IamA board certified obesity doctor who has helped thousands of patients lose weight without surgery. AMA!

What's the best advice you can give for someone trying to lose weight?

Great question. The first question I always ask my patients who want to lose weight is that "What is the value that the weight loss will bring to your life?" So I have patients really think about the subject. This could be health, quality of life, the way they look, feel, etc. My most successful patients are the one that have a clear picture of WHY they want to lose weight and what a specific measurable result is that they are trying to achieve. Obviously a lot of it related to health but surprisingly the real drive for most patients is not health but other things have to deal with quality of life and things they will achieve once they lose the weight.

One of the techniques I have found that is very helpful is for patients to create a Dream Board to see where they see themselves a year, 6 months and 3 months down the line. How they look like, how they dress, what sports/activities they do, what type of job (if applicable), friends, etc. I ask them to either bring the board or take a photo of it on their phone and show it to me and talk about their "Weight loss Story" like they've already reached it. This will help clarify exactly How much they want to lose in pounds or kilograms and WHY and baed on that, as well as their health and markers, we come up with an appropriate diet and lifestyle transformation plan for them to get there.

Hi Doc. If like to lose 80 lbs, what would be an acceptable/ practical time from to go from 260 to 180?Also any tips on what type of dieting has show good results?

Great question. the speed of weight loss depends on many factors such as age, gender, ethnicity to name a few. A healthy weight loss is typically between 1-4 lb. per week but it could be more initially but slows down as one loses weight. Depending on body mass index (BMI) and body fat a healthy higher protein, lower carbohydrate (such as Zone type diet) might be a good place to start and then modify based on weight loss.

21 year old white male here. Interesting you list ethnicity as a factor. How is ethnicity relative to weight loss? Thanks for the reply!

Based on my experience, certain ethnicities are more prone to diabetes and high blood sugar vs. high cholesterol, hypertension, etc. Also eating habits of each culture plays a very important role when devising a diet plan. For example, a very low carb, paleo type or ketogenic diet won't work for cultures who are strict vegetarian or vegans or cultures who consume a lot of starch such as many asian countries. These are all very important things to consider when evaluating a patients and wiring them a diet.

What kind of diet would you recommend to those who eat a lot of starch?

replacing simple starches with more complex starches and fiber is a great place to start. so for example, replacing white pasta with Quinoa pasta, whole wheat pasta or shirataki noodles (konjac starch). Also trying to have starches earlier in the day, preferably before 4pm and avoiding starch at dinner. Starch is broken down to glucose which increases the insulin level and results in storage of fat rather than utilizing of body fat and eventually causes weight gain in a calorie neutral individual. I also recommend fibers such as psyllium husk, methyl cellulose, chia seed, hemp seed, flax seed or cacao nibs to foods which provide with fiber as well as reducing hunger and can be added to starch, salad, shakes, etc.

How much of a role does genetics play in whether or not someone has trouble losing weight?

Great question and a very important topic. Ones genetics can play an important and a very complex role in ones weight loss journey. Therefore a reasonable weight loss goal is always the best way to approach this topic. However, with advancement in science and the topic of "epigenetics" we are finding ways to turn on and off certain genes and we will have a lot more information about this in the future.

What I have found is that there is no perfect diet and for each person, different diets result in different outcomes. One might be genetically prone to diabetes, high insulin levels, low thyroid function etc. and diagnosing and addressing those, will greatly improve the outcomes. Also using a detailed history, personal and family history would greatly help when devising the diet. Another subject that I discussed above is the topic of Probiotics. These are the "good bacterias" in our gut that can help us turn on/off certain genes and improve her metabolism, absorption of food and are our defense system. Having a diet that promotes growth of these bacterias and provides them for us is important. Research has shown that overweight and obese individuals have up to 40% less levels of certain bacterias in the gut and when they've replaced those in animal models through stool transplant from a thin to an overweight mouse, it has resulted in weight loss.

How do you feel about the HAES movement?

I think it is a movement that helps change the focus from "Die-ting" to achieving Health and quality of life. There are thin people who are not necessarily healthy and might have a higher body fat than some obese individuals. Again before starting any weight loss and lifestyle transformation program, I always recommend one gets real clear on why one wants to lose, exactly how much and what is the value the weight loss will bring into their life.

What is your opinion on the ketogenic diet?

great question.A low calorie, Mildly ketogenic diet (between 40-50 grams of carb/day) is something for individuals who do not have a contraindication (gout, kidney issues, liver issues, etc.) is a great way to lose body fat and improve metabolic markers such as blood sugar, fasting insulin and cholesterol panel. It is also a sustainable diet once an individual get into a ketoadaptive stage. I am not a big advocate of the very high fat, low carb ketogenic diets which is mostly used for individuals with seizure disorder, Parkinson's and some other metabolic or neurologic diseases and revert those to the experts in the field.

Thanks for the reply! I am actually on keto right now for fitness oriented reasons, as well as being 100% fat adapted and I can say that its possibly one of the most satisfying diets I have used for fat loss. I am having tremendous results and feel much better then I ever did on higher carb diets. We have a fairly large community here on reddit in r/keto, where there are many people that have had fantastic results in losing weight.

That is fantastic Stinkynugs. I would love to hear about other people's experiences with the ketogenic diet and how it has impacted their lives.

How can someone maintain the weight after weight loss? In my case I have reach near my target weight 5 times in my life, but I always gain weight afterwards.I lose and gain again about 50 pounds every 2-3 years.

Great topic. Majority of time Weight Maintenance is a lot harder than Weight loss and depending on the program or method you use to lose weight, this might be earlier or more challenging. I usually recommend 5-7 lb. wiggle room once an individual reaches their goal. the challenge I have seen for most people is that once they reach their goal, some of the old habits start sneaking in and gradually cause weight gain. My most successful patients are the ones who have had the most value from their weight loss and have really transformed their life. Here are some recommendations which I use in my practice:

1. 80/20 Rule: People who eat 80% healthy (like when they were dieting) can afford to have 20% of guilty pleasure or "cheat meals".
2. sticking with some type of an exercise program at least 5 days a week is key. Find an exercise one loves and enjoys and look forward to doing. This could be something as simple as walking or classes such as dancing, etc.
3. Having soluble fiber such as psyllium husk, Konjac starch, etc. everyday
4. having lighter meals or skipping dinner a couple of times/week and mimicking a 12 hour fast.

