 Good evening, I'd like to welcome everybody this evening. I'm Van Hubbard, Director of the Nutritional Sciences Branch within NIDDK. And this is the sixth and final lecture in our NIDDK Clinical Nutrition and Obesity Lecture Series that has been going on all spring and also with the cooperation of the nutrition department here at the Clinical Center in providing the CEUs for the dietitians. I appreciate the turnout for this lecture, as well as all those that have attended the past lectures. And with the feedback that we have been getting from these various lectures, I would like to say that we will try to continue this lecture series again next year, again in the spring. If any of you do have other comments about all the topics that you might like to see with regard to clinical nutrition and obesity areas, if you could leave some comments on the table in the back at the end of the session tonight, we can review that material and take that into consideration in the design of the lecture series next year. Tonight, we are fortunate to have Dr. John Ferrette, who's professor of Department of Medicine at Baylor College of Medicine in Houston. He's also director of the nutrition clinic there. He's a member of our National Task Force on the Prevention and Treatment of Obesity. Has contributed numerous articles to the journals preparation of books and book chapters and has been active in the science of studying obesity, especially as it relates to the behavioral approaches of obesity and other eating disorders. He has conducted a number of different clinical studies as well as being involved in direct patient counseling concerning these problems of eating disorders and obesity. And we welcome him on this evening to provide his thoughts on living without dieting. And he tells me that he also has a book of the same title, although he did not bring copies of that book here. Good, thank you. I'm very pleased to be here this evening and I thank Dr. Hubbard and NIDDK for inviting me to participate in this series. This first slide is a slide of one of my patients, Linda. I just wanted to show her to you. Linda lost, there she is, Linda lost over 100 pounds and then has maintained her weight loss, her 100 pound loss for over eight years now. And Linda said, when you show my slide to people, tell them that the only way I can maintain a weight loss of over 100 pounds is I work at it every minute of every day. From the moment I open my eyes in the morning, I think about my weight and I spend my day planning exactly what I'm going to eat. I always eat the same food. I always exercise at least one hour every single day. I always do exactly the same stress management strategies to maintain my lifestyle in the way I've structured it. She's changed her family. She's changed her career several times. I have a contract with Linda whenever she regains more than 10 pounds, she calls me and then we readjust her lifestyle and then get her back to where she was. In the last eight years, she's called me about seven or eight times. Last time was over Christmas and we put her back in one of our programs. My question to you this evening as we talk about living without dieting is I want you to think about is Linda a success or is Linda a failure? That is the amount of psychological energy that Linda spends every minute of every day maintaining her weight loss. Is that what we're trying to do? I mean, is that success? Or are you trying to, is that really failure? And that's what I want to think about over the next few minutes as we talk. This comes from Parade Magazine. It was a question of the week a while back that Sunday supplement was, is it okay to be fat? The answer by Chris Nissen, an 18 year old student from Kettering, Ohio replied, I cannot stand fat people. Fat is like a pet peeve of mine. I know there are people who have glandular problems and can't do anything about it, but a person who's fat who could lose the weight if they just weren't so lazy, I can't stand. It's not an unusual response. So when you see people who are heavy, who have sometimes carrying extra weight, you will sometimes see emotional problems. And it's important to separate when you see them in some people, whether, for example, the depression caused the weight problem or the weight problem caused the depression and so on. So it's very, very important to sort through that. Clearly people who have weight problems who are heavy in our society are discriminated against. There's well documented evidence showing the discrimination and the prejudice against heavy people starting at an early age. Well, this is Venus. Venus comes from a small town in Austria, Villendorf. She is what women should look like. She is that percentage of body fat that really does show the female form back in prehistoric days. And if you look quickly through the centuries, you see what say one of Renoir's paintings called Seated Nude. And if you look at the average percent body fat, compare Renoir's Seated Nude to the average percent body fat of the average female today, which is 22 to 24%. In Renoir's Seated Nude, you see her percent body fat is approaching 50%. More than double of today's average female. If you look at Peter Paul Rubens, if you look at Rubens Three Graces, you look closely at the percent body fat. Again, you see body fats in excess of 40%, roughly double of the average female today. Those three graces were not lean young ladies. If you look at, say, Rembrandt, again, you see and compare percent body fats, you see, again, a similar trend. This is painted by Picasso when he was a young man. Picasso painted this in 1895, and it shows right around the turn of the century. So at the beginning of the 20th century, you see the idealized female form, at least by someone like Picasso. I don't know what happened to Picasso. Here's one of his later ones, young girl on a blue couch. So as we get into the 20th century, our perceptions of body shape, body size, body form begin to change. Picasso also influenced John Miro. This is called young girl. So a 20th century artistic work exemplifying female form is quite different than the earlier days. Obviously, we have photographs in the 20th century, so I remember growing up as a boy in Wisconsin. My dream girl was here. But it's interesting to me, as I look through my 1993 eyes at Marilyn Monroe, I don't know if it's happened to me or if it's happened to Marilyn, but she's gotten heavy. And if you look at the 59 metropolitan tables, and that's kind of a research definition, take the midpoint of the midrange, multiply by 20%. Marilyn Monroe was an obese woman. She was obese in the 50s. We just didn't know it. And it's interesting to see what's happened since the 1950s. As you recall, those of you that recall the 1960s may recall the shift in our perceptions between, say, the 40s, Betty Grable, the 40s, Jane Russell, and then the 50s, Marilyn Monroe and Jane Mansfield, and then you get something like this for the 1960s. So you see a shifting in cognition, thought patterns, beliefs, perceptions, and people like Twiggy had a large influence on the way we thought about our bodies. So we get into the 70s and then the 80s here. Some of you may recall Jamie Lee Curtis in a movie called Perfect, which was a search for the idealized female form as exemplified by her. Does anyone remember the male lead in the movie Perfect? Yeah, very good, yeah. And I just ask that because John Travolta, who was the male lead, exemplified the ideal male form for the 1980s. So we get into the 90s, of course. You can pick up any magazine, as I'm sure you all do, and look, see articles, something like this, the lead article being nine bodies for the 90s. If you wanna see what women should look like, this is from that magazine article. That's one of the body shapes that women should be, at least as exemplified by the media, what a woman should be looking, one of the 1990 bodies. This is Giacometti, a contemporary Swiss sculptor. You may be familiar with Giacometti's work, again, showing that shift in shape and size. The other trend is this trend toward androgyny, and let me ask first, let me ask the women, how many find this attractive? How many of you find this on women? You do a little bit? Yeah, who else? One, okay, there's one. Who else? Women, just the women, no. Okay, two, okay, so kind of like two and a half, anymore, any else? Are either of you working out, do you work out? Sometimes, yeah. Does the other person? Or are you an instructor? Are you an aerobics instructor? Okay, now let me ask the men, how many find this attractive on women? No, let me see your head shaking. There's one, okay, okay, so all right. Usually you'll get many more women than men, so it is an interesting trend though, and it does seem to be here to stay for a while, this kind of muscles on women trend. Animals, certainly animals are interested in losing weight and trying to be thinner than their next-door dog. I don't know how many of you have cats, but if your