An interview with our founder, Annika Kahm and her colleague Carolyn Hodges Chaffee

Gürze just published an interview with Annika Kahm (our founder) and Carolyn Hodges Chaffee. The interview was motivated by the publication of their book, Measuring Health From The Inside. Here are a few excerpts from the interview:

What are some of the complications that affect the brain’s neurotransmitters as a result of compulsive exercise?

Exercise does affect the neurotransmitters in the brain. Exercise in moderation or making sure the body is adequately fueled for the level of activity can have a very positive effect on the neurotransmitter levels. However, when exercise becomes compulsive and the body is not adequately nourished it can have a negative effect on the body.

Exercising at a high level and restricting the intake for prolonged periods of time causes an increase in cortisol. Elevated levels of cortisol for extended periods can lead to cellular death.

There is also a feedback mechanism that occurs with compulsive exercise that increases the risk of addiction. When an individual exercises, the brain gets a burst of dopamine in the reward/pleasure center of the brain. For those individuals, the more they exercise the more they feel compelled to exercise.   As those individuals continue to exercise it becomes compulsive, unable to take a day off, having it interfere with their daily living, and doing exercise that for them doesn’t count.

From an eating disorder perspective, what are the different ways individuals develop malnutrition or become nutritionally depleted?

Malnutrition can occur in many different ways; when the body is underfed for an extended period of time (anorexia, orthorexia), when it operates at a calorie deficit because of a high level of energy expenditure (compulsive exercise), or when the body is unable to absorb nutrients (bulimia).  The body is designed to tolerate brief periods of malnutrition, but how well depends on the body’s nutritional status and how much body fat the body is able to mobilize to endure the starvation.

When an individual restricts their intake, there are mechanisms that occur in the body that lead to a decrease in hunger.  The metabolic rate will gradually decrease, causing fewer hunger cues.  As weight is lost, the gut will eventually develop gastroparesis which slows the emptying of the gut.  This results in bloating and discomfort when eating which makes it more comfortable to not eat (restrict) or get rid of what was eaten (purge).  Regardless of the behavior, the body will eventually become malnourished.

When working with clients who are diagnosed with eating disorders, what do you find are the merits of using Metabolic Testing (MT) and Body Composition Analysis (BCA)?

It’s invaluable, especially since many clients don’t think they have an eating disorder unless they are seriously underweight or actively purging.  If they have been diagnosed with an eating disorder, but are in denial, the MT and BCA give empirical evidence to the malnutrition it has caused for their body.  A low metabolic rate (hypometabolic), using excessive protein stores to meet their caloric needs (catabolic), low phase angle (indicative of poor cell integrity), and body fat well below normal ranges for age, sex, and height are all examples of information gained by the testing.

Today’s diagnostic criteria miss some seriously disordered patients because blood work is usually within normal limits, even in very sick individuals.  Scale weight is not an indicator of an individual’s fat, lean or health.  This is why we fail this patient population.  A patient can be normal weight or overweight and still have an eating disorder and weight restoration is only part of recovery.

Also, we do BCA at every visit, giving them feedback of how the body responds to their food intake. We let the patient know if they are eating enough to allow for not only daily needs, but also for repair and healing of their malnourished body.  This way they are actively involved in the recovery process.

One of the goals during hospitalization is to weight restore the patient.  Without the MT and BCA it is very difficult to determine, as well as convince the patient that is weight restored, that they are still malnourished and may need to gain more weight.  If an individual is not fully nutritionally recovered, it increases the likelihood and risk of relapse.  When the individual sees their actual test results, it is easier for them to follow treatment recommendations.

The full interview can be found here.

Evidence That Our Method Works: One of Our Patients

Maria, a 17-year-old girl, was five feet tall and weighed 95 pounds. She was on the varsity crew team and practiced two hours every day for nationals. She had her first period when she was 14, and over the past three years she had had a total of 10 periods. She was eating 1400 calories a day and wanted to weigh 90 pounds. She weighed herself at least twice a day. If the scale was up one day, she made sure it was down the following day. Two years earlier, she had a stress fracture, but no bone density test had been done. Metabolic Testing showed she was severely hypometabolic, burning only 386 calories a day and therefore using her own lean tissue (organs, muscle, and bone) for fuel. Other medical tests revealed that she was anemic, deficient in vitamin D, and had osteoporosis (bone loss). 