Do you see any evidence that some people really cannot lose substantial amounts of weight on a "typical" calories in-calories out system, i.e. by simply reducing their caloric intake below caloric expenditure?

Absolutely. I have found that just cutting calories will not be a very sustainable way to lose weight. It might work in short term but the type of calories cut and consumed is very important. For example, a 1000 Calories of chocolate is not the same in terms of metabolism and bioavailability as 1000 calories of steak or broccoli or alcohol. For some, the body has to use its own sources to breakdown the protein the vegetables slow down metabolism as well as fats, therefore urging hunger and alcohol turns into pure calories or what I like to call fire. What we need to control is to lower blood sugar and eventually insulin. By lowering insulin, we guide the body into utilizing fat as fuel rather than glucose or glycogen and fat is a more sustainable source of fuel than glucose.

I'm probably too late to the party here, but could you provide peer reviewed evidence about the long-term unsustainability of running a caloric deficit for weight loss? I would be particularly interested in longitudinal studies.

Also, as a follow-up question to your reply to /u/rivke, why make the comparison between 1000 calories of chocolate and 1000 calories of broccoli/steak/alcohol? Is it your experience, both in your own practice and in your knowledge of research in your field, that people's actual dietary habits reflect such a gross nutritional imbalance that bioavailability becomes a practical concern for most people? Or, put another way, controlling for bioavailability of diet, can't you lose weight by managing your calorie deficit?

In general, I am more of an advocate of a diet based on whole foods which contain more bioavailable vitamins and minerals and taste better. The reason I made that comparison is to make the point that calories between various foods does not have the same impact on the body and by eating certain foods and avoiding certain foods can impact the success of the diet. In other words someone who is following a lower carb ketogenic diet will not get as hungry as someone who is on the same calorie but consuming more starch and sugar and less protein or fat.

Calorie deficit has always shown to cause weight loss, however based on my clinical experience most of very low calorie diets are not sustainable unless designed in a fashion to keep the carbohydrates low and protein and plant based fat percentages a bit higher.

I have over the last couple years lost a lot of weight. The only problem I have is that I lost the weight so quickly that I have a lot of excess skin around my belly. Other than surgery (and the obvious of diet and exercise) what would be some suggestions to rid myself of this?

excess skin is always a challenge after weight loss and it varies from person to person. In addition to the amount of lost weight, Age, ethnicity, skin type and many other things can influence it. Besides surgically removing the skin (tummy tuck, abdominoplasty or panniculectomy) there are some other options that might work such as laser liposuction and Cryolipolisys (e.g. Cool sculpting) which also might work. If you give the area time and practice core based exercises such as yoga or pilates, it might also help improve the area.

I have previously lost a LOT of weight using sibumatrin, but after about 10 years, the loss is more or less back. I'm currently dropping about 1,5 kg per week by changing diet alone (as sibumatrin is no longer available), and have been doing so for about 2 months.

I am not subscribing to any special diet, but eating more or less the same, as I want my new lifestyle to be permanent and not 'go off' something when I am done; I only eat more vegetables, smaller portions and only have 1 serving - tracking calories to under 2000kcal per day.

Last week I discovered that apple cider vinegar helps a lot (not feeling as much hunger), and drink about 3 tablespoons mixed with water per day.

Q1: any other household ingredients you can recommend to feel full.

Q2: tips on how to mentally keep from gaining weight once the target weight is reached? Something like ACT maybe (wich I found very useful) centered on diet.

Q1. Besides Apple cider vinegar which I also recommend, fiber also helps greatly to make you feel full and help lose weight. In general if someone likes pasta or starchy food, I recommend looking into adding Konjac starch (e.g. Shirataki noodles or Miracle noodles) to their diet for meals. It tastes great with pesto sauce, tomato sauce, etc and is very filling. Also Chia seed, Flax Seed, Cacao nibs are superfoods which provide energy, fiber and are great sources of plant based fat.

Q2. Going back to the value that weight loss brings to ones life, the joy one gets from eating needs to be replaced by something else. For example, I have patient who has lost 200 lb. in about a year. He went from being a 400 lb. security offices with minimal physical activity to an avid runner who runs over 40 miles/week and gets a lot of joy from it. He does not run to lose weight but really enjoys it. I recommend people to revisit their dream board and modify it during their journey and keep the focus.

You mention the importance of mental health for people trying to lose a lot of weight; I agree completely. I have watched friends suffer and agonize due to a desire to lose weight and seen them develop painful and long-lasting eating disorders instead. How does one maintain a positive mental attitude about weight loss? Is it a matter of making weight loss more goal oriented ("I'd like to be able to run a 5k" vs "I need to lose X amount by Y date"), or is it more individual?

Yes, unfortunately focusing solely on weight loss can be counterproductive and can result in eating disorders. Media is also not helping us either and puts a great deal of focus on losing weight. You are absolutely right in changing the way we ask the question from weight loss to a value or goal one can achieve such as running a 5 K, or hiking without getting short of breath, or being able to zip line, etc. We all do thing in life to FEEL GOOD and Avoid FEELING BAD. So if we can focus on getting more functions that would promote long lasting pleasure and reduce pain it would help more.

As an example a patient of mine at 400 lb. could barely walk but now at 200 lb. is running half marathons almost every week and is addicted to it despite some aches and pains here and there but he started from 5k and worked his way up.

Have you tried/recommended Weight Watchers? I recently came across this article citing WW and Jenny Craig to be the two programs that work the best.