cat is not a jogger, you have to, our cats are very interested into that physical fitness form, being the right shape and size. So it's interesting, certainly then, as you know, I mean, as a nation, we are clearly obsessed with our body shape and our body size. And to me, it's interesting first why and then what we've gotten ourselves into and then what is the answer, what are the answers? Let's look first at the psychology for a minute. This was a national survey done last year asking Americans their top five, their top hassles, and here's the top five of their hassles. Last year's top hassles were not Saddam Hussein, the economy, the recession, but the top number one hassle of adult Americans in a national survey was concern about my body weight. Isn't that interesting, if you think about it? And that was followed by health of a family member rising prices, health maintenance, and just too many things to do. Now why, why would the number one hassle of adult Americans be what we weigh? Well, if we look at what we weigh, the average man in the United States is five foot 10 inches tall. The average man today weighs 172 pounds, that is average, has a 33 inch waist. Now if you ask the average man what he wants to be, the average man wants to gain one inch. He wants to go from five 10 to five 11. The average man wants to lose one pound, drop his weight from 172 to 171, and he likes his 33 inch waist, thank you very much. Now, my question is, do you think women are like men? No, you know. The average woman is 134 pounds, five foot eight. Sorry, the average woman is 134 pounds, five foot three, and a half, and has a dress size of 10 to 12. If you ask the average woman what she wants to be like a man, she wants to gain an inch, she wants to go from five foot three and a half to five foot four and a half. She wants to lower her weight from 134 to 123, and drop her dress size from a 10 or 12 to an eight. Now my question this evening is why? Why does the average woman want to lose 11 times the weight of the average man? Any guesses or thoughts? Media, good, I think so. This is, you may have seen this, this is David Gardner's slide, but these, this jiggly line are the weights of Playboy Centerfuls through the years. This is yours, and this is percent of average weight. This is Haines data, National Health and Nutrition Examination Survey data, showing average weights of females, same age, same height, everything, except not Playboy Centerfuls. And so as you see Haines data showing us that women are getting heavier as are men, but this is female data here, women are getting heavier. Playboy Centerfuls through the years, now this only goes up to 78, but a friend of mine recently updated this through 91, I've never seen these myself, but what I've been told is up through 91 now, the average Playboy Centerful is about 82%, this is 83, it's about 82% of average body weight. In other words, women who are in Playboy Magazine, do you know where they keep the Playboys, by the way, she did her study at the New York Public Library, do you know where they keep the Playboys in New York Public Library, anyone know? It's in the Rare Book Room, this is true, I mean this is a true story. And when she was doing her research for this article she was writing for a magazine, she asked for Playboys and they would bring three at a time and the guard would stand over her shoulder and watch as they did height weight measures and so on, and so I don't know, but anyway, it's 82%. So therefore, if, well I should make my point on this slide, okay sorry, the cognitive dissonance, if you use this as your benchmark in 60, and remember Marilyn Monroe was kind of in the 50s there, the average woman was about the same, the average Playboy was the centerfold, was the same as the average female, pretty close. Look what's happened though, see through the years and then as women continue to get heavier and Playboy centerfolds stay down here, the cognitive dissonance that can be created if a person, some people, average, average, would look at this and say there's something wrong with me, she's okay, she must be the way we're supposed to be and look at there's something wrong with me, the dissonance created this compared to this, then explains to some degree as you said, why you get one out of two to one out of three women dieting at any point in time, it's not unusual, it's not hard to figure out why people are dieting, why people are trying to lose weight. Many people need to lose weight, there's no question that obesity is associated with many risk factors, the question is not whether many people need to lose weight, many people do need to lose weight, the question is what's the best way to do it? And I'm just going to talk tonight about dieting being the wrong way to do it, there are ways to do it, but not through dieting. If we first look at diets, the average eating pattern of caveman, caveman was a meat eater, but by the time he tracked down that deer, that venison was very lean, it's with the domestication of animals, with the refinement of the sugarcane and the refinement of the sugar beet and putting them together, that is taking a glob of refined sugar beet and a glob of fat and selling it as a Twinkie, selling it as a little Debbie, selling it as a Snickers bar, that you start seeing that fat sweet tooth and then the rise of, with the corresponding drop in fiber, et cetera. Even as young children, as you know, are eating 34% and compare that again to caveman eating about 10%, not that he may have had the best diet, but just relative to the shifts in our eating culture. The psychology of obesity then suggests that it's better to be lean and fit. And again, the media exemplifies that and I think very few of us would disagree a lot that if we could be lean and fit, we're probably better. The problem, as many of the feminists argue, is that many women in particular, some men, but certainly many women, spend all their time worrying about their weight and they try to do, they're yielding to be pressures to become a kind of a person that they feel they ought to be at the expense of cultivating their other talents. So at the expense of self-actualizing, when they could really be moving in areas that are vitally important, there as Linda does, she spends every minute worrying about her weight and her life then focuses on her weight. And they argue, many feminists argue that that's the wrong approach and that's the wrong way to look at things and I think they're probably right in many cases. Well, what's wrong with dieting? I mean, we can lose weight, I don't argue that. You can drop your weight if you stop eating or cut your calories back drastically, sure you can. Well, there are lots of problems with dieting and let's just look at a couple first of all and then let's really spend the time and see what we can do about this. Well, one of them is unnecessary dieting and people close to healthy weight. If one out of two to one out of three women are dieting, clearly a lot of those people need not be dieting by dieting, I mean, cutting back calories drastically, skipping meals, trying to eat a certain, like a woman trying to eat 1,200 calories or 1,100 calories or 1,000 calories. And a lot of people don't have to do that. I'll argue nobody has to do that, but at least many people don't have to do that. Overweight people aspiring to unrealistically low weights trying to get to the weight you were when you were 16 or 17 or 18 years of age and then trying to get back to that some whatever that means to you and younger and younger people dieting. So you start seeing these, as you know, these very, very young children skipping meals now. A colleague of mine just recently mentioned to me that her three and a half year old daughter said to her, laid down her spoon and said, ah, I've got to get on a diet three and a half years of age. So, and it's true story, it's true story. Well, what are the effects of dieting? So let's look at diets and again, by dieting, I mean is eating less than you would choose, consciously restricting your intake. For women, a diet is typically 1,200 calories. There are exceptions, obviously, but let's just take 1,200 calories as our example. Well, lots of things happen, as you know. First physiologically, when you cut your calories back drastically, then things happen to your body. And if you look at the literature, you'll see things like calorie conservation, metabolism obviously drops, preference for fat may increase, although that's controversial. There are some recently, more recently, published articles suggesting that does happen. It clearly happens in animals. There are animal research to suggest that. And perhaps binge cycles and yo-yo dieting in some people. So there are, when a person cuts back their calories, clearly there are changes. I mean, clearly there are changes. And then the question is, what do they mean and so on? If you look at the physiology, I was taught as a graduate student, you