Weight Loss Advice: It Doesn't Have to Be So Hard

An Expert Interview With David L. Katz, MD

David L. Katz, MD, MPH; Laurie Scudder, DNP, NP


September 27, 2013

In This Article

Key Messages

Medscape: From your perspective, are there key messages that you would like to emphasize for healthcare professionals?

Dr. Katz: I would like to emphasize the incredible power of a short list of lifestyle factors. Clinicians need to get behind that message. We are really important when people get sick, but when it comes to building vitality from the ground up -- things like physical activity, not smoking, getting enough sleep, managing stress, and ideally having love in your life -- the literature attesting to that short list of actors as the major determinant of medical destiny is voluminous and decisive. That same literature indicates that those factors also influence gene expression.

So another important message is that the power of lifestyle reverberates through our DNA. We can in fact nurture nature. Both patient and clinician place an undue emphasis on willpower. In particular, we as clinicians have to be careful about that. We have to be careful not to think that just because a patient isn't losing weight or isn't improving their behavior that they lack willpower -- that they are not motivated enough. They may be motivated enough, but just have no idea how to get there.

One important concept here is skill power as the critical adjuvant to willpower. You have to care, and I think part of our job is to help make people care. Clinician and patient alike need to be thinking about their relevant skill sets. Think about anything in life where there is something new to do, such as use a new computer: You read the instructions. You have to learn how. Sometimes it is easy, sometimes it is hard, but there is generally a period of acclimation and skill acquisition.

We acquire skills to ride bicycles. We acquire skills to drive cars. We acquire skills to use the newest iPhone®. In a modern world that conspires mightily against eating well and being physically active, to get there from here requires skill power. I think it changes the nature of our interaction with patients who think that way.

We published a number of articles over the years on the topic of impediment profiles. This basically hypothesizes that for any given behavior change, there is some universal set of factors that makes it hard, and any given patient has some subset of those factors that are relevant to him or her. If we can identify those -- in other words, if we can profile the specific impediments that are pertinent to this patient's efforts -- we can then troubleshoot those, and troubleshooting those will generally require a program, a resource, a tool, or a skill. That orientation toward the challenge is very important.

We also need to be thinking about what we might call the edge of the wedge. Are there little things we can do to start to modify behavior in a way that will favor better health outcomes without any heavy lifting involved? I have been focused on that notion for a long time. Several years ago, I cowrote a book about the stealthy little tweaks you could make to your daily routine, which can add up to make a huge difference.[4]

One of the things we have been studying at the Prevention Research Center over the years is small dietary adjustments that can be made that can then potentially exert an outside influence on overall health outcomes and the quality of diet or physical activity patterns. We developed some very simple physical activity programming that, over the course of the day, can add up.

In the case of food, one of my current preoccupations is the notion that changing even one food in the diet may have an effect on diet quality that mimics tossing a pebble into a pond. It is interesting that we in the healthcare community issue advice about food, as if an individual food were walled off from all other foods. For example, we warn people against the cardiovascular effects of eating eggs. Frankly, I think we were wrong about that, but if even if we weren't wrong, I don't think we ever anticipated what the effects of that would be. If people eat fewer eggs, what will they eat more of instead? I don't think we ever really asked that question or answered it effectively.

Maybe the answer now is America runs on Dunkin. Maybe we ate fewer eggs and started eating more donuts. We have to ask ourselves, is that what we really wanted? I am very intrigued by the importance of the notion that if we change something about diet, it may change something else.

At our center, we have several studies, including one that is currently ongoing, where we have administered walnuts as an addition to the diet. Walnuts are a rich source of alpha-linolenic acid and omega-3. They have a wide variety of other nutrients that are associated with health effects. We have now seen in 2 studies that have been published that this change is associated with beneficial effects on overall cardiac risk.[5,6] One of the things we found is that there appears to be a net beneficial effect on overall diet quality -- because if you add 350 calories of walnuts as a daily snack, you are not just getting the benefit of what you are adding, you also are pushing out the other foods you would have been snacking on instead. You are taking out sugar, salt, and junk, essentially.

We are currently conducting a trial in over 100 adults looking at the effects of adding walnuts daily on diet quality, weight, and body composition. Our data to date suggests that the addition of this very satiating, nutrient-dense food actually helps people fill up and stay full and may reduce total calorie intake, with a favorable effect on energy balance and weight while improving total diet quality.

This is an example of the kind of thing we might think about doing more. We might make recommendations for a variety of specific food additions to the diet and maybe provide further coaching about eating these instead of these other foods as a snack, and then patients benefit twice. They benefit from the rich array of nutrients in the foods we are recommending, but they also benefit from what they are leaving out of their diet. So, it may be a strategy that we emphasize more as kind of an easy means to start to shift diet in the general direction we would like to see it go.

We certainly have a lot of good information about some basic patterns of helpful eating. But when we tell people to change everything all at once -- adopt the Mediterranean diet -- it is overwhelming, and nothing tends to happen. It may be that food-specific advice is one of the strategies that will help us get there from here.

Medscape: The no-fat, low-fat craze that has been popular is an example.

Dr. Katz: That has been an absolute debacle. One of the things I devote a lot of my time and literary effort to opposing is the focus on a single nutrient as the problem. Most recently, I have been raising my voice against the notion that the only thing wrong with our diet is fructose. There is no question that we eat too much sugar, but there is also no question that we could have sugar-free junk food and be no better off. If we keep eating artificially sweetened foods and, because they are sugar-free or fructose-free, we think we can eat 4 times as much, we will all wind up fatter and sicker.

It's called the halo effect, and that is just what we have done so far. We all cut out fat and started eating fat-free cookies and got fatter. Then we decided to cut out carbs, but we ate low-carb, high-calorie junk food and got fatter and sicker. We could do that again and again.

We really need to be focused on overall nutritional quality of food, the overall quality of the diet. Ultimately, we need to be thinking not about macronutrient categories, such as carbohydrates, because of course everything from lentils to lollipops has carbohydrates. Instead, we need to be thinking about specific foods and offer very practical, actionable advice to patients. Here is a food you should make a part of your diet routinely, every day or several times a week. It isn't long before you have an inventory of the kinds of foods that can truly have an influence on the diet. If you are eating 10 or 15 really nutritious foods as part of your weekly routine and they are bumping out less nutritious foods, you have got a major shift in the overall quality of that diet.


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