I have not joined Weight Watchers or Jenny Craig directly but have tried their type of diet which is a balance low calorie diet and as you stated and articles have shown, they work. Weight Watchers creates a very safe community for patients/clients to discuss their challenges and keep each other accountable on a weekly basis. A big part of losing weight and transforming ones life is to have a community support because all of us will fail from time to time during a diet and need someone to coach us and help us get up and refocus. Many of my patients see me and attend Weight Watchers simultaneously and I basically tweak the diet based on their health and goals. Weight Watchers also provides great online support for tech savvy individuals.

When using any kind of intake restriction whether general dieting or specific types of dieting over a period of time, should people be monitored professionally and how often?

Great question. This depends on the heath of each individual but I recommend anyone who wants to take a dramatic change in their life to lose weight to be evaluated before dieting to make sure they are healthy and do not have any silent issues which would prevent them from following certain diets. For example, if one has high uric acid levels, following a high protein diet might result in a gout attack or kidney stones. Also during any diet, it is best to check liver and kidney function as well as some other markers to make sure there are no surprises. Initial blood work also helps with planning and choosing the correct diet and planning certain goals such as lowering blood sugar, cholesterol, improving certain vitamins, thyroid function, etc.

What's one of the most touching/exciting/shocking story you ever came through ?^{sorryI'mjustcurious}

:p

So many to pick from! The one that comes to my mind is a patient who was referred to me by a long time friend of him who has been my patient for many years as a primary care (not weight loss). My patient cared greatly for his friend and was hopeless. He was worried that his friend was going to have a sudden heart attack. When I saw this individual, his blood pressure was very high, 200/100 and his kidney and livers were failing. He was on multiple different blood pressure and pain medications prescribed by various specialists but because he did not have a main family doctor, some of his medications were double dosed and had resulted in the liver and kidney problems. He also came from a family where food was a great issue. He had always been overweight throughout his life but had a great quality of life, very active and an overall happy individual with many friends. When I spoke to him, I realized that he was not so much concerned about his weight but more hip pain which was preventing him from being active and interfering with his life. Therefore, I put a lot of focus in fixing his hip pain with an anti-inflammatory diet and water therapy. To my and his friend's surprise, he dropped weight very rapidly and defied all odds. He was able to lose over 160 lb. in 15 months because it made his pain go away and brought back some of the activities which provided him with Joy. Since he is a real people's person, his success resulted in many of his friends and co-workers taking action and all of them together were able to lose over 1000 lb. in 18 months and provide support for each other, a truly community health improvement movement which brought tear to my eyes and I use it as an inspiration for other patients.

wow!! Inspiring answer!! I am 44 pounds overweight. I started my journey 1 month ago and lost 9lb already!! wohooooo!! I feel so motivated because I am seeing results and I feel SOOOO good!! :)

That is awesome. Congratulations! I am very excited for you. Best of luck in the next 35 lbs. keep the fats melting away and say goodbye to them forever

What's I a good way to motivate someone to lose weight? How do we go about controlling his diet without making him feel like were constraining him. He always gets annoyed when we tell him to watch his weight and all. He is 20 now and obese. What exercise regimens do you reccomend as well

Great question. If you want to help someone change any habit, it is first best to see where they are in terms of their readiness to make a change. There are 5 stages in the "Continuum of Change", Precontemplation, Contemplation, Preparation, Action and Maintenance. If someone is in the Precontemplation stage but we force them to lose weight or change a habit, they will get turned off and rebel against our will. So in that stage, it's best to in a sense leave them alone and try to guide them to the next stage, contemplating why we are concerned about the excess weight so they decide that maybe weight loss is a good option. This is very tough and a very sensitive subject. Eating healthy and being active around the individual without directly being obvious is key. Also maybe having them get a general check up of a Physical exam by the doctor so they see numbers and lab values might help.

In terms of exercise, the best exercise is one that someone loves to do and can commit on doing on a regular basis! I am a big advocate of technology and recommend using pedometers or apps on smart phones to count steps and activities, start small, maybe 5000 steps/day and work your way up to 10000-12000 active steps/day. Also committing even 15 mins of some type of activity such as walking, hiking, swimming, etc. would work. Best exercises in terms of health and fat loss are interval or circuit training type exercises paired with yoga or pilates.

Our issue mainly is that he really gets defensive and agfresuve when we mention his weight. He knows he's overweight but there's nothing pushing him to lose it. We've given him the health scare multiple times but he hasn't really lost any considerable weight. He does play some tennis but not regularly. Thank you for your advise :) the one step we haven't taken is brining him to a doctor so I shall recommend that.

I feel for you, teenagers and young adults are probably the most difficult to motivate and unfortunately a health scare is not very effective. Fitness centers such as Crossfit provide a very safe and supportive network of young individuals and besides exercise, also support a paleolithic diet and provide education and support and I have found it helpful for some young adults.

How does stress and emotions play into weight loss?

Thank you for your question. This is a great and a very important topic. Stress and emotions play a great deal, physiologically and psychologically into ones's weightless journey. Stress hormones such as cortisol and adrenalines make us retain fat, retain fluids, feel down, depressed, anxious, hypertensive, bloated and tired. Mentally we would feel unmotivated and feel helpless to lose weight. Choosing an anti-inflammatory diet, full of micronutrients and bioavailable vitamins and minerals and healthy fat not only helps lose weight but usually significantly improves ones mood and energy level and I see this time and time over for individuals who are ready to make a change.

Thank you for responding! I feel like I do well enough to eat healthy, I work out pretty regularly and vary between high intensity cardio and strength training, but I am getting nowhere. However, I am always depressed/stressed out and my sleep pattern is terrible, and I wonder if this is why I can't seem to lose it.

Sleep is another subject that can not only improve ones health and mood but also address weight loss, hypertension and weight related issue such as insulin resistance. There are hormones that get secreted during sleep, the most important being Leptin that can help improve the metabolism and result in fat loss. When one does not get enough or high quality sleep, the leptin levels do not rise or one becomes leptin resistant and will have a challenge losing weight. Therefore talking with a sleep specialist or a primary care specialist about potentially getting a sleep study is not a bad option.

What is your opinion of ketogenic, alternate day fasting, and sub 1200 calorie a day meal plans? And I mean individually, not all at the same time.

