Know when to fold ’em

I read Will’s recent post about trying to cut down on soda with no small amount of dismay.  He writes:

It is commonly said that soft drinks are “empty calories.” Not just devoid of nutritious content, but is also comprised calories that don’t even fill you up. Therefore you can get rid of the soft drinks without feeling more hungry, shedding yourself of tons of sugar content along the way. Would that it were so simple. Often, getting rid of soft drinks ends up ramping up your sweet cravings. And so the end result can be that instead of drinking sugary drinks, you’re eating sugary candy bars that are loaded with saturated fats.

My experience with dieting is that it’s like whack-a-mole. There’s never any one thing, because when you bash it, something else will typically take its place. I know that for my part, when I do miss my soft drinks, I do start to feel hungry. And it’s not just in my (conscious) mind, because I will sit in the evening wondering why in the world I am so hungry and then realize that I haven’t had a soft drink since breakfast. And nearly every conscious diet I ever embarked on involved giving up soft drinks first. And all of them failed. My weight loss actually came by accident, and with copious amounts of soft drink consumption. And when I tried to cut down from 3-5 soft drinks a day? I ended up drinking 2-4 soft drinks a day… plus a caramel mocha. Hit this mole, there comes another.

Oh, dear.

It’s no longer anything close to news that America has an obesity epidemic.  Being obese is a risk factor for numerous other health problems, and not just in adulthood.  For example, type II diabetes was once fleetingly rare in children, and it has become a sadly an increasingly common diagnosis for pediatricians to make.  When patients are overweight, it’s not a problem I can ignore. [edited for better accuracy]

So, what do I do when I have an obese patient?  The first thing I ask is how much of a problem the patient/parent thinks it is, and how motivated they are to make a change.  If the answer is that they’re not particularly concerned, then I don’t waste much more of anyone’s time on the issue.  (I also thank them for their honesty.)  Asking people to make changes in the foods they enjoy or the activities they don’t is hard enough if they’re willing to try.  If they don’t think the problem is a big deal in the first place, then there’s no real point in harping about a solution.  A common paradigm for healthy lifestyle choices is the “5210” set of guidelines — 5 servings of fruits and vegetables every day, 2 hours of screen time (television, computer and video games, excluding schoolwork), 1 hour of daily physical activity, and 0 sugar-sweetened beverages most days.  For some kids, 5 may as well be the number of leprechauns they’re supposed to catch every day.  I’m a big believer in the “stages of change” model of behavior modification, and if the patient is clearly “precontemplative” (meaning they don’t really think about the problem, and aren’t interested in making any changes) then my only goal is to get them to “contemplative” (meaning they’re at least aware that there’s a problem, and thinking about whether they’re willing to make changes).  Anything more ambitious is likely to fail.  Now, let’s say the patient is ready to make a change.  A problem has been acknowledged, and there is some motivation to do something to correct it.  I only ever ask patients to make one change at a time, and to pick the change they think is least likely to disrupt their lives.  The more unpalatable a change is, the less likely it is to be sustainable.  And what change do I often suggest?  Drink less soda.

I have patients whose soda intake is (to paraphrase Waylon Smithers) truly heroic.  Mountain Dew is an amazingly popular choice, despite my suspicion that it is scraped from the inside surface of nuclear reactors.  I have plenty of patients who consume hundreds of calories of fizzy, caffeinated sugar water every day.  (Many of them also have horrible sleep problems, and never consider that their steady stream of liquid stimulant may have something to do with it.)  I never ask patients to cut soda out completely, because I try to avoid giving advice that I know patients will ignore.  But for willing patients, I recommend a reduction in soda intake.  And, at least in Will’s case, that only seems to create problems in other areas.

The truth is that obesity is a depressingly difficult problem to fix.  It can be quite intractable, even for highly motivated patients.  At a conference I once attended, the darkly cynical presenter reported that the only truly successful solutions to obesity are bariatric surgery and appearing on “The Biggest Loser.”  And he wasn’t half wrong.  No medical intervention that I am aware of has proven itself to be both safe and effective in the long term.

