Wait...what?

I know. I just violated the first rule of weight loss. For decades, we've been told losing weight is as simple as eating less and exercising more. Everyone "knows" this is true. And we all feel bad because we have no willpower and we fail. 

This idea is based on the faulty equation:  (calories in) - (calories out) = change in body weight. Although thermodynamically it makes sense, biologically it doesn't always.  As it turns out, this equation is a gross over-simplification of how our body works. Our bodies have not evolved to shed weight easily. 

In addition to pushing highly processed, carbohydrate dense foods, our culture has suggested that we need to spend hours each week on machines doing "cardio" to maintain a healthy body weight. Since most people already do their best to follow the faulty USDA food pyramid, they often focus on lack of exercise to explain their inability to lose weight.

When I gently bring up the idea of losing weight with my patients, almost universally I hear, "I know, I need to get back in the gym..."

Not only do I think exercise as a means to lose weight is unnecessary, particularly in my orthopedic patients, it will very likely be harmful. To take a joint which has been damaged by osteoarthritis and subject it to additional, repetitive, potentially high-impact activity will very likely worsen the symptoms and accelerate the degeneration.

And yet because the large lower extremity joints (hip and knee) experience forces of 3-5 times body weight with every move they make, weight loss can be helpful in reducing pain due to arthritis. Additionally, obesity is an independent risk factor for infection following orthopedic surgery. Worse yet, poorly controlled diabetes has a synergistically negative effect with obesity on infection. Clearly, weight loss is needed. Exercise is not the way to achieve it, however. 

My previous posting began to explain how WHAT we eat may be more important than how MUCH we eat. My spontaneous 25 pound weight loss occurred without entering the gym once. As an orthopedic surgeon, I am on my feet all day in the office and in the operating room, and although I consider myself "active", I did not change my activity level at all during my nutritional experiment.  

Lets look at the caloric implications of exercise for a moment. A pound of body fat contains 3500 calories of energy. An average person would burn about 500 calories during an hour of jogging. Assuming you could jog for an hour every day of the week, this level of exercise would burn about 3500 calories of fat by the end of the week. If this level of activity were maintained for an entire year, about 50 pounds of body fat would "melt away." Simple. Except for a few biological problems: Appetite is not constant. Basal metabolic rate (the amount of energy you burn at rest) is not constant. Not even highly trained athletes can sustain daily exercise with no rest days and not become injured. And lastly, exercise creates inflammation, which is linked to weight GAIN, and chronic disease.

There is excellent experimental evidence suggesting an increase in appetite and calorie consumption following exercise. The sense of entitlement that often accompanies physical exertion, can undermine proper food selection, because after all, you earned that dessert by running those 5 miles this afternoon.  Studies have shown a reduction in basal metabolic rate as well as reduction in non-exercise activity thermogenesis (fidgeting) when energy expenditure exceeds intake. Cardiovascular exercise fueled by carbohydrates generates oxidative stress as sugars are converted to energy in our mitochondria. Additionally, stress hormones like cortisol can be released in response to exercise, and through a variety of pathways cause weight gain.  Remember our brains evolved when food was not abundant. If our energy output exceeded intake for long we would not survive. We evolved to conserve energy, and to seek out calories.  This probably worked very well historically when food was scarce but has become counterproductive in the modern world where highly processed, palatable, energy dense food is omnipresent. These concepts are further developed and supported in "The Calorie Myth" by Jonathan Bailor. 

Please understand that I am not recommending becoming sedentary. I am simply suggesting that we think differently about attempting to use exercise as a means to lose body fat. I recommend remaining active. Take the stairs. Don't look for the closest parking spot. Walk around the block instead of watching TV. 

If you really want to lose body fat, I recommend you focus entirely on your diet. I recommend a nutrient dense, low carbohydrate, high fat diet. This does not require calorie counting. You should not feel intense cravings or blood sugar instability. Consider this a longterm/permanent lifestyle change as opposed to a diet- which generally suggests temporary, unpleasant restrictions. 

Future postings will explain why I believe this way of eating helps people to lose weight, and why even those who don't need to lose weight should do it anyway. I will also explain how exactly to transition to a well-formulated low carbohydrate, high fat diet, and what you may experience while doing so. 

At first glance, it may seem strange for an orthopedic surgeon to be interested in diet. Let me explain how I got here. 

Throughout my life I "knew" that fat was bad, whole grains were good, and when people were overweight it was because they ate too much and exercised too little. Simple. Like many people, I did my best to keep a low fat, high carbohydrate diet. I felt guilty when I ate steak, bacon, and ice cream. When I was hungry between meals, I would often snack on pretzels because they contained no fat. When I was thirsty, I would often choose 100% fruit juice. 

I remember hearing about the Atkins diet while I was in medical school. This was a diet that involved limiting carbohydrate intake and eating mostly fat. It sounded completely ridiculous to us at the time. Everyone knew that a high fat, low carbohydrate diet was clearly dangerous. I recall a biochemistry lab session where we "proved" eating in such a way offered no metabolic advantage with regard to weight-loss. The explanation was that the diet was so disgusting that people were repulsed by the fat they had to eat and therefore simply ate less. 

