The Change Your Biology Diet: The Proven Program for Lifelong Weight Loss

Author’s Note

The #1 Health Care Problem

Why don’t people just lose weight? If losing weight were easy, two-thirds of adults in this country would not have weight problems. All it would take is cutting calories. It’s more complicated than a matter of willpower. Obviously, something else is going on that makes weight management so difficult.

When I lecture new students at Weill Cornell Medical College, I explain the limits of willpower in weight loss with a simple demonstration. I ask a student to hold her breath for a few seconds, then for longer and longer intervals. I instruct the student to do this every day and to hold her breath for five more seconds every week. In a year, she should be able to hold her breath for an hour, right? At that point, everyone in the class laughs at the ridiculous notion. They know their classmate’s body won’t allow her to hold her breath that long. Something tells her to breathe, because she’s suffocating. Strong physical signals will communicate to her that her brain is starved for oxygen. The same thing happens with weight control. Something signals you to eat, because you’re starving. It’s not as immediate as breathing. Instead of reaching a crisis point in a matter of minutes, it might take days or weeks with eating, but it’s the exact same mechanism.

If I do anything in writing this book, my primary goal is to reassure you that having difficulty losing weight is a medical problem, not a lack of self-control. When you try to lose weight or hit a plateau on a diet, do you get the sense that you are struggling against something? In fact, you are. I call it weight loss resistance. Research has given us new insight into what is behind weight gain and how your body resists losing weight. We have discovered that eating too much highly processed, starchy, sweet, fatty food damages the appetite-control center in your brain and precipitates other changes in your body that contribute to fat production and storage. I want to share what we now know about breaking through the physical barriers to weight loss. With a greater understanding of how the body controls weight, we have been able to create diets that work better than ever. What does work better mean? It means that it’s easier to stick with the plan and that you can lose as much weight as possible. The Change Your Biology Diet offers you a science-based program and a set of strategies to help you alter the biological processes that are preventing you from losing weight and keeping it off.

How I came to specialize in obesity and weight management is a classic story of finding a calling. When I was a Fellow in Internal Medicine at Weill Cornell, funded by the Kaiser Foundation, in the mid-eighties, I became interested in cost-effective care—in other words, the economics of health care. Increasingly sophisticated technology had made intensive care units an important part of hospital treatment by the mid-seventies. I set out to do a cost analysis of who should go into intensive care. I was intrigued to discover that patients who were obese cost two or three times more to care for than patients of average weight.

At the same time I was performing this study, I had a patient at the clinic in her late thirties, who needed a walker to get around. Her coronary arteries were severely diseased. She was about five feet two or three and weighed 250 pounds. I wondered how someone so young could be so sick and what we could do to help her. Being that overweight was not as common then as it is today. It seemed obvious that losing weight would be a good start. I found myself thinking about how we could solve her weight problem and whether losing weight would restore her health. At that time, there was no proven relationship between obesity and illness. We could not explain what fat cells had to do with overall health.

When I joined the faculty of New York Hospital-Cornell Medical Center in 1986 along with two other doctors, the chairman wanted each of us to set up a program. Dr. Orli Etingin, one new faculty member, worked on building the Woman’s Health Center; Dr. Jonathan Jacobs, the other, set up the Center for Special Studies, which focused on HIV. When I suggested an obesity program, the chairman, Dr. R. Gordon Douglas, had the foresight to think it was a good idea. At the time, being overweight was considered strictly a behavioral problem, but we suspected there was a lot more to the story. If it were simply a matter of cutting calories, overweight people would not have such a struggle dropping excess pounds. We were one of the first research and treatment programs in the country devoted to helping people lose weight.

Almost thirty years after we founded the program, I am the Sanford I. Weill Professor of Metabolic Research at Weill Cornell Medicine where I direct the Comprehensive Weight Control Center. We are making great strides in understanding what a complex disorder obesity is. What has become evident is that being unable to lose excess weight is not a question of willpower or motivation—it is a medical problem that involves your genes, your brain, your fat cells, and your hormones. We now know that weight problems should be treated like a chronic disease in order to succeed at lifelong weight loss.

A lot has changed since we launched the program. Obesity has become a pandemic. Now, more than two-thirds of the adults in this country are overweight, and half that number—one in three people—are obese. Global estimates of obesity rates indicate that the number of adults and children with severe weight problems has doubled in the past three decades. Being overweight is so much more than a cosmetic problem. Dr. Lee Kaplan has catalogued more than sixty illnesses that are the direct result of accumulating too much fat—breast cancer, liver disease, arthritis, pancreatitis, asthma, depression, infertility, sexual dysfunction, to name only a few of the conditions that can be caused or exacerbated by being overweight. And that’s on top of the diseases that are commonly connected to obesity, such as diabetes, heart disease, high blood pressure, and stroke. The estimated annual health care costs of obesity-related illness are $190.2 billion, nearly 21 percent of yearly medical spending in the United States. Childhood obesity is responsible for $14 billion in direct medical costs. Obesity-related medical costs are expected to rise significantly as today’s overweight children become overweight adults. A Cornell study reported that an obese person spends on average $2,741 more on medical care annually than a person of normal weight. If it were any other problem, we would be declaring a national health emergency. Effective weight management has clearly become our number-one health priority.

