Yesterday I posted the following picture on Facebook.  I stated that the meal contained meat, potatoes, rice, cabbage, asparagus, and strawberries.  After posting I asked the question “How many calories are on this plate?”  Before you scroll down for the answer, take a look at the photo and take a stab at it yourself.

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The answers ranged from 400 calories to 1200 calories, all the way up to “GET THAT IN MA BELLEH” (with my wife also being a smartass and suggesting that it was 4500 calories – Love you baby).  After taking guesses a dietitian colleague of mine and I independently totalled up the plate using online calorie software.  And interestingly enough, we got totally different answers!

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Her total was 1500 calories whereas mine was closer to 1000.  But when we looked at the reason for the differences they were largely attributable to differences in the estimated sizes of the portions on the plate (we both agreed that the meat was probably pork).  However, the big point here is that whichever estimate you agree with the fact remains that the food on that plate represents far more calories than most people should be consuming in a single meal.  It also means that even trained professionals have a hard time agreeing on quantities when looking at a plate like this.

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With the Christmas season upon us and the number of parties, dinners, and potluck events that will inevitably be a part of it, I think that this plate would actually even be a conservative estimate of intake for a lot of people.  There are almost always pre-dinner treats like veggie trays, hummus, and chocolates kicking around.  An even then a single plate of food might be less than most people eat (you know…try a little of everything and then go back for a second helping of the stuff you really like).  Combine that with the calories from wine, beer, and desserts (you know you HAVE to try at least one slice of each kind of pie right?) and you’ll be consuming a boatload energy that will ultimately be stored as fat.

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Doing this task made me think back to previous holiday seasons where I hadn’t paid much attention at events like these.  This year I think I’ll be a little more attentive to what I’m eating.  If nothing else, when you’re making up your plate this holiday season I hope this task inspires you to be a little more cautious with your consumption to0.  After all, the best way to lose weight in January is not to have gained it in the first place.

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Have a great weekend!

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PS: Today is the last day to save $100 on the Peak Diet and Training Summit and (due to popular demand) there is now a 2 pay option for those who prefer to pay in installments.  This package is a true beast with 15 DVDs, 2 info packed manuals, 2.0 NSCA continuing education credits, and a bunch of other bonuses available only this week.  There is no risk as the product is fully refundable so go and pick it up before the deal disappears.  Order your copy HERE.

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Over the past few weeks I’ve put together an extensive (and I hope valuable) series on training clients with obesity.  In Part I of the series I described the categorization and classification of obesity.  In Part II I shared some resources and very important concepts about obesity management.  In Part III I discussed how I would go about training those with a BMI greater than 35.  In Part IV I talked about the training I would use for those with a BMI below 35, but still above 30.  And in Part V I presented a summary of the various types of bariatric surgery that are most often sought by those with obesity.  Today I want to finally bring the series to a close with a final piece about nutrition for those with obesity.

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What We Know About Diets

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I think some of the largest trials comparing diets in the real world (such as the famous A to Z Study) have demonstrated that while low carb diets generally get the lead for early weight loss, after a year they aren’t really that much better than moderate or higher carb diets.   Granted, there was a statistically significant difference in the A to Z Study, but is it really significant in terms of what it means to you or your clients?  Here are the results from the paper.

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Mean 12-month weight loss was as follows: Atkins, −4.7 kg (95% confidence interval [CI], −6.3 to −3.1 kg), Zone, −1.6 kg (95% CI, −2.8 to −0.4 kg), LEARN, −2.6 kg (−3.8 to −1.3 kg), and Ornish, −2.2 kg (−3.6 to −0.8 kg). Weight loss was not statistically different among the Zone, LEARN, and Ornish groups.

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So basically, the Atkins group lost an average of 10.3 pounds, the Zone group lost 3.5 pounds, the LEARN group lost 5.7 pounds, and the Ornish group lost 4.8 pounds after one year!!!  In this case the “best” diet yielded an average weight loss of approximately 0.2 pounds per week.

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What I feel this study really tells us isn’t that one type of diet is superior to another for weight loss, but that our biggest issue with diets is compliance.  In fact, what I think you’ll find if you talk to any client with obesity is that many of them have tried numerous diets for weight loss in the past and some of them may actually have done VERY well (losing even 100 pounds or more) only to put it back on.  The key here is not to find some magical diet that will elicit the most rapid fat loss possible, but to find a nutrition plan that the client will be able to maintain for life.