Initially, she reluctantly agreed to eat 2,000 calories a day. She was asked to stop exercising to correct the Relative Energy Deficit in Sports. After two months she got her period, and after four months of eating close to 2,200 calories a day, she reached 100 pounds. This frightened her. Her Metabolic Test and Body Composition Analysis showed major improvements, but her metabolism was still not corrected. She felt that she should be rewarded, and so her parents allowed and encouraged her to start exercising again. Three weeks later she was re-tested and her metabolic rate had plummeted from 1,000 calories to 437 calories a day. She had lost lean mass and her fat weight had increased. She had returned to being very hypometabolic and catabolic. It's as if her body was saying, "Don’t mess with me...I'll show you, you are hurting yourself!"

Maria and her parents were wrong in thinking that just because she had reached 100 pounds and had gotten her period that she was recovered. It took another three months, eating 2,500 calories per day, for her body to recover and to have a normal metabolic rate with a healthy amount of lean mass. She ended up weighing just over 100 pounds. Her percentage of body fat was lower than her first visit. She admitted that she had been in denial and would have continued being in denial if it wasn't for the Metabolic Testing and the Body Composition Analysis. 

The Data that Dieting Doesn't Work

Does dieting work? Well, it depends on how success is measured. And what the medical and diet industry mean by success is not what ordinary people mean. Let me explain.[1]

In the 1940s, success was measured by getting people to a “normal” BMI (an unscientific height/weight ratio),[2] but diets didn’t help most people get there. So in the 1950s they simply changed the measure of success to losing 40lbs, but 95% of people couldn’t do that.[3] As a result, in the next decades, they simply lowered the bar again to 20lbs.[4] But 20lbs is quite different for someone who is 150lbs than someone who is 300lbs, so in the 1970s, they changed it, yet again, to 10% of one’s starting weight. But since 80% failed at this,[5] in 1995, the Institute of Medicine lowered it to 5%.[6]

This is obviously nonsense. In a study of 130 female dieters, no one said they would be satisfied with losing 5%. These women averaged 218lbs, and their goal was to lose more than 70lbs (not even close to 5%!), and none of them reached this goal. Enough people lost 5% for the researchers to claim the diet was a success, but none of the participants thought they had succeeded.[7]

No matter what kind of diet you’ll try, many studies show that you’ll lose about 5-15 pounds over 4-6 months. But that’s too short of a range, since everyone wants to keep the weight off. The long-term studies do not bode well, and the best ones show that about half of dieters will gain weight within four to five years. The Weight Loss Industry refuses to make their data public because, they say, “Dieters will be discouraged if they are provided with realistic outcome data.”[8] Of course, they make lots of money on failure, indeed, the average Weight Watcher customer tries it 4 times![9]

There are a few decent long term studies that are revealing. One study starved obese people in a hospital for 38 days, and of those who were tracked for three or more years, 83% gained back more weight than they lost,[10] and in studies that tracked people even longer, the participants gained even more weight.[11]

Traci Mann and colleagues decided to track down every decent long term weight-loss study and see what the data showed.[12] They found that dieters, on average, had managed to keep off 2lbs and 40% gained weight from the diet! But, it’s even worse than that! They found that all of the studies were flawed, which suggests that the measly 2lb loss is optimistic.  

