Why It’s Hard to Lose Weight — and Why Most Diets Fail
Diets come, and diets go — but one saying seems to persist: Weight loss depends on calories in versus calories out. According to Dr. Laura Lefkowitz—who transitioned to nutritional science after she split her pants while doing a routine check-up on a patient and realized that before she could preach health, she needed to be healthy herself — it’s not always that simple. After using herself as a guinea pig in the early days of her practice, Lefkowitz (who did this Q&A with us about hormones, weight gain, and infertility due to PCOS) has coached legions over the years to effective and long-term weight loss, from the genetically blessed (supermodels), to those who are suffering debilitating effects from poor diet. Ultimately, it’s slightly more complicated than a basic math equation, but not intimidatingly so — Lefkowitz breaks it all down below.
Goop: You obviously help a lot of people with waistline control and issues of the diet. What’s the real breakdown in terms of attribution here, i.e., what percent is diet, what percent is exercise (or lack thereof), and what percent is due to elements that might be beyond a person’s control, like genetics or hormone issues? Is it true that it effectively boils down to calories in versus calories out?
Ten years ago, I would have disregarded gender and answered 50% diet, 20% exercise, and 30% genetics, however my clinical experience has changed my conclusions.
Primarily, we need to stop scapegoating our genetics and hormones. If you think you can’t lose weight because of your genetics or hormones, you are shortchanging yourself and might as well give up.
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All humans are born with the same 24,000 genes (fewer than we anticipated when the Human Genome Project started). Our genes are constantly being activated and silenced based on our environment—their expression is not written in stone. This means that your genes are not your complete destiny, and that actions can potentially change how your genes are expressed. In medicine, this new consideration is called Nutrigenomics.
Nutrigenomics means that diet-induced changes in gene expression can influence network interactions and cellular information flow. In layman’s terms this essentially means that what you eat can change how your genes are expressed and determine health outcomes. Essentially this is “you are what you eat.”
Nutrition-packed vegetables can activate the expression of good genes and silence bad genes, your body can function better and you can live a healthier life. Consuming sugar, refined carbohydrates, and poor quality fatty foods can influence harmful genes and silence good genes resulting in poor health.
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But achieving healthy weight is a complicated process. In my practice, my evaluation is individualized, taking medical and emotional histories, physical composition, and activity level into consideration. I then design a personalized diet and exercise plan.
I find patients fall into two major categories:
Hormonally blessed
Hormonally challenged
If you are hormonally blessed, your body has the innate ability to work efficiently. A hormonally blessed woman can usually lose weight with any diet (as long as she follows it) or by significantly increasing her physical activity. These women usually respond quickly to dietary changes and can maintain their weight loss as long as their caloric intake is balanced with their metabolic expenditure.
On the other side of the spectrum is the hormonally challenged patient who finds losing weight very difficult. Once a hormonally challenged woman is on an appropriate diet, changes happen in her genetic expression and hormones which shift her metabolism into fat burning or glucagon dominant mode which results in weight loss. Glucagon is a lipolytic (breakdown of fat) hormone that works in opposition to insulin (fat storage hormone).
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Remember that muscle cells are constantly burning calories; 1lb of muscle burns 7-10 calories at rest and significantly more calories depending on quality and quantity of exercise. The more muscular you are, the more calories you burn doing activities of daily living, exercising, and even sleeping than someone with little muscle mass. Height is also an advantage as you burn more calories going about your activities of daily living and exercising than shorter people. Taller women usually have larger organs, which burn more calories at rest.
Therefore, a taller hormonally challenged woman with significant muscle mass can lose weight based 85-90% on diet and 10-15% on exercise. Through proper diet to re-align her hormones, she can transform and function like a hormonally blessed person and start to effectively burn fat.
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However, shorter (under 5’4″) hormonally challenged women who have low or very low muscle mass are the ones who find weight loss the most difficult. These women believe that “genetically,” they just cannot lose weight.
