Weight Expectations

In the United States, at any given moment, half of all adults are on a diet. Mary Duenwald checks the ups and downs of our progress.

Eat less. And exercise more. There, I've told you the most effective—no, make that the only possible—way to lose weight. It's simple. It's easy to remember. And yet it must be the hardest advice to follow ever given. Almost two-thirds of American adults are overweight, and according to the National Center for Health Statistics, that number, like a tape measure looped around the waist of an aging gourmand, slips into a higher range with each passing year.

The problem, as everyone knows, is that dieting takes determination. Mealtime arrives three times a day—more often if you count bedtime snacks, tea, and elevenses. Try cutting back even for a day and hunger, one of the most powerful protective forces nature ever contrived, begins to build. Like gravity it pulls downward on your brow, your shoulders, the corners of your mouth. It darkens your outlook, blocks your concentration, and ultimately gets you to put off dieting another day.

And so people have tried 1,001 ways to outwit hunger and trick themselves into compliance. Some simplify the challenge further: eat only protein and fat; only cabbage soup; only prepackaged meals delivered by the gourmet diet service. Stop eating altogether and drink all meals from a can. The strangest I ever heard called for alternating between two restrictions—only tangerines one day, only dairy the next.

People have tried hypnosis, jaw wiring, and stomach stapling, weight-loss earrings, and pills that promise you'll "lose weight while you sleep." One of the newer approaches involves attaching electrodes to your muscles and supplying current to burn calories without breaking a sweat.

As a health journalist for 15 years, I've heard most of the gimmicks, and even helped publicize some: testimonials from people who've lost weight on the kind of high-fat diets that give the American Heart Association high blood pressure, and from those who swear by fasting and colonics. In 1994, by writing what I intended to be an objective article for a beauty magazine, I inadvertently boosted the popularity of fen-phen, a diet drug combination that was later shown to have possibly fatal side effects.

What's become increasingly clear is that the search for a magic way to lose weight has clouded the picture of what it really takes to succeed.

Well, that cloud is about to pass. The next big thing in weight loss, nutritionists say with relief, is a steady diet of reality. Perhaps it's because we're getting adept at facing cold, hard truths—the threat of terror, the anemic economy. But dieters are no longer interested in fooling around and wasting time. People finally want to lose weight, and lose it for good.

For some, this is merely a matter of dialing back on calories—challenge enough, as anyone knows. Some will consider taking new kinds of prescription drugs. And for a very few, the latest in bariatric (weight loss) surgery may be the ticket.

The good news is, no one needs to go it alone. Weight-loss experts—doctors, counselors, dieticians, spa directors, and yes, even surgeons—can help you weigh your options and face the challenge head-on.

Grasp the Fundamentals

How much would you like to lose? Some people want to drop a few pounds so they can look better, move better, and generally feel as light on their feet as they did when they were 18. Others need to lose weight because they've reached a point where fat is threatening their health. If it's not already obvious where you stand, it's time to become familiar with a simple concept known as body-mass index, or BMI.

"The weight chart of the new millennium is the BMI chart," says Madelyn Fernstrom, Ph.D., an obesity researcher and director of the Weight Management Center at the University of Pittsburgh. "If your BMI is over 25, you are overweight. It's not just that you look a little pudgy in your clothes. You're facing possible health risks."

BMI correlates weight with height and the resulting numbers have proved fairly accurate in predicting overall health (although it doesn't apply to bodybuilders and pregnant women). On average, the risk of stroke, heart disease, diabetes, osteoarthritis, colon and breast cancer, and sleep apnea rises when a person reaches a BMI of 25. If it reaches 28, your risk may be three to four times greater than average. By the time it's at 30, you're officially obese, with a significant chance of obesity-related diseases such as diabetes and hypertension. As a guide, a six-foot-tall man who weighs 184 has a BMI of 25. If he's 221 pounds, his BMI is 30. A five-foot-six-inch woman must weigh 155 for a BMI of 25 and 186 for a BMI of 30.

The easiest way to figure out your BMI is to use an on-line calculator such as the one offered by the National Institutes of Health (www.nhlbisupport.com/bmi/bmicalc.htm), where you can simply type in your height and weight. Play with the weight figure and see how much you will need to lose to get your BMI below 25.

Look too at a tape measure around your waist. Abdominal fat is the most dangerous kind as far as heart disease and diabetes are concerned. So if your waist measures 40 inches or more if you're a man, or 35 if you're a woman, it's time to drop a few pounds.

But beware of aiming for too great a weight loss. Nutritionists and doctors know from experience that unrealistic expectations can lead to failure. "Ask yourself, 'Is this a diet I can see myself sustaining for the rest of my life?'" advises Lisa O'Donnell, M.P.H., R.D., nutrition manager at the Miraval spa in Catalina, Arizona. "You want to find a weight where you feel good, your energy is good, and your clothes fit, but where you don't have to battle hunger and obsess about food all the time."