could not make this rat heavy. You could not put weight on this rat, make it obese. Without, you know, cutting out the ventromedial-nucleic-lateral hyper, the ventromedial-nucleic-lateral hypothalamus, destroying the apostate center, doing drastic things to him. But basically, you know, it grows up to be a nice, you know, like this. They eat what they're supposed to, et cetera. You know why. Well, what if, let's look at a USA diet. What if you offered a rat a choice between this and the USA diet? I mean, rats don't get heavy because they eat rat chow. If you haven't had rat chow, I recommend it to you this evening. On your way home tonight, stop at the store and pick up a 25-pound bag. I like my own self. I like perina. But I've tried others. Perina, you can eat it. I mean, rats eat it. But what you should do is eat it. I like it with a little Nutrisweet on it. And then with warm water, if you eat it with cold water, it tastes kind of like straw, like you're eating straw or hay, you know. And it doesn't taste very good. Well, I think that's why rats don't get heavy because it doesn't taste very good if you give them rat chow. Now, if you offer them a choice between rat chow and this, let's say what our friends eat, then offering a rat a choice between this and rat chow, as you know, within just a very few, within a few days, it's a good science experiment for your children that to show that given a choice between a high-fat diet and a low-fat diet, a rat will choose a high-fat diet. I mean, it's no secret. And you can show very nicely what happens. If you look at third-world countries and you introduce fat into the diet, they get heavy. As you know, if you introduce a McDonald's to Beijing, the people then get heavy and so on and so on. So it's not any secret why people get heavy in terms of why dietary patterns get unbalanced. Binge eating. Physiologically, then, the preference for fat may increase in many people. The DSM-4, the Diagnostic Statistical Manual of the American Psychiatric Association, the new DSM-4 will be out in 1994. It's coming out next year. The category called Eating Disorders has currently, there are four eating disorders, anorexia nervosa, bulimia nervosa, pica, and rumination. Then there's a group called Other. And in the DSM-4, apparently, as of today anyway, under Other, one of the Others will be binge eating disorder, BED. I think many of you are familiar with it. The proposed categories for binge eating disorder in the DSM-4, summarizing it, are here. It's a little more than this. But basically, it's eating a large amount of food in a short amount of time under two hours. And large amount is defined as more than the average normal person would eat. So more food. It has to be not one M&M or one cookie, but it has to be a large amount of food more than the average person would eat in that amount of time, in a small amount of time under two hours, along with the feeling of being out of control. Along with that is rapid eating, doing it rapidly, and having bad feelings about it. Oh, I shouldn't have done this. I feel terrible. I ate too much. I really feel bad about it. And then at least two times a week over six months. So that's kind of a summary of the proposed criteria. Now, does then dieting cause binge eating? It's a very interesting controversy, and it appears in some people it does. Now again, you can argue what the chicken or the egg, but certainly they are associated with each other and many people. And it may be a result of, again, the deprivation that diets produce. Well, there are things one can do, of course. I don't know how many of you have along with binge eating, but you can also get into bulimia. Bulimia is binge eating with vomiting, so as you know, as way some way. So I don't know how many of you have a copy of this book, but I do on my bookshelf. It's called Responsible Bulimia by Glenn Tillitson, and it says, is it possible one man's testimony? And in the book, what Glenn does is teach that you can binge eat, but then the next step, I can do it. You want me to do it, Van? If I press just a little more and then wiggle, what you do is take these two fingers and then press down and wiggle, then you elicit the gag reflex and you can handle your binge very responsibly, very, not in front of an audience, but in the bathroom, so. Other ways, vacu-pants you may be familiar with, but this is Sandy Martin here, has her vacu-pants on and her vacuum cleaner hose stuck in and then you turn your vacuum cleaner hose on and it sucks out the calories, so that's another way. This is Slim Sleepers, where these are magic pajamas that you don't have to diet, don't have to exercise, don't have to take pills or shots. All I have to do is sleep in these sleepers, pajamas made of a miracle Dupont fabric, which sucks the calories out of you while you're sleeping, so the longer you sleep, the more you lose. Now you smile, but I have a very sad case, one of my patients bought a pair of these, overslept one night, disappeared, so you have to be very careful how much you can lose way too much. You can put staples in your ears. There's a branch of the vagus nerve that runs behind the ear here, so when you get hungry, you push the inside part of that staple across into the vagus nerve, which then takes away your hunger, so that's not a bad strategy. You can wire your jaw shut, of course, to stop your eating. We had one young lady, a physician, wired her jaw shut. Physician told her to go home, drink only seagull, some diet drink. Came back to see one of our dietitians and in the meantime, she had gained, with her jaws wired shut, she had gained 22 pounds. It's a true story. Think about how many gallons of seagull you'd have to drink to gain 22 pounds, so in other words, you can still ingest food with your jaws wired shut. And the bubble, you may be familiar with the bubble, but this is the Garen Edwards, where a gastroenterologist will introduce it into the stomach and then it's pumped up. If you haven't seen one, it kind of looks like a Coca-Cola can. It's a smaller, it's more like one of those little orange juice cans and it's plastic, so you put it into the stomach and then pump it up and then it's like you have a Coca-Cola can in your stomach, so you can only eat so much and then as you eat, then you can fill your stomach. The problem with it, of course, so here's the Coca-Cola can, see, in your stomach and then when you fill it with food, I mean up to it and then it bumps against it, but the stomach is a good digester of anything put in it, so after about 90 days, it kind of gets mushy, so you have to pull it out. But I always show, this has been pulled off the market now in this country, but I like to leave it in because there are six other ones being, at least six, probably more than that, are being tested in Europe. One of them where you leave the hose hanging out of your nose, so when this gets crumbly, you kind of pump it up again and so you keep it in for long periods of time and then, of course, the gastric bypass, which is so popular today. In terms of these different strategies then, what we see is the weight fluctuation. We recently finished a study where we looked at weight fluctuators, that yoyo dieters, and it looks like our conclusion is that the dieting is producing the fluctuation, yoyo dieting, losing weight, regaining, and what we found is the weight fluctuation is strongly associated with negative psychological attributes. We look both in obese people and in normal weight people, normal weight people who go up and down in their weight, also show very strong negative self-attributes, lower well-being, lower quality of life, more depression, more stress, and other factors. And again, chicken and egg, you have to look through both of these, but we now have five years of prospective data on these people and it also is holding very strongly. Fluctuation clearly is a problem and it may be a major real problem, both physiologically and psychologically. Weight stability, even in obese subjects, is a sign of greater well-being than is weight change and that we documented in looking at this. Heavy people who stay heavy, who modulate their weight from a psychological point of view, really look very, very healthy psychologically. It's the people who are going up and down that are the unhealthy ones and that's both in obese people and normal weight people, and normal, normal people who stay normal, who stay stable in their weight, look healthy, obese people who stay stable in their weight, look healthy, psychologically. They may be at risk medically, but I'm just looking at the psychology of it. So from a psychological point of view, what's wrong with dieting? Well, there are lots of things. Reduced energy, if you cut back to 1200 calories over a period of time, you can look at the old studies of the people who are on starvation kind of eating programs and you see those changes in those five major areas, but one of the areas is energy. You just don't feel