For Healthier Weight & Better Health …

On December 4, 2015, I delivered the Knorr Family Healthy Lifestyles Lecture at the 35th Annual Family Medicine Winter Symposium of the University of Kansas School of Medicine Wichita. An approximate slide-by-slide transcript of my plenary on Nutrition Myths and healthy Dietary Advice appears here.  Below is an approximate transcript from the breakout session that followed.   Slides are available here.

Slide 1 – Information about the event

Slide 2 – For Healthier Weights & Better Health, Don’t Focus on Food Calories!

For those of you who did not attend the talk last hour, my name is Sean Lucan and I am family doctor in the Bronx. Like many of you, I see patients of all ages and all stages of life, and in the families that I care for I see a lot of obesity and a lot of largely preventable diet-and-weight-related chronic conditions (e.g., diabetes, high blood pressure, sleep apnea, cancer, and others). As a family doctor and one trained in public health, I recognize there are many challenges faced by individual and families trying to eat better.   But one of those challenges should not be misguided—and misguiding—clinical advice. And that’s what I want to talk about today.

Slide 3 – Disclosures

I have no disclosures to make except for serving on the Scientific and Nutritional Advisory Board for Epicure (a Canadian food product and cookware company, dedicated to making healthy eating flavorful and convenient). I don’t believe my relationship with Epicure has in any way biased the content of this talk.

Slide 4 – Examples for reviewing “myths”

In my presentation last hour, I reviewed reductionist component-based nutritional claims that are based on myth: that is, concepts poorly supported by the evidence or even contradicted by it.   I discussed myths around Vitamin A, calcium, sodium, saturated fat, and fiber. This session what I am going to focus on myths around food energy, which in the U.S. is measured in calories (or more precisely Kilocalories)

Slide 5 – The 3,500-calorie myth

We’ll start with the 3,500-calorie myth that is so pervasive among patients and providers. The 3,500-calorie myth comes down to energy balance. Patients may ask how many fewer calories they need to eat, or how many more calories they need to burn to lose weight. The prevailing belief is that to lose 1 lb. of body weight a patient would need to achieve a net deficit of 3,500 calories (Kcal). The math works out neatly such that running a 500 calorie deficit every day for one week will result in 1 lb. of weight loss.

Slide 6 – Complex biology, not simple math

Unfortunately, as emphasized last session, humans operate by complex biology, not simple math.   The 3,500-calorie rule ignores the dynamic, nonlinear response of body weight to sustained changes in calorie balance.   In other words, even if individuals could sustain a 500-calorie per day deficit, their weight would not drop linearly. This is a figure from Kevin Hall, who may just be the world’s leading authority on energy balance. What the plot shows is that with a constant stable decrease in dietary energy intake, initially you see a big—almost linear—fall-off in weight. But a 200-lb patient losing a pound a week does not vanish after 4 years …

The line obviously curves and very quickly you approach a plateau where there is essentially no further weight loss.   Does this look familiar to anyone who has tried to lose weight themselves, or tried to help patients do the same? When individuals lose weight, compensatory mechanisms go to work to prevent further weight loss and promote regain. Thus you get curvilinear, not linear, results.

Slide 7 – False expectation/disappointment

The 3,500-calorie rule is a set-up for failure. The only thing this myth does is create false expectations and lead to disappointment.   If a patient were to under-consume 100 calories per day (about the equivalent of a single banana), the 3,500-calorie rule would predict a weight loss of more than 50 lbs. over 5 years. In reality, accounting for biological compensation, a loss of only about 10 lbs. might be expected. Notably 50% of that weight loss (5 lbs.) might be achieved in the first year. It would take about 3 years to achieve 95% of the total weight loss. And there would be only about a ? lb of weight loss over the last 2 years combined (despite the same effort and 100% adherence). So this is frustrating.    

Slide 8 - Too focused on weight not health

But perhaps equally if not more frustrating is all the focus on weight as opposed to health (… in the literature, in the media, in conversations with patients, etc.). Let’s be very clear that obesity is *NOT* a quantitative problem of lbs. on a scale. Obesity is a qualitative problem of altered body metabolism. And while we are constantly focused on weight and its related metric the body mass index (BMI), we know that weight and BMI are relatively poor measures of adiposity (body fatness) and health in individuals. It is possible to be overweight, but metabolically healthy (think professional athlete for instance). It is also possible to be normal weight, but metabolically obese (especially since fat mass weighs less than muscle mass). Here is a recent study showing that central obesity is associated with higher mortality than BMI-defined obesity. In other words, it is not about weight, it is about fat, how that fat is distributed, and the physiologic changes that occur with elevated fat mass.

