point, the choice whether to use a diet approach where excess hunger is a nuisance to be tolerated, or a diet approach where excess hunger is considered a threat to success and is to be avoided (and excess hunger is primarily considered as a symptom of something more needed to be understood or changed for that person).

One might term the first choice “Hunger Therapy”. As tempting as that is, that delicious term would be misleading as there is actually no intent to cause hunger, hunger just happens to be the standard outcome. On the other hand, I suspect it is a term that many people who have been through multiple cycles of limited-calorie diets would instantly relate to. There is some merit, though, to the use of a term like “Hunger-Inducing-Treatment”.  This would yield the acronym “HIT”.

This might seem like just having some fun with words. It might also seem like an attempt to be nasty or to pick a fight and throw names at people who have been doing their best to provide the best care they know to people who have a real medical need to reduce their body fat. Neither is true. No-one can lay claim to knowledge of a medical treatment for reduction of excess body fat that is scientifically proven in a large population of people to be both safe and effective in the long, long term – none exist.

For all these reasons, the conversation must be opened up. Things that have been taken for granted, assumptions that have been made, things that “every-one knows are true” all have to be brought out and looked at from the ground up. I think that naming hunger as an under-considered harm is one aspect of the broad re-considering that must be done.

Hunger? What of that?  Aren’t we supposed to ignore the hunger and “stick to the diet plan”.  Isn’t that the advice that pervades society, from agencies and health practitioners alike, repeated over decades?  Isn’t the hunger little more than a nuisance, to be ignored or managed as best as possible? Conquered, even? A test of one’s character?

There is the outcome on the individual directly of the attempt to endure sustained hunger (and of “failing” to do so). There is a whole extra set of problems when the professional/agency advice to put up with sustained hunger becomes incorporated into a general societal attitude that expands and gets passed down over generations.

There are rumblings (angry screaming?) that the persistent, excess hunger (and the other outcome of this professional/societal attitude that hunger can be safely ignored and, in fact, you are displaying approved behaviour if you do) is an unsuspected, slow-onset, toxic bomb that goes off in the individual and in society over the course of months, years, decades.

There are many people who have made this point long before me.

If “Hunger-Inducing-Treatment” is in doubt as a promising way forward, perhaps it is time to give the alternate approach (option 2 above) at least a good try.

Perhaps a useful term would be “Satiety-Focused Weight Health”.

To be continued …

Related articles:

  • They Starved, We Forgot  LINK to post on Ancestral Weight Loss Registry
  • Nov 21/12 LINK to new post by Gary Taubes, “What would happen if…? Thoughts (and thought experiments) on the calorie issue.”

Ketogenic diet for a body weight control system gone bust?

Body Snark Free Zone Sign

Body Snark Free Zone Sign (Photo credit: The Lingerie Addict)

Body Weight Control System Gone Bust?

If you can’t fix it, patch it …

Nutritional ketosis may work as a patch for you.

For decades there has been interest in the idea that a person’s body weight control system can start to mal-function. This has been thought to be part of the reason that it can be very difficult for people who have been obese to return to a normal body weight and maintain that over time.

This topic became prominent again last week with the publication of a paper that sheds a tiny bit of light on the matter.

To read about this study, see:

Obesity-programmed mice are rescued by early genetic intervention.”

“effectiveness of treatment to normalize body weight and adiposity declined progressively as the level of obesity at the time of Pomc induction increased. Thus, our study using a novel reversible monogenic obesity model reveals the critical importance of early intervention for the prevention of subsequent allostatic overload that auto-perpetuates obesity.”  LINK to FULL TEXT

The meaning of all this is just that it supports the notion that a person’s body weight control system can start to malfunction in a way that doesn’t just recover when the cause of the weight gain has been corrected.  It doesn’t prove this and doesn’t tell us how this might happen or what to do about it.

If you can’t (for now) fix it, find a work-around.