very good because you're thinking about food a lot, the cognitive, affect, feeling, labial mood shifts and behaviorally, or behaviorally you're always, it's hard to concentrate and so on. Negative emotions, cravings, of course, increase and irrational justifications, like you're always struggling to maintain, can I get through this minute? Can I get through? I wish he'd stopped talking. I'd love to go get some food. That kind of people on diets are always thinking about that kind of stuff. Well, all right, that's the cause of dieting, of a few examples. Why do people regain? Well, probably lots of reasons among them and we always like to liken it to trying to breathe through a straw. If you breathe through a straw, you can do it for a while, but after a while you're gonna gasp for breath. It's the same as dieting. You can diet for a while, but the body is going to simply gasp for breath and that's going to, you're gonna see a shift in all kinds of factors, both psychological and physical. Certainly return to old habits, that may be a reason and some, we think the diets are just too restrictive. What happens in one sentence, if you diet, you're gonna get hungry and you're gonna feel deprived and that deprivation is gonna lead to physiological hunger. Physiology always overcome psychology. So hunger will always overcome willpower in the long run. So you're gonna lose. So the problem is not you, it's the diet. The diet is the problem. Diets are too restrictive and again, people set up unrealistic goal weights for themselves. What are the effects of the regain then? First physiologically, what are the effects of regaining body weight? Maybe added fat stores. And again, if you look at Piessonnier's work, depending how much you gain and so on, you see shifts in that. A slower return to normal metabolic rate or at least the weight that you were, if you look at Tom Wadden's, slow regain of his metabolic rates over time, relative to where the person was and increased preference for fat. The effects of post-diet regain psychologically, self-blame, negative emotional states, reduced self-efficacy and so on. I mean, people who regain body weight just feel awful about themselves. Well, let's look at the state of the art then. Where are we today in terms of dieting and what does it all mean? The state of the art is the behavioral self-management approach and this is, I've published on this, this is my area and we've looked at very closely, behavioral self-management is the state of the art that is dealing with the environmental contingencies related to eating, staying on a diet. So a behavioral self-management approach, as all of you know or most of you know, certainly deals with looking at the antecedents that is all the environmental cues that are associated with eating, why we eat. Hunger is one, but the environment where we're at watching television with people at parties, all of these are cues, television set, commercial maybe a cue and so on. The behavior, there are a lot of behaviors associated with eating and then the consequences of eating. The goal of behavior modification is to help people stay on a 1,200 calorie diet, typically 1,500 maybe for men and using the behavioral approaches to try to get people exercise but certainly the dietary part has been used quite a bit. You use these strategies to teach people to stay on a diet. I mean that's why we have people keep food diaries and stimulus control, et cetera. The problem, what's the problem with that? It works very well and of course it does. I mean we have data on that. Behavioral modification requires self-control. That's what you're teaching. You're teaching self-control, that's self-management. The problem is restrictive dieting by itself, lower self-control. So in times of emotional stress or social situations which are the two primary causes of rebound, the very self-control you need is gone. So that's the problem. You get hungry, you feel deprived, you get hungry and the behavioral principles that teach you to stay on this diet are not strong enough to stay on the diet. Occasionally you can use some motivational trick but that's few and far between. Let's look at obesity then. If you look at the literature from 1985 to present up to about a year ago and we did this, we found roughly 8,600 publications. So there's a lot of work in obesity. If you narrow that down to the treatment publications, of actual treatment and then following, you get this is the number roughly. 1986 there were 161 treatment articles, 87 to 194 and then it starts going down, 150, 89, 87 and then we're just 91, 92 yet we're looking at but it seems like it's going down each year as people require, as journal editors require longer follow-ups before you get your articles published the number gets less and less. Why is that? Well, let's look at what the results do show. First of all, how about commercial programs? How well do commercial programs work? I mean we see them all over the place but really how well do they work? Well we don't have any control data. There are a few multiple case studies now that are coming out where they look at so many people over such a time but if you really look at a kind of a well-done, well-run clinical trial or at least just a good study on it, there aren't any to speak of. Self-help groups, what about 12-step programs? How well does over-eaters anonymous work? I wish we knew. It certainly works with some people, I don't argue with that but it would be nice to get a study to see who it works with. How about popular diet groups like Weight Watchers or Tops, Takeoff Pondsensibly or lots of them out there. How well do they work? We have no data at all on control data. How about people losing on their own? Self-changers. People like your friends or maybe yourself if you've lost weight and kept it off. None of that is in the literature to speak of. There was an old article by Schachter a few years ago but not a very well-done study. So what we really need to look at that, if you look at say the Consumer Reports data, Consumer Reports article that came out two weeks ago when 95,000 of their readers wrote in about 25% said they lost weight and maintained it. So those are the, it's very good data. I mean it's very interesting. People who tend to write in tend to be more successes than people who don't but still those are the kind of data that we need. We need more of data like the Consumer Reports article. I should say, let me go back one here. The dietitians and physicians. Most, the most overweight people are seen by doctors. How well do doctors do? How well do dietitians who treat overweight people do? We have in private practice. We have some university studies but in private practice. We need that. Now most of the data then that are published and I'll show you what the results are come from universities or medical schools obviously because that's what these guys do for a living. So university-based programs are the most researched and these tend to be done in a semester now they're getting longer surely but those kind of, so you get a kind of a select sample of people who go to medical schools or universities to be treated. But of those that go, this is what you get behavior modification programs and behavior mod with very low calorie diets. That's like Optifast and so on. And behavior modification with drugs like Prozac or Finfluoramine and so on or surgical approaches. And so of that, this is what we have. The behavioral data first. Typically a behavioral program will teach a 1200 calorie diet for a woman. Use a food diary, that's self-monitoring. With stimulus control that is identifying the cues in the environment that are associated with eating and then changing those, controlling those. And then rewarding contingency management means reward for behavior change. Teaching stress management, how to manage stress and then teaching kind of attitudes. Well if you do that, this is what you get. This is as of 1993 now or at least in the 92. Today the average treatment length in the literature is 18 weeks. Average dropout rate is 13%, which is very good by the way. The older studies had much higher dropouts. Average weight loss is quite good. The average weight loss for behavior modification program today is 22 pounds. Average maintained for one year, that is if you go, if you stop treatment at the end of 18 weeks and then find them one year later, one year after the 18 weeks, the average person will have regained a third. So we'll have maintained a loss of about two thirds. Of the studies that are published three to five years, there aren't a lot of them, but of those that are published, the published ones show weight is regained completely. There are no studies that I'm aware of five years later that will show any treatment effect at all. Not that it should, but I'm just saying this is the state of the art. If you look at the very low calorie diets, you get a similar data. You get better weight losses because the calories are