I should note here that I didn’t crowd the slides in this presentation with references as I did with the last one. For references supporting all points, please see the links to papers on the slide at the end of this talk.

Slide 9 – Calorie-focused thinking

Let’s move now to calorie-focused thinking.   I find this concept incredibly unhelpful and detrimental to those struggling for healthier weight and better health. What I am calling “calorie-focused thinking” is the idea consuming more calories (eating more) and/or expending fewer calories (moving less) causes obesity. The idea being that if people just had more self-discipline, if they just had more will power and self-control, they could “eat less” and “move more” and all would be well. While intuitive, straightforward, and well-intended, I will argue that this idea creates and blames victims and can make people demonstrably less healthy. And when you think about it, the whole idea of counting calories is a set up for failure …

Slide 10 – Counting calories is implausible

For instance, how many of you think you can determine how many calories you take in (not just what you put in you mouth, but what your body actually absorbs from the food you eat), and simultaneously determine how many calories you burn (not just on the treadmill but in all those silent unnoticeable ongoing metabolic reactions occurring within your body), and do so with sufficient accuracy and precision to meaningfully guide real-time behavioral decisions like how much less you should be eating or how much more exercise you should be doing? For myself, I have degree from a pretty decent medical school, I do research on nutrition, and I even helped co-author a book on the subject, and I will admit to you today that I have essentially no idea how many calories I am taking in or burning on daily basis.   That said, what I do know is that those two quantitates match each other almost exactly because over the last several years, my weight has changed essentially not at all, and with no conscious effort on my part.

Slide 11 – Calories in = Calories out

The reason is that calorie intake and calorie expenditure are physiologically coupled. They are paired or linked; they are dependent on one another. And you can recognize this in your own lives. Think about a time when you really exerted yourself more than usual—maybe you went the gym and did an especially hard workout, or maybe you ran a road race for charity, or maybe you just spent all day playing with your kids. After the activity that day, did you feel especially hungry? And did you wind up eating more that day than you otherwise would have? Or think about a time when you tried to eat less than your body needed. Did you feel fatigued and have low energy? Were you disinclined to move much? The point is, while there may be some small day-to-day variability, things stay pretty stable overt time without substantial caloric excess or deficit unless some uncoupling occurs.

Slide 12 – “But doc, I swear …” (frustrated patient)

So a patient might says to me “But doc, I swear, I’m choosing low-calorie foods, I’m controlling my portions, and I’m really not eating that much. And I’m trying to exercise (but I don’t really have much energy ... and I’m always hungry) … I just can’t seem to lose any weight.” When a patient says this, I believe her. And I believe her because …

Slide 13 – A calorie is NOT a calorie

“A calorie is not a calorie.” Yes, a calorie is a unit of energy and 1 unit of energy equals 1 unit of energy just as one unit of anything equals another unit of the same anything.   But that is not to say that two different foods having the same number of calories will have the same biological effects. Different foods may have different effects based on the types of calories they contain (that is, their compositions of calorie-providing fats, carbohydrates, proteins, and alcohol). Different food may have different effects on pathways involved in appetite vs. satiety, and energy burning vs. energy storage.

Slide 14 – Calorie focus misses the point

So choosing foods because they are low in calories not only misses the point, it may guide our well-meaning patients in precisely the wrong direction and literally sabotage their efforts for healthier weight and better health. That is because a focus on calories almost inevitably becomes a focus on dietary fat (dietary fat having, by far, the highest calorie density of any food component). Reducing calories usually means cutting out the fat or, more often, replacing fat with lower-calorie carbohydrate.   But higher-calorie fattier foods are not necessarily bad. In fact, some higher calorie, higher-fat foods (like nuts, olive oil, and oily fish) are convincingly linked to healthier weights, better health, and longer life. Conversely, lower-calorie lower-fat foods are not necessarily good or healthy as we shall see.

Slide 15 – Calorie-focused thinking (diagram)

Back to the drawing board or back to the diagram, “Calorie-focused thinking” would advise my patient to consume low-calorie foods in smaller portions and then blame her when she is hungry and tired, and does not have the will power or self control to “eat less” and “move more”, even as she may become more obese in the process, doing what she was told to do, adding insult to injury.