Early on in my practice, I advised these under 5’4″ hormonally challenged women to abide by an extremely low calorie diet geared to align their hormones. My hope was to cause a caloric deficit to push their bodies to tap into their fat stores because they had so little metabolic expenditure. But in practice I was disappointed: I saw that these hormonally challenged women ate very little but still barely lost any weight. As it turns out, these woman burn so few calories even when they exercise, that they barely need to eat at all.
I needed to take their physiology into consideration. I realized that an extremely low calorie diet just slowed down their metabolisms even more, as their bodies panicked because they were operated on so few calories. These patients were better off on a very limited carbohydrate diet, not an extremely low-calorie diet, which re-aligned their hormones in order to get them into a glucagon-dominant state. Then they need to significantly increase their time exercising. In terms of percentages, 70% diet and 30% exercise seemed to work best.
They need to get their limited muscle mass working, rev their metabolic engines up so they can tap into their fat supply, and start losing weight, which then further improves hormone function and ability to lose more weight. Hence the “domino” effect.
The difficult part is that women with low muscle mass are usually the ones who never gravitated toward exercise in the first place, hence the underdeveloped muscle mass. It can be very difficult to convince these woman that not only must they exercise, but that they need to spend a significant amount of time doing it (at least 1 hour per day, 90 minutes being ideal). Even just walking can make a huge difference. I must also reinforce that although they need to increase their physical activity, they cannot increase their food intake. If they make these dietary adjustments and commit to exercise, they can transform their bodies!
So this is the big conundrum: The most physically unfit women are the ones where exercise can have the greatest impact, but in my experience these are the woman who tend to want to rely on diet alone, which does not work for them.
When one of your clients fails to lose weight, what is usually the culprit?
These are the three most common reasons weight loss plateaus or fails:
1. UNINTENTIONAL NON-COMPLIANCE
I define Unintentional Non-Compliance as a perception that one is following a diet better than they actually are. Usually the first two weeks after a consultation, patients are very motivated and the parameters of the diet are fresh in their minds and they adhere strictly. After about 2-4 weeks people stop looking at their written plans and believe they know the details. This is when they start making small errors that add up over time.
For example, I may recommend that a patient choose one serving of fat at lunch, i.e. dressing, cheese, or avocado. Over time I see the patient starts choosing 2 or 3 at lunch, not one. At one meal that may not seem like a big deal, but if over a week you add 1-2 extra servings of fat to a every lunch (¼ cup avocado is 60 calories, ¼ cup cheese is around 115 calories, 1 TBSP olive oil 120 calories), that’s anywhere from 420-2500 extra calories of fat over a week that will slow down or stop weight loss. Because it seems so insignificant at each individual meal, they don’t even realize they aren’t adhering to the diet. For weight loss some extra avocado or a “healthy food” doesn’t raise a red flag like a piece of cake or a bag of chips, yet over time it blocks weight loss the same way. It’s not necessarily “cheating,” because it is an “allowed” food, but if used incorrectly it can undo a diet.
People get frustrated and think the diet is not working, when in actuality, they are not following the diet precisely. I call it Unintentional Non-Compliance because you are still eating “diet-friendly” foods, just too much of them or at the wrong times.
2. THE BLT’S
I once heard this term when I was trying to lose weight and it stuck with me. The BLT’s do not refer to a bacon, lettuce, and tomato sandwich (which would also slow your weight loss down). The BLT’s refer to “Bites, Licks and Tastes.”
For example, you are eating your salad with grilled chicken but you start sneaking a few bites of your husband’s pasta, a few licks of your child’s ice cream cone (so it doesn’t run down their arm, naturally) and a taste of dessert when out with friends. More often than not, a few French fries and a big bite of molten chocolate lava cake is all that you need to stop your weight loss.
The BLT’s are different than Unintentional Noncompliance because people know the BLT’s are not diet-friendly foods, and they know they are cheating. The BLT’s are usually the number one problem for women with children. It is so easy to taste your kid’s food while cooking, sneak a few goldfish while driving to after school activities, or feel bad throwing out leftovers. But all these extras can wreck a good eating plan.