The front line of defense against the obesity epidemic rests with primary care doctors, yet fewer than 5 percent of physicians are treating obesity and excess weight in their patients. Instead, these overworked doctors tend to focus on treatable conditions such as high blood pressure and type 2 diabetes. Even though they realize that weight is the cause of much of the patients’ problems, primary care physicians often relegate weight problems to the bottom of the list, because there are no wonder drugs or a standard protocol that works for every patient.

My professional focus has been on state of the art research and developing treatments to help people better manage their weight. I have performed, designed, or supervised more than sixty weight loss studies and consult regularly with other innovative researchers around the world. I have treated thousands of people trying to lose weight, working with them to find the most effective dietary, behavioral, lifestyle, and medical approaches for lasting weight loss. Doctors from all over the world refer their toughest patients to me—those patients who are usually between 50 and 150 pounds overweight. I help many of them drop an average of 15 to 20 percent of their initial weight, the amount they would expect to lose if they opted for lap band surgery. In addition to my practice and research, I am getting the message out to health care providers and educating them on how to deal with this growing health care crisis.

I want to make our weight management strategies available to you. Whether you are ten pounds overweight or fifty, weighing too much can hurt you and could eventually make you sick. If you have tried diet after diet to lose weight, my message is to not give up. In my practice, I measure success one pound at a time. I have seen the program work for our patients, and believe it can work for you. With simple changes in the way you eat and move, your weight can drop, putting you on the road to good health.

Louis J. Aronne, M.D.

Introduction

Have You Ever Noticed that Your Weight Goes Up, But Won’t Go Down?

After the age of thirty, most Americans put on ten pounds a decade—a pound a year. A pound a year may not seem like much, but the gain is insidious and can add up before you even realize it. You do not have to remain stuck in a weight gain pattern that keeps spiraling upward. You can lose weight and maintain the loss. If you are like our patients, you have tried many diets and met with some success, only to gain back the weight you lost and more. Chances are there is nothing you would rather do than lose weight, but nothing seems to work long term. It’s easy to become discouraged and to blame a lack of self-control for your inability to lose weight. After all, you were able to drop more weight than you expected during the two weeks you spent on the latest crash diet, but you couldn’t keep it up and fell back into old habits. The Change Your Biology Diet can make yo-yo dieting a thing of the past.

I can say with authority that being overweight is not simply a matter of willpower failures or bad habits, but a medical problem with medical solutions. The availability of inexpensive, tasty, high-calorie, high-fat, high-carb food does play a role, as does not getting enough of the right exercise, but the dynamics of weight gain are far more complex than calories in/calories out. After decades of denying a physiological basis for obesity, research has shown that a number of interconnected systems contribute to slowing metabolism and increasing fat storage. Part 1 of The Change Your Biology Diet will give you an understanding of what is happening in your body that promotes weight gain and makes it hard to lose those extra pounds. I am going to give you a comprehensive picture of the internal biological processes that drive your weight up and put the brakes on weight loss. When our patients know the science behind their weight gain and why they are having difficulty losing those additional pounds, I believe they find it easier to comply with our weight loss program. As a result, they are more successful. They backslide less often, and, when they do, they can get right back on track, because they understand where the problems are.

Shame and guilt are not part of the program. The underlying message of recent findings is that your weight gain is not your fault. Genetics are part of the picture, but the newly emerging field of epigenetics is showing that what you have inherited is not your destiny. Though it is early, it appears that what you eat affects which of your genes turn on and which turn off. I examine the factors in modern life that contribute to the obesity epidemic. From medications with weight gain side effects to not getting enough sleep, from endocrine disruptors in the environment to the rise in the use of air-conditioning, I discuss the many causes of weight gain that often go undetected. So many factors are at play to produce the alarming prevalence of weight problems.

We have made substantial breakthroughs in understanding the biology of weight gain and weight loss resistance. Recent studies show conclusively that having difficulty controlling your weight reflects disrupted communication in your body. The food that you eat has a direct physical effect on your brain. Your body isn’t designed to handle too much highly processed, starchy food. Poor eating habits actually damage your brain and appetite feedback system. Food addiction also plays a role in the obesity epidemic. Processed foods—filled with sugar, salt, and fat—are engineered to be addictive. Eating too much processed food stimulates the brain’s reward pathways, making you need more food to feel satisfied. Understanding the mechanics of these alterations in your brain should make it easier to change the way you eat. Knowing what is going on biochemically in your body should give you all the motivation you need to follow the smart weight loss program you will find in these pages.