The goal in the long run is to have the best functioning of your body that is possible, within the context of what you find worthwhile. That includes the best functioning of your body weight control system – which is expressed in the functioning and balance of the appetite/satiety system.

There are countless things that can interfere with the proper functioning of these systems – leaving you fighting a tendency to gain weight or having great difficulty in losing weight without chronic hunger (or, on the other hand, being too thin or too easily loosing weight).  Some of these things can be changed and some can’t.  Hopefully , over time research and new understandings will keep shifting these interfering things from the “can’t do anything about it” group to the “this is what you can do about it” group.  Some things might theoretically be in the “you can change it” group, but those changes might be out of reach (currently) for the individual.  Some examples of that may be certain medications that are currently essential for that person or chronic poor sleep they are (currently) unable to find a way to remedy.

The core strategy, from the start and ongoing, is to do as much as you are (currently) able, or (currently) know how, to support the best functioning of your body weight control systems. All too often, though, that is not enough to allow a person to meet their body weight goals (without sustained hunger). Yes, the core strategy still is to keep trying to find ways to improve your health, including ways to improve the proper functioning of your body weight control systems. But if you are still struggling with your weight health or hunger, is there something more you can do while you are waiting for the perfect answer or personal perfection (not recommended)?

I think that nutritional ketosis is, for most people, a valuable option here. I have addressed this topic in more depth in my recent post:

To take this from concept to real life, consider the personal stories posted on

Overnight Fasting a Key?

From The Salk Institute comes an intriguing study relating to the timing of meals, snacking and the length of over-night fasting:

Scientists have long assumed that the cause of diet-induced obesity in mice is nutritional; however, the Salk findings suggest that the spreading of caloric intake through the day may contribute, as well, by perturbing metabolic pathways governed by the circadian clock and nutrient sensors.

The Salk study found the body stores fat while eating and starts to burn fat and breakdown cholesterol into beneficial bile acids only after a few hours of fasting. When eating frequently, the body continues to make and store fat, ballooning fat cells and liver cells, which can result in liver damage. Under such conditions the liver also continues to make glucose, which raises blood sugar levels. Time-restricted feeding, on the other hand, reduces production of free fat, glucose and cholesterol and makes better use of them. It cuts down fat storage and turns on fat burning mechanisms when the animals undergo daily fasting, thereby keeping the liver cells healthy and reducing overall body fat.

The daily feeding-fasting cycle activates liver enzymes that breakdown cholesterol into bile acids, spurring the metabolism of brown fat – a type of “good fat” in our body that converts extra calories to heat. Thus the body literally burns fat during fasting. The liver also shuts down glucose production for several hours, which helps lower blood glucose. The extra glucose that would have ended up in the blood – high blood sugar is a hallmark of diabetes – is instead used to build molecules that repair damaged cells and make new DNA. This helps prevent chronic inflammation, which has been implicated in the development of a number of diseases, including heart disease, cancer, stroke and Alzheimer’s. Under the time-restricted feeding schedule studied by Panda’s lab, such low-grade inflammation was also reduced.

“Implicit in our findings,” says Panda, “is that the control of energy metabolism is a finely-tuned process that involves an intricate network of signaling and genetic pathways, including nutrient sensing mechanisms and the circadian system. Time-restricted feeding acts on these interwoven networks and moves their state toward that of a normal feeding rhythm.”

The way this study has been presented in some media could be mis-leading. Have a look at the above link to understand what the study did and what it found.  The critical facts are that this was done in mice (human implications can only be guessed at), rodents respond to intermittent fasting much differently than humans do, mice normally eat at night and sleep in the day (which can get a little confusing as you read about the study) and they were fed a 60% fat diet, which probably means about 20% or more of carbs.  Any time a diet is studied that has a mix of fat with this much or more carbs, the results cannot be taken as showing what the results would have been with low-carb eating.

