Losing weight is really hard. Gaining is much easier.
I had the privilege of counseling hundreds of adults over almost five decades about their weight, why it was too much, what habits were leading to their gaining, how to make nutritionally sound changes, and most important, how to make changes that result in durable weight loss.
Individual Counseling and Weekly Groups
Early in my medical career, my counseling was primarily in sporadic one-on-one office visits. But in Orchard Health Care, the membership practice I founded in 2006, I had the time to organize a “weight management group” that met weekly or biweekly in the evening for over 15 years.
The typical meeting was an hour’s discussion and instruction after a weigh-in. We also frequently went on group excursions, such as to a large supermarket where we explored how to purchase healthy food and which aisles to avoid. Or we dined out together to learn how to order well at popular restaurants without overeating. Think the Chateau in Waltham where the side dish of pasta weighed 1 lb. and contained 800 calories, a good Chinese restaurant where we always overorder and overeat, an Outback steak house where there is a 7-oz steak alternative to the 16-oz ribeye, and so forth.
Meaningful Weight Loss Outcomes
Weight group members were mostly middle-aged men and several brave women, all of whom were 20 to 60 lbs. overweight. Since I began the group in 2007, we were in the pre-GLP-1 drug era until the pandemic, when a few of the members who were type II diabetics began a pre-Ozempic GLP-1.
We had real success. For example, two of the men started at about 245 lb., worked at making the suggested behavioral changes, and gradually but steadily over 18 months got below 200 lbs. They even subsequently continued over the next year to get down to a size-appropriate 185 lbs. Not everyone did that well, but the large majority lost meaningful weight typically at a modest but sustainable rate of 2-3 lbs. per month.
Equally important, they largely kept the weight off and used the continued meetings to reinforce their new behaviors.
“Effective Eating”
I believe the vast majority of adults who are overweight or mildly obese by BMI standards are capable of normalizing their weight over time without medication such as GLP-1. What is required is learning a proper selection of food to eat in appropriate portion sizes at regular daily meals that are both satisfying and nutritious. I developed this counseling framework, which I call “effective eating,” through working with my individual and group patients over multiple decades. I think the mental framework for effective eating can be well illustrated through multiple small descriptive observations:
OBS 1: “Everyone Who’s Fat Eats Too Much”
That quote is a slightly hard-edged statement of the physical reality that we are not born fat, we become fat. It’s also the title of an instructional slide show on eating that I produced over 20 years ago. There are many reasons people eat too much, but that is how we become obese.
Many people who are substantially overweight in their 50’s were normal, trim weight in their 20’s and 30’s when they were full grown. But most of us are surrounded by food and readily available calories. Social situations frequently revolve around food. Portion sizes are large in the US, dramatically less in many European countries. The weight sneaks on, often just a pound or two a year. But if uncorrected that makes 10-15 pounds a decade. I directly saw this progression because I followed hundreds of patients more than 30 and 40 years.
Stopping the weight gain is hard enough, but reversing it is really difficult. Why is that so? Fat is a highly efficient storage medium for calories. Each pound of fat holds about 3500 calories of energy. Fat cells themselves don’t burn up much energy. Long-term observations of weight loss and my own clinical experience show that men on sustained effective diets (without meds) can lose about 3 lbs. per month or 20 lbs. in 5-6 months. Women are more like 2-3 lbs. per month on sustained loss. That translates to perhaps 350 calories per day net negative, or about one-tenth of a pound of fat. So, in real life it takes 10 days of steady effort and focus to lose one pound.
OBS 2: No Diet — Permanent Change Is Needed
You don’t go on a diet. A diet is like going on vacation for 2-3 weeks, except diets usually involve deprivation and are unpleasant. Then you come home and resume doing what you were doing. You need to achieve acceptable permanent change of your dietary habits.