Great Question. So I will answer each individually:

1. Ketogenic Diet: I am a fan of a mild ketogenic diet (less than 40 grams of carb/day) and practice it myself every so often. It is a great diet to help lower blood sugar, help lose abdominal fat and improve other health markers. Also compared to other non-ketogenic low calorie diets, once one gets into ketosis, it is easy because the caloric intake is not as much of an issue since during ketosis once does not get hungry.

2. Alternate day fasting or 12 hour fasting has clinically shown to increase metabolism and improve sugar control and increase insulin sensitivity. I use it for patients who are interested to follow it and also it helps when during a weight loss program one hits a plateau to restart weight loss and improve the metabolism.

3. For sub 1200 KCal diets, if it is a non-ketogenic diet, the hunger issue might be tough. So I make sure if someone wants to follow a very low calorie diet, they are taking at least 1.3 grams of protein per KG of body weight and are taking adequate amount of fat and can lower their carbs below 60 grams so they don't get hungry

What are your thoughts on the HCG craze a few years back?

A great Question. I do not practice the HCG diet. As you are aware, HCG is a pregnancy hormone that in some clinical trials has shown to mimic luteinizing hormone (LH) and increase the metabolism and suppress hunger. However, it also has other side-effects. A typical HCG diet plan is 500-800 Kcal of a low carb diet along with daily HCG injections and typically someone follows it between 20-30 days. What I have found is that an adherent patient will typically lose weight rapidly on it in a short period of time, but after they stop it, regain the lost weight and more back quite rapidly. The biggest challenge of any weight loss program is the Maintenance phase of the weight loss and because the HCG diet is so dramatic, many people who follow it do not learn how to maintain the lost weight and after the weight loss phase is over go on a carb or caloric binge and gain the weight back.

Hi! What do you think about the mediterranean diet? And the Dukan diet? Thanks!

Mediterranean diet is one of the most studied diets and usually head to head beats most diets in long term studies in terms of improving health markers. However, the issue is that there is no one "Mediterranean diet" and based on various regions in that area, there are many diets. The weight loss with a typical Mediterranean diet is not as fast as a ketogenic or Dukan diet but it is more sustainable in long term and is also more fun for people who love variety of food, colorful foods and taste. Dukan diet is a great diet in terms of speed of initial weight loss and the structure. If one follows it, they have to make sure that after the lost weight has been achieved, they have a well structured maintenance plan to be able to maintain the lost body fat.

Do you have any tips for skinnyfat people? Basically anyone who isnt overweight but wants to reduce bodyfat?

I have a lot of Skinny Fat patients!! We check body fat on whoever is interested and most body fats are above normal range. for patients who are skinny fat, there are not a lot of diet options since the metabolism is low. So we start with a blood panel and check hormone levels such as thyroid, insulin, etc. and if all are normal, usually recommend a mildly ketogenic or a very low carb diet to improve metabolism and result in fat loss. I try this approach myself every few months and have found it very effective.

My husband has been struggling to lose weight for 10+ years. How can I help him?

Probably the best place to start is

1. Have a deep conversation with your husband and try to really extract why he wants to lose weight (health, looks, quality of life, exercise, etc.) and how much. Try to really get clear on the Value the weight loss will bring into his and your life and put a dollar amount to it. For example, for an early stage diabetic, dramatic healthy weight loss might save them millions of dollars of healthcare costs (drugs, doctor visits, labs, time off from work, etc) over their lifetime. After that construct a Dream Board of all the things he will get by losing weight.

2. If he is ready to take action, plan on seeing a physician, preferably a weight loss specialist. Good resources are societies such as The American Society of Bariatric Physicians (asbp.org), The Obesity Society (obesity.org) and Institute of Functional Medicine. Hopefully the physician can do a thorough evaluation and come up with the right diet and lifestyle transformation program for your husband.

I seem to do really well keeping my weight down but every few years I have to take prednisone for this or that and I end up gaining tons of weight. I could live on ice cubes and still balloon. Why does this drug, or any drug, have that effect on users?

Thank you for your question. Great job maintaining your weight. Weight maintenance is a much bigger challenge than weight loss and mastering it takes a lot of courage and expertise.

Unfortunately the biggest side-effect of steroidal anti-inflammatories such as prednisone, cortisol, etc. is increased appetite, weight gain, high blood sugar, diabetes, fluid retention to name a few. However, if one must take it for health reasons, probably it is best to talk to the prescribing doctor or the primary care physician about potentially being on a mildly ketogenic diet or another form of low carb/low calorie diet during the course of steroids to avoid weight gain or fat gain if there are no contraindications.

What is your opinion on Joel Furhman's work and his diet principles?

I belong to the Institute of Functional Medicine and have met Dr. Furhman during meetings. His diet principals are great for individuals who decide and commit to follow it and he has a lot of clinical research to back it up. His diet is very high in micronutrients and phytonutrients which have clinically shown to improve metabolic markers and improve conditions such as autoimmune disorders and some cancers. Again picking the right diet is a very subjective issue and a lot of it has to do with how dramatic of a change one wants to make and Dr. Furhman's program is one of the great many options out there.

I'm not obese but I am certainly overweight. What are your best tips to lose weight? I know this could be difficult because this sounds pretty complex, but please give it you best shot!

First it is best to really get clear on Why one wants to lose weight (health, looks, quality of life, mobility/exercise, etc.) and exactly how much in pounds or kilograms (or dress size). As I've mentioned before, creating a dream board and looking 6-12 months ahead and working the way back is usually helpful. Then these general rules might help:

1. with each meal, have 2-4 ounces of organic/grassfed or plant based protein.
2. Eat the biggest meal in the morning, smallest at night
3. If there are no contraindications, drink 8-10 glasses of water daily.
4. have 6 cups of vegetables (colorful) and 2 cups of fruits (seasonal) daily.
5. Try to skip dinner 2 nights/week.
6. use a pedometer and try to get 10000 steps/day.
7. have 20 grams of fiber daily, added to meals.
8. Probiotics (yogurt, Kimchi, kombucha) daily with meals. I cannot stress the importance of Probiotics in general health and weight loss
9. Finding a buddy to keep one accountable and provide support during the journey is also very helpful.
10. If all fails, see a weight loss specialist (ASBP.org, Obesity.org)

Is Myrbetriq the answer?