Still, I think this is a very important study.  It is also one that, BTW, contributes to the a-calorie-is-a-calorie food fight (but that is not likely to be acknowledged). This study does not actually demonstrate that these factors apply to humans, but it is certainly possible, at least even to some degree.

IF humans actually respond similarly to the way the mice responded in this study, what would that mean?  I think it is worth addressing that question, keeping in mind that this is just theory so far.

(1) It would suggest that it is generally best to have a relatively longer time between your last food of the evening and your first food the next day.  For example, having your dinner as early in the evening as works for you (that is, without setting up a situation where you are repeatedly or persistently hungry) and then avoiding snacking in the evening or night.

None of this at all changes my opinions and concerns expressed on the page “Restrict/Rebound” or in my writings about “Satiety-Focused Weight Health“.  So, from my perspective, this would mean working with your body to establish daily eating habits and routines that allow you to meet these goals without putting up with ongoing hunger.  Of course, sometimes when you are changing your eating patterns or metabolism there may be some extra hunger for a few days or a week or so as your body adjusts.  For example, if you are in the habit of getting up in the night to eat, it may be a useful strategy to just stop this and tough it out for a few nights while your body adapts (unless, of course you have a specific medical need, such as being a diabetic who can have hypoglycemia overnight).

Many people who adopt a low-carb or at least a controlled-carb lifestyle find that they are much less interested in snacking.  This is probably for different reasons for different people, due to the various ways that eating low-carb promotes satiety.

(2) Even further, it might suggest that it is best to avoid having food still in the early part of the digestive process as you go into the later evening (when your digestive system would be starting to slow down) and on going to bed (your digestive system slows overnight).  This would be influenced by the timing of your evening meal relative to your circadian rhythm, the mix and amount of food eaten and also the functioning of your digestive system.

I could imagine a perfect storm for this would be a diabetic, who has delayed stomach emptying from nerve damage, on a medication that slows stomach emptying eating a large meal containing fat (slows stomach emptying) and protein (slows stomach emptying) and lots of very slowly-digesting starchy food (e.g. legumes, “al dente” pasta) who eats from 8 pm to 9 pm and goes to bed at 11:30.  That person’s digestive system just isn’t going to get any rest.

(3) What about creating a longer fast by skipping or delaying breakfast?  Sorry, I’m still a “Nope, I don’t think so” on that one.  I’m not an anthropologist, but I think the wisdom of the ages in human culture has pointed to a regular intake of meals, including breakfast.  Young, metabolically healthy people can get away with it for a while, but I don’t think it’s a strategy that holds up as the decades start to pass or if you are metabolically unwell or you are under chronic stress.  (See Restrict/Rebound page and comments.)

(4) In the day, moving away from snacking may be beneficial (again, working with your appetite/satiety system on this).

On the subject of meal timing, as I recall other studies have shown that your digestive tract and your appetite/satiety system work best when you have a regular, predictable circadian pattern (wake, sleep and activity) and also when you have regular meals of a generally similar make-up.  That is, your body functions best when it can get into the habit of digesting, for example, a lunch eaten at about the same time each day and containing a similar amount of food and mix of types of food day to day.  Your body wants to anticipate a certain job it has to do with your breakfast, and a certain job it generally has to do at lunch time and also a certain general job you expect from it at supper time.

When I was growing up, we rarely ever snacked in the evening.  There was always tasty stuff in the fridge and always cookies or other baking on the counter.  We ate dinner at about 6 pm, had a small dessert and the simple fact was that none of us thought about food again until the morning.  On the other hand, none of us would be happy with being up long at all in the morning before eating breakfast and none of us would ever have been happy skipping lunch.

This study from the Salk Institute does not provide solid information about human biology, but still I would suspect that the human body functions best when the digestive tract and metabolism can rest at night.

Addendum: another take on the same study, from Sweat Science http://t.co/ABOAeQg5

Short link for this post Overnight Fasting a Key?   http://wp.me/p2jTRh-7d