Susan Pierce Thompson: How to be happy, thin and free

the-3-huge-mistakes-report

This March, Susan’s first book, Bright Line Eating: The Science of Living Happy, Thin & Free, arrived in bookstores.

Here’s what she had to say:

Susan, in Bright Line Eating, you argue that the reason so many people struggle with their weight is that the human brain blocks weight loss. How so?

The human brain was designed to keep us stable in a right-sized body. But modern processed foods and the modern pace of life have hijacked various systems in the brain, and the result is that now, in the present-day environment, the brain does indeed block weight loss.

Here’s how: willpower is a finite resource in the brain. And it doesn’t just help us resist temptations or persevere in the face of challenges – it helps us do all kinds of things, like make decisions (e.g., checking email, going shopping), regulate our emotions (e.g., having kids, being in traffic), and regulate our task performance (e.g., working in Excel, giving a presentation).

After a brief period of time doing any of these things, if we start to think it might be a good time to get something to eat, we’re likely to fall into the Willpower Gap.

This is why so many of us order out for pizza or take-out on a Friday night after a long week, irrespective of how sincere we were when we pledged that this time we would stick with our diet until we lost all our excess weight.

In our modern society, the Willpower Gap is waiting for us, nearly always. Most plans of eating implicitly ask you to rely on your willpower to stick with the plan over the long term. The truth about your brain is that that will never work. You need a plan of eating that assumes you have no willpower at all (because, at any given moment, you may not), and works anyway.

To avoid relying on willpower, you suggest people adopt 4 “bright lines” into their eating habits. What are they?

Bright lines are clear, unambiguous boundaries that you don’t cross, no matter what–similar to how a smoker who wants to quit and get healthy throws up a bright line for cigarettes. The four bright lines I recommend are:

  1. No added sugar or artificial sweeteners
  2. No flour of any kind
  3. Eating only at meals–no snacking or grazing
  4. Bounding quantities of food, both to make sure you get enough vegetables, and to make sure you don’t eat too much of everything else.

What’s one thing everyone reading this can do right now to improve their chances of maintaining a healthy weight?

To really bridge the Willpower Gap, start writing down what you’re going to eat for the day in a little journal, ideally right after dinner the night before. Do it religiously until it becomes a habit. The next day, your job is to eat only and exactly that, no matter what. Make sure there’s no sugar or flour in your food plan for the day, and, ideally, stick with three meals a day, because three meals are much more automatizable than five or six.

Within a few weeks these habits will be automatic, and eating the right things, and not the wrong things, will start to be as easy as brushing your teeth.

 

(From original interview by Ron Friedman)

Planning a pregnancy: the importance of getting slim before you get started

newborn baby

In Europe the World Health Organisation estimate that more than 50% of men and women are overweight or obese and 23% of women are obese.

In a pregnant woman obesity raises her chances of gestational diabetes and pre-eclampsia. She is also more likely to get metabolic syndrome and type two diabetes later in life. The resulting children are more likely to come to harm in utero and at birth and also more likely to become fat children. They are then more likely to develop higher blood pressure and excess weight in early adulthood.

Despite the push to improve the outcome for the babies in utero, lifestyle changes and medical interventions have largely proved unsuccessful.

Women with a BMI over 25 find it more difficult to conceive in the first place and then are more likely to miscarry compared to their slimmer sisters. The miscarriage rate is 1.67. Congenital abnormalities become more common.

The placenta responds to maternal insulin levels. In normal weight women they become 40-50% less sensitive to insulin but this bounces back within days of delivery. Obese women show greater decreases in insulin sensitivity, this affects lipid and amino acid metabolism. African Americans and Southern Asians get these changes at lower body masses than Europeans.

Obese women are more likely to go into labour early. They also may need to be delivered early. They have a higher rate of failed trial of labour, caesarean sections and endometritis and have five times the risk of neonatal injury.

Anaesthetic complications are more common. The Royal College of Obstetrics and Gynaecology recommend that women with a BMI over 40 see an obstetric anaesthetist before going into labour. Epidural failure is more common. The woman may have lower blood pressure and respiratory problems and the baby may have more heart rate decelerations in labour.

Broad spectrum antibiotics are recommended for all caesarean sections. Despite this, overweight women get more post- operative infections. The wounds are also more likely to come apart.

Obese pregnant women are obviously at even more risk.

Babies of obese mothers are usually fatter at birth compared to other babies. Obese mums tend to put on more weight than average during the pregnancy and then find it even harder to lose weight after delivery.

Recent randomised controlled trial  have shown that interventions started after pregnancy have little or no effect. These include increasing the mum’s physical activity and cutting the dietary glycaemic load. These things reduced the weight gained in pregnancy a little but did not affect adverse pregnancy outcomes and the birth of fat babies. Thus there is now a bigger push to intervene before pregnancy.  