Myrbetriq a drug to treat over-active bladder has shown to activate brown fat and increase metabolism in small studies. However, I have not used it off label for weight loss and aside from hearing about it during meetings, do not have any personal experience with it. In treating fat loss, I usually try to stay away from the concept of a magic pill or a one size fits all diet because different individuals respond differently to various drugs and diet and I've noticed that if I put a lot of importance on a specific diet or drug, I will set the patient and myself up for failure and disappointment. However, brown fat and its importance in improving weight loss and metabolism is a very hot topic and there will be a lot more coming up about this subject.

Any thoughts about the Slow Carb Diet (Bean Diet)?

The "Slow Carb diet" is another type of low carb (non-ketogenic) diet based on slow metabolizing carbs (low glycemic, high fiber) paired with lean protein, legumes and vegetables. It is a healthy diet and since it contains complex carbohydrates and vegetables, fairly easy to follow and sustainable. I am a big advocate of the type of philosophy that Slow Carb also advocates, less processed carb/sugar, more healthy protein and whole foods.

Hi! I'm going to sound like a baby because my problem isn't big but it's still important to me. I've lost over 100lbs on my own but it took me about 10 years of trial and error, ups and downs. I've been fighting roughly 10lbs of fat for maybe 1 year now and I just can't get it off. I'm frustrated to the point where I actually considered surgery or using steroids, 2 things I'm very strongly against. I'm going to include a couple of pics to provide context

This is 260lbs, i was 300lbs at my heaviest

This is about 200lbs, showing the fat on my lower abdomen

200lbs, not pulling on it

I train hard, drink lots of water and eat pretty clean. What else can I do?

Great job losing 100 lb. That is incredible! You must be proud of yourself to do this without surgery or meds. What you are struggling with is a very common issue that many people deal with after a large weight loss and that is excess subcutaneous fat. What a proper diet helps losing is internal or visceral fat. The fat that is between the intestines and organs. Unfortunately, the superficial fat, the one under the skin is hard to lose and many diets do not help with that. This might improve with time but Cryolipolysis (e.g. Cool sculpting) is a non-surgical option to look into as well as laser liposuction. However, none of them will guarantee that the area will become completely flat. I always recommend looking for a board certified plastic surgeon who specialized in body conturing.

I have a cousin who said he and his wife cut out sugar, did not work out, and lost 30 lbs in 2 months...I have a friend who cut out alcohol, did not work out, and lost 15 lbs in 1 month...What are your thoughts on this? Thanks!

Great stories. What I have found is that weight loss is about 80% dietary changes (e.g. cutting sugar and alcohol) and 20% diet. at the beginning of any weight loss program, I usually advise against any type of intense work out because it is usually counterproductive. Working out lowers the blood sugar and makes one feel hungry, it also gives an individual a false sense of hope that "now that I've worked out for an hour I can eat whatever I want" an hour of intense work-out usually results in roughly 500-1000 calories energy loss which can be easily replaced by a starchy food in a short period of time. I usually recommend walking or light cardio during the first month or so of weight loss and then as they get used to the new lifestyle, gradually add activities.

So your cousins story as well as your friend's story are inline with what I've seen in clinical practice.

Hello. This is something my Wife and I are working on as well as we can. We are on a low carb diet and avg 40-50 carbs a day. We seem to be stalling after losing approx 20 lbs. We have a habit of drinking Sugar free Energy drinks, could this be stalling our progress?

Great question, This question takes us to the topic of probiotics and their importance for our gut and overall health. A standard American Diet (SAD for short!) does not promote growth of these useful gut bacterias. Everyday there are more and more data about the importance of keeping and maintaining a healthy gut flora. There are date from animal and human studies that show Overweight individuals have 40% less gut bacteria than their normal weight individuals. Sugar Free Energy drinks have shown to decrease growth of these bacterias and do not improve their growth. Therefore I tend to recommend either avoiding them or get drinks containing Stevia or maybe trying Kombucha. However, Kombucha does contain about 7 grams of carb per serving.

Wow, Thanks for the great response. Would coffee be a good Caffeine replacement? We have them more because of that rather then just the flavor.

Sure, regular coffee or even better Green tea would be great caffeine replacements and would provide you with tons of phytonutrients

Do you have any advice for men that lose weight yet still suffer with gynaecomastia?

Another great question. Unfortunately gynecomastia is a condition that with excess fat gain and rise in estrogen level it is common in us men. I have found that in some individuals a mild hypoglycemic, ketogenic diets significantly reduces the size of breasts and improves sex drive and free testosterone levels and lower estradiol levels. However, if the gynecomastia has been there for a long period of time or is side-effect of some pharmaceuticals (e.g. testosterone or anabolic steroids) it is more challenging to treat. I usually recommend patients see an endocrinologist (gland specialist) to discuss their non-surgical options since there are some pharmaceuticals that help (aromatase inhibitors) but severe cases would require a visit to a plastic surgeon.

Has the HAES movement affected any of your patients' view on obesity? If so how do you deal with them?

A very important question. When patients ask me what is my "Ideal Body Weight" and they usually revert to the old BMI chart, I tell them that the Ideal weight differs between individuals. There are a lot of overweight but healthy and active people and lot of underweight or normal weight individuals who do not have enough lean mass/muscle or have excess abdominal fat. So the HAES movement takes the focus away from an ideal weight to improving Quality of life and preventing or reversing disease. To give you an example, one of my patients used to weigh close to 400 lb. and suffered from high blood pressure and severe hip pain/arthritis and kidney and liver failure. His biggest issue at the time was hip pain. It prevented him from walking and he was in pain all the time. Due to the high blood pressure and liver/kidney issues, he could not take most conventional pain meds. So for him, weight loss was mostly to get him a candidate for hip replacement. He had always been overweight throughout his life but was very active and really enjoyed his life.