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Wait a Minute…

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Isn’t that what I usually say for non-obese clients too?  Gee willikers.  Could we be on to something here?  Does this mean there is no magic diet that will instantly result in ripped abz for only $39.99?  Could it also be that if we simply identified and address the barriers that prevent us from being able to adhere to ANY diet we’ve selected that we’d get better results?  Nah…couldn’t be.  That would make too much freakin’ sense.

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Anyway, the biggest nutritional factor that is required to result in weight loss success is a moderate calorie deficit.  As simple as it sounds, the key is to make sure the calories consumed by the client are less than those that are burned.  I should reiterate again that this should be a MODERATE deficit and your client need not lose weight rapidly and you must resolve to teach them the proper way to lose weight despite their insistence that they’d like it to go faster.  The more severe the plan, the less likely the client is to stick to it for life which (as we discussed above) the single MOST important element of any nutrition plan.

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I should note that in some medical obesity management programs very low calorie diets (VLCD) consisting exclusively of nutritional protein shakes totalling 800-900 calories per day are sometimes used for rapid weight loss.  You should NOT follow this practice with your clients.  Programs like these MUST be medically supervised as there are risks associated with gall stones from rapid weight loss (possibly leading to pancreatitis), low sodium levels, and life threatening blood sugar crashes if the person is on insulin (as many with obesity who have Diabetes are).

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Aside from that, the diet should contain enough protein for muscle maintenance, fiber, and plenty of fruits and vegetables.  But I need to state again that creating a moderate calorie deficit and finding a nutritional lifestyle program that will stick (along with identifying and addressing barriers to compliance) are the two biggest concerns.  Without these, you can pretty much forget about everything else.  And, of course, since these clients often struggle with sudden change and making it stick in the long term (as do most clients actually), it is important to implement progressive behavior change to get the client onto the plan rather than an instant jump to super strictness.  Doing this will empower the client and make them more willing to take further steps as their confidence grows.

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In short, there is no magic but consistant and slow behavior change and a reasonable diet.  Anything else is just setting your client up for failure.  And if you doubt it, I’ll leave you with this.  Below is an image of the weekly weight values of a client I’ve worked with for the last nine years.  The first year averaged a 2-3 pound per week weight loss and beyond that it was much slower.  But the point to be really taken is that weight loss is easy.  Long term maintenance which is where the truly gifted trainer aims to shine.

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As usual, if you have any questions, comments, or random insults you can leave them below and I’ll make sure to address them.

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Also, if this article has been useful to you please don’t hesitate to share, “like”, tweet, +1, or whatever funky social media thing you can do to spread the word.

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Recently I started writing a series on training obese clients that has evolved into much more than I had expected.  In Part I of this series I described the categorization and classification of obesity, in Part II I shared some resources and very important concepts about obesity management, in Part III I discussed how I could go about training those with a BMI greater than 35.  In Part IV I talked about the training I would use for those with a BMI below 35, but still above 30.

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Today I want to begin talking about nutrition for those suffering with obesity.  However, discussions about nutrition and the obese client would be lacking without at least a brief mention of gastric bypass surgery.  So today I will cover that, and then I should have only one more post on nutrition related stuff that should wrap things up.

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Now before you tune out because you think gastric bypass has nothing to do with you or your clients, trust me when I say you need to hear this.  Even if you are not a believer in this type of surgery, chances are that if you train obese clients long enough you’ll run across one that is considering or has had some form of bariatric surgery.  If or when that happens, you should be informed with the best possible information so that you can provide appropriate guidance and support.

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And even if you never happen to personally train someone who has had this surgery or wants to have this surgery, it will help to inform you that this surgery is by no means “the easy way out” that some may perceive it to be.  I feel that fitness professionals should make an effort to at least understand the basics bariatric surgery as this is part of weight management for many (even if you don’t agree with it).  So…let’s get at it!

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Laproscopic Banding

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The first and least invasive type of bariatric surgery is simply called laproscopic adjustable banding (popularly known as the Lap-Band).  With this surgery, a small adjustable band is inserted through very small incisions and placed laproscopically around the top of the stomach.  This limits the amount of food that can enter the stomach and thereby causes people to lose weight.  This is called a restrictive surgery because of this limitation.  People that have had this surgery also have a port below the skin in the abdomen that allows them to have saline added or removed to make the band tighter or looser depending on their needs.  Of all of the bariatric surgeries available, this is the least invasive and it has the smallest surgical risk.  It is also removable so if some decides it isn’t right for them, the band can be removed.