The truth is that we (doctors, nutritionists, the First Lady, etc.) don’t really know how to dent this problem.  Unlike many doctors, I know what I want to say when I discuss obesity and weight loss with at-risk patients.  I just don’t have much confidence that it makes much difference.  It obviously does no good to ignore the problem, but at this time it’s not clear what will do any good.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. The issue, I think, is that people invariably overestimate their physical activity and underestimate their calorie consumption. You eat two Sausage McMuffins for breakfast–just a little bit of food, a small meal that hardly even fills you–and that’s seven hundred fifty calories! Then you go out and walk around the block, your feet are sore and you’re dripping with sweat, and you’ve burned twenty.

    So it’s easy for someone to say “I’m working my butt off and hardly eating anything, but I can’t lose any weight, so I’m just not going to bother”.


    People who yammer on about “good carbs versus bad carbs” aren’t helping anything. The problem, at its core, is that people eat too damn much food. There is no magic power in meat-only diets that makes you get thin. There is no evil corn conspiracy that makes you get fat.

    I think the worst thing is people forwarding me this crap about how diet soda is associated with obesity. “Oh, you drink lots of Diet Coke, you should watch out!” Yeah, I drink Diet Coke because I’m diabetic, you idiot. And the reason it’s associated with obesity has alreay been noted by comedians who describe the 450-pound man ordering a Triple Whopper with extra cheese, a large fries, and has a Diet Coke to go with it.

    • Density, there actually is reason to believe that Diet Coke does actually contribute to obesity. Some animal studies have demonstrated that it causes a faulty insulin response. A combination of inhibiting fat-burning and can increase hunger.

      I agree with your broader point about people underestimating consumption and overestimating expensidure, but what you eat does matter. At the very least, some foods appear to satiate hunger better than others. My weight loss began not with a reduction in my eating regimen, but with the inclusion of a high-fiber breakfast that lead me to be far less hungry throughout the day.

      The body is a complicated thing. It’s not quite so simple as input/output. The body deals with different calories differently.

      • But aren’t you just saying “empty is hungry is needs to eat”? It seems that breaking that equivalence–which, in a First World context, is entirely mental–is a ‘stage of change’ just like you describe.

        • I’m saying that hungry is bad for dieting. Maybe unavoidable in some circumstances, but the less of it you have (controlling for caloric intake), the better.

          My current average breakfast is roughly 400-450 calories. It keeps me full, more or less, for about 5 hours. One item on my old breakfast menu included a sausage, egg, and cheese breakfast burito, which was about 450 calories. That would have kept me full for about 2-3 hours. So I’d need to get two to tide me over before lunch. Or, I could get one and then get hungry a couple hours later and spend two hours fighting off the vending machine. And I would need to make sure not to overconsume at lunch because, well, I’m hungry. Some days I might win, some days I would lose, but with my current breakfast, it’s not even a battle I need to fight because I’m not hungry again until lunchtime.

          If diet coke increases hunger, that forces someone that’s already fighting a tough battle to fight an even tougher one. For some, that might be the lesser of evils. But it’s still something to avoid, if you can.

          Also, if you go from eating 4,000 calories a day to eating 2,000 calories a day, your hunger is very real. Your body is expecting that 4,000 and will register its protest at the sudden decline. That feeling subsides as your body acclimates, if you can fight it off for long enough, but putting yourself, and your body, in that position is often going to be setting yourself up for failure.

          I attribute a good part of my success to the fact that I managed to avoid physical hunger. Both by eating satiating foods and by cutting back a little at a time. Some people may need to crash, but they will be in torment when they do. Their body may have enough fat stored up to get you through the winter, so to speak, but it’s likely to urge you in the strongest possible terms to eat more before it starts using them.

          • Except that isn’t “magic evil diet coke power”, that’s appetite management–and appetite management is exactly the kind of discipline that I’m talking about when I say “stop thinking that empty means hungry means eat”.

          • If something makes you more hungry, it’s more likely to lead you to eat in the first place. That’s my main point. Anything that makes you more hungry is more likely to make you eat more. Can some people achieve a sort of hunger and appetite management* to endure it? I’m sure there are some (such people are probably not those that become overweight in the first place). But there’s a lot of people that can’t! And for those people, Diet Coke can and does contribute to obesity. And thus, does contribute to overall obesity.

            Is it the cause? No. I never said it was. But when you’re dealing with a significant portion of the population that can’t find that perfect zen and simply do not have that degree of control, you need to find ways to avoid hunger. Drinking diet coke is going to be counterproductive in many cases**. It contributes to the thing (hunger or appetite) to the thing that contributes to overeating that contributes (along with lack of exercise and genetics) to obesity.