restricted to 800 calories or so for on the average 12 weeks. Nice drops in blood pressure, cholesterol, glucose, and so on, very nice, but then the return is similar. By one year, you get the same two thirds maintained, one third regained, and then three to five years, all of it is regained. So by three years typically, certainly by five years, and again, the best studies published here are Tom Wadden's work. What do we know then? What does the literature show? Well, first dropouts, there are three predictors of dropouts, binge eating as we looked at. So binge eaters are very important to assess and look at that separately. If a person is a binge eater, it's important to look at separately. That's different from obesity. One third of obese people are binge eaters. Two thirds are not. So that third obese binge eaters, binge eating should be looked at separately and treated separately. High stress, a person who doesn't do well at first tends to drop out, obviously. Now what are the factors that predict weight loss? I put question marks on these because the literature is still controversial. Body fat distribution. People who have weight above the waist tend to have more trouble losing than weight, sorry, the reverse. People who have weight below the waist have more trouble losing than weight above the waist. Probably, but the literature is controversial. People who are more depressed have less, have more trouble. People who restrain, that means like eat up to fast or eat only bananas or eat only grapefruit and eggs. Those people tend to do better at first but then the bingeing. Weight cycling, they tend to do pretty poorly. People who are cyclers and the binge eaters, we know they drop out, but do they also do more poorly? It looks like they do, but again, those are controversial. What do we know? Well, we know four factors predict, four treatment factors predict better weight losses. The longer you have treatment, the better the weight losses, obviously. The more you stress exercise, the better the weight losses. The more you encourage support, family, friends, groups, the better the weight losses. And the more you use closed groups, that is the group starts together and stays together, the better you do. What are the client factors that predict weight loss? There are four of them. The heavier the client, so the more obviously. I mean, the more you weigh, the more you're gonna lose in a program. The higher you're resting metabolic rate, these are bigger people. The bigger you are, the higher your metabolic rate. The higher your metabolic rate. So those are bigger people lose better. The more fat cell numbers you have, the more you're gonna lose just because you're bigger. You can't keep it off if you have lots of fat cells. It means hard to keep off, but you can lose it because you're bigger. And the more self-efficacy you have, the more you lose. That is the confidence that you can handle problem situations. What are the correlates of weight loss? There are five of them. If you do well early in a program, you'll do better. If you attend classes, whatever the program is, the people who attend do better. People who keep food diaries do better. People who set reasonable goals do better. And people who tend to slow down their eating. One of the big problems, as you know, with some heavy people is faster eating. Long-term maintenance. Who does best over the long run? The goal is always what predicts relapse. There are two major always predictors relapse. One is emotional eating. Number one, emotional eating. That's stress and any other kind of depression, anxiety, hostility, anger, et cetera. And social situations. Eating out tonight in a restaurant after this talk. Kiss of death. Anytime you're in a social situation. So what predicts long-term maintenance? Well, there are five. One is exercise. That's, as you know, the best predictor of long-term maintenance. People who exercise do better than people who don't. So the one good, really strong predictor in every study ever published that looks at maintenance data shows exercise. That's hard to get people to do. I know it is. But those that do it do well. Self-monitoring, that's keeping a food diary. Exercise diary. We're really paying attention to what you're doing and writing it down in some way. So write down your exercise, write down your eating, write down what you weigh, et cetera. A problem solving. That is identifying when you're feeling emotional, having emotional problems. I'm under stress now. So I better watch it and this is what I better do. I better not bring this cheese home because I know I'm gonna eat it all or don't buy the Oreo cookies. Continued contact. Continued contact means continued contact with a professional, healthcare professional, a dietician. So you dieticians who work with obese people, how long must you see your clients if they're gonna be successful? The answer is forever. That is the longer you see them, the more you send them Christmas cards, the more you call them up, the more you say how you do it, the better your clients will do. And the more a person controls his or her stress, obviously. All right, when you factor all these down and you look at all the studies, and this is all these factors that I pulled out for you and looking at all those 8,600 articles. Not really, but the treatment articles. What you find is still, you get treatment successes of 5% to 10%. 90 to 95% of people will regain their weight. What's wrong? Why? The problem is the diet. That is, in my opinion, it's the diet. The diet is too restrictive. There are other kinds of models than the behavioral model. You see the behavioral self-management model then has been used to teach people to stay on diets. And the diet itself is too restrictive for most people. Not everybody, some of you people, can live on 1,200 calories. But not your clients. Many of your clients cannot live on 1,200 calories. That is the problem. And then what happens is the fat consumption sneaks in there. So the self-management model, which is the state of the art, suggests that obesity is due to a lack of skill in controlling the stimuli and the rewards that come in eating. There are other models, for example, now we've published several articles now on a food dependency model, which suggests that uncontrolled eating is caused by dieting and other distorted thought patterns related to social pressure and body image and all these things we were talking about earlier. Media pressures, we've got to be so skinny and blah, I can't go to that classroom reunion because I don't look like I did when I was graduated from high school and all that kind of stupid thinking. And then you diet and that's really why people get in trouble. You develop this dependency then, food is used for other reasons. The assumptions of the two models, and I'm just comparing the two for just purposes of next minute or two to show you differences. Behavioral self-management says human beings are rational individuals, so you should be able to teach a very simple kind of behavior modification manual, give a client the Kelly Brownells Learn Manual, which is a very well done manual, excellent, and they should be able to follow it and lose and maintain weight. Problem is humans are irrational people and the problem is self-control fails when people get hungry. So there you get into self-control lessons rather than increases. So control is not possible without social support. The management model when you have these techniques, stimulus control, contingency management, food dependence, the focus should be on thought patterns, should be on feelings and thinking about and talking about and dealing with emotions related to obesity and social support, fighting these pressures that all of us have every day, particularly women. The nutritional self-component then is what I've been arguing this evening for this time I have with you, is that the problem is the diet itself. You get too low in calories. You teach people to self-monitor that low, that's the crazy part, see that's the abnormal part, is highly restricting people. Food dependency then is really emphasizing don't diet. The first thing you do in a food dependency model is to stop dieting. And I don't mean by that just unlimited eating and I'll show you what I mean in a minute, but I mean focusing on healthy eating, eating only when hungry rather than when appetite occurs and so on. And then finally the source of support is family and friends versus peers in the food dependency. Finally then, how can you live without dieting? I think living without dieting is the only approach for most people. First let me say one more time, people, many people do need to lose weight. I don't argue with that. Some people need to lose weight because weight may affect their blood pressure, their cholesterol, their glucose, may put them at risk for heart disease and some cancers and so on. I don't argue with that. I think people have to lose weight. I'm just saying