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From the data I’ve seen at conferences and from hearing surgeons talk about this procedure, it seems as though the weight losses seldom meet the expectations of the patient, weight is almost fully regained in many cases, and the band is frequently removed.  As a result, it seems that gastic banding is losing favor in some circles.  One of the things that strikes me as most interesting about banding is that we’re basically providing a removable (temporary) treatment for what I’ve suggested is a chronic condition.  If removing treatment results in the return of the condition, it might be wise to question the use of temporary solutions.  Of course, I’m not saying that there isn’t a place for banding (they often use them when they feel such a surgery is warranted in children – don’t even get me going here), but the data I have seen on them is generally not promising.  I won’t ignore that some have great success with these, but I think this is the exception rather than the rule.

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Sleeve Gastrectomy

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The sleeve gastrectomy is also a laproscopic procedure in which part of the stomach is actually cut off and removed.  The remaining section of the stomach is actually quite small which limits the amount of food a person can consume and allows them to lose weight.  This too qualifies as a restrictive procedure and it is only slightly more risky than the laproscopic band, but it is permanent.  This surgery generally has greater weight losses than laproscopic banding and (from what I’ve seen) is better in terms of preventing weight regain.  However, the results aren’t as great as with the “gold standard” gastric bypass surgery we’ll talk about next.

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Roux En Y Gastric Bypass

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While there have been many versions of this surgery over the years, the roux en y gastric bypass is now the gold standard against which all bariatric surgical procedures are compared.  In this surgery, like the sleeve gastrectomy, part of the stomach is removed to limit the amount of food that can be consumed except that with the sleeve the stomach can hold 150ml of food while this procedure typically limits food to about 30ml (two tablespoons).  Then, the small intestine is cut part of the way along and attached to the new stomach pouch.  This prevents much of the food that is ingested from being absorbed by the body resulting in even greater weight loss.  For this reason, this procedure is classified as a restrictive and malabsorptive procedure.  It is obviously not reversable.

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The highlights of this procedure is that the weight loss is typically greater than the two previously mentioned.  It also does have some greater weight loss maintenance than the other two as well.  What is more important though (and probably why this procedure gets so much appreciation from physicians and patients) is that it can be an almost instant cure for Type 2 Diabetes.  In other words, you could be a Type 2 Diabetic today, get the surgery, and then you’re pretty much off your meds.  There is even some talk about doing this procedure on non-obese Diabetics whose disease is really difficult to control, but I’m not sure whether this will pan out.

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I want to be clear here with my own perspective in that I don’t think the data on this is 100% reliable as the follow up isn’t the best in many of these studies and some are not randomized controlled trials.  The big issue with follow up is that the people that are probably most likely to make themselves available for this are those that are doing well.  Those who aren’t probably don’t want to be followed up.  For this reason, I think that perhaps this surgery may be good for some Diabetics, but I’m cautiously optimistic.

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I also want to be clear about some of the downsides.  First, the surgical risk is higher with this than the other surgeries I’ve mentioned.  I don’t think it is terrible, but worth noting.  And because the surgery is malabsorptive, there are some major nutrient deficiencies that occur with many patients.  Of course, they are typically told to take certain vitamin and mineral supplements for the rest of their lives following surgery, but some are non-compliant with this and they end up with serious issues.  There are also other issues like increased rates of suicide, divorce, addiction, and other issues following this surgery that make it important to weigh the risks and rewards of this procedure.

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Biliopancreatic Diversion with Duodenal Switch

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This procedure is the most intensive procedure of them all and it is only usually considered for the very obese patient.  Generally it begins with the restrictive component where the stomach is reduced very much like the sleeve gastrectomy.  From there, it becomes difficult for me to describe so I’ll just use a video to illustrate for those who are interested.

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This procedure can be done in two parts with more severely obese patients.  In the first procedure, the restrictive part is done to reduce the size of the stomach.  Then, after the patient has lost some weight and is less of a surgical risk, the surgeon can go back in and add the malabsorptive element to continue the weight loss.  While the roux en y is the gold standard, the duodenal switch can also be used for those who have regained weight after this procedure as it is pretty much the only thing left in the surgical arsenal.