We have made a major shift in our thinking about the function of fat cells. We used to think fat cells were passive storage vessels. Now we know that fat cells are endocrine organs that produce dozens of hormones. I will explain the complex interactions of some of these hormones and the biochemical factors that prevent you from losing weight. With this information on how your body controls weight, you will know what you are up against. You will be ready to take action to combat the forces that have kept you from achieving your goal. The motto in my office is: never give up. What’s the alternative? Gaining more weight?

Part 2 presents the program that we use here at the Comprehensive Weight Control Center at the Weill Cornell Medical College. I have to warn you that the Change Your Biology Diet is the antithesis of the fast, dramatic weight loss chronicled on reality TV shows. Severely overweight people on those shows can lose twenty pounds in a week by using extreme measures like not drinking water for days before weigh-ins or exercising five hours every day. These shows set up unrealistic expectations that can result in frustration and resignation.

I am opposed to fad diets, which are ultimately destructive, because people give up after repeatedly failing to keep off the weight they lost. People who have been yo-yo dieting for years come to see me in despair, saying, I’ve tried everything. But they have been trying magic bullet diets that make big promises and have no scientific basis. If they eat an 800-calorie asparagus diet, they will lose weight. The fact is that no one can battle the extreme hunger of such a restrictive diet for long. Rather than sweating in a sauna for hours and exercising to exhaustion, my patients learn to practice other habits that help them dial down their appetites. Most of the people I treat do not lose ten pounds in ten days, but they do lose weight steadily and keep it off. My mission is to help my patients adopt long-term improvements in habits, tastes, and lifestyle that help them to control their weight.

I am very practical about losing weight and do not believe that driving yourself too hard is effective. If a diet is too restrictive, there is no way anyone can keep it up for long, which is why so many popular diets do not produce lasting weight loss. As people gradually revert to their old way of eating, their weight goes back up, sometimes higher than where they started. I suggest a way to eat that we believe will actually allow your brain to repair itself and your hormones to work as they should. A low-glycemic, low-carb, high-protein diet will keep your energy steady and turn on your fullness switch. To get you ready for the program, I explain the Breakthrough Dozen: 12 Proven Strategies for Successful Weight Control. Our research shows that when people adopt these habits they can reduce their biological tendency to gain weight.

The fact is that the best weight loss program is the one you like the most. If the diet is easy to follow, you are more likely to stick with it. If the diet is customized to solve your specific issues, you’re more likely to comply. I am offering you two diets in this book. If one doesn’t work for you, the other should. We’ll teach you how to make them both flexible and exciting over the long run.

The Quick Start Change Your Biology Diet is a six-week, three-stage program that uses protein shakes for a meal or two a day to jump-start weight loss. If you do not like protein shakes or feel deprived with meal replacements, then the Two-Stage Change Your Biology Diet is for you. This low-carb, low-glycemic eating plan should get your appetite center running well again, and you should be satisfied eating less food. Stage 1 is Weight Control; stage 2 is a Lock In Weight Loss Plan that allows two servings of bread or starch a day. It is just not realistic to expect you to live without bread, potatoes, and pasta forever. I know I could not do it. I will explain the importance of portion control and food timing when you reintroduce some simple carbs to your diet. Stage 2 gives you a way to eat for the rest of your life. To make your transition to healthy eating easy, you will also find 14 Days of Change Your Biology meal plans and recipes.

Changing the way you eat is much more effective for weight loss than exercise, but I am not giving you a pass. You still need to move more, starting with getting out of that chair or off that couch. Simply standing more often during the day can help you lose weight and improve your health. As you will learn, being sedentary can take a terrible toll on your health. You might be surprised to know that adding more everyday movement throughout the day is more beneficial than running on a treadmill. You might spend forty minutes on a treadmill, but what are you doing the remaining twenty-three hours and twenty minutes? Moving more all day long has to become a habit.

For long-term weight maintenance, breaking through plateaus, and reversing fullness resistance, you have to move. Many of you will be relieved to hear that you are not required to exercise for hours on end on the program. In fact, there are much more efficient and effective ways to build exercise into your life. I recommend a two-step approach to exercise—lifestyle movement and high-intensity strength training—and explain why. Adam Zickerman, a high-intensity workout pioneer, author of the New York Times best-seller Power of 10, and owner of InForm Fitness with branches in New York City, Long Island, California, Virginia, and Colorado along with a mobile gym, has designed three at-home high-intensity resistance workouts specially for this book to help you build muscle. The first workout is a beginner’s introduction to high-intensity resistance training, the second progresses you to a more challenging level, and the third hits a high intensity peak. You can do the eight exercises in each of these workouts in less than ten minutes, and you only have to do the workout twice a week. In twenty minutes a week, you will be building muscle mass. One of the reasons this is so important is that lean muscle burns more calories than fat. Every pound of muscle in your body burns thirty-five to fifty calories a day, even when you’re not moving. As you age, you lose muscle. Resistance training will maintain your lean muscle mass and will make you a healthy, calorie-burning machine. That’s worth twenty minutes of exercise a week, isn’t it?