Figure that one pound equals roughly 3,500 calories. Yes, some people metabolize faster than others, and yes, exercise burns extra calories on any given day. Still, the 3,500-calorie formula works well as an estimate over the course of a diet. "Let's say you want to lose one pound a week," says Fernstrom. "Then you have to cut out about 500 calories a day." A pound or two a week, by the way, is an ideal pace for a diet. Lose any faster and it won't only be fat you're dropping but lean muscle mass as well, doctors say. And you'll probably gain it back. "Studies that compare people who have lost weight and kept it off with those who lost weight but gained it back show that the people who relapse are those who go on rigid, punishing diets," says Katherine Tallmadge, a spokesperson for the American Dietetic Association.

Finally, a point about exercise. Choose whatever form of physical activity you like and aim to put in 30 minutes to an hour most days. You'll build muscle while you lose fat, you'll burn calories faster, and your cholesterol will most likely drop. Perhaps most important of all, exercise will make the diet more effective and you'll be more likely to stick to it if you see results.

Try the Variety Diet

High-protein diets got a huge PR boost last summer when The New York Times Magazine published an endorsement of the late Robert C. Atkins' low-carbohydrate plan. The article made a strong argument against the old low-fat diet dogma: Eating a diet that is high in carbohydrates but low in fat means being hungry all the time—one is never able to take advantage of fat's proven ability to quash hunger. And a diet that is too heavy in carbohydrates can, through the effect of insulin, make it easier to store fat and harder to lose it.

The article also described new research showing that diets high in saturated fats can be relatively safe, in that they do not raise cholesterol levels through the roof, as some doctors have warned. But it is on this point that many diet experts take exception. The evidence for the safety of high-fat diets is still preliminary, they say, and the risk that they may lead to cardiovascular problems is still real. "One little six-month study is nothing compared to the long-term research we have showing the damage that a high-fat diet does to your heart and your resistance to cancer," Tallmadge says.

In any case, an exclusive preference for high-protein foods means cutting out foods that may contain other essential vitamins and minerals. Fruits and vegetables, for example, which are restricted on the Atkins diet, are some of the most nutrition-packed foods on earth. "A weight-loss program that makes certain foods taboo is really hard to sustain over a long time," says Barbara Schneeman, Ph.D., professor of nutrition at the University of California, Davis. What's more, diets that severely limit food choice keep you from learning a pattern of eating that will keep you lean for a lifetime.

Bottom line: 90 to 95 percent of people who follow high-fat or low-fat diets eventually put the weight back on. "If the Atkins diet were the answer," says Jules Hirsch, M.D., an emeritus professor of human behavior and metabolism at Rockefeller University in New York, "the awful illness that is obesity would have vanished." In fact, a new report in the Journal of the American Medical Association reviewed close to 100 studies published in medical journals since the 1960s and concluded that losing weight on a low-carbohydrate diet is a result of decreasing calories, not carbohydrates.

It's clearly time to move on from both high-fat and low-fat diets. And move up to what we shall call the variety diet.

The variety diet has two rules: Choose foods that are fresh and packed with nutrients: whole grains and fresh produce, dairy, meats, and fish. And keep your calorie count low enough that your body uses up some of its reserves. Within these guidelines you are free to choose the content of your meals according to your personal tastes.

Besides emphasizing variety and freshness, nutritionists recommend that you give preference to foods that can help you tame your appetite. For example, choose fiber—in whole-grain bread, cereals, fruits, and vegetables—because it keeps you feeling sated long after the meal ends. Fiber amplifies the feeling of fullness that is triggered by fat, explains Schneeman, who has studied fiber's effect on appetite. "When someone is on a diet, they often have decreased fat intake," she says. "Having fiber in the meal gives you greater benefit from the fat that is there, and for a longer period of time."

Nuts, rich in both fiber and unsaturated fat, are a good choice for anyone trying to lose weight, Schneeman says. Fish is another excellent choice. The omega-3 fatty acids contained in fish may lower blood pressure and triglyceride levels in some people. And according to a recent study in Africa, eating fish seems to increase the body's sensitivity to the hormone leptin, which plays a key role in making you feel sated.

Find a Proper Coach

Given the complexity of nutrition science and the vast selection of foods available, it pays to have help making your choices. Personal nutritionists can teach you to gauge both the calorie volume and the vitamin and mineral content of the foods you like. Plus, a nutrition coach can provide weekly inspiration. "Weight loss is ninety-nine percent psychological," says Tallmadge, who also runs a private practice in nutrition counseling in Washington, D.C. Studies show that dieters are more likely to be successful if they get support along the way. And although groups like Weight Watchers do the trick for millions, one-on-one sessions with a nutritionist are even more effective.