Slide 16 – Calorie-focused thinking vs. more-nuanced thinking (diagram)

Another way of thinking shifts the blame and vindicates my patient. With what I am calling “more-nuanced thinking” the ultimate problem is not the number of calories in the foods people eat but rather the type of calories that those foods contain. And specifically it is the calories from rapidly absorbable carbohydrates (i.e., refined starches and added sugars) that are the biggest problem.

Slide 17 – Calorie-Focused thinking vs. more-nuanced thinking (examples)

What I’m talking about specifically are the white rice, white breads, white pastas, and white potatoes (particularly the peeled variety that is processed into snack chips).   These foods are essentially isolated starch, which our bodies effortlessly and immediately convert to sugar.

Then, there are the sweets engineered from sugar directly: the candies, the frozen treats, the baked goods, and most especially the sugary beverages.

And then, perhaps less intuitively, are all the surprising products that the food industry injects with obscene amounts of added sugar: products like the bread mentioned earlier, and processed pasta sauces, “healthy” breakfast cereals, low-fat yogurts, and low-calorie fat-free salad dressings.

The rapidly absorbable carbohydrates in these products cause wild blood sugar and hormone fluctuations, which increase appetites and specifically our appetites for more for more starchy and sugary things, setting up a short-term reinforcing loop.

Over the long term, consuming rapidly absorbable carbohydrates leads to resistance to specific hormones involved in satiety and energy storage (e.g., leptin and insulin), what might be called “obesity on a metabolic level”. This results in powerful signals in the brain to the heart, and gut, and to the muscles, to “move less” and “eat more”. Thus what is often put forth as the cause of obesity (“moving less” and “eating more”) might actually be the result of becoming obese through food-induced neuro-hormonal changes.  

And it could be the low-calorie foods that struggling patients strive to eat (because we tell them to!) which are the most problematic in this regard …

Slide 18 – A tale of two snacks

To illustrate, consider two possible snacks: a handful of nuts vs. a piece of cake. Even though both snacks may be the same size (100 g in this scenario), the walnuts will have almost twice as many calories with more than 5 times as much fat!

So the cake is already much lower in calories and the food industry could almost certainly concoct a low-fat version that would have even fewer calories, swapping out some of the fat for more starch and sugar, widening the already sizeable difference in carbohydrate content shown here.   So is cake a healthier, more-weight friendly snack than walnuts? And would low-fat cake be even better? Actually, quite the opposite

Slide 19 – Single snack vs. whole day & beyond

Whole foods like nuts are filling. So even though a serving may have more calories than a serving of cake, the nuts will be more satiating, working against additional consumption later in the day, keeping overall calorie intake for the day lower. Plus, nuts promote overall better health and healthier weights and may even help extend life (this is regardless of their calories and maybe even because of their fats!)

Conversely, refined products like cake drive hunger and compel continued eating. Its hard to gorge on walnuts; you get pretty full pretty quickly. Its very easy to have a second (or even third) piece of cake, and to crave other foods like chips or soda with it, especially once that spike in blood sugar bottoms out and leaves you famished.  Foods like cake program us to overeat and to continue to eat the wrong kind of foods, leading to hormone fluctuations that promote obesity and related diseases like diabetes. And I want to emphasize here that the difference in effect between walnuts and cake has precisely nothing to do with the quantitative difference in their calories!

Slide 20 – A tale of two salads

Let’s take another example: a tale of two salads. Both salads start with lettuce. But for the one on the left we will toss in refined white bread croutons, sugary dried cranberries coated in high-fructose corn syrup, and syrupy fat-free dressing. For the salad on the right, we will toss in whole sunflower seeds, fresh avocado, and extra-virgin olive oil. So there is no question that the salad on the left is much lower in calories. In fact, it might have half the calories of the salad on the right.   But it is not the calories that matter. The salad on the left is comprised of artificial products with highly processed ingredients. The salad on the right is comprised of real whole foods. As a consequence, the salad on the left will be less satiating, provide less appetite control, and result in more subsequent eating during the day.   Thus even though the calories of this index meal might appear lower for the lower-calorie option, functionally they may actually be higher for the “lower-calorie” option (when subsequent intake is considered).

Slide 21 – A yogurt make over

Let’s take another example. This time, we’ll do a yogurt makeover. We’ll start with a cup of sugar-sweetened full-fat yogurt.   Now the question is: how to make this item healthier/more weight friendly. One option is to take away the fat so that we have a sugar-sweetened non-fat yogurt. Another option is to take away the sugar, so that we have an unsweetened full fat yogurt.