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As you might guess, the risks for this surgery are higher than those associated with any of the previous, but the results are also usually pretty darn good too.  Ultimately, the more risky the surgery, the greater the potential weight loss.  However, with all surgical procedures you really have to look at the pros and potential cons of this operation.  Similar to gastric bypass, there are many possible issues that can present.

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I honestly can’t tell you what to do in the case of a client that has had any of the above surgeries because they’ll all present differently.  My primary goal with this post was to bring a basic understanding of surgical weight management to the fitness world in the hopes that it will begin to build a bridge between fitness and physicians as we attempt to understand each other’s methods.

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I can tell you that without lifestyle modification any of the above surgeries can result in weight regain and the reappearance of obesity related issues like Diabetes, hypertension, and so on (remember what I said about obesity being a chronic condition?).  So even if we don’t agree with the methods, it is important that we be prepared to partner with people that have had them (and their physicians) because many family doctors are at a loss for what to do with these patients.  By having at least some understanding, you will be in a position to help.

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If you want more information on this topic I would highly recommend you take the time out to read Dr. Sharma’s series called Why I Support Bariatric Surgery.

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There are 5 parts and they are all fantastic.  They can be found here. 1, 2, 3, 4, 5.

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But before you think I’m totally going to allow only the positives to be highlighted here, Dr. Sharma wrote a 5 part follow up series called Why Bariatric Surgery Can Fail which I think is also solid and provides more information than I can possibly cover here in this single post.

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You can read this series here. 1, 2, 3, 4, 5.

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In the end, I guess I didn’t teach you much about how to handle these clients, but being aware of them, what they’ve had done, and the potential issues can only point you in the right direction.  If nothing else, you probably just learned something you never thought you’d learn in this industry. 

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If this article helped you in any way or you think it may help others you know, please share it on Facebook, Twitter, Google+, or whatever social media outlet is your addiction.  Or if you’re lazy like me just hit the “like” button or +1 button.  Thanks.

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PS: I know I possibly covered a lot of unfamiliar ground here so if you’ve got questions, drop ‘em below.

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PPS: Check out Part VI of this series HERE.

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A couple weeks back I wrote a post in the benefits of writing action plans to implement small behavior changes to bring about long term results.  Frankly, I think that this is the best way to overcome stumbling blocks in getting started with an exercise or nutrition program for the beginner and for reaching new levels of achievement for advanced trainees.

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As a result of that post, I’ve had a few questions and I figured that today would be as good a day as any to one of them.

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Question: If I successfully implemented a behavior last week, do I have to change it or increase it this week?

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Answer: Definitely not.  If last week you decided you were going to exercise 3 times for 30 minutes and you achieved that goal, there is no reason to expect that this week you should attempt to do 4 days per week or increase the time to 45 minutes.  However, the aim of an action plan is to make regular small steps forward in ANY behavior the leads you towards your goal.  So this week you could very well maintain your previous exercise goal and address another behavior instead.

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For example, if your long term goal is weight loss and last week you began exercising as was discussed above, perhaps this week you can begin to address another simple habit like sleep as this can also effect weight management.  If you regularly go to bed late and get up early for work you might set an action plan to go to bed by 9:30 at least one night this week and build on that in later action plans.

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Ultimately, the when thinking about action planning it helps to take a look at what the ideal situation would look like for you to achieve your goal.  For fat loss you’d likely be exercising a few times per week, lifting weights, eating less junk food, maintaining a moderate calorie deficit, eating plenty of veggies and fruit, consuming adequate protein, drinking mostly water and few calorie containing beverages, sleeping 7-8 hours per night, and so on.  Doing all that at once is easily a recipe for failure (which is why most people that try this do not actually succeed in the long term), but breaking it down into very small managable actions will make it possible to implement this over a very long time line and make it more likely that you’ll be able to maintain it.

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So you select the easiest possible remaining behavior that needs to be changed and start working on it in the simplest possible way for you whether it be only one meal per week or one day per week.  Over time, new habits will form and the results will come.  They key is patience and consistency.  If you can accept that it will take time, the wait will pay off and you’ll eventually leave all those trying more severe programs in the dust as they struggle to maintain their new habits and eventually regain the weight they lost.