"We can help you lose weight, and we can help you bring your cholesterol levels and blood pressure down dramatically," Tallmadge says. A food coach will remind you, for example, to watch how much food is put on your plate. A recent study at Penn State University confirms an obvious truth: Hardly anyone can easily stop eating before an overloaded plate is empty.

A coach will also help you to be patient enough to accept a slow—but permanent—weight loss. "The quick-fix mentality is hard to change," Tallmadge says, "but we know that radical diets backfire."

To help her clients modify their eating, Colleen Keller, professor of nursing at the University of Texas Health Science Center in San Antonio, recommends that they think less about cutting out foods they love (desserts and candy, for example) and more about adding in nutritious morsels such as apples, pears, or celery. "Plan to eat an extra piece of fruit every day," she says. "Soon you'll be eating fruit not in addition to some other snack, but instead of it."

Many nutritionists have you keep a diary for the first week or two so you can record every bite within 15 minutes of eating it. That gives a realistic view of what's going in each day, which can then be fine-tuned.

One weekly session with a personal nutritionist costs anywhere from $65 to $200, depending on how much time you spend and where you live. Look for a nutritionist who is a registered dietician by going on-line to www.eatright.org.

Jump-Start Your Diet At a Spa

With 35 pounds to lose at age 60, Moataz Gandor of London put his weight loss in motion by spending a month at the Hilton Head Health Institute in South Carolina. He bicycled around Hilton Head Island 25 to 30 miles a day, attended nutrition seminars, and ate low-calorie gourmet meals. "In that month they changed my software," says Gandor, CEO of Metito Overseas Ltd., a U.K.-based company that builds water-treatment and -desalination plants around the world. "I started looking at myself differently, treating myself differently. I learned what to eat and how to exercise."

A week at a spa—at $3,000 to $6,000—provides basic training in nutrition and exercise. O'Donnell, at Miraval, teaches her guests such dieting tricks as putting down utensils between bites and paying close attention to how food looks, smells, tastes, even sounds. "I try to help them learn to slow down so they can get back in touch with their own intuitive wisdom about food and eating," O'Donnell says. "They learn to identify that point of comfortable satisfaction at the end of a meal—when they're not too full, but not hungry either."

And she warns against self-loathing. "Extreme criticism and judgment lead to rebellion," she says. "I've seen it over and over. It leads people to think, 'I'm going to blow it, and I'm going to blow it big!' "

Of course, a week at a spa also works to wake up out-of-shape muscles. Daily hikes over the red-rock canyons of Utah, at Green Valley Spa in St. George, can steel you for a lifetime of regular exercise.

Diet Drugs

If your BMI is 30 or higher, or if it is above 27 and you suffer from at least one weight-related illness—diabetes, atherosclerosis, or osteoarthritis, for example—you might want to talk with your doctor or an obesity specialist about taking diet drugs.

For the short term, some doctors prescribe pills designed to suppress the appetite. Among the most widely prescribed is phentermine (brand name Ionamin), the phen half of fen-phen, which when used by itself does not damage heart valves. But the FDA approves the use of phentermine for no more than a few weeks because it can lead to hypertension and it is not known to be safe or effective any longer than that.

"I'd never want the FDA to change that rule," Fernstrom says. "All phentermine does is reduce the signal for hunger. It teaches you nothing about how to manage your appetite."

Recently some doctors have tried combining phentermine with Prozac, but this strategy is not widely practiced, in part because Prozac has never been shown to reliably promote weight loss, Fernstrom says.

Two drugs that help train a dieter to eat sensibly and are approved for long-term use by the FDA are sibutramine (Meridia) and orlistat (Xenical). Both have been shown to help people lose anywhere from five to nine percent of their body weight (sometimes it's as high as 20 percent).

Meridia, taken once a day, regulates the effects of three different brain chemicals in such a way as to increase the sense of feeling full. "It stops you from being preoccupied with food," Fernstrom says, "so you can focus on other things—like physical activity." The monthly cost ranges from $95 to $130, depending on the pharmacy and how many pills you buy at one time.

Orlistat, a drug taken with each meal that contains fat, is not an appetite suppressant. It blocks the absorption of about one-third of calories from the fat. "If you eat too much fat, you will lose it through the bowels," Fernstrom explains, "which is why orlistat can also cause diarrhea and cramping." A one-month supply of orlistat costs about $120. If you binge on carbs and protein, however, this drug will not work for you.