Here’s why. Most of the studies made people diet before the official study diet to see if they could do it. If they could not, they were not included in the study. Thus, those who had difficulty dieting, which is very common, were not included, skewing the success upwards. Furthermore, on average, 20% of the participants dropped out of these studies, and they have shown that if you fail, you’re far more likely to drop out because you don’t want to confess your failure to the researchers. Moreover, participants were almost never weighed in person – weight was conveyed by email or phone. But other clever researchers have called to ask people their weight and then shown up at their home with a scale, and, on average, obese people say they weigh 8lbs less than they do, and the rest say they weigh 5lbs less than they do. And last but not least, 20-65% of participants in these studies were on other diets at the same time. In other words, they had tried the study diet, failed, and then started a different diet when the researchers followed up, and thus their recorded weight-loss was really result of the wrong diet![13]

If you add these flaws into the mix, the supposed average puny loss of two pounds is optimistic and unrealistic. All in all, the net result of dieting is, in all likelihood, weight gain rather than weight loss.

All of this is to say that dieting does not work! Just say no to dieting! Dieting is too difficult: it is painful, miserable, hard work, and it is definitely not worth it. While this may seem depressing, we think it is liberating: you are much better off spending your energy simply trying to become healthy.

 

[1] The studies in this blog post are discussed in greater detail in Chapter 1 of Traci Mann’s excellent Secrets from the Eating Lab (Harper Collins: NYC, 2016).

[2] Thomas R. Knapp, “A Methodological Critique of the ‘Ideal Weight’ Concept,” JAMA 250, no. 4 (Jully 22, 1983): 506. http://jamanetwork.com/journals/jama/article-abstract/387502

[3] A. Stunkard and M. McLaren-Hume, “The Results of Treatment for Obesity: A Review of the Literature and Report of a Series,”  Archives of Internal Medicine 1 (1959): 79-85.

http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/562795

[4] R. R. Wing and R. W. Jeffery, “Outpatient Treatments of Obesity: A Comparison of Methodology and Clinical Results,” International Journal of Obesity 3, no. 3 (1979): 261-79. Abstract here: https://www.ncbi.nlm.nih.gov/pubmed/395116

[5] Rena R. Wing and Suzanne Phelan, “Long-Term Weight Loss Maintenance,” American Journal of Clinical Nutrition 82, no. 1 Suppl. (July 2005): 222S-225S. http://ajcn.nutrition.org/content/82/1/222S.long

[6] Institute of Medicine, “The Nature and Problem of Obesity,” in Weighing the Options: Criteria for Evaluating Weight-Management Programs, ed. P. R. Thomas (Washington D.C.: National Academy Press, 1995), 55-58. https://www.nap.edu/read/4756/chapter/1

[7] Robert W. Jeffery, Rena R. Wing, and Randall R. Mayer, “Are Smaller Weight Losses or More Achievable Weight Loss Goals Better in the Long Term for Obese Patients?,” Journal of Consulting and Clinical Psychology 66, no. 4 (1998): 641-45.

[8] R. Cleland et. al., “Commercial Weight Loss Products and Programs: What Consumers Stand to Gain and Lose. A Public Conference on the Information Consumers Need to Evaluate Weight Loss Products and Programs,” Critical Reviews in Food Science and Nutrition 41, no. 1 (January 2001): 45-70. https://www.ftc.gov/reports/commercial-weight-loss-products-programs-what-consumers-stand-gain-lose

[9] Weight Watchers International Business Plan, 2001. For an interesting discussion see, http://www.slate.com/blogs/browbeat/2015/11/03/why_weight_watchers_doesn_t_work.html

[10] David W. Swanson and Frank A. Dinello, “Follow-up of Patients Starved for Obesity,” Psychosomatic Medicine 32, no. 2 (March 1, 1970): 209-14. http://journals.lww.com/psychosomaticmedicine/Abstract/1970/03000/Follow_Up_of_Patients_Starved_for_Obesity.7.aspx

[11] D. D. Hensrud et al., “A Prospective Study of Weight Maintenance in Obese Subjects Reduced to Normal Body Weight Without Weight-Loss Training,” American Journal of Clinical Nutrition 60, no. 5 (November 1, 1994): 688-94, http://ajcn.nutrition.org/content/60/5/688.abstract

; F. M. Kramer et al., “Long-Term Follow-up of Behavioral Treatment for Obesity: Patterns of Weight Regain among Men and Women,” International Journal of Obesity 13, no. 2 (1989): 123-36.