that dieting is the wrong way to do it, that's all. So let's look at how you can live without dieting and still lead a healthy kind of lifestyle. Well there are many ways to do it. Here are five of them and I'll just highlight just these five for now. There are other ways too, but let me just show you these just for time purposes. Fat versus calorie reduction, normalized eating patterns, very gradual changes, realistic all weights and peer support. First, fat versus calories. I think calories, the approach has typically been calories where you're lowering calories to 1200. That's the wrong way to go. First step is to forget dieting at all. Don't diet. Then that's number one and that's hard for people to do. I mean this guy's crazy, you know that kind of, and I don't mean by that just unlimited eating but what I mean by that in a very gradual way, you want to start, you want to avoid the deprivation that dieting causes. If deprivation's the real problem, which leads to hunger, then you want to avoid deprivation. How do you do that? Well clearly the culprit is fat. Okay, we know that. I mean, dietary fat's the culprit, nine calories per gram. So you want to gradually shift away from that, doing it real tiny, tiny, tiny, slow steps, 12 months to do it, which that's what we're doing now. We have a three year study where we've been doing this over three years. By giving unlimited amounts of fruits and vegetables, breads and cereals, so the other food groups, the more healthy food groups, by gradually shifting away from fat. The trick is to avoid deprivation. You must have your clients say, I am not hungry, this is wonderful, I'm eating all I want, but making little tiny steps. Second is normalizing eating patterns. Many people who have problems have disorganized, disordered eating patterns. So it's important to get people back onto sensible eating. Now I know you all try to do that, but it's really a critical element in this program is to get people to eat breakfast again, get them to eat lunch, even though they're not hungry, and get them to each dinner. Along with that is between meals, you want to teach people, and here's the key, teach people to separate hunger, which is hunger from the gut. That's the stomach grumbling, grumbling. Many Americans do not know what hunger is. To separate that feeling, to teach people what that feeling is, and to separate that from appetite. And appetite is psychological. Appetite is everything else that happens, the television set and the friends. And then teach people to do that for themselves, to figure out when they're hungry, and eat only in relation to hunger. So if they get hungry between meals, they ought to eat. They ought to eat all they want to. They ought to focus as best they can on fruits and vegetables, breads and sails as best they can. Slowly. They need fat too, but you want to do it slowly. If it's appetite, you want to teach people a series of steps to avoid eating, or at least reduce the eating. At least so they recognize. So separating hunger from appetite. And it's hard to do. So again, this is not easy. You can't do this tomorrow. This program takes at least one year to do. And then you want to build in a lot of sensible kind of snacks and so on. Third, you want to do this very gradually. You do not want to hurry with this. What we find with our clients and our programs is that they want to do this tomorrow. And if you do it tomorrow, it doesn't work. You have to do it. So you have to avoid deprivation. Every step, you have to avoid deprivation. So exercise. You want to self-regulate exercise very slowly. You want to take six to 12 months to change eating. And you want to lose no more than, say, a half a pound or a pound a week. I mean, just a little tiny amount. Exercise is so important because the literature is clear on that. I just want to put the plug in for exercise again. Improves psychological well-being, improves mood, improves self-concept, improves self-esteem. It has limited effect on overall personality functioning. But it does decrease mild anxiety. It does decrease mild depression. And it does decrease mild stress. It affects on stress, responsivity, and cognitive functioning are unclear. Although in older people, it clearly has some effect on some cognitive functions. So exercise is clearly relevant for many, many reasons. You do not have to diet, but you have to exercise. The benefits of modest weight loss, how much weight do you have to lose? You only have to lose little tiny amounts to start showing effects. Hypertension can decrease with little amounts of weight loss. 10% weight loss can normalize blood pressure frequently. Type 2 diabetes decreases with modest weight losses. All kinds of psychologically depression decreases in self-esteem increases. You only need, when you start seeing it already, around 10 pounds. When you lose 10 pounds, you start seeing all kinds of shifts. By 20 pounds, it's all you need in many cases. In many cases, that's all you ever need. Realistic old weights are a number of formulas. And we publish these in Living Without Dining. But I tell you, Cormelots from Buenos Aires has done a little kind of a complex formula of how many years you've been overweight and what was the best weight you ever weighed and all that. And it fits. It works. Kelly Brownell has published a reasonable weight, which is, what is the weight you, as an adult, have been able to maintain without highly restrictive dieting for at least one year? And then that's a reasonable weight to get back to. We talk about where you take the weight you were as an adult for at least a year, the weight you are today, and then take the halfway point. I think you could throw away all of the weights and throw away all the scales and just do behavioral goals only. The bottom line really is healthy eating, sensible eating. And we know what that is. We know the dietary guidelines. We know what is a healthy eating plan. And we know what a healthy exercise, American College of Sports Medicine, has very good guidelines for what is a sensible exercise program. And that's a few minutes a day. You can get into a very good exercise program, very healthy eating plan. And then don't worry about your weight. Here's a study we did. This is over two years. These are all real weights, weights on the clinic. I mean on the balance scale in our clinic. So none of this, none of these weights are self-report. 150 overweight Americans, this is zero. One group got exercise only, that's this group. One group got diet only, that's this group. No exercise, this is no dieting. This is diet plus exercise. These are all weekly classes and then monthly classes. So for a year, we had a treatment program. Both the diet groups, this is diet only. If you want to lose the most weight, diet only. I'm just being facetious, but that does produce the best weight. Diet plus exercise, you get this. Then you see what happens. Here, this is starting to gradually regain, even with classes. These continue to go down. Then we stopped all classes. And then one year later, we got them all to come back again, put them on the scale. So this exercise only group, dinking along, dinking along, hardly losing anything. But look what happens. The minute the professionals, the healthcare professionals, dietitians in this case, stop seeing the clients, the diet only we would have predicted. They gained it way back again. But this group, that's diet plus exercise. Diet plus exercise regained all their weight back in one year. Why? It's the aversiveness of the diet that overcomes the potential benefit of the exercise program. Dieting is so aversive that the minute you stop a treatment program, it'll all come back. The winner in all this is exercise only. There was no dieting at all. Now you don't lose very much weight. We have body measures and everything else on these people and they look really good. We're now doing a five year follow up on these same people and all these groups. So I've got about a third to a half in and we just need a few more yet to see what it looks like. But clearly the worst thing you can do with people is dieting. So finally then peer support. Social control is much more important than self control. Self control does not work under emotional states. Self control does not work in social situations. Occasionally sure once in a while. We all know that. But in the long run, only social control. That means peers. That means groups. That means friends. It's the only thing that works. Control of overeating and control of under eating. That's dieting. You must control under eating by having people eat breakfast, lunch, and dinner. Making sure people are getting lots of food to prevent deprivation. Reject concepts of fatism and lookism and people have to look in a certain way. All of us cannot be healthy. All of us cannot be skinny. All of us can be healthy. All of us can eat well, write. All of us can exercise right. All of us cannot be skinny. All people cannot be