You must like your food, it must be tasty and interesting, and it must be satisfying so that you are rarely if ever hungry. At the end of every day, you must be able to tell yourself, “I liked my food today. It was tasty and interesting. I am not hungry. I am not deprived. I want to do the same thing tomorrow.” If you undereat and try to starve yourself, you will fail. It is not a vacation. You are moving to Tucson. You have to like the desert and cacti. There is no going back.
OBS 3: Episodic Eating Is Destructive
Eating too much at a restaurant, or an event, or after dinner several times a week will severely undercut any attempt at weight loss. You can easily regain more weight through episodic overeating just on Friday and Saturday night than you lost all week. Any time you feel bloated a half hour after dinner, you have overeaten by at least 500 calories. Since successful, sustained weight loss is 300-350 calories daily (reduced intake, increased activity), it takes you a day and a half just to get back to even. Have another overeating episode or two over the week and you find that you were “dieting” for a week and lost nothing.
Episodic eating has to be controlled if you expect to achieve sustained weight loss and control.
OBS 4: How to Limit Quantity at Supper
Most overeating occurs in the evening meal and after, where uncontrolled hunger is particularly destructive. The stomach and intestines give hormonal signals to the brain not only that you are hungry, but also that you are being fed and can calm down. Those satiety signals are slow and take 20 minutes and more to reach your brain.
So eat slowly. Chew your food. Allow the fullness hormones time to work. You want to take most of a half hour to eat your dinner, certainly at least 20 minutes. Dinner should be the completion of eating for the day, not the beginning of eating for the evening.
Drink a glass of water at the start of the meal. It will initiate the hormone response even though water is not nutrition. Or start your meal (if you can) with a light soup. You’ll be amazed at how it reduces hunger. It’s the miso soup at the Japanese restaurant that allows you to walk away after a subsequent light sushi dinner and not be starving, even when you thought you would be.
Or start your dinner with a green salad. The salad bulk induces a sense of fullness even though it is very low in calories. That’s the high-volume, low-calorie density approach that Jane Brody of the NY Times accurately popularized.
OBS 5: Have Three Effective Meals Daily
Three meals a day works better for proper nutrition and weight control than any other approach. An effective breakfast satisfies your hunger and sees you comfortably through to lunch without snacking. An effective lunch sees you comfortably through at least to late afternoon without snacking. A small predinner snack is acceptable so that you are not ravenous when you sit down to dinner. An effective dinner satisfies you until you turn in for the night, without additional food.
Three meals prevents ravenous hunger that leads to episodic overeating. Three meals also enables you to be more accurate and reproducible with your portion sizes to avert regular overeating. Grazing all day, alternate day fasting, and various strange diets are usually not effective and rarely followed for long periods. Three good meals works.
Avoiding unscheduled snacks is also important. For example, if you skip breakfast the majority of midmorning food readily available at work (think donut, bagel and so forth) is dramatically inappropriate in content (usually heavily carbohydrate and little protein) and high in calories (a typical bagel is 300-350 calories, as much as a reasonable full breakfast, and a Dunkin’ muffin even more).
OBS 6: Examples of Effective Meals
An effective breakfast should contain meaningful protein and be about 300-450 calories. In addition to coffee or tea, it could be 2 eggs, 1 piece toast and 4 oz cottage cheese. Or 6 oz regular or Greek yoghurt with blueberries and a piece of toast, or steel cut oatmeal made with 2% milk with bananas and brown sugar. It could also be a left-over chicken thigh and some cooked vegetables from the night before. Your call. But you should like your breakfast food and it should keep you from meaningful hunger until a normal lunchtime at noon-1p.m.
An effective lunch should be 350-500 calories or so also with meaningful protein. It can be a bowl of lentil soup, an Asian noodle bowl that is not outrageously salty, a peanut butter & jelly sandwich (quite caloric depending on your dose of peanut butter), a yoghurt smoothie (or our friend cottage cheese) with what good fruit is seasonably available, or that other left-over piece of chicken or a few strips of steak from last night’s dinner. You should have some liquid whether water or seltzer or 1% milk or apple juice.