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And for those who are more advanced, the same thing appliles.  You may have already implemented behaviors that have set you on the path to your goals.  The key now is to identify which ones still lie between you and your intended outcome, pick the easiest one to change…and get after it.

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In the end, it is nice to read this stuff, but unless you’re actually doing it, you might as well have not wasted your time.   What is your action plan this week?  If I get enough people sharing theirs I’ll share my own next week.

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PS: If this post has helped you or you think it might be helpful to someone you know, please don’t hesitate to share it.

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Facebook Arguments - This is How I Roll

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So Sunday I sent out an email to my newsletter subscribers and, as I usually do at the bottom, I invited my subscribers to join me on Facebook to connect and share in the discussions on my wall.  More specifically, this time I mentioned that my Facebook is indeed the place to be to enjoy the rants, arguments, and tirades that take place on my statuses from time to time.

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Interestingly, despite having invited people to add me many times before, it seems that you are all more excited to chat it up if you think there is going to be disagreement and rage filled rants.  In short, ya’ll are sick!    Of course, this is good news because I am also one for such discussions.  For the rest of you who have yet to connect and participate in said discussions (shame on you), please feel free to add me HERE.  I know you’re just as sick as the rest of us.

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While you’re at it, don’t forget to follow me on Twitter and subscribe on YouTube as well.

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Down to Business

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Okay…enough chatter.  Time to get to work.

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Last week I wrote a little bit about the state of the research on refeeds, but I was very careful not to say that they don’t work because the truth of the matter is that just because there isn’t any research to help us determine one way or the other in well designed weight loss studies in humans.  As you could probably tell from the tone of my post, I’m not totally convinced at this point and I don’t often use structured refeeds with my clients.

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That said, I know that there are many very smart folks who do use refeeds with their clients and I think it is only fair to consider their opinions as well.  I feel that many fitness professionals – myself included - can sometimes become a little too dogmatic about their own methods so I wanted to ask my good friend Erik Ledin (who has worked with many high level bodybuilding, fitness, and physique competitors) to share his perspective on how to use refeeds and when they are most effective.

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*Note – To be clear here, we’re talking about structured higher calorie and higher carb meals.  Refeeds are not the typical “cheat meal” where a bodybuilder will go out to a restaurant and kill a steak, a pizza, and a plate of pasta washed down with a couple Cokes.*

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Here’s what I asked Erik

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“At what point do you feel refeeds become important? Do people at any percentage of body fat benefit from them? In other words, are they valuable for everyone who is trying to lose fat?”

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Erik’s response

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“You could really draw an answer out but just to keep it short, when progress stalls, or when a person is lean.
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Fatter people don’t need refeeds since body fat is protective to the regulatory hormones; it’s when someone gets lean and is further and further away from their metabolic set point that things tend to get all jacked up.
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People can argue this all they want, but the reality of actual PEOPLE going through this is hard to ignore.
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I don’t know what body fat percentage that would be as I could bet it would differ from person to person again based on how far they’ve come from where their bodies want to naturally gravitate towards. Those who have come from further probably will benefit sooner and vice versa.
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So I’ll look at progress, gym performance as well and a general assessment based on what they’re looking like.  Sometimes I’ll put one in, only to pull it back out because maybe my application of it wasn’t timed right.
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My Thoughts

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As most of you know, I like to wait until the dust settles in terms of research before I make a definite conclusions about whether something works or doesn’t work.  However, I am not against trying things in the interm provided that the theory is sound and there is practical evidence suggesting that it works in the applied setting.

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In this case, it appears that if you’re going to try refeeds, you at least need to have hit a standstill in terms of weight loss that can’t be explained by overconsumption of calories or too little activity and likely be relatively lean.  If you’re just starting to follow a nutrition plan and you’re trying to justify using refeeds as a way to over eat on the weekend because you need to maintain your leptin levels you’re probably deluding yourself.  A more moderate calorie deficit is probably the key to success and if you’re going to use refeeds, you should probably wait until they are truly warranted.

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I should also note here, that while we are talking about the effects of leptin on hunger and metabolism, we shouldn’t forget that other hormones like ghrelin and PYY have effects on hunger as well and none of these hormones operate in isolation.  In fact, some of them are actually effected just be THINKING that something is more filling.  So we can’t ignore the possibility that other hormones as well as social and psychological factors can play a role in fat loss.  While refeeds may indeed work, there is still so much more we can learn.

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