Currently between ten and twenty percent of obese women lose weight between pregnancies. This has been found to reduce weight gain in the next pregnancy and also the risk of pre-eclampsia.  Supervised intensive lifestyle interventions can be done, work and are safe, even in breast feeding mothers. Pre-pregnancy classes to get women fit for pregnancy would help improve the outcome for the babies of the future.  The metabolic environment, a mixture of inflammation, insulin resistance, lipotoxicity, and hyperinsulinemia,  can then be optimised prior to conception. After this, it is really too late.

 

Adapted from Obesity and Pregnancy. Patrick M Catalano and Kartik Shankar from Cleveland Ohio and Little Rock Arkansas Universities.  BMJ 18 February 2017 BMJ 2017;356;j1

Weight plateaus are a normal, but frustrating, feature of your weight loss journey

frustration

 Here are some words of wisdom and encouragement from a health care professional who knows how discouraging weight loss plateaus can be. Don’t let weight stabilisation lead you to jack in your efforts.
When Losing Weight, Warn ‘em!

Diabetes in Control November 8th 2016

I work in obesity medicine. As many of us know, losing weight isn’t the problem for most, but weight regain is.

As the saying goes for many, you can’t be rich enough or thin enough. Many of our patients come in with unrealistic goals regarding their weight loss, and don’t give themselves enough credit for the weight they have lost. Many, for many reasons, regain.
Woman, 58 years of age, class II obesity, prediabetes (A1C 6.0%), HO depression, on antidepressants, weight of 188, BMI 38. Started on metformin and lower carb meal plan.
Warned her early on it’s not just about losing weight, but what’s important is keeping it off. We need plans for both.
Her treatment plan does not end when she loses weight.  Over 6 months she lost 22 pounds. This is a 12% weight loss. BMI 33.5 now.  No further weight loss since the 6-month period, but no weight gain.
Patient frustrated. She has upped her exercise. No longer wants to continue metformin. Encouraged her to continue her meal plan, metformin and bump up her exercise plan. Praised her for her weight loss and not regaining.  And, reminded her this is what we discussed from the start. She remembered and said she’ll stay with the plan.
Lessons Learned:
  • Keeping weight off is a different stage of the weight loss journey.
  • Reminder that losing 3-5% total body weight can improve health outcomes.
  • 5-7% weight loss was shown in the DPP to prevent or delay type 2 diabetes.
  • From the beginning, let patients know there are stages to losing weight. First is to lose, then it’s to keep off the weight lost. Make a plan for both.
  • Regarding weight loss, put more emphasis on the food side.
  • Regarding weight maintenance, put more emphasis on exercise.
  • Remind patient of discussion and encourage patient to embrace the weight loss they have been able to achieve and keep off.

Anonymous

Margaret Coles: Invite this Physiotherapist into your home

At  www.movingtherapy.co.uk. you can find Margaret Cole’s free educational resource to help your health and well being.

home-physio

Margaret worked as a community physiotherapist and when she retired she decided to put her knowledge and experience to good use. She produced videos covering a lot of different situations that you can face regarding your physical and mental states and has put them on the site. She also gives advice on how to lose weight.   People from all over the world have visited the site since 2011.

NHSinform Scotland and her local authority also promote the site.

 

 

PUBLIC HEALTH COLLABORATION: WHAT TO LOOK OUT FOR WHEN STARTING A LOW CARBOHYDRATE DIET

PHC-Space-Top

 

FOR EVERYONE

As you start a low carbohydrate diet your kidneys get better at excreting salt thus you will usually find that you lose a lot of water from the tissues of the body.  This can make you instantly slimmer, particularly around the legs, but also can give some cramps in the muscles when you exert yourself.  Be aware of this and add extra salt to your food, and drink plenty of water.  When you are on a low carbohydrate natural foods diet you will be consuming considerably less sodium chloride, which is present in many processed foods including sweet ones.  Bread for instance has a lot of added salt that most people are completely unaware of, therefore feel free to be liberal with the salt cellar.

 

BLOOD PRESSURE

Blood pressure comes down, partly due to less water retention, but also due to lowered natural insulin levels in the body.  As the weight comes down as well, blood pressure tends to drop.  For most people who are not on any antihypertensive drugs they may feel slightly lightheaded from time-to-time.  This can be abolished by adding more salt to the diet.

For people who are on medication to reduce their blood pressure they should have their blood pressure measured by their general practitioner and cut back on medication on embarking on a low carbohydrate diet if their blood pressure is under 140/90.  After a few weeks on a low carbohydrate diet they will be adjusted to a lower level of blood pressure.  Thereafter blood pressure only requires to be checked on several occasions with each extra half stone of fat loss.

