Posted by: sayamika, the killer bunny | 2007 September 14

Simple math

Family medicine has a number of unique features, not least the responsibility to take on the chronic management of problems in social and lifestyle issues: smoking, diet, alcohol consumption, exercise.

Patients have a tendency to come to the doctor’s office saying “help me lose weight.”

I know as well as any of my patients how hard it can be to lose weight. How hard it can be to not eat that bag of potato chips in the car on the way home, to not have the buttermilk pancakes and bacon at Sunday brunch, to not have the bowl of ice cream while watching Gray’s Anatomy. I know how hard it is to fit regular exercise into a busy life.

But don’t bullshit me please.

When I ask you about your diet, if you say, I don’t get it, doc, I hardly eat a thing, I know we aren’t going to get very far. At that point I want to say, Bye now, see you when you are ready to work with me. You don’t get to 240 lbs without eating.

If your weight is stable, the math is simple:

calories in = calories out

So, suppose you are a 5’6″ (167 cm) woman weighing 200 lbs (90kg). If you didn’t leave your bed, you’d still need 1700 calories a day. Supposing you actually DO anything (and everybody tells me they are far more active than the average person, that they in fact are always running around chasing after the kids and whatnot), the number is far higher. That very active overweight woman needs at least 2800 calories a day to maintain that weight.

So if in fact you are not losing weight, you are certainly consuming at least the number of calories per day you need at your activity level to maintain your weight. Busted.

To lose weight, you can either decrease the calories coming in (diet), increase the calories going out (exercise), or do some combination of both.

There are a couple of things about this equation that make it frustrating for the dieters of the world (myself included): once you have managed to lose weight, if you relax and go back to the old amount of exercise, and the old amount of food, you are going to go right back to the old weight. Oprah is right about some things, and changing your lifestyle to maintain your weight really is necessary.

That amount of food at that amount of exercise for that person reaches a set point at that weight. So that’s it, if you’re relying on Atkins or South Beach or even ye olde Scarsdale, if you want it to have long-term results, you have to commit to it forever. Which is a long time to avoid carbs in my opinion, but I LIKE carbs.

Things I think everyone should know if they REALLY want to lose weight:

It is vanishingly rare for a weight problem to be “hormonal”, so don’t fool yourself.

It doesn’t matter if it says “low fat,” if you eat four of them.

Soft drinks count. Alcohol counts. Food sneaked at midnight counts. Food snarfed on the run counts. Everything counts.

Lying to me (your doc) doesn’t help. First, I care but I don’t care that much. Second, I’ll know you’re lying the instant you step on the scales so why bother?



  1. Dammit, that means all the obscene quantities of Rosh Hashanah food consumed at my parents’ house over the past three days counts too.

  2. OK, first of all, you must be skinny. While I do agree with what you’re saying, the truth is that while many of us fatties ate a lot to get where we are, our metabolisms are usually screwed up once we change our minds and want to lose weight.

    Especially after yo-yo dieting, which most of us have done.

    As a PCP, I experienced people who would cut their calories down to 1500 calories and do aerobic activity for an hour a day and still not lose more than a pound a month.

    Now, I do agree that for the average person, nutrition know-how is weak at best. But to think that all patients are lying to you is not fair to you or to them and may make you “unapproachable” to the people who so desperately need your help.

    By the way, I love your blog. I subscribe via Bloglines and read every post.

  3. Thanks FD (love yours too, as you know).

    Not skinny. I lie to myself too, and pretend the chips don’t count. I pretend the up-and-down-the-stairs a million times a day counts as exercise. I am always shocked at what the scale tells me. I LOVE food and it’s a constant struggle.

    There are always exceptions. But not everyone can be an exception, and it really was just a rant to make myself feel better about not just my patients but myself. Rereading, it comes across higher and mightier than I was feeling, for sure. Hazards of writing…

  4. interesting blog.

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