Through a moderately low calorie zone type diet as well as a lot of water based exercises, he was able to drop over 150 lb. to become a candidate for hip replacement. after he recovered from surgery, he became more active and said that he feels more comfortable if he gains some weight back and he is still much lighter than he started, but heavier than his lowest weight. Therefore individual goals in terms of weight really matter.

Follow-up if you don't mind, why isn't the BMI chart considered to be a good measure?

Body Mass Index (weight in Kg/square of height in meters) is one of the ways to categorize an individuals weight but it does not take into account the body fat and solely focus on weight and height. Therefore for muscular individuals and athletes majority of them would fall in the overweight/obese category while their body fat is very low, typically for men below 14% and women below 18% and are extremely healthy. The same applies for people who are muscular built. Therefore, I recommend not only checking BMI but only body fat and focus the weight loss on excess fat loss rather than weight loss which could result in loss of lean body mass as well.

In your opinion is obesity on the rise because parents are having children at a younger age than the last generation?

Hmm.. great question for me to look into. I'm not sure. A few generations ago as well as in many other countries, Asia, South America, parents are much younger than here in the US and parenthood age is on the rise in general with freezing the eggs, etc. Processed food and food additives as well as refined sugar and starch are great contributors to the rise of obesity and obesity related diseases such as diabetes type 2 in children which we used to call "Adult Onset" diabetes. Unfortunately with the rise of Westernization of Asian countries, obesity in children is on the rise in countries like China at a great speed.

Do you think that the rise in technology has also paved the way to childhood obesity?

Absolutely. With the rise of use of technology, video games, smart phones, etc. Our children are not as active as they used to be and as parents, we do not feel safe to let the children play outside as much. Also as parents, were are indulged and use indoors more and do not get out as much and our children copy us. Therefore treating childhood overweight always starts with the parent(s) and is a bigger challenge than treating adults because children do not have the same health urgency that adults do to lose weight. My very first patient many years ago was a 14 year old boy who was 450 lb. and suffered from congestive heart failure and was in the ICU but still did not think he would die from the heart failure and it forced me to use a lot more of visualization techniques about the value he would gain from eating healthier and losing weight to motivate him than the scare associated with his weight and heart failure.

So encouraging parents to be more active, use less technology or dedicate some time to preparing healthy food and being active, outdoors is one of the pillars to help the entire family.

Do you see obesity affecting one ethic group more than others

Yes, prevalence of obesity is slightly more in certain ethnicities compared to others. Here is a great link to some raw data state by state: http://kff.org/other/state-indicator/adult-overweightobesity-rate-by-re/

Do you notice it more in women vs men or does sex play a role at all

Statistically women are more proactive about seeing a doctor and seeking care and are usually the ones pulling their partners to see a doctor. So I see more women who seek advice and care about their diet and weight related struggles. However, overweight is a condition that I see in 60% of my patients and I am not sure if there is a gender difference there. In terms of weight loss, men tend to lose weight faster (i.e. in a shorter period of time) due to higher amount of lean muscle mass when age and weight are taken out as factors but I have found women adhere to a program for a longer period of time and hence in long term the weight loss results are similar.

Hi and thanks for doing this AMA ! Have you worked with occupational therapists and if so, what did you do/areyou doing ?

You are very welcome. I have worked with physical therapists but not occupational therapists when we have mutual patients to help them lose weight and improve their anatomy, specifically core muscle building.

I would be interested to work with occupational therapists though. How do you think we would be able to work together in concert?

Thanks for your answer !

I was thinking about how the person manage to do the "little things of life" (activity of daily life), if their environnment (house, workplace, leisure, etc) is adapted to their handicap, how they are inserted into society (vocational rehabilitation for exemple).

I'm very curious on how to work with people who are overweight and obese and how other professionals and other countries work ;)

That is a great point, than you for clarifying your information. I never thought of occupational therapists like that. That would be a great complement for weight loss. Some of the available modalities that help make the environment assist with weight loss (Non-Exercise Activity Thermogenesis or NEAT type activities ) are standing desks, walking meetings in work places as well as more ergonomically designed desks and tables but it is a great idea for an occupational therapist to maybe look at an individual's home or workplace and improve the look to assist with quality of life.

have you treated patients who were overweight and pregnant? What are some guidelines for a pregnant patient who has been told to stop gaining or to try to lose weight?

Yes, I typically work with their Obstetrician. Maintaining a healthy nutritional environment during pregnancy is very important to the health of the mother and the child and can literally have an impact on the child's life. During pregnancy for overweight patients, the goal is to keep healthy nutrition, taking the appropriate vitamins, folic acid, DHA, as well as protein, whole foods and avoiding as much processed food, processed starch, soda, caffeine and sugar as possible. This obviously will be more strict for individuals with gestational diabetes but based on the start weight of the patient, we expect little weight gain in the teens during pregnancy. Some individuals who are obese tend to lose weight during the pregnancy.

Exercise is also another key factor to improve both mother and child's health during pregnancy and I encourage keeping an active lifestyle if there is no contraindications to it.

Is it really just nutrition and calories out minus calorie in?

Nutrition and Calories out minus in is certainly a major contributor to one's health and weight. However, many other factors contribute to weight gain from one's birth (the mother's health and weight and diet during pregnancy), to genetic predisposition, quality of food one consumes and how much nutrients (fruits, vegetables and nuts) one consumes and also level of activity. Not just exercise but how active one is. For example, people who live in small towns and walk or bike everywhere such as a lot of European countries, are typically a bit lighter. Her in the US we can actively set some time aside to walk more, park our cars farther, take stairs vs. elevators. In general, caloric restriction is the most effective way to lose weight but not very effective to maintain the lost weight unless it is paired with permanent lifestyle and behavioral changes.

What do you think of the variants of intermittent fasting, specifically the Every Other Day Diet? It seems to have a lot of science backing it up.