Part 3, Beyond Diet and Exercise, covers medical treatments to assist weight loss when lifestyle changes alone are not working. Just as being overweight used to be viewed as evidence of a lack of willpower, weight loss medication was considered an unhealthy crutch. Those days are over. You do not have to feel guilty or like a failure if you can’t lose weight with lifestyle approaches alone. If you have diabetes and your blood sugar can’t be controlled, you would take medication. The same thing goes for high blood pressure, high cholesterol, or heart disease. Obesity is no different. As you already know, being overweight can raise the risk for just about every disease on the planet. I give you guidelines for when using weight loss medications makes sense. I cover the various medications on the market, how they work, their potential benefit, possible side effects, and the type of person each is best for. This chapter will provide you with enough information to have an informed conversation with your health care providers.

Though most people can lose weight and dramatically improve their health without surgery, some people, for whom lifestyle approaches in combination with prescription medications don’t do the job, opt for surgery. Lap band, sleeve gastrectomy, and gastric bypass surgery are the most frequently used procedures. I explain the surgeries, describe the pros and cons of each, the expected outcomes, and the best candidates for each method. I discuss new procedures we have begun to perform, including the vBloc vagal nerve stimulator, endoscopic sleeve gastroplasty, and Orbera and ReShape intragastric balloons, which I believe represent significant advances.

One of the benefits of my position is that we are at the forefront of the weight management field. Our own research is helping to develop treatments of the future, but we also get to review the work of my brilliant colleagues everywhere. Throughout this book, I report on the latest breakthroughs and areas of future research. We are up against an epidemic that is destroying the health of millions of people globally. Research to understand what is behind the catastrophic rise in obesity and what we can do to promote weight loss is a top priority.

If you are overweight or obese, the time to do something about it is now. Prevention is a better path than trying to restore the good health you have lost. If you are already experiencing health complications from being overweight, I have some good news for you. You don’t have to lose that much weight to improve your health.

Part 1

It’s Not Your Fault

Chapter 1

A Plan that Works

No one wants to be overweight. In our celebrity-obsessed society, we are bombarded with images of impossibly thin or voluptuous women and sculpted men with washboard abs. These idealized images of beauty are not good for anyone’s self-esteem and can be devastating for people who are overweight. Internalizing today’s standard of beauty, people who weigh more can feel unappealing, ashamed, and frustrated regardless of how many pounds overweight they are.

To add to their own image problems, society stigmatizes people who are heavier. They are judged to be lazy, incompetent, and lacking in self-discipline and intelligence, because they cannot control their weight. My patients tell me that they face prejudice and discrimination every day—on the job, in social situations, in education, and even from health care professionals. If they are severely obese, they may be subjected to looks, stares, and comments about their size. Overweight children are teased and bullied and are the last ones to be picked for the team. People struggle to lose weight, because no one wants to feel inferior or be the object of contempt. They are willing to try anything to slim down.

I see the frustration my new patients have experienced when they first come to my office. By the time we meet, many of them have tried everything they could think of, every fad diet that came along, without dropping those excess pounds and keeping them off. I am glad that I can help them break that disheartening cycle with a flexible plan that helps them to achieve their goals.

Mondo Diet

In 2012, an estimated 108 million American adults, roughly half of the adult population, were dieting. A typical dieter tries to lose weight four times a year. A huge industry has sprung up to serve this needy market. Last year, the diet industry earned $46 billion on products including gym memberships, weight loss programs, and diet sodas, to name just a few items. Forbes reports that two-thirds of American dieters regained all their lost weight within a year and 97 percent had put it all back on in five years. That backsliding phenomenon means that the diet market is self-renewing and continues to grow. The diet industry is more than ready to flood the market with new fads, products, programs, and regimens to satisfy the increasing demand. Our culture has become mondo diet.

Today, the buzzwords seem to be juice fasts and gluten-free. Both are supported by burgeoning businesses. All sorts of people are selling prepackaged cleanses, and most supermarkets have special aisles selling a wide choice of gluten-free products. You might lose weight if you only consume fresh-pressed juice and some raw vegetables for a few days, but take a look at what goes into those juices. When fruit is turned into juice, the sugars found in the fruit become readily absorbable. Very few juices are made only from green vegetables. Sweet fruit and vegetables are used to make the juice palatable, and the resulting sugar content can be high. Besides, you can’t stay on a juice