Slide 22 – A yogurt make over (continued)

In truth, the modification here should start with the unsweetened full-fat yogurt because this is the whole, unprocessed product.   Adding in sugar or subtracting our fat represents processing, and is based on the reductionism we discussed last hour.  The clear healthy choice here would be the full-fat unsweetened yogurt.

Slide 23 – Two ways of thinking about food

The yogurt example illustrates two ways of thinking about food: calorie-focused thinking (which is just a kind of reductionist thinking that we discussed last hour) and whole foods thinking.   These two kinds of thinking definitely have some overlap in terms of the foods they would recommend. Both would encourage vegetables, legumes, whole fresh fruits and unprocessed or sprouted grains as well as lean meats, poultry, and fish. Both would discourage sodas and other sugar-sweetened beverages; candies, baked sweets, French fries and batter-fried foods, snack chips.   But calorie-focused thinking would be concerned mostly about fat and would discourage fatty whole foods like nuts, avocados, olive oil, oily fish, and whole dairy.   Calorie focused thinking would instead recommend refined and processed products, low in fat and full of starch and sugars.

Slide 24 – Clinical and public health problem

So the question for patient care and public health is, “would the food choices that could result from a continued primary focus on calories be best for individuals’ weight / health?”

Slide 25 – When diet recs do harm

“Calories” might essentially be considered just another word for “fat”. From a reductionist viewpoint, foods with too many calories or too much fat are bad. Fats in foods and fattier diets became he enemies of clinical and public health campaigns in 1980s-1990s. Lower-calorie sugars replaced higher-calorie fats and oils in many foods. And consumption shifted to carbohydrates (often the rapidly-absorbable kinds).   But what happen was not that people got thinner. People ate more!

Slide 26 – Dietary trends over time

You can see in this figure of dietary trends over time that fat consumption may have gone down a little (at least in men). But carbohydrate consumption increased as did total calorie consumption. Ultimately people got fatter and less healthy. Obesity rates increased. Diabetes rates increased too, which is all very consistent with the reinforcing loops discussed earlier. Certainly these findings do no support continuing to move forward based on calorie-focused logic.

Slide 27 – Destructive thinking about obesity

Which brings me to destructive thinking about obesity. In a 2013 editorial in American Journal of Public Health, the president of the Institute of Medicine listed gluttony and sloth as ‘obvious’ ‘deadly sins’ for public health to address. His argument suggested obesity and related diseases are matters only of personal resolve and self-control; if people just had more motivation and will-power, they could consciously control their calorie balance sheets, eat less, move more and lose weight. It stands to reason that those subscribing to the Institute of Medicine logic might blame an over-consuming, inactive adolescent for growing fat. But would they blame the same over-consuming, inactive adolescent for growing tall?

Slide 28 – Destructive thinking about obesity (continued)

Just as children do not enter puberty and grow tall because they overeat and sleep more, neither do individuals start to fatten and become obese because they eat too much and move too little. In both cases overconsumption and inactivity are intermediate effects; neuro-hormonal changes are the cause.

Slide 29 – More destructive thinking

“Count calories, eat less, and move more” is clinical advice that creates & blames victims. Imagine comparably misdirected advice, to “Count fluid ounces, drink less, and urinate more” (Advice that might likewise result in temporary weight loss -- but no fat loss -- and be uncomfortable, unsustainable, unreasonable and unhelpful; and likewise oppose coupled neuro-hormonally driven physiology in futility)

Slide 30 – The problem

The bottom line is that the real problem is this: the refined products of industry. Ultra processed fare leads to increased calorie intake, decreased calorie burning, unhealthy weight, and poor health.

Slide 31 – The solution

The solution is real food: the whole products of nature. Foods like nuts, seeds, vegetables, fruits, grains, make “eating less” and “moving more” more possible, and support healthier weigh and better overall health.

Slide 32 – Final thoughts & Rx for health

So here are the take-home points: healthy eating is about overall food quality, not food calories. Calories absolutely count, and individual should absolutely NOT be counting calories. Individuals should choose foods that allow them to control calories unconsciously. They should enjoy natural whole foods, irrespective of their calorie (or fat) content, and choose foods from living botanical plants, not industrial processing plants

Slide 33 – Thank you. References here:

Thank you sincerely for your attention. If you’d like more information about what I discussed in this talk, here are some links to related short papers (with references for all the points made here today). If you would like to get in touch with me by email and social media, the info is here. I wish you all healthy eating and good health.

(slide with references available here)