            I am reluctant to say what it takes for people to lose weight, because everybody is different. But I can tell you from firsthand experience that for at least some people it is possible to lose weight by avoiding, rather than confronting, hunger. I would go a step further and say that this notion that losing weight requires suffering is one of the big things that sets people back. Every single effort I have ever made that involved the discomfort of wanting food and denying it to myself has failed miserably. I buckled. I broke. I found myself eating a cold burrito out of the fridge at three in the morning. The more conscious the effort, the more spectacular the failure.

            Meanwhile, I am 75lb lighter than I was three years ago. I’ve lost significant amounts of weight before (70lb in high school, 30lb just after college) and it came back. That’s always a risk. Upwards of 95% of all diets fail in the long term. But in none of the three cases did it involve ignoring my body that’s asking for food. Every time I tried to do that – and, perhaps coincidentally or perhaps not, every time I tried switching to diet coke – I failed. I lost 10lb once over three months. It came back in a few weeks.

            Now, if you’ve been able to lose a significant amount of weight with the attitude that you describe, I’m thrilled for you. I’d like to hear your testimonial. But I suspect that for most people that find themselves obese in the first place, telling them that they’re not hungry when they surely feel hungry isn’t going to do it.

            * – The difference between hunger and appetite is that appetite is seeing a cheeseburger and wanting it and hunger is being willing to eat anything that’s available. When we talk about significant calorie reduction, we’re talking about hunger (as well as probably appetite). For my own part, I had to accommodate both appetite and hunger. I found that I could not go without some of my favorite foods no matter how hard I tried, so I figured out ways to accommodate the appetite. And when I got hungry, I ate. I would keep a lot of snack food around the house and when I start to get hungry, I eat. The main reason being that if I allow myself to get really hungry, I’m going to go eat a lot more than if I listen to my system and nip it in the bud rather quickly. I actually took advantage of the fact the fact that it was hunger rather than appetite and ate celery, early on. I don’t like celery, but when you’re hungry it doesn’t matter so much.

            ** – Everything is relative, of course. If you substitute beer for Diet Coke, you’re probably coming out ahead. I would say the same for soft drinks, but that doesn’t seem to be true in my own case. You pick your evils, and for some that may actually be diet coke. For me it was the regular kind.

          • Hungry is bad for dieting if you lack the willpower to not be that guy eating cold burritos out of the fridge at three in the morning.

            “Oh but it’s hard, I have these cravings–” Buddy, if you are unable to function mentally due to hunger pangs then you don’t have a diet problem. You have the kind of problem where if you were a heroin user we’d sign you up for methadone without a second thought. If celery is able to answer your food cravings then you’re eating food as a habit, or as a transference activity, and in neither case have you moved past “empty is hungry is eat”.

            Like I said.

            But hey, if blaming something external and using magical thinking is what it takes, then who am I to say that’s wrong? If it works, then it works. And I guess that you have to be evangelical about it, because if it isn’t a Universal Truth–if it’s just something inside your own head–then the whole thing immediately falls apart, because if you could control what happened inside your head then you wouldn’t be in that situation.

          • Duck, why do I need anyone or anything to blame? I’m not making excuses for failure. I’ve succeeded. It is in these efforts that I have learned that a reliance on willpower and letting yourself suffer is not conducive to success. And that things that make you want food, however mythical or self-imposed you believe this desire to be, can lead to weight gain or hinder weight loss in those who lack your fortitude.

          • Will, I congratulate you for your weight loss. However, anyone who looks at those pictures will suspect (as I do) that your weight loss was due to the tragic leprosy that obviously also claimed your facial features. (It also seems to have hit the people featured in the pictures with you, leading me to guess that you took a family vacation to Kalaupapa.)

          • I guess I need to expand a bit (as it were); “eat less” is a bit too pithy, too glib. Because when you say that you replaced the midnight burrito with a celery stick? That’s eating less. “Eat less” doesn’t always mean “deny desires”.

            And that’s actually something important to remember about all this. I think that for many people, there’s a sensual component to eating that we simply don’t want to acknowledge or discuss because it’s too close to sex. (And we know how weird Americans get about sex.)

          • What, other than celery, did you find helped satisfy hunger?