3. THE COCKINESS FACTOR
The Cockiness Factor sets in when people have lost a significant amount of weight, feel more confident, and are receiving compliments. I see this all the time! They feel better so they start thinking, “I’ve worked so hard I deserve a treat!,” or more commonly “Let me see what I can get away with.”
People start testing if their actions will really affect their weight. Increasing alcohol consumption and dipping back into the bread basket will make those skinny jeans tight again. People quickly forget how miserable they were when they felt overweight and don’t realize how quickly the weight can come back on. We get amnesia. We forget the weight will come right back on if we go back to the choices that made us gain weight in the first place.
Once you achieve your weight loss goal the work is not done. You must consolidate the weight loss by maintaining your weight for at least a year and establish a new weight set point. People’s weight yo-yoes because as soon as the weight comes down they don’t work on maintenance, they go back to old behaviors and see the weight creep up again.
Any methods for ensuring long-term success? Are you a proponent of writing stuff down?
1. CONTROL BLOOD SUGAR
Controlling your blood sugars via the food you ingest is the key to weight loss. When you eat sugar and carbohydrates your body releases the hormone insulin (a fat storage hormone) to keep your blood sugars in the normal range. As long as you are pumping out insulin you are essentially blocking your ability to lose weight—you stay in “storage” mode.
The hormone glucagon (a lipolytic or fat burning hormone) works in opposition to insulin. By ingesting high fiber, low-carbohydrate vegetables, lean proteins, and small amounts of healthy fats you can keep your body in a glucagon dominant or fat burning state and effectively lose weight. This type of diet works universally for everyone, even if you are hormonally challenged.
2. MOURN, GRIEVE, WEEP, AND GET ANGRY—THEN FIND A NEW WAY TO LIVE
There is no question that when you try to lose weight you must make sacrifices. You must give up things that you believe make you happy like pizza, French fries, ice cream, and margaritas. This sacrifice is very hard for people who use food to comfort themselves and/or to have a good time.
My weight yo-yoed for years. It was so frustrating, but I finally identified the cause and decided to change my behavior. All week long I would diet and exercise trying to get my weight down, but on weekends I would go out with friends and drink wine. After a glass or two of wine I would make bad food choices because I wasn’t thinking clearly and then be miserable in the morning and disappointed in myself. On Sunday mornings I would realize the discipline all week long to lose 1-2lbs was gained back in one or two nights. I would muster all my strength and start all over again and never see any real change.
One day when my pants split in front of a patient I decided that losing weight and keeping it off would bring me more happiness than wine and tapas ever could.
I still went out with friends, but I stopped drinking alcohol and found that I made better food choices because I was thinking clearly and my blood sugars were stable. Without alcohol, I could eat well all weekend and really make a dent in my weight loss. Instead of lying in bed all weekend from being out late, I could get up and exercise in the morning and feel great. I set the tone for healthy living and weight loss. Over time, I achieved my 30lbs of weight loss and was happier and more confident.
To be completely honest, I had to mourn the loss of enjoying wine with friends on weekends. I was angry that I couldn’t order pasta for dinner and still fit into my pants. I cried that it wasn’t fair that other women could get away with eating certain things that I couldn’t. I let the emotions out. I let myself grieve, and allowed myself to be sad about the things I had to give up. But I can say the sacrifice has been worth it.
Once I kept the weight off for over a year, I started allowing myself an occasional glass of wine or bowl of pasta from a place of control and when my weight feels very stable. I mindfully savor treats when I am feeling well. I don’t drink or eat when I’m stressed or unhappy because it just leads to more unhappy feelings.
It’s ok to be upset about giving up things you love. Mourn and grieve just like you would if you lost someone you loved. When someone you love dies, there is no bringing them back. You must adapt to life without them. You have to find a new way to go on without them. You can be sad or angry that they are gone, but eventually you must accept the loss. From time to time something will come up that reminds you just how much you miss them, but you remind yourself that you can’t bring them back.
Patients need to see unhealthy food this way. These foods aren’t a part of your life anymore. When I’m at a children’s birthday party and I see pizza and birthday cake, I miss it, but I rarely give in. Eating cold pizza standing at a birthday party is not going to make me happy in the long run. It’s the not the path I choose to follow anymore.
