Weight Loss

The topic of losing weight is one that is charged with emotional significance for many individuals. Perhaps in keeping with that fact, and certainly due to a lack of clear research in this area, there is an incredible amount of misinformation available on this topic.
We have recently completed an exhaustive review of the available clinical research relevant to this topic and we will try to summarize what we discovered here.

First the good news: if you are diligent and, especially, if you seek out help for those aspects of the task that are hard, you should be able to lose about 10% of your body weight using one or more of the techniques that we will discuss below. Moving beyond that is harder and will require a serious effort that you will probably need professional help with. We are certainly happy to help you develop a plan for further weight loss.

Taking Stock

First things first, any effort to lose weight needs to begin with taking stock of where you are right now. The best way to figure that out is to calculate your body mass index (BMI). The BMI is the standard way of comparing people with each other and will give you an idea of what strategies you may want to consider in the long run in order to lose weight. To calculate the BMI you need to know your height in inches (convert feet and inches into just inches) and your weight in pounds. The calculation is:

BMI = [(weight in pounds) x 703] / [(height in inches) x (height in inches)]

An easy way to do the calculation is to use the BMI calculator from the National Institute for Health.

Now that you have your BMI let’s see where you stand in terms of weight loss treatment. The most recent expert consensus guidelines suggest dividing people into the following groups:

Level 1: BMI < 27 Self directed diet and exercise
Level 2: BMI 27-29 Self help program, commercial program, behavioral program
Level 3: BMI 30-39 Supervised diet program possibly / probably in conjunction with pharmacotherapy
Level 4: BMI >39 Very intensive intervention and possible consideration of surgical options

This discussion here is probably going to be most useful for those with Level 1 and 2 issues. For Level 3 and 4 you are definitely going to want to have a more formal evaluation and the development of a more comprehensive treatment approach. Read this but also, please, talk to your clinician at Gateway Psychiatric Services about wanting a formal weight loss consultation.

Set a Realistic First Goal

We think it is very, very important that you set an initial weight loss goal at somewhere around that level. We are not arguing that 10% is ideal, nor even that it is the endpoint for your weight loss, but we do know that it is very important that your first efforts with weight loss lead to success. Needless to say, building on an initial success is a much better strategy than trying to convert partial failure into motivation for more hard work.

Our overwhelming experience, and the experiences of many others who have worked to help people lose weight, is that you are more likely to reach your ultimate goal (whatever that is), if you break the task down into smaller pieces and, especially, if you stabilize (using your new habits and supports) your weight between episodes of weight loss.

What we know does not seem to ever work is to set a goal for initial weight loss that is greater than 10% of your total body weight (some people seem to get really optimistic in this phase and imagine themselves achieving a weight that is less than they have ever been at… this is an extreme example of unrealistic). This leads to the following consequences, almost inevitably:

  • There may be initial success, but this initial success may make you feel even more over-confident.
  • The going gets harder and harder after that and after that initial period, weight loss slows down (this is a natural phenomenon that is almost universal and the source of it remains somewhat obscure).
  • At some point the incredible pressure you are under gets to be too much and you come off the diet, often with a dramatic episode of eating foods off the diet (a binge).
  • At this point, you have achieved quite a significant success, a result which you would really have been proud of weeks ago when you first thought of losing weight, but because you can see so clearly that you are far from where you wanted to be it feels like a failure.
  • Because you have failed you really can’t get the energy to do the hard work of building a new, healthy, weight maintenance program… possibly setting the foundation for a further weight loss effort… so you fairly quickly regain the weight you had lost, sometimes overshooting that initial weight.
  • This is called the weight loss “yo-yo”. It is incredibly frustrating and unnecessary.

Weight Loss Diets

This is, of course, where most people begin the process. You are well ahead of the game because you know where you stand, and you have set a realistic goal for your initial weight loss attempt.

Now before we get into the sexy and exciting topic of which diet is best, let’s add in a few additional pieces that distinguish successful from unsuccessful diet efforts:

  • Social support: It is a funny thing, but almost universally the world around us (including family and friends) will do everything wrong when you get started on a diet. So, you are going to need at least one person, and preferably a couple of them, who can be your “diet buddies”. One of the reason that groups like Weight Watchers and Overeaters Anonymous work is that they have built in support. What you need is someone that you can talk honestly with on a daily basis about your diet. Someone who won’t lecture you and who will celebrate your successes. Email or phone check-ins work fine. Other online supports may be useful as well.
  • Choose your moment carefully: Do not start out on a diet when you are feeling depressed and hopeless or overwhelmingly anxious. If that is where you are right now then you should really focus on getting into a better space psychologically (we know, we know, if you could lose all that weight you would feel better… but it is our experience that for most people getting out of depression and anxiety really needs to proceed significant weight loss).
  • Visualize success: You should take a little bit of time really visualizing what it will be like to lose that initial 10% of weight. In doing so it is absolutely essential that you find a way of seeing that as a success. One of the best predictors of a return to initial weight is how you feel about your new, lower body weight. If you focus entirely on what you haven’t accomplished yet, how far you are away from your ideal, then you will quickly get discouraged. So, right now, think about feeling thinner but still, probably, heavier than you would like, and see if you can imagine being happy about that success. If you can’t, then this may not be the right time to diet. You may need or want to talk to your clinician about ways of changing how it feels to get part-way to a goal.
  • Begin a gradual exercise program: Exercise is not as important in the weight loss phase as it is in the weight maintenance phase, however long term weight loss over time is better predicted by exercise than it is by diet. And exercise can help you feel better, which will make the work of a diet that much easier. So get started. For more information click here .