Well, the Every Other Day Diet is a bit less confusing and perhaps easier to follow than the 5:2 diet but still requires a lot of planning and might come with a lot of mood swings the first couple of weeks of following it. Also choosing the right caloric food on the Low Calorie days, i.e. 500 Kcal days, is important. I think for some individuals it is a good diet to follow if they are trying to lose quick pounds in a fairly short period, however, for individuals who are trying to lose more than 10-20 lb. I would use it only during times of Plateau to boost the metabolism.

What would you recommend for long term weight loss for people with a lot of weight to lose? The eat less move more mantra is kind of inexact. I like the specificity of the every other day diet.

If one can follow the every other day diet, then as long as it is done under supervision of a doctor and there are no contraindications to it, it's effective. The key is if one can follow it over a month or longer. I've found a 1200 Kcal Zone diet (40%carb and 30% protein and 30% fat) and Mediterranean diets the most sustainable over long periods

What diets have you tried before and what are some of the challenges you've faced?

Have you heard of time restricted eating? It's sort of like intermittent fasting but you basically constantly fast. So for example, you eat during a 9 hour window (11 am until 8 pm let's say) and then the rest of the 15 hours you fast, every night. In rats, it not only protected against diabetes (increased insulin sensitivity I think) but also reduced fatty liver deposits and rats tended to lose weight.

It sounds like if you incorporate regular fasting into your routine you're good? Do you need to fast for longer than 15 hours regularly?

12 or more hour fasting has shown to improve insulin sensitivity and significantly improve pre-diabetes. Therefore, I advocate it for my patients at least 2-3 times/week. 15 hours might have a larger impact and be more effective. I usually recommend eating earlier in the day and stopping earlier to get the most reduction of insulin levels at night when insulin sensitivity is lower in general and we get more spikes of sugar.

Hi Doctor,

I'm 3 months into my weight loss regime. I started as a 27 yo male, 5'11 285 pounds. I'm currently 32 pounds down after 11 weeks and I feel great. I do however have some concerns about loose skin, I'm most likely going to have quite a bit of it.

Are there any legitimate methods to reduce loose skin while I'm working towards a normal weight?

Edit: phrasing

Hello and thank you for your question. Wearing compression clothing during weight loss and keeping the skin soft with lubricants as well as regular exercise hopefully will avoid stretch marks and help firm up the skin. However, if one loses a significant amount of weight, there might be a need to look into Cryolipolysis (e.g. Cool Sculpting) which is a fairly painless and affordable procedure or, Laser liposuction or body conturing surgery. To give you a couple of personal examples, I have a 50 year-old patient who has lost over 80 lb. and her skin eventually firmed up and did not need anything but a 40 year-old gentleman who lost 200 lb. and needed major body conturing surgery to reduce excess superficial fat which weighed over 20 lb. So once you reach a normal weight, give it some time and see a few doctors before making a decision.

1. is it true that even splenda cause increase sweet cravings/threshold and therefore causing more carb consumption?

2. i love the probiotic drink yakult. do you recommend its use after antibiotic induced diarrhea vs lactinex/ florestor?

thanks

1. Artificial sweeteners reduce viability and growth of gut bacterias and also cause a spike in insulin release and due to the lowering effect of blood sugar, cause sugar cravings and hence more sugar and carb cravings.

2. It is usually recommended to take probiotics a few hours after antibiotic intake and also following the course of antibiotics for many months. Each course of antibiotics deplete the gut bacteria for a few months and regular intake of probiotic can greatly improve health and immune function to name a few.

1) Have you ever heard of "leangains" or other forms of intermittent fasting? What do you think of the different fasting diet protocols?

2) What kind of diet do you personally follow?

3) What is the best way to approach someone who is sensitive about their weight in order to support them? For example this person drinks many soda pop beverages. How can I suggest they stop without hurting their feelings?

1. Intermittent fasting of 12 hours or more has shown to improve metabolism, specifically sugar metabolism. I recommend it to individuals who are interested, have pre diabetes, and hit a plateau to name a few and it typically helps improve weight loss. Also a protein sparing modified fast is a great approach for rapid weight loss but needs to be paired with a sustainable maintenance approach.

2. I have tried many diets including hypoglycemic ketogenic, 14 day juice cleanse, liver cleanse, Atkins (very low carb), Zone, Paleolithic, Mediterranean, Vegetarian, Vegan and pescetarin to name a few. As maintenance, I follow a Paleolithic diet with occasional whole grains such as Quinoa, wild rice, etc. however, I try to follow the 80/20 rule (80% low carb, 20% cheat days) and have been able to maintain my weight and body fat since 2010.

3. Take the "weight" discussion out of the topic and focus more on Quality of life. Focus on How is the quality now and what it could be with some fat loss and improvement of body structure, muscle gain, fat loss. It is always best to focus on improving happiness, wellness and wellbeing and avoiding pain and if losing weight contributes to those, it can be paired to that to have lasting effect.

Can you be healthy and obese?

How do I explain to my family their life choices will lead them to diabetes, high blood pressure, and high cholesterol?

Edit: When do you feel prescribing amphetamines for weight loss would be appropriate?

Great question, it depends how you define "healthy" but yes, you can be healthy and obese and also you can be unhealthy and normal or underweight. Excess abdominal fat or abdominal adiposity is directly linked to conditions such as high blood pressure, diabetes, heart disease and many cancers such as breast cancer, colon cancer, etc. Many of these conditions take time to show with conventional testing such as blood work, imaging etc. and when they do show symptoms, sometimes it is too late. Based on my experience seeing a trustworthy family doctor and having him show facts and numbers and recommendations goes a long way and can have a great impact.

I use appetite suppressants usually as an adjunct for people who reach a plateau or struggle with over-eating, binge eating, etc. I do not use it as first line for treatment of obesity and tend to use it for the shortest period of time and have found that philosophy work. Appetite suppressants and pharmaceuticals have their own place but nothing takes place of real food and behavioral change but if used properly, they are great resources for additional help.