An effective dinner should have 4-7 oz protein (fish, chicken, beef, or tofu), some kind of green vegetables, and perhaps 4-6 oz of starch (potato, rice) or beans, and perhaps also a salad or light soup that is really useful as a first course. That should add up to 1000-1200 calories for men, likely 700-800 calories for women. Clearly amounts will vary by age and size. But portion size matters especially for protein. A 12-oz sirloin steak is about 1000 cal by itself, far too much for an appropriately sized dinner (and enough saturated fat for the entire day). Get the taste of the steak from a smaller portion, but get your fullness from the vegetables, the salad, maybe a soup, etc. That is the high-volume low-calorie-density strategy to achieve satiety.
OBS 7: Emergency Food Snacks
We all find ourselves urgently hungry from time to time but awkwardly placed in terms of getting an attractive and calorie-effective snack. Get to know your emergency foods and have them available. You should be able to beat back your hunger for 100-150 calories with a real food that is tasty and that will hold you for at least 2 hours.
Our friend cottage cheese (with chives is a good choice) where 4 oz with 4% milkfat is 120 calories and really filling. Another dairy product, kefir (cultured milk) is similarly terrific. It’s liquid yoghurt, tasty, can be tangy, and truly filling for well under 150 calories. Or another piece of that grilled chicken. Nuts are healthy but very densely caloric. For emergency hunger you need some volume and fat, which makes the dairy options so useful. Popcorn, crackers, chips do not induce satiety. Many “power bars” are too caloric for the purpose.
Find your own emergency snacks. Know where they are when you need them and they shouldn’t cost you more than 150 calories.
OBS 8: Weigh Yourself Daily
To lose weight you have to know your weight. Weigh yourself every day, first thing in the morning, after using the bathroom and before eating anything, in the same clothing or unclothed. Keep a log. Of course you need at least a decent bathroom scale so that when you recheck your weight immediately the two values are within a half-pound. That is as reproducible a weight as you can measure.
Weight changes take time. You may be improving your diet and think you should be going down but sometimes nothing changes for 2-3 days. Usually by the fourth day your weight will show a decrease if you have actually been moderating your food. You are only looking realistically to see a 3/4 to 1 lb. weight loss per week. If there is no weight reduction by the fourth day, you are not losing weight. You need to adjust your intake.
Taking daily weights also adds to the precision of the measurements so the trend, whether down, level or up, will be clear. Once-weekly weights may have too much noise to be actionable and can be inappropriately reassuring or disappointing.
OBS 9: Predict Your Weight Each Morning
The scale is your friend. Before you step on the scale each morning, ask yourself what you think the scale should show. Down a bit, no change, or perhaps up a bit. If you see no change, or even a slight increase when you thought you should be down, use that moment to review what you actually ate in the past 24 hours. It may be that your perception of your food volume was inaccurate. By checking your expected and actual weight daily, you will help yourself calibrate your actual food volumes going forward and improve your dietary choices. Such detailed food review is impossible with weights only weekly.
Also, in the daily weigh-in remember that fluid retention from salted food can dramatically affect your weight. For example, if you eat other than a really modest dinner at a Chinese restaurant, expect to be 2 lbs. heavier the next day. Most fast foods are highly salted and frequently fatty, even if tasty (e.g., KFC). You already know that. Water weight may take two days to be excreted.
OBS 10: Weigh Your Food to Understand Portion Size
Get a good food scale and weigh a sample of the foods you eat for a few weeks until you get to know what your actual portion size is, especially of the most caloric foods. And read labels. Was that a 7-oz or 10-oz piece of steak? At 80 calories per ounce, that’s a 240-calorie discrepancy. How much cottage cheese was that? It’s only 30 calories per ounce, but cheddar is more like 150 calories per ounce. What about that potato? And so forth. You don’t have to do this indefinitely, but weighing some of your food will help you immensely in achieving appropriate portion size.