OK, now how about that all important question of whether the grapefruit and lobster diet works better than the butter cream frosting diet…. (Sorry, but there is an incredible amount of silliness on the internet about how to diet).

The Atkins Diet.

A recent pair of studies published in the New England Journal of Medicine confirmed what many of you have already concluded. For initial weight loss a modified Atkins diet (low simple carbohydrates) seems to work more quickly than a low fat diet or than a simple calorie counting diet. However, what the studies also both found was that the dieters who lost weight following the Atkins diet actually seemed to have a harder time making the transition to the weight maintenance phase and that, as a result, the weight lost by the end of the process (weight loss and weight maintenance for one year) was the same with Atkins as it was with the low fat approach.

We don’t exactly know why this is the case, but the Atkins diet puts your body into a state of ketosis, this state, for a number of reasons, makes weight loss easier. On the other hand, you can’t stay in a state of ketosis for the rest of your life and it may be that those who achieve early success with the Atkins diet are going to need more effort in the transition phase (more support, more visits). Before getting started with an Atkins diet you may want to read the information at i-diets.com which is a somewhat negative but pretty balanced review of the pro’s and con’s. And before you start an Atkins diet, unless you are young and very healthy, you probably should go talk to your doctor and get some baseline laboratory studies.

The Low Fat Diet.

This is the approach that used to be the one most consistently recommended by nutritionists.

Pritikin Diet is one of the oldest types of low fat diet. Although it has now gone upscale with a spa where you can begin the diet without temptations close at hand.

The success of the Atkins Diet as well as the continued weight gain in America despite greater access to low fat foods, has raised questions about the effectiveness of low fat diets. The studies from the New England Journal of Medicine previously cited show that an appropriate low fat diet is as effective, over the course of a year and a half, as the Atkins Diet. It does seem to be a slower approach, because it doesn’t induce ketosis. On the other hand, the transition from a low fat diet to the maintenance phase is much easier. For many people this is still the best approach. However, there is now no question that the low fat diet approach needs to be combined with caution not to substitute simple carbohydrates and sugar for the missing fat. A nice summary of the evidence for and against a low fat diet and some links to useful information about low fat diets is found on the i-diets.com website .

Portion Control Diets

Many other diet programs focus not on making big changes in what you eat but rather on getting you to eat a more realistic amount of food.

Portion control diets have the advantage that the transition from the weight loss phase to the maintenance phase is not as difficult, you have been eating the same balanced diet you will want to be on long term, but they may be harder to stick to.

  • Weight Watchers is mostly a portion control diet, although with the added benefit of lots of support, including a pretty good online application and website. It definitely works for many people. And you can find programs in many places.
  • BistroMD is another approach to delivered portion control food, but the food is much more appetizing than Jenny Craig. Several of our patients report that they were very satisfied with the food which is delivered weekly in FedEx freezer packs.

Other Diets

Other diets have not been as well studied for weight loss, but are worth considering or exploring…

The Paleo Diet builds on the concern that a diet of too much refined food may be the problem. It is a hard diet to follow because so much of what we eat is processed but some people report a real boost in energy that comes with switching to less refined food.

The Mediterranean Diet is not really a weight loss diet. But it may be the ideal diet to aim for after you lose that weight. The evidence that it is associated with significant improvements in almost all aspects of physical and mental health is accumulating rapidly and is by now pretty overwhelming. We have written about many of these studies…

Mediterranean Diet Improves Cognition

Anti-aging Effects of the Mediterranean Diet


For many people self-help and a good diet plan is not enough. If you have struggled with this issue on your own we strongly encourage you to consider getting some help. A good dietician can be very helpful.

Many of our patients have found Sabine Haake to be both helpful and insightful. She combines a solid knowledge of diet with a real interest in the psychology of weight loss and weight gain.

A couple of people suggested that we look into a new program called JumpStartMD. It is a medically supervised weight loss program that combines elements of working with a dietician (the customization) with a host of support resources that you usually only find with one of the large weight loss programs.