skinny. Just doesn't go together. We have genetic, all the ideological reasons why that is. Develop new norms about behavioral patterns. What is health? What is well-being? Why do we have to look like these people in magazines? It's stupid to spend our time looking like people and trying to look like people that we can't achieve. You wouldn't want to look like those people anyway, I would bet, if you really met a lot of those people. And alter self-concept, learning to really get a life. I mean, the bottom line is get a life. People that spend their time worrying about their weight and their whole life is regulated by the scale, to me is just, I mean, what is a life? That is relationships, working with other people, building relationships, forming friends. That's what life's about. It's not about what you weigh. Certainly you should eat healthy, no question of that. Certainly you can lose weight if you have to, sure. But the way to do it is this way without deprivation. Finally, identify all the money for research purposes. I'd focus some of it to prevention. Not teaching people not to diet. Certainly children. The worst thing you can do is put a child on a diet. But emphasizing the concepts of living without dieting, regular exercise, sensible eating patterns, and then whatever weight you achieve is a healthy weight for you. Then and only then will we see a decrease in the prevalence of obesity in our society. Thank you. Good, thanks. Anyone have any comments, comments, questions, thoughts? Yes. Yes. Things that you do with your clients. Yeah. Especially when we have a weight problem. The biggest thing is they're not going to go to a health club. Right. They often won't even walk in the street. No, absolutely not. You manage the courage. Right. Two things. There is what's two types of exercise that we encourage. There are really three types, but two we encourage. One is lifestyle. So first, the studies, many studies are suggesting that lifestyle exercise programs work better than programmed exercise. So lifestyle exercise means teaching people in their everyday life to improve a little bit here, a little bit there. Those kind of walk up the flight of stairs rather than the escalator when you're outside. That's number one. So one is regular exercise, kind of lifestyle. Second is programmed exercise. That is the aerobic. And we teach walking. And we do that. There are variations that you can do in the house. You can do in the neighborhood. And we can do it when we have our classes. And we do it in the classes. We walk with our clients and so on. We also encourage them all walking, et cetera. There is a third type as the anaerobic is the strength training and that we are not doing that. Other people are and finding some benefits in that. You can shift some of the fat to muscle. Obviously, that has many beneficial effects. Psychological and physiological. We haven't done that yet, but we've done the first two. So we've done the lifestyle change and the programmed exercise. And what we do is gradually increase by minutes. Start at five minutes, 10 minutes, wherever the person is. But we try to build them to about 40 minutes a day and five days a week. Now, that's a lot. I understand that. But again, we work with people over three years now. So we have a three-year program. It's supported by NIDDK. And what we're seeing in this program are just remarkable. Some of these people are just no dieting at all about these steps. I mean, healthy eating, clearly. And we're seeing the weights come down, the self-esteem going up, exercise. So it all fits. Works together very, very well. But you've got to do it slow. Don't start fast. Yes. The hardest thing to teach in this program, by the way, just the bottom line here, is people don't want this because they want to lose weight very rapidly. So I really want a diet. Give me the diet. So cognitively, our greatest challenge is to teach people these steps not to diet. And it takes about six months, six to one year. Some never get it. Some get it right away. And in others, it takes much longer. Everyone's different, depending on their cognitive style. Yes? Eight years. Yes. Eight years. Well, she lost it eight years ago. And she's kept it off. She's had trouble seven or eight times. But she's kept it off. But she spends every minute doing it. But she lost it eight years ago. She lost it in one of our programs and has kept it off for eight years. Up and down a little bit. But basically, she's still. I talked to her recently, and she's doing fine again. But for her, not for me. For her. Yes? Yes. Sure. Could you comment on that? Well, I would like to see data. My comment with any program, including ours, is to always ask, where are the data in peer review scientific journals? Very much what you said. Well, any approach is sensible. Oh, no, no, I'm not arguing. I'm just saying that you'd want to. To me, for a person who's heavy, I wouldn't want to have a lot of Oreo cookies around the house all day if I had a problem with Oreo cookies. But clearly, there are lots of people. The anti-diet movement in this country, of course, is just growing by leaps and bounds. And you get the nutty people that say, don't do anything, because nothing doesn't seem to work very well. So you shouldn't do anything versus, you know, I think people need to lose weight. Many people need to lose weight. The question is just, if you put people on diets, that just doesn't seem to work. So what is the answer? I mean, what is a person supposed to do? This might work for some people. It seems to. I mean, I think it works for most of us. But we'll see over the next few years. Right? Yes, it is. Yes. They still have not published anything yet. Peer review. Peer review. OK. We'll go back here first. Yes, sir. Sometimes, what about the binge eaters and the people who are more of the obese? How do they do it? Yeah, that's a good question. We have another study where we're looking at 240 binge eaters. We're looking at binge eating, per se. And they're very different people. You also have to deal with other issues. And these are more emotional issues. The approach, I think, still will work. But you have to add the element that you have to get a little deeper with some of these in the emotional aspects for binge eating. Binge eating is caused by many things, dieting being one. But I think there are some other elements, too, that we're seeing. Sure. Yeah. Right. Sure it is. Sure. No, there's no question that binge eaters are a different ballgame here. I think the principles are still going to work. But there may be some additional ones, too, we need. Yeah. Well, living without dieting, the book's inexpensive. So I mean, you need a good support system, which means community resources. You need certainly a loving family. If not that, then a good neighborhood or a good community center. Jewish community center, the YMCA, church groups. There are lots of ways to form peer groups that can go through these concepts. We have a number of dietitians using this program around the country. So there are ways to do it that don't have to cost any money, very little. But you have to be creative. Yes. Yes. Yeah. Right. Yeah, I know. Somebody always raises that. What we teach is you want to eat breakfast, lunch, and dinner. And again, the reason for that, all the dietitians, are you a dietitian? OK. You know the reasons why people should eat in the morning. So many people we work with do not eat in the morning because of all these reasons. But we want to get them. So we tell them, eat in the morning. And we use the old Callaway approach that if you eat for 10 days, then you're going to wake up hungry. If you eat breakfast for 10 days in a row, then you're going to wake up hungry. And then that's what you want. You want to recondition so you're getting some metabolism and some fuel in the morning. Sure, it's breaking the chains. So that's the reason. But you want to so the anchors are breakfast, lunch, and dinner. In between, it's separating hunger from appetite. But you want that for health purposes, you want breakfast, lunch, and dinner. Yes. American College of Sports Medicine. But what you're a sensible exercise program is what works for you. I mean, it starts slowly and build up. And if a person's really bad, they should see their doctor. And so all the standard. But it's basically for most of us is to get up and start walking a little bit and then do a little bit more each day. Yeah, you're right. You mean in the field itself? Well, there isn't anything. I mean, again, put that on the list. We have a three-year study testing this now. So we're finishing our third year now. So we're getting ready to publish, but it's not published yet. So we're going to, I mean, that's a valid... Well, I think all journals are looking for a good peer review article. I mean, our good experimental studies. So I think the anti-diet movement has to publish good studies too. And I don't, I mean, I'm not here to support them. I'm