Patients frequently ask me why they are having trouble losing weight.  It’s an incredibly common and frustrating issue for them.  They sometimes want a simpler, faster solution than the tried and true path of diet and exercise.  They may report continuing weight gain regardless of the diet they are on.  When asked about caloric intake, they numbers in the range of 1200 to 1400 calories per day and still seem unable to lose weight. 

The first thing I often dispense with is the notion that weight loss medication is an answer.  Medications such as Adipex (phentermine) suppress appetite and result in weight loss, but are not always safe and, once the medication is discontinued, weight will reappear.  So, bad idea—let’s look at a different approach. 

There are some medical conditions that can interfere with attaining or maintaining normal weight.  This includes hypothyroidism, Cushing syndrome, heart failure and kidney disorders (which will result in fluid and water retention).  Other issues that may impair your ability to start and maintain an exercise program include osteoarthritis of the knees or spine, coronary artery disease, varicose veins (that can cause edema of the legs, emphysema, or other chronic lung conditions.  These conditions need not prevent you from daily exercise but must be adequately treated and adjustments may be necessary.

Now, what diet should you choose?  I’ve seen so many diet programs and fad diets.  Many of them do initially work in achieving a weight loss goal.  The problem, similar the one encountered with weight loss medication, is that the weight will always return if you haven’t made a long-term commitment to an altered lifestyle.  This means decisions about eating differently, and maintaining an exercise program.  Although weight loss doesn’t actually require an exercise program, it improves and hastens results, and improves overall health.  So, I always recommend it be included in a weight loss plan.

I actually don’t believe diets “work”.  I suggest that you simply choose to reduce the daily caloric intake by cutting back or cutting out certain items that you are accustomed to eating.  It doesn’t require drastic changes, especially if exercise is a part of the program.  Try targeting 500 calories of daily reduction.  This can be achieved by slightly reducing portion sizes, stopping a meal while you are still “slightly hungry”, substituting in between meal snacks with a cup of coffee or a glass of water, reducing desserts, reducing “carbs” such as starches, noodles, breads, chips, cookies and crackers, and eliminating desserts for most meals. 

A reduction of 500 calories per day, in conjunction with 30 minutes of aerobic exercise done on 5 out of 7 days of the week, should result in a one to two pound weight loss per week for most people.  Patients often can’t easily appreciate linear or consistent progress, so they grow frustrated, and may give up too soon.  If the above program doesn’t seem to be working as expected, what do you do?  Often it is unnecessary to do anything other than be patient.  I would give yourself at least 3 or 4 weeks to get into a rhythm of a lifestyle change such as this to see if it starts to work as expected.  If you reach a plateau after that, you have two choices:  further reduce your intake or ramp up your exercise program to burn more daily calories.  As you make decisions about what to reduce, give priority to cutting carbohydrates and sweet items.

I recommend weighing yourself daily so that you always know where you stand.  You should also give thought to setting a reasonable, achievable weight loss goal before you start your program.  The ideal benchmark is to achieve a “normal” BMI (body mass index).  This is a standard metric achieved by combining one’s weight and height.  Normal is up to 25 and 30 or above is considered obese.  You can obtain a body mass index calculator from the internet and use it to determine how many pounds you will need to lose to reach “normal” weight.  Then, by using the “one to two pound per week” rule, determine how long it should take to reach your goal.  Then use that date as your target.

For example, if I weigh 195 pounds and am exactly 6 feet, my BMI calculation is 26.4.  To reach a BMI of 25, I need to weigh 184 pounds.   Therefore, my weight loss goal is 195-184=11 pounds.  If I lose one pound per week, it will take 11 weeks and, if I lose 2 pounds per week, it will only take 5 1/2 weeks.    For most, the one pound per week goal is more comfortable and more realistic, so I usually recommend this approach. 

You may insist that you are carefully limiting calories, but still cannot lose weight.  My initial response is to evaluate possible medical issues that may interfere with weight loss or cause fluid retention.  These include hypothyroidism, kidney disease, and heart disease.  It is also important to review your medications to see if they could be affecting your weight loss attempts.  An example of a medication that results in weight gain is Seroquel, a drug used to treat mental conditions such as bipolar disorder.  Other antipsychotic/major tranquilizer-type medications such as Zyprexa have a similar effect.  An antihypertensive agent, amlodipine often causes peripheral edema and may result in weight gain due to fluid retention. 

When medical conditions have been excluded, attention should be turned to conducting a formal food diary and obtain an accurate daily calorie count.  This should be done carefully and systematically over at least a three day period.  This often leads to better understanding of where the “problem” lies with the inability to lose weight.  Once this is done, I like to “re-boot” the process, establish a weight loss target and schedule follow up visits about every 4 to 6 weeks to monitor progress. It is important to reassure patients who become frustrated when they don’t lose a pound for several days to keep a longer-term perspective and review the past 7 to 10 days, rather than worrying about not losing over the past one to three days. 

It is also important to emphasize that nutritional health and weight control is a lifelong lifestyle adjustment, not just a temporary weight loss program, so accept that the rest of your life will be a “weight loss/weight control process”, necessitating daily reassessment and adjustment to maintain your target weight. 

What do I tell patients who still come in and relate frustration at not being successful in losing weight?  My advice is simple:  If what you are doing isn’t working, change something!  You have four choices:  reduce your overall caloric intake, change your calorie distribution (carbs, fats, and protein), or increase your exercise duration or intensity. The use of apps should also be considered as a helpful tool.  They are available, for free, for both iPhone and android smart phones, which can be downloaded from the carriers’ “app stores”.  The two I use most often are “My Fitness Pal” and “Lose It”.  These apps allow you to set a weight loss goal and track intake and exercise sessions.  It will let you know if you are on track to meet your goal and, if not, provide the feedback needed to make adjustments in either your caloric intake or your exercise level.  I have found that, after a week or two of using the app, you are able to get a fairly accurate idea of what changes are necessary to meet weight loss goals; but, for the initiation of a weight loss program, especially if you are doing it on your own, there may not be a better method than use of one these apps.

CWS