It is helpful to buy your own blood pressure monitor as measurements done when you are relaxed at home tend to be more accurate than those undertaken in a surgery.

As many blood pressure medications have more than one use, and different effects on the body, it is worth discussing with your general practitioner which ones would be better to cut out altogether or which ones could be reduced in dose.  This is because certain drugs such as ACE inhibitors and sartans have an extra protective effect on the kidney and this can be important for diabetic patients. They also help improve heart function in cardiac failure.

Beta-blockers are sometimes given to people with atrial fibrillation, or who have had a heart attack, or who suffer from angina, and continuing these may be a priority for some individuals.

BLOOD SUGAR REDUCTIONS

Blood sugar reductions happen rapidly with a low carbohydrate diet.  This is mainly due to the lack of sugar and starch being turned into blood glucose.  This has several effects.

The most pronounced and rapid effect could be on the eyesight.  The lens of the eye adjusts to a particular blood sugar and if the level goes suddenly up, or suddenly down, your vision can become blurry, particularly for reading print.  It is worthwhile avoiding getting new spectacles for about 6 months to give time for the lens of your eye to adjust otherwise you can end up having to get another pair of spectacles at a very short interval and this can be rather expensive.

 

INSULIN and ORAL HYPOGLYCAEMIC DRUG USERS NEED TO TAKE EXTRA PRECAUTIONS

Type 1 diabetics will have been using insulin from the time of diagnosis.  Increasing numbers of Type 2 patients are going on insulin as their pancreas needs more support as time goes on.  A rapid change in pattern of sugar and starch intake can give dangerously low levels of blood sugar unless the insulin dose is proportionately reduced from the outset of the diet.  The amount of reduction will depend on how high your blood sugars run normally, and how strict your low carbohydrate diet is.

For many people who are taking insulin, or sulphonylurea drugs which also have a marked blood sugar reduction effect, starting on a moderately low carb diet of 100g or so a day may cushion the effect somewhat.

Most diabetics will need to cut their insulin quite dramatically, particularly if they go on less than 50g of carbohydrate a day.  It is normal to have to cut insulin by a half or even two thirds in some individuals.

A close eye on blood sugar monitoring needs to be done and we would recommend that, for particularly people who are operating machinery or driving, they start a low carbohydrate diet over a period of holiday when there are other people around who can assist them should they have low blood sugars, and also people to undertake driving on their behalf.

 

Your own general practitioner or hospital endocrinologist is the best person with whom to discuss your planned reduction in insulin or sulphonylurea medications.

Many patients on sulphonylureas are able to stop these drugs completely prior to starting a low carbohydrate diet and thus remove the risk of low blood sugars completely.  People who use insulin however are not able to do this and must have a degree of background insulin to prevent them developing dangerously high blood sugars and ketoacidosis.

  The normal blood sugar ranges between 4 and 7 at most times.  Drivers must not drive unless their blood sugar is at least 5, and they should re-check their blood sugar after every 1-2 hours of driving.  To treat a hypo use 15-20g of glucose and do not drive till blood sugars are completely normal and you have fully recovered.

Setting an alarm to check blood sugars in the middle of the night, and taking blood sugars at 2½ hourly intervals through the day is advised in the first few days for insulin users.

The normal correction dose is one unit of rapid acting insulin for every 2.5 units of blood sugar elevation. This can be helpful to know if you have cut down your insulin doses a bit too much.

Aiming for blood sugars between 6 and 8 mmol can be a safe strategy in the first 2 weeks after starting a low carbohydrate diet.  Thereafter the blood sugars can be tightened up when insulin requirements are more predictable.  To prevent blood sugars going up and down unpredictably it is best to stick to 3 main meals a day and avoid snacking.

EDUCATIONAL COURSES

For insulin users and people on sulphonylureas it is best to fully understand the implications of a low carbohydrate diet and know how to control your blood sugars and insulin as well as having a good grasp of carb counting prior to undertaking a low carbohydrate diet.  There are many educational resources on the web to do this.  Some of these resources are Dr Bernstein’s Diabetes University on you tube, diabetes.co.uk website and Low Carbohydrate Course which is web based, and diabetesdietblog.com which has two written courses.

LONG TERM

Although it can be daunting to think about the initial difficulties that can occur with a low carbohydrate diet, the long term benefits of improved blood sugars, weight, blood pressure and lipids make the outlook for pre-diabetics, the overweight and people suffering from diabetes much brighter indeed.  It is worth educating yourself about your condition and how to effectively use a low carbohydrate diet to change your health destiny.  The extra planning that you need to do for meals, more frequent shopping for fresh ingredients and often increased expense are worth the long term health benefits.