Feel your emotions don’t suppress them. Be sad you broke up with chocolate covered pretzels, be angry that you can’t have your cake and eat it, too. Cry and then try to find a way to be happy without them. Replace these unhealthy foods with new ones that make you feel and look good. Find ways to move and exercise that makes you feel good in your skin.
3. ASK FOR HELP
Studies have shown that weight loss is more successful when you have a partner, whether it’s a doctor, nutritionist, trainer, spouse, or friend. I believe it’s because you have someone to talk to and help you get back on track when you stumble. We’re only human and we all mess up. Having a supportive weight loss partner to pick you up when you are down makes all the difference.
Sometimes I find it very ironic that patients are thrilled to come to appointments when they have reached a goal or are feeling great. In my opinion, if you are doing well and the scale is moving in the right direction, you really don’t need to see me as much. The most common mistake in my practice is patients cancel appointments or stop coming when they are not doing well. They are ashamed and want to hide from me.
When I reach out to check in on them they tell me, “I’m afraid you’ll be disappointed and yell at me.” Or “I was too embarrassed,” or “I feel like a failure.” In all my years of counseling, I have never yelled at a patient. It is all projection, a theory in psychology in which humans defend themselves against unpleasant impulses by denying their existence in themselves, while attributing it to others.
Avoiding me is avoiding facing themselves. When you avoid your weight loss partner things get worse. When the scale stops dropping or moves in the wrong direction, that’s when you must reach out to your support system and have them help you get back on track. Don’t hide from your partner. Ask for help when you need it. There is no shame in asking for a pep talk or problem solving session.
4. KEEP FOOD JOURNALS
People who keep food journals are more successful for two reasons:
A food journal is a window into my patients’ daily lives.
I can see what they are doing all the hours I’m not with them and catch mistakes they don’t even know they are making. I can see patterns emerge that hinder weight loss and can provide strategies of prevention. I can offer more variety to improve adherence and still evoke weight loss.Dieting Causes Short Term Memory Loss (I’m kidding. Sort of.)
I can’t tell you how many times people tell me, “I don’t understand why I haven’t lost weight.” They always say, “I have been eating so well I don’t get it.” After digging in a little deeper they usually say, “Saturday night I drank and had dessert…” or, “I forgot I skipped a meal and ate my kids’ pretzels…” or, “I ran out of yogurt so I grabbed a bagel.” People get frustrated that the scale isn’t moving because they “forget” the errors they made.
If you write down what you eat in a food journal and you don’t see weight loss, you can review your food journal and calm yourself down by saying, I didn’t lose weight this week because I made these poor choices. If you can see the reasons for your lack of progress it is less scary. People get upset when they feel like weight loss is out of their control. If you document the reasons for your success or lack of success, you feel a sense of control or order to the process.
5. BE REALISTIC AND IN IT FOR THE LONG HAUL
If you didn’t gain all your weight in two weeks, don’t expect it to come off in two weeks. Weight loss is a complicated, long-term commitment. There is no easy way out and fad diets do not work. In fact they usually slow down your metabolism, tax your organs, and lead to nutritional deficiencies. Slow and steady wins the race. Losing weight quickly is not good for your hormones, either, as it throws them out of whack and puts your body in a panicked state that will slow your metabolism down and cause you to store fat. Losing at a pace of 0.5-2lbs per week is a realistic and healthy goal, which everyone in some way can achieve.
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Dr. Laura J. Lefkowitz graduated from SUNY-Stony Brook School Of Medicine in 2002, where she received her M.D. with honors in Obstetrics and Gynecology, Psychiatry, Internal Medicine, and Radiology. Dr. Lefkowitz’s interests then shifted from treating disease in the traditional sense and she refocused her attention on prevention and treatment through nutrition and self-care. She attended Columbia University’s Institute for Integrative Nutrition where she has studied many different dietary theories and complementary treatments to traditional medicine. Dr. Lefkowitz works in Florida, and consults patients via Skype.