[12] Traci Mann et al., “Medicare’s Search for Effective Obesity Treatments: Diets Are Not the Answer,” American Psychologist 62, no. 3 (April 2007): 220-33; Traci Mann, A. Janet Tomiyama, and Britt Ahlstrom, “Long-Term Effects of Dieting: Is Weight Loss Related to Health?,” Social Psychology Compass 7, no. 12 (December 2013), 861-77.

Here: http://www.dishlab.org/pubs/MannTomiyamaAmPsy2007.pdf

And Here: http://www.dishlab.org/pubs/2013%20Compass.pdf

[13] Mann, Secrets from the Eating Lab, 11-15.

Weight MANAGEMENT

Some people would be healthier if they lost some weight, and we can help them. Perhaps you wish to lose weight because you are concerned about your heart, your blood pressure, you have low energy, or perhaps you are prediabetic.  Perhaps you’ve been trying to diet, on and off, for years and have been unsuccessful and have added some additional weight. Do you feel stuck and frustrated?

Losing weight is difficult. It requires patience, perseverance, up-to-date nutritional knowledge and technology, namely, Metabolic Testing and Body Composition Analysis. Weight loss can be achieved when realistic goals are established, but the weight loss industry and society at large, has mislead dieters by providing unhealthy and unrealistic goals.

The Pitfalls Of The Usual Approach

The optimal weight for each person differs depending on sex, age, genetics, environment, lifestyle, and other variables. Because of today’s diet, fashion and media industry, as well as doctor’s recommendations (based on old fashioned height/weight charts created by insurance companies in the 40s and 50s), most people’s ideal weight goals are set too low. Too many people would like to have bodies like Gisele and Tom Brady and believe that with enough grit and willpower such transformation is possible. It is not. However, even those with far more modest goals routinely fail, as is shown by the well-known statistic that more than 95% of dieters gain their weight back. 

Losing weight is hard, often frustrating, and can even be harmful to your body when done inappropriately. Simply cutting calories is often not the answer. Caloric restriction can even be dangerous and backfire, since it has the ability to lower the metabolic rate. When the metabolic rate drops, the body breaks down muscle and organ tissue and uses it for fuel while simultaneously increasing and storing fat. This may seem counterintuitive, but we’ve seen it frequently in our practice, especially if the majority of the calories are consumed in the later part of the day. When fewer calories come in, the body worries about starvation, so it lowers the rate at which it burns calories, and shifts to consuming organ and muscle tissue while stocking up on fat for when it is absolutely necessary. If you would live through a real famine, this mechanism would help you survive much longer. Please watch our video for a visual representation of how this works.

With enough willpower it is possible to lose weight this way, but the price is far too steep for one sacrifices health for weight. Symptoms of food restriction include obsessive thinking, low-energy, compulsive exercising, depression, insomnia, constipation, anxiety, and distorted hunger. If losing weight this way is difficult, maintaining the weight loss is even harder. It is one thing to deal with these symptoms for a few weeks, it is another to deal with them for a lifetime – the body will fight hard to get back to an optimal and realistic weight.

Weighing a person on a scale is an insufficient measure of health because there is no way of seeing if someone is malnourished and if their metabolic rate has dropped. People of normal weight may be terribly unhealthy, while those who are slightly overweight may be very healthy, etc.

Our Better And More Realistic Approach

We need to stop focusing on the numbers on the scale and accept realistic weight goals and focus on real inner health. Losing and maintaining the weight is possible only when one fuels the body with the appropriate calories while also keeping an eye on the metabolic rate.

Metabolic testing and Body Composition Analysis can tremendously help chart sustainable and healthy weight loss paths. Metabolic testing determines how efficiently the body is burning calories and if the body is using its own muscle and organ mass as fuel if underfed. Body Composition Analysis measures the amount of fat and lean tissue (muscle + organs).

Unlike knowing weight, these tests reveal a deeper and far more accurate assessment of an individual’s health. With these tests one can monitor when cutting calories is counterproductive.