Hi there, I'm a medical student in New Zealand and my current goal is to become a doctor in a similar vein to your work, I hope I'm not too late to catch you :). The reason that I'm thinking of this is that I'm really frustrated at the way that people with type 2 diabetes are being treated in a way that simply assumes that they do not have the willpower to lose significant amounts of weight. Rather than giving them a realistic options for weight loss, I find that they are almost always treated with medication and the condition just gets worse. Anyway, my question is whether you have any advice for me in my goal of opening my own clinic? I don't have much in terms of financial means and I'm at a loss as to where to train as I'm really unsure if there is anywhere in this country that is at all modern in their view of diet and weight loss.

My second question is a much more specific one, what are your opinions on artificial sweeteners? I have to admit to being somewhat biased on this because they have helped me to lose a fair amount of weight myself but I have become somewhat convinced by reading that they are significantly worse than just drinking water. Do you think them a reasonable substitute for sugar sweetened drinks, a good stepping stone or do you think people shouldn't drink them at all?

Hello to New Zealand, I was going to call it a night but will gladly answer your questions... To answer your first questions, I completely hear you. I started my training in plastic surgery believe it or not but found myself more fascinated in treating chronic diseases while operating on patients and caring for them pre and post operatively. Then I switched to family medicine and trained in an academic but pharmaceutically geared institution. Hence my goal and passion started when I saw pharmaceuticals fail in treating a 14 year-old obese boy who was in congestive heart failure and was dying and his family members were still bringing chips and Nachos to the ICU! So you got a big challenge. Majority of academic institutions and big groups with high volume patients are geared towards using pharmaceuticals as first line agent. To be honest, it is very challenging to run a private practice but it is also very rewarding. If you have any specific questions, please let me know.

About artificial sweeteners, research has shown that they reduce gut bacteria, hence increase risk of autoimmune disorders, leaky gut, chronic fatigue, to name a few. Also sucralose has shown to increase a spike in insulin and contribute to insulin resistance. So it is probably better to stay away from them and stick with water and natural whole foods. Good Luck!

is honey as a healthier substitute to white sugar/splenda? (assuming person is not allergic to honey)

I think in small amounts honey is a great sweeter and so is stevia. In large amounts, honey does contain a lot of simple sugar which can cause a spike in blood sugar.

I am learning so much from this AMA, thank you!

What advice to you have for someone who diets, and fails, and diets, and fails, again and again?

Clarity on the specific result one is trying to achieve from weight loss is key. Ask the question why and how much. What is the value one will receive from weight loss? Health, better look? Better job opportunity? Health or less medications? Can you put a dollar amount to this value? Clarity about weight loss and the right diet that is sustainable are key to avoid yo-young

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Well, great question. I am sure your father appreciates your concern for him. What are some of the challenges you are encountering?

You have to first see if he is ready or contemplating weight loss or not. It is a very sensitive subject and in no way there is an ideal weight.

Some people are more factual and if they see a doctor, have blood work done which shows abnormalities, or if a doctor recommends some weight loss, it might be more effective than a family member.

Some baby steps are also effective: 1. Getting Grassfed red meat (if available or affordable) and limiting it to less than 8 oz./week. Also trying free range chicken, organic pasture fed eggs and wild fish 2. trying one hamburger bun rather than 2, Whole grain, replacing white rice with brown or better wild rice or Quinoa and using more spices such as turmeric, cayenne pepper (if one can tolerate it) 3. Having some probiotic (e.g. plain yogurt, kombucha, kimchee or probioic capsules) everyday 4. having a green salad everyday. Add more olive oil and spices to make it tasty. You can use Amino Acid mix which gives some taste to the salad as well. 5. Maybe you can go for a walk, even 15 minutes outside everyday. Of if he is a tech savvy person, get him a pedometer and track the activity. This is not so much exercise but just to move and improve energy and hopefully use as a motivation tool. 6. There are a lot of documentaries also available on streaming sources such as Netflix, some extreme, some less extreme and address food and weight gain and might be worth watching.

Again this is a sensitive subject and for each individual is very personal. The most important thing we can do as family members, coaches, physicians is to create a safe and healthy environment that motivates the individual to make a change and then help them throughout the challenge.

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Thank you for the info. I am glad he likes Kimchee, it's a great source of probiotics. Kombucha is another source of probiotics (besides plain yogurt and kefir) and it can be made at home with fermentation and it is a great soda replacement. It's great that he loves smoothies, that means he will probably like protein shakes to replace one meal per day (if there are no allergies, liver/kidney issues or contraindications to use of meal replacement protein shakes), mixing some protein powder with water or unsweetened almond milk or low fat milk and adding a cup of fresh fruit provides great taste and nutrients for a meal. One can add some fiber to it to make it more filling as well. Taking baby steps are exciting and more sustainable in long run.

We hear all about calories in/out but its obvious that this does not work theoretically or experimentally so how do hormones, type of nutrient and micro-nutrients affect body composition?

Eating 1000 calories worth of carbs with create a massive insulin spike storing far more energy as fat after all the carbs turn into all the glycogen you can store, but eating 1000 calories worth of protein will not produce anywhere near the amount of fat storage due to lessened insulin response and gluconeogenesis. Therefore eating excess carbohydrates is worse than eating extra protein when it comes to reducing fat storage. Right?

Hi, thank you for the detailed explanation. I hope I understood you question correctly. Eating 1000 calories of carbs would cause a large insulin spike which in turn would cause the lipoprotein lipase to increase and put the body in fat storage mode. A lower carbohydrate diet would reduce insulin, increase hormone sensitive lipase which in turn would put the body in a fat burning or lipolysis state. Protein when broken down also turns into glucose and consuming a lot of protein would also prevent the body from fat burning but it is a more metabolically active substance and the body would have to use some energy/calories to break the protein down to amino acids to absorb, use some for building muscles and the rest store.

The above processes assume perfect absorption of the nutrients from the body. However, many of us who are deficient in some probiotics, fiber and gastric enzymes might not absorb some of the protein or carbohydrates and hence suffer from bloating or indigestion after consuming certain foods.