As a practicing orthopedic surgeon, I see patients with severe arthritis involving knees, hips and shoulders everyday. Since obesity is a risk factor for osteoarthritis of the hips and knees, many of my patients are above an ideal body weight. The knees and hips are subjected to multiple times body weight with every movement and thus losing weight can have a multiplicative effect on reducing joint pain. This is a standard first-line recommendation for joint pain. This was something that we routinely recommend, but rarely occurs. 

I routinely evaluate my techniques and results in an attempt to maximize good outcomes, and minimize complications. In the course of doing this, I identified 3 major risk factors linked with orthopedic infections: obesity, diabetes and smoking. This prompted a literature search which revealed that my experience was not unique. The bad news is that a large proportion of our patients had at least one of these risk factors, many had all three. The literature suggests synergy between these factors. This means the negative effects aren't just additive, but may multiply the danger. 

Based on this information, I changed my practice immediately. I discussed this information with the local primary care doctors, attempting to enlist their help to keep our patients safe. I feel that each of these risk factors is modifiable. Just as we wouldn't take a patient to the operating room for a total joint replacement if they had active pneumonia, or severe coronary artery disease, we should make every effort to improve these risk factors. 

I continued to get a steady stream of patients that had one or more of these risk factors referred to me because they were "ready" for their joint replacement. I then had the challenging and unusual task of explaining that while they may be mentally prepared for surgery, but were not yet medically optimized. Needless to say, patients were often surprised to hear a surgeon talking them out of surgery. An orthopedic infection is generally a big deal, often requiring multiple operations and long-term intravenous antibiotics. Once I explained my concerns to patients, many agreed to try to improve their risk profile. 

Stopping smoking can be relatively simple compared to losing weight and controlling diabetes. 

We gave examples of the USDA food pyramid, recommended low calorie options, focused on appropriate serving sizes, and offered referral to nutritionists. Several patients became frustrated with me, because they were unable to lose weight. They tried to eat less and exercise more. A common theme was that exercise was impossible due to the arthritis and they could only be hungry for so long until their willpower was exhausted.  Some patients decided to find another orthopedic surgeon that didn't care about their risk factors. Some patients decided to undergo bariatric surgery (sleeve gastrectomy) and lost weight rapidly, but this seemed to be an extreme measure to control weight. 

One day I was discussing this information with a couple. The husband was rail thin, and his wife (who was here to discuss joint replacement) was very heavy. While explaining my concerns and discussing nutrition with this couple I had a life changing revelation. The husband explained that they both eat the same food, that his wife often ate less than he did, and that he knew that she did not snack or eat secretly because she didn't drive and he did all the food shopping. I suddenly realized something we were never taught.

Different people must process calories differently. And maybe all calories are not equal?

I began researching alternatives to the standard  American diet. I came across a very interesting book. "The Big Fat Surprise" by Nina Teicholz. This book alleged that all of what I knew about nutrition, despite my training as a physiology major in college, and medical school was wrong. This prompted me to read yet another book. "Good Calories, Bad Calories" by Gary Taubes. I couldn't get enough. I came across a podcast "Bulletproof Radio" by Dave Asprey. Self-described as a "bio-hacker" this network security expert managed to lose over 100 pounds and keep it off eating a high-calorie, high-fat diet. Since then I have read many thousands of pages and listened to hundreds of hours on diet, nutrition, biochemistry, and exercise. The recurrent message was that carbohydrates aren't as healthy as we think and fat isn't necessarily dangerous. Our modern diet has progressively emphasized processed carbohydrates and excluded dietary fats. While the evidence suggests that Americans are indeed following the recommendations, our difficulty with obesity, diabetes, heart disease, and dementia continues to worsen.

I never had a weight problem. Like most people I had gained a bit of weight since high school, but appeared fit.  Nevertheless, I decided to do an experiment on myself. I began a high-fat, low carbohydrate diet. Just like the diet we discredited in medical school.  My plan was to try this for 2 weeks. The changes were immediate. I felt much better. I lost 10 pounds and my pants were loose. I decided to extend the experiment for another month.  I was so amazed at the results it is now 2 years later and I continue to eat this way. I lost a total of 25 pounds. My waistline shrunk by 3 inches. My body fat percentage is now 10%.

This was awesome, but it gets much better:

I was always mildly hypertensive (high blood pressure), and I had an occasional migraine. By the end of my first 2 week experiment, my blood pressure was perfectly normal. I have not had another migraine since the week before changing my diet.  I still have a "type A" personality, but my colleagues have noticed that I am much more relaxed. I have noticed improved mental sharpness, and physical stamina. 

Although this experiment was started in secret, the results were immediately obvious to friends, family members, and colleagues. Once I finished reassuring everyone that I was not ill, I then had to explain how dramatically reducing my carbohydrate intake and increasing my fat intake was responsible for my dramatic weight loss.

Even more amazing, is that my weight loss occurred rapidly and without hunger.

I believe there is mounting evidence that the long-term consumption of processed carbohydrates and exclusion of dietary fats is responsible for most of the health problems in western society. Subsequent blog postings will further develop these concepts.