For instance, one pound of fat has approximately 3500 calories, and thus to lose one pound of fat in a week you would need to cut 3500 calories/week (or 500 calories/day). For most people, however, this rate of caloric restriction is too steep and will drop their metabolic rate. Their health deteriorates as their bodies will likely break down healthy tissue, using muscle as fuel, while stocking up on fat. We’ve seen lots of people who have lost weight, but they have far less muscle and far more fat. It is unsurprising that they feel terrible. For most people, a more realistic and sustainable goal for losing 1 pound of fat is to take at least 1 to 2 weeks. In other words, cut too much too fast, and your metabolic rate drops, and dieting doesn’t work. With these tests we can monitor each individual’s metabolic rate and customize a plan to ensure that they will actually lose weight without tripping the metabolic wire. Furthermore, there comes a point at which people reach their optimal weight, and they must stop trying to lose weight. This is a hard but necessary truth for many. To roughly consider whether one’s weight loss goals are genetically realistic, one can look at one’s family members.

Some argue that “mindful intuitive eating”, i.e. following one’s hunger signals, is the best guide to eating healthily. This, however, only works for those who are already truly healthy. For when the metabolic rate drops, hunger signals drop as well, and thus offer a very poor guide to healthy eating. They feel less hungry, and so eat less than they need, which further drops their metabolic rate, and they feel even less hungry, etc. Such vicious cycles often lead to more serious eating disorders.

Performing the Metabolic Test and the Body Composition Analysis at regular intervals enables you to know that you are on the right track, and it warns you when the line has been crossed and dieting is causing internal damage. With improved knowledge comes far more realistic goals and plans for increased wellness. And when you know that you are dealing with more realistic goals, you are far more likely to be motivated and therefore to actually reach those goals and keep the weight off. Please reach out to us and see how we can help you.

WHAT IS METABOLIC TESTING?

WHAT IS METABOLIC TESTING?

Metabolic Testing measures how many calories someone is burning, and enables us to see if they are burning more or less than they should. When a person is underfed, it also measures how much lean mass (muscles, brain, organ tissue, etc.) is being used to fuel the body. In slightly more technical terms, metabolic testing measures an individual's metabolic rate by determining the Actual Resting Energy Expenditure (AREE), namely,  the amount of calories burned while in resting state. It does this by measuring oxygen and carbon dioxide exchange, a process called indirect calorimetry. During the testing procedure, an individual reclines and breathes under a lightweight canopy hood for 20-30 minutes. Immediately after the procedure, the nutritionists analyzes the AREE alongside the PREE (predicted resting energy expenditure) to assess if the body is burning the amount of calories it should be (a normal metabolism), fewer calories than it should be ( hypometabolic), or more calories than it should be (hypermetabolic). In addition to this, metabolic testing also measures the amount of a person’s protein stores being used to help fuel the body. The body normally uses less than 15% of its own protein stores to fuel itself, but when the body uses more than this, it is breaking down its own lean tissue for energy. This is referred to as being catabolic, which means that it is breaking down its own lean cells (muscles, bones, organ tissue, brain), and using them as energy as a substitute for food. This is a very expensive fuel source!

WHAT IS BODY COMPOSITION ANALYSIS?

Body Composition Analysis measures the amount and proportion of fat and lean mass in a person's body. It also measures the body's cellular integrity. In slightly more technical terms, Body Composition Analysis measures lean mass, body fat, lean dry mass (muscle), total body water, intracellular water, extracellular water, and phase angle. BCA is a quick and non-invasive procedure. Electrodes are attached to a wrist and a foot and a small electrical current is sent through the body. By measuring the resistance and reactance to the current as it passes through the body, it can measure the proportion and amount of lean tissue and fat. The rate at which this current passes through the cells of the body is how BCA determines the integrity of a person's cells. The measurement of the body's total resistance and reactance (which is independent of a person's height, weight and body fat) is called the phase angle. A low phase angle indicates a breakdown of cell membrane. As the body is nutritionally restored, the cell membrane becomes more intact and the phase angle improves. This is quick, painless, harmless and extremely informative data!