ALCOHOL

Alcohol can be a pleasant part of life.  Many alcoholic drinks are high in sugar, such as beer and sweet wines, and also cocktails.  These need to be eliminated for success in a low carbohydrate diet.  Spirits such as whisky, gin and vodka have less impact on the blood sugar, and dry red and white wines are also suitable.

For insulin users, and particularly Type 1 insulin users however, alcohol can tip them into unexpected hypoglycaemia if they are consuming more than 1-2 units of alcohol without a corresponding increase in dietary carbohydrate.  This is because alcohol limits the ability of the liver to manufacture glucose, and also blood sugars tend to run much more towards the normal range, around 4.6, when diabetes undergoes an apparent reversal on a low carbohydrate diet.

EXERCISE

Exercise is a very beneficial and pleasant adjunct to a low carbohydrate diet for increased mood and health.  For insulin users and those on medication such as sulphonylureas, adding exercise into the regime early on in the stages of a low carbohydrate diet add an increasing layer of complexity to blood sugar management.  We therefore recommend that unaccustomed exercise is avoided for the first 2 weeks until blood sugar stability is achieved.

 

Dr Katharine Morrison

 

 

Public Health Collaboration: Free booklets

 

LA2-vx06-konsthallen-skulpturThis is the link to the Public Health Collaboration site where you can download for free or order print versions, at a modest cost, of illustrated health booklets that will help you:

 

know what to eat for a wide variety of good health outcomes

plan your meals

count your carbohydrates

lose fat

https://www.PHCuk.org/booklets/

 

Hopefully you will end up somewhere between the extremes of our sisters up there!

Bariatric surgery better than diets for sustained weight loss

Bariatric surgery has been shown to be the most effective treatment for substantial and sustained weight loss with a significant reduction in obesity related conditions and long term mortality according to the National Confidential Enquiry into Patient Outcome and Death 2014. Bariatric surgery operations are likely to become more popular as a result.

Bariatric surgery is particularly helpful for diabetics because it can greatly improve blood sugar control and even induce complete remission of type two diabetes. NICE recommends that those with a body mass index over 30 who have had diabetes for under ten years are considered for the operation. Asians may be considered at even lower BMIs.  Simple observation will demonstrate that there are many more people eligible for these operations than can currently be dealt with on the NHS. Indeed currently just under a third of patients pay for the operations themselves.

There are various types of surgery. Some reduce the area of the stomach like the laparoscopic adjustable band,  and some reduce absorption of nutrients like the sleeve gastrectomy. Some are a mixture of the two like the Roux-en-Y gastric band which is the commonest procedure that also produces the greatest weight loss.

Excess weight loss can be as high as 58% with patients’ weight levelling off after two years. Weight gain can recur and this can be due to not following the diet or a surgical failure than needs adjustment.

Once referred to a bariatric clinic the advantages and disadvantages of the various types of surgery is discussed. Psychological support and dietetic support is given. I recall that a bariatric surgeon told me that people referred to his clinic had very marked self- esteem issues and often defaulted from the clinic.

The short term problems after surgery include wound infections, vomiting, intolerance to pureed meals, problems swallowing and leaks at the staple lines for some operations.

Long term patients will need to continue to restrict calories and take multivitamins.  Acid suppression therapy is often required and patients should avoid non- steroidal anti-inflammatories. Gall stones may occur and may require surgical removal.  Hair loss may occur but is temporary.

After a Roux-en-Y operation calories are restricted to less than a thousand a day.  Patients have to take a protein rich diet so they do not become deficient. Iron supplement are particularly needed by women. Most people require vitamin B12 injections every 3 to 6 months. B vitamins, calcium and vitamin D, and the fat soluble vitamins A, D, E and K may be needed.  Annual checks of full blood count, electrolytes, liver function, glucose, iron, ferritin, vitamin D, B 12, calcium, parathyroid hormone, thiamine, folate and selenium are required.

The good news for diabetic  is that blood sugars often improve a great deal and for many  return to normal. Thus insulin and drug requirements will lessen or even stop.  Blood pressure, lipid problems and obstructive sleep- apnea also improve or resolve.

Women may find that they are able to conceive after bariatric surgery but this is discouraged for about 18 months after surgery because of the rapid weight loss and nutritional deficiencies that are common at this time. There is more risk of pre-term and small for age births in women post- surgery.

It can be seen that should the number of surgeries be increased to anything like what is required to deal with the obesity/diabetes epidemic, that resources for long term follow up of these patients will also need to be improved. Support for General Practitioners  will be needed, particularly as there is not sufficient structured follow up, particularly for those who have had operations out with the NHS and even abroad.

Based on article by Vamshi P Jagadesham and Marion Sloan from Sheffield in British Journal of General Practice August 2014.