          • Burt, the biggest thing for me is the high-fiber breakfast, which helps me avoid the hunger in the first place. But as far as snacks go, it’s going to very from individual because some of the criteria is subjective (Will you eat it? Will you be able to put it down?).

            For my part, other than the celery with chipotle-mustard, I eat:

            Dry cereal – GoLean, which I also eat sometimes for breakfast, though usually stick with Fiber One. Not bad on either fiber or protein and better dry than some of the Fiber One offerings. If you need something that tastes better, FiberPlus Cinnamon Oat Crunch and FiberOne Caramel Squares are good (though the latter a little too good). Drinking a cup of water after eating high-fiber foods is generally beneficial. I’m inconsistent about this.

            Wheat Thin Fiber Select crackers – They have two flavors, the 5-Grain can be a little hard to put away, but the Vegetable get old fast. I go with the veggie when I feel like I’ve been consuming too much, but usually just take out a handful of the 5-Grain and put the box away. The wife has some super-duper fiber crackers that she has to special order, but the stuff tastes like cardboard to me and in order to eat it, I have to put a lot of junk on it, which is counterproductive. Before WTFS, we ate another brand called GoBran, which was fine. The reduced fat regular Wheat Thins will work in a pinch. They aren’t big on fiber, but they’re not as addictive as regular Wheat Thins.

            Sugar-free candy – This is more for appetite (needing something sweet) than hunger, but I thought I would mention it. They’re typically very high in fat, but because they have sugar alcohol you *have* to limit consumption. Early on, I would use these to induce myself to drink…

            Milk – The sugar free candy isn’t filling, but milk really can be. I usually drink water with food and save the good drinking for in-between meals, where (I think) it helps me stave off hunger.

            Smoked chicken or turkey sausage – It goes well on the crackers. You can heat it up or eat it straight (assuming you get the “prepared” kind). There are multiple brands. Some are good and some are bad, so if you find it tasting awful, you may have just bought the wrong brand.

            Turkey pepperoni – It’s a great option for a quick munch. I’ve actually come to prefer it over regular pepperoni. Because of the strong taste, I am disinclined to eat too much at once and typically eat less than 100 calories. You can combine this with cheese, though I try to avoid that.

            Low-fat cheese (cream cheese, specifically) – For the crackers. Combine with the sausage. This works particularly well for a mini-meal with seven (with their honeycomb shape, that’s how they fit together) or 9 of the GoBran or WTRF (though to do this you have to cut the sausage up in more ways than one). Not ideal if you have plans for three full-sized meals for the day, but it keeps me from greater dietary sin.

            Obviously, you need access to a fridge for a lot of these. When I’d substitute, I’d mostly stick to the GoLean or take some crackers with me. That would be enough to keep me away from the vending machines.

            This is what works for me, anyway. YMMV, obviously.

          • Duck, we may quibble on the details (the extent to which the body treats different calories differently, different bodies respond differently, and the difficulty involved in consumption behavior modification), but I largely agree. At the core of it, it comes down to input vs. output.

            I drill down a level deeper, though, to the question of how to make the reduction of intake occur. I have found this to be a more complex issue than a lot of people believe. I’ve found that excessive denial (outright denial of hunger, denial of what your system is asking for) isn’t only unnecessary, but actually an counterproductive over-reliance on willpower. What I did, a series of slight modifications by way of food substitution and portion control, also requires willpower. But while I could not muster the willpower to go hungry (without overcompensating later) or outright deny myself the foods I love, I could manage the series. A lot of people, I fear, lack the willpower for even that. Which is one big reason why diets have such an awful success rate in the long term (another big reason, I believe, being impatience with the slow process and relatedly an overestimation of long-term willpower in light of the slowness of the process).

            And I believe the logistical questions of how to reduce temptation (including hunger or sensations emulating hunger) are important. For me, it was crucial. Which is why I am so passionate on the subject. The weight loss came in large part because I used to consume about 3,500 calories a day and now consume about 2,900. But the big question is how I got from here to there, and how other people might do the same.

            I don’t disagree at all that there is a sensual aspects to it. It’s part sensual, part biological, and part psychological. Not necessarily in that order (different orders for different people).

            {Sorry for the yet-another-long-response. Like I said, this is something I am passionate about and has preoccupied me much of my adult life with various successes and failures.}

  2. I had a doctor who had a tactic I thought might be good. He broached the subject carefully, something like “And your weight… you know what I have to say about that, right?” And when I affirmed, he made me tell him why it was a big deal. Hearing something is different than saying it.