just saying that the dotting approaches don't work. So what else are we gonna do? Here's one way. There may be other ways too. And we need to look at those. But what we're doing today with dotting certainly isn't effective for most of us. So let's think about some other ways. Sure. And how do you achieve a balance? Yeah, that's where exercise is so important. Clearly as you lose weight, your metabolic rate drops because you're smaller. So metabolism naturally is gonna drop. But what you also wanna make, how much if it drops too much relative. But basically what you wanna do is build your exercise pattern to try to keep that drop from becoming too dramatic. So that's where exercise, that's another reason exercise is so important. But clearly again the goal, you have to think not weight, but think health. And the goal in all this is to eat healthy in terms of balance, balanced eating plan, and regular exercise. And then not worry so much about the weight and the weight factors. And that's hard for people to do. But I think it's the only thing that's gonna work ultimately. And be satisfied with yourself. You know, get comfortable with yourself. That's really the bottom line in all this. So, and weight is not, again, the most important thing in the world, so. Yes? Yes? Obviously you're talking about a lot of white folks. Yes? The large number of young folks calls me people asking about his efficacy in something like this kind of approach. Because he didn't use behavior, therapy and exercising and he hadn't tried it on purpose. I was wondering whether or not there's a role, what would that role be? Well he clearly is the first to say that the behavioral strategies are really important. You know, lifestyle management is certainly critical and he'd be the first to say that as he has in his articles. But again, you know, there is a, my guess is I don't try to criticize anything. Clearly his study is very important to suggest some people as long as they're on medication can maintain lowered body weights. I won't, I mean, I don't argue with that and I think we need a lot more research in that for some people. But again, the minute he took those people off, as you know, the weight came right back again. But surely for most of us, both practically and philosophically, do we want to, you know, go that way? But sure, I mean, if drugs work with some people, I'm all for them, I'm not against that approach. I'm just saying it's probably not a very realistic approach for most people in this country to start talking about we're gonna put the nation on Finfluoromy and Finthermin or Prozac, so. I was a dietitian, it's so frustrating with this whole thing, you know. Sure it is. But the bottom line is what you just said about getting comfortable with yourself. It's not so much convincing a person not to diet, but that they may have to do with a weight. Absolutely. You put your finger on it, that's exactly right. Well, I don't know if it's sad. Well, you've got to teach them that. You need to teach them not to link happiness with weight. And it's very difficult to do, I agree with you. I'm not trying to minimize it. No, I don't. I don't. I want to get it over here. Yeah, I know. Okay. I'm just trying to be in the image that most people are not gonna be, that's over, and it can visit people. That is sad, okay, I agree, yes. Yeah. Would I think I heard you say that you use fat, meat, and vegetables? As long as you're hungry, that's the key. Well, you try to achieve a balance. And again, what you do is, by working on the fat, you want to try to avoid the deprivation. And again, the key in all this is to separate hunger from appetite, eat when you're hungry, learn what a balanced eating plan is, and then try to stay within that as best you can. But not restrict, there are no forbidden foods, there are no restricted kinds of categories, as long as you watch your fat level. And again, I know that's hard for people to do, and I'm not minimizing this. I'm not just saying, oh, just go out there and eat less fat. I know how difficult it is for people to do that. Yeah, go ahead. How do you know that you're eating? Well, no, no, no, I mean, we look at, I mean, we work with clients and teach them what sensible eating is. And I mean, that's how we do it. We measure what they're eating for our research purposes. But I mean, you raise a very valid point, I'm not, you're right. I mean, you have to be careful what people are eating. But we don't, I mean, we haven't seen any, unbalanced kinds of eating programs yet. Maybe we will, and we should be on guard for that. But as long as you watch fat and teach people to eat sensibly, let's try to do that very slowly. It seems to work reasonably well. Yes, well, I ask all of you, people, if they eat more at night, do they gain more weight? Yes, yes. I ask the experts, I mean, do they, it seems to us, but we argue for that reason, if they eat at night for psychological reasons, that they tend to eat more because their control is less, because they've been so hungry. Again, we argue that it's the deprivation. It's the hunger, so they lose control if they try to limit their calories to the evening. There may be physiological reasons too that many of you who work in this area may know better than, a lot better than me. But psychologically, it seems to make more sense to shift the calories throughout the day for, to try to prevent the deprivation that frequently occurs in the evening. Response are in the field of psychological analysis. Yes. In our work with certain forms of non-phototoric, the enterprise and those that come through successfully, those that don't exercise do not show this change in the function. There are two symposia coming up at the American Psychological Association later this year in Canada that are looking at data like that. And I've also in the dietary area and in the, there are a few articles that have recently come out. We haven't done any of that yet, but you raise some very interesting points that really need much more study looked at. And at American Psychological, there are gonna be some of that presented. It is hard. You need a group to do that. I'll tell you, get a, you know, groups are work better than the one-on-one. And the more you get, if you get a good group going, that'll do more than anything else in the world. Peer support is absolutely critical in this program. That I've seen in a lot of the clients that I've worked with has been the whole idea of monitoring. When you start, I mean, we had this big thing in Calgary County for years and now we're shifting to, and we of course wanted to watch the scale and now we're looking at fat. But it sounds to me like you're not advocating that people actually write down the programs that better, but where are you? Well, they can, yes. I mean, we provide them skills. I mean, we're not anti-behavioral approaches. Behavioral approaches can be used for people that need those kind of approaches. But I'm saying it's not the answer. You look at it the other way. You look at it, what does a client need? What does a person need to help them eat healthy and exercise regularly? And for some people, we have little checklists in the book that a person can use if they choose to. Rather than the other way around, which is behavior modification approaches, here is a diary and this is what you must do. It's the other way. So, yeah, I mean, there are a lot of strategies that kind of overlap. It's not either or, but we don't advocate by definition that you must do this or that. Sure, oh, it's very helpful for many people. It's still rated number one of all of the behavioral strategies. Nothing. Is the thought patterns. It's really the kind of the lack of deprivation, trying to prevent the onset of deprivation by hunger, by hunger. You want to do that slowly in a healthful way. So it takes time. It's not easy to do. But it does work. I mean, it seems to work so far. Yes? Right, it takes in a low and fat. Yeah. But a lot of them seem to substitute, should we give it a play? Yeah, that isn't that the truth. Yeah. I know and that's, I know that's a big problem with a lot of people who don't know any stopping mechanisms, who don't separate hunger from appetite. One more? Did you have one? Yes. Just that, but there's a lot of other patients that come to us. They have a lot of other problems like hypertension and diabetes. Yes. Yes. Like cholesterol, whatever. And those people who need to follow some kind of regimen that... Sure. That gives them... Oh, yeah, no question. Many people do need to lose weight for their hypertension or their diabetes. This approach can work. This approach can help people lose weight and lower their cholesterol, lower their blood pressure and so on. So there are many people who can use this approach to lose some weight, but you don't do it by dieting. That's all I'm trying to argue tonight. Well, let's stop. Thank you. And if you have any more, I'll stick around. But thanks. Thanks for inviting me.