OBS 11: Weight Loss of Course Includes Exercise
Clearly you will help your cause of weight control or weight loss by increasing your level of exercise. Most any form of aerobic exercise contributes; so does strength training. All burn off some calories and make you more fit. But I think the greatest importance of exercise is that, through it, you tell yourself that you are taking better care of yourself, and that positive feedback in turn spills over to support good eating habits. Exercise itself is ultimately a healthy adjunct to dietary changes. You can lose weight without drastic changes in your activity, but realistically you cannot lose weight just by exercising if you don’t improve the nutritional pattern that got you overweight.
OBS 12: Have Realistic Goals, Don’t Backslide
Remember that weight control is not a short-term project. You’re moving to Tucson. It’s the rest of your life, because even when you reach your goal, you will still need to follow your portion control and more careful eating indefinitely to prevent resurrecting old habits and regaining weight. That’s why you have to like your food and why it should be tasty and satisfying so you have no motivation to regress.
It is realistic for an adult man to target a rate of weight loss up to 2 lbs. every 2 weeks (3-4 lbs./month) and make sure he loses at least 1.5 lbs in that time. For an adult woman, 1-1.5 lbs. every two weeks (2-3 lbs./month) with 1 lb. minimum loss.
Be prepared for setbacks –they happen. A wedding or birthday party, for example. Prepare for the event and think before you go there how you’ll handle the hors d’oeuvres, main courses and desserts. Enjoy your event but limit the caloric damage, which is usually quantity-based (a classic overeating episode). Right afterward, focus on rigorously following your new healthier nutritional pattern. You can recover from a single episode of substantial overeating within a week.
OBS 13: How Much Weight to Lose? Check Your Collar Bones
For anyone more than 15-20 lbs. overweight, an aspirational target often requires too large a weight loss to be successfully actionable. Instead, plan for weight loss in attainable increments. I suggest you first determine to lose 5 lbs. When you have done that, congratulate yourself and move on to the next 5 lbs. Even if you want to lose 40 lbs. ultimately, that amount is too daunting and too far on the horizon for you to use as your goal. Your initial accomplishment of 5 lbs. may look puny compared to the ultimate destination and thereby discourage you just when you need continued emotional support. Just do 5 lb. increments, celebrate, rinse and repeat.
What about an actual end goal? The BMI tables are based on unisex tables of height and weight that are overly broad and are inappropriate for individuals. I’d suggest you instead study your collarbones by looking in the mirror with your shoulders relaxed. You should be able to easily see the hollows above your collar bones.
That is true because the collar-bone hollows are covered only by skin and fat and not by the shoulder and chest muscles. When you gain substantial non-muscle-mass weight, your body fat fills in the hollows so the collar bones eventually disappear. In that event, based on my many decades of exam-room observations, you are a minimum of 20 lbs. overweight and likely substantially more.
So, if your collar bones are hidden, you have a lot of work to do. If they are beginning to be visible, you are getting closer and can be proud of your accomplishment. Your ultimate weight goal should be in reasonable reach.
However, you can still sport meaningful excess belly fat even with visible collar bones, but your overweight is almost certainly less than 20-25 lb. and therefore is more of cosmetic than biological importance. Nevertheless, I’d continue to encourage you to keep up the effort to get trim without important belly bulge. That is the healthiest state.
Brief Afterword: Mild v. Severe Overweight
You can achieve weight loss of 20-30 lbs. over 6-9 months by effective eating as just described. During my decades of medical practice, I helped scores of adults to lose substantial weight, and largely keep it off, by reworking their nutritional patterns. I offered above a distillate of what I believe are the most salient food behavioral issues to confront and approaches to apply for adults who are overweight or mildly obese by BMI classification.
For adults who are more than 50-60 lbs. overweight (at least class II obesity by BMI), GLP-1 drugs are of immense use, despite their frequent annoying side effects, and have been life-altering. Long-term risks remain of concern because the class of drugs is new enough that their long-term safety is not yet established. Nevertheless, even the adults using GLP-1 drugs need to develop healthier and more effective eating habits as I described above if they are to be able to sustain their weight loss and ever to be able to consider discontinuing those drugs.