    I’m not sure how well that would work with kids, but it might work with the parents of kids?

    On the other hand, I am just supremely skeptical that knowledge and raw willpower are the issue. With rare exception, people know it’s unhealthy. Imparting in dire language how unhealthy it is can just make them feel bad about themselves. And contrary to the view of some (the type of people who often think that obese people are obese due to lack of fat-shaming), I don’t think successful, durable weightloss comes from self-hatred. It’s a hard line to walk, and the line changes from individual to individual (meaning that some people are more quick to self-loathe than others).

    Regarding Mountain Dew, that’s my primary sugary-vice. It accounts for 60-75% of my consumption, including all of the various flavors they have and its generic clones.

    Oh, and (of course) I have all manner of sleep problems these days. I think it’s more the cigarettes (of which my consumption has been moving in the wrong direction) than caffeine, but my typical “no tobacco after 8, no soft drinks after 6” rule hasn’t been followed. If it weren’t for Melatonin, I wouldn’t be getting to sleep until 5 or 6, probably, and since my body doesn’t like to sleep past 10… On the other hand, if it weren’t for Melatonin to fall back on, maybe I would be able to follow the 8/6 rule.

    * – By complete coincidence, my wife uses those exact words when it comes to cigarettes. She doesn’t do the follow-up that the above doc did, though.

    • That’s actually relatively similar to how I broach the subject with my patients. I go out of my way to avoid any impression that I’m trying to shame them, and for patients who are clearly uninterested in what I have to say I don’t make them sit through a lecture.

      As I mentioned in the main post, I also try very hard to avoid any change that will be too radical, thus triggering the hunger/sense of deprivation you describe. Once patients have managed to succeed making relatively painless changes, and see that they can alter their eating or activity patterns if they try, I will sometimes shoot for bigger goals.

  3. I went on South Beach a few years back.

    Eggs. Bacon. Cheese.
    Steak. Chicken. Spinach. Cheese. Peppers. Onions. Tomatoes.

    After two weeks, we added handfuls of fruit to breakfast and dinner.

    I lost 35 pounds over the course of two years.

    My testosterone production skyrocketed at the same time that I stopped tasting food.

    At the end of the two years, I was a walking glare.

    I’m sooooooo much happier being chubby.

  4. “For example, type II diabetes was once fleetingly rare in children, and it has become a sadly common diagnosis for pediatricians to make.”

    Well, it’s MORE common than in the past. From your supporting link:

    Population-based prevalence estimates for other [than Native American] ethnic groups were not available. In a retrospective study of such reports, a referral center in Cincinnati, Ohio, found an incidence for type 2 diabetes of 7.2 per 100,000 for African Americans and whites aged 10-19 years in 1994. By comparison, the national incidence of type 1 diabetes among those aged 10-19 years is 19 per 100,000. In most of the U.S. case reports, type 2 diabetes accounted for 8% to 46% of all new cases of diabetes (type 1 and type 2) referred to pediatric centers. The magnitude of type 2 diabetes is probably underestimated.

    The CDC seems to be saying that it doesn’t have any solid numbers, but 7.2 per 100,000 is the best estimate that we’ve come up with, although that’s probably an underestimate. Even taking into account that it’s probably an underestimate (and keep in mind that before all this obesity awareness, it was even less likely to be detected if present), I wouldn’t call that “common”.

    I’ve heard people say that soda is bad partly because it does not reduce the number of calories consumed elsewhere, but I’ve also seen at least one article with a nutritionist saying that soda was bad because it displaced other, more nutritious foods. Personally, I have found that soda does have an effect on satiety. But I don’t like soda that much and don’t often drink it.

    You may be interested in reading Dr. Sharma’s blog; he frequently grapples with the lack of effective methods for making people permanently thin. He has also proposed an interesting “obesity staging system” as an alternative to BMI to help guide recommendations and treatment:
    You may also be interested in reading about what it takes to permanently maintain significant weight loss, from someone who is doing just that:

    I guess I’m kinda linkspamming; this is a pet cause of mine.

    • Had to fish this out of the spam filter.

      Anyhow, your criticism is apt. I did overstate things a bit in the original post. The diagnosis is much more common that it used to be, but it’s still relatively rare.

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