Surgical Alternatives

Gastric-bypass surgery, in which the stomach is divided into two sections—a small pouch above and a larger "gastric remnant" below—is, as Dr. Hirsch puts it, "a counsel of despair." Doctors reserve it for those patients whose BMI is 40 or higher, or 35 if the patient has a severe health problem related to obesity. That's at least 295 pounds for a six-foot man, or at least 248 pounds for a five-foot-six-inch woman. It permanently alters the digestive system (although reversible by another operation) and is designed to physically prevent a person from overeating. As we already know, thanks to the publicity garnered by patients like Today Show weatherman Al Roker, surgery does work. In fact, bariatric surgery is the only weight-loss strategy that has proved to work for most people who try it.

Patients typically lose anywhere from 50 to 75 percent of their excess body weight, assuming they exercise and pay careful attention to nutrition, says Daniel Herron, M.D., a surgeon who performs gastric-bypass operations at Mount Sinai Medical Center in New York. If you're 200 pounds overweight, you'll likely lose 100 to 150 pounds.

With their stomach capacity reduced to only five or six ounces, bypass patients can only take in about 18 ounces of food a day. And they must learn to manage the stomach pouch by drinking liquids only between meals, never with them, says surgeon Latham Flanagan Jr., M.D., of Eugene, Oregon. "If you drink liquids during meals," he explains, "it will make a soup out of the food, causing the pouch to empty sooner. So you feel hungry sooner."

The surgery can be done with a laproscope through a series of small incisions. The procedure takes at least one to two hours, and the $10,000 to $25,000 cost is covered by many insurance companies.

Two other surgeries are becoming increasingly popular. One is a lap band, which is surgically placed around the top end of the stomach and tightened. The stomach's usual football shape is pinched, so food takes longer to pass through. The other alternative is the duodenal switch, which involves more complicated plumbing arrangements than are used in gastric bypass. The operation usually takes longer—up to three to four hours—and is therefore more expensive. Some surgeons believe it works better.

Liposuction, by the way, is not good for weight loss, only for recontouring the body, especially after reaching a stable weight.

Stay the Course

Surgery is effective because it is permanent. It cannot be ignored or abandoned, like another diet book, a bottle of pills, or good intentions, in that it requires permanent lifestyle changes and careful postoperative management. The lesson it teaches about dieting is that the key to success is sticking with it. "It does take continuous attention," says Hirsch. "There are similarities with something like alcoholism. I'm not saying the biology is the same, but the psychology is similar. Behavior has to be changed for a lifetime to succeed with weight loss."

Schneeman, the nutritionist at UC Davis, recently lost 25 pounds by following a healthy variety diet. It took her six months, but she's kept the weight off for more than two years. "You really have to think beyond the diet itself," she counsels.

Think ahead, especially, to your body at its healthiest and most beautiful—and how happy you'll be living in it for years and years to come.

Weighing Inn

DUKE DIET & FITNESS CENTER Here you'll immerse yourself in one to 12 weeks of intensive training in how to change your eating patterns and make a habit of daily exercise. The health-centered approach includes a complete physical and regular measurements of cholesterol, blood sugar, and blood pressure. Clients at Duke learn how weight loss will lower their risk of cancer, boost their energy levels, and even improve their moods. Lodgings are at local hotels. Rates (lodgings not included): $675-$775 per week. At 804 West Trinity Avenue, Durham, NC; 800-235-3853; www.dukedietcenter.org.

GREEN VALLEY SPA This hiking-oriented spa is more for those looking to shed a few pounds than for the extremely overweight. Hikes in surrounding red-rock canyons come in "walkabout," "fitness," and "strenuous" varieties. Rock climbing, cardio boxing, power cycling, yoga, pilates, and tai chi are other exercise options. Rates: $4,160-$4,725 per week. At 1871 West Canyon View Drive, St. George, UT; 800-237-1068; www.greenvalleyspa.com.

MIRAVAL LIFE IN BALANCE RESORT & SPA Miraval offers an alternative to draconian diets and other quick-weight-loss schemes. Each guest can choose to receive a detailed nutritional evaluation and is taught to adopt lifelong healthy-eating patterns. A variety of activities, from golf to rock climbing, are offered. Rates: $3,465-$6,615 per week. At 5000 East Via Estancia Miraval, Catalina, AZ; 800-232-3969; www.miravalresort.com.

HILTON HEAD HEALTH INSTITUTE This Sunday-to-Sunday weight-management training program caters to people of all sizes. Balanced low-fat meals and daily exercise—including lots of walks along the beach—are combined with lectures on stress, nutrition, disease prevention, and life management. The week begins with a weigh-in and blood-cholesterol check, and each person's daily intake of calories and fat is meticulously recorded. Rates: $2,895- $3,595 per week. At 14 Valencia Road, Hilton Head Island, SC; 800-292-2440; www.hhhealth.com.

Mary Duenwald writes frequently on health and medicine.