Professor Trim's Becoming Gutless

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PROFESSOR TRIM’S BECOMING GUT LESS

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PROFESSOR TRIM’S PROFESSORS Professor John Blundell PhD C Psychol. MBPS, Professor of Bio-Psychology, Leeds University, UK and Board Member of the International Association for the Study of Obesity (IASSO) Professor Wendy Brown BSc (Hons), MSc, Dip Phys Ed, PhD Professor of Physical Activity and Health, University of Queensland Professor Ian Caterson MBBS BSc (Med) PhD FRACP Boden Professor of Human Nutrition, Sydney University and Vice President, International Association for the Study of Obesity Professor Terry Dwyer MBBS, MPH, MD, FAFPHM Director Menzies School of Health Sciences Hobart, and University of Tasmania Professor Garry Egger MPH PhD MAPS Director, Centre for Health Promotion and Research Sydney Adjunct Professor of Health Sciences, Deakin University Professor Kerin O’Dea BSc, PhD Director of Menzies School of Health Research, Darwin Professor Stephan Rossner MD, PhD Director, Obesity Research Program, Luddinge Hospital, Stockholm, Sweden and Past President of the International Association for the Study of Obesity (IASSO)

Professor Boyd Swinburn MD, MBChB, FRACP Professor of Population Health and Nutrition, Deakin University

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PROFESSOR TRIM’S BECOMING GUT LESS THE WEIGHT-LOSS PROGRAM

for men Dr Garry Egger By the originator of the ‘GutBusters’ waist-loss program

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First published in 2003 Copyright © Garry Egger 2003 All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without prior permission in writing from the publisher. The Australian Copyright Act 1968 (the Act) allows a maximum of one chapter or 10% of this book, whichever is the greater, to be photocopied by any educational institution for its educational purposes provided that the educational institution (or body that administers it) has given a remuneration notice to Copyright Agency Limited (CAL) under the Act. Allen & Unwin 83 Alexander Street Crows Nest NSW 2065 Australia Phone: (61 2) 8425 0100 Fax: (61 2) 9906 2218 Email: [email protected] Web: www.allenandunwin.com National Library of Australia Cataloguing-in-Publication entry: Egger, Garry. Professor Trim’s becoming gut less: weight loss for men. Includes index ISBN 1-7 4114-017-X 1. Weight loss. 2. Men—Nutrition. 3. Physical fitness for men. I. Title. 613.70449 Set in 11/12.5 pt Adobe Garamond by Midland Typesetters, Maryborough, Victoria Printed by Griffin Press, South Australia 10 9 8 7 6 5 4 3 2 1

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CONTENTS Introduction

vii

Part I: The how and why of weight loss Chapter Chapter Chapter Chapter Chapter

11: 12: 13: 14: 15:

Why should men worr y about their weight? Just what is fat anyway? A word about metabolism How do you know if you have a problem? What works and what doesn’t?

1 3 12 20 29 35

Part II: Putting it into practice Chapter Chapter Chapter Chapter

16: 17: 18: 19:

Changing habits Changing what you eat Not exercising–moving! Plateaus, motivation and trade-of fs: good news or bad? Chapter 10: Getting fur ther help Joining Professor Trim’s Medically Super vised Weight-Loss Program Appendix II: The exerselector questionnaire Appendix III: Some meal and desser t ideas for Becoming Gut Less

45 55 78 99 114

Appendix I:

123 125 129

Other books by Garr y Egger

135

Notes

137

Index

139

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Appreciation is expressed to Rosemary Stanton for her contribution to the GutBusters Waist Loss Guide

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GUTBUSTERS—NOT A ‘WAIST’ OF TIME In 1990, some colleagues and myself started the GutBusters ‘waist loss’ program. This was a different kind of weight-loss program. It was aimed primarily at men, and it included scientific aspects of weight control designed to change lifestyles and keep weight down over the long term. It wasn’t a diet or an exercise program; nor was it a ‘quick fix’ or a ‘magic cure’. We intended it to be ethically and scientifically valid in an era of weight control ‘con jobs’. We achieved our goals; our success was acknowledged in several international publications and we were invited to make presentations to esteemed international medical groups.1 GutBusters was originally developed in conjunction with the New South Wales Health Department. It grew from there to become the world’s biggest men’s waist loss program. Over the ensuing decade over 100 000 men signed up to lose their gut. GutBusters filled a gap in the market at the time; there were no such services available. While women could sign up for any number of health programs, including weight loss, men, who die on average seven years earlier than women and who lead women in the first fourteen main causes of death, were being almost totally neglected in the health stakes. In the meantime, much of my other work had been for bodies such as the World Health Organisation and the National Health and Medical Research Council, in weight control and obesity management and in educating medical practitioners about weight control. This included starting the world’s first Postgraduate Medical Certificate in Weight Control and Obesity Management through Sydney University’s School of Human Nutrition. So GutBusters was entering the medical arena. It appeared that the time was right for a new approach, for women as well as men: more medical, with greater ongoing supervision from a range of experienced disciplines, but no less scientific, and no less fun. It also seemed logical to focus the delivery of the program through that large army of dedicated doctors vii

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(25% of the Australian general practice community) who had completed at least one-third of the Sydney University’s Weight Control Certificate course. Changes in the Australian health care system in 2000 made it possible, for the first time, for doctors to work closely with other health-care professionals, such as exercise physiologists and dieticians, to adopt a more comprehensive approach to health care.

DOCTORS ADD THEIR WEIGHT TO THE FAT-LOSS FIGHT There was much agonising over the name for the new program. GutBusters was such a good name. It meant serious business, but it also meant not taking oneself too seriously, as many weight-loss programs tend to do. But it wasn’t really inclusive of women, or others in the community. We tossed around dozens of alternatives, but finally settled on Professor Trim’s Medically Supervised Weight Loss Programs. So Professor Trim’s takes over from GutBusters. But it also takes GutBusters to a new level. Owing to demand among Australian women who have tried everything themselves and who liked what they saw happening to their men with GutBusters, the program has been expanded. Now, as well as this Becoming Gut Less program for men, Professor Trim’s (PT) has separate medically supervised programs for women and the whole family. Depending on your needs, there is a hierarchy of programs available through your participating GP, from simple and inexpensive Quick Start versions to ongoing personal supervision by a registered PT professional. For more details and to locate a PT doctor in your area, visit the PT website at www.professortrim.com. You can also get personalised attention through a PT weight coach, assigned to work with your doctor and the PT program.

LOSING WEIGHT AND KEEPING IT OFF All the best research shows that quick weight loss is easy. For men it’s usually easier than for women, but for both an initial loss usually presents no problem. Indeed, I can guarantee huge weight losses for anyone. All I have to do is lock them up and throw away the key! Of course they’ll regain what they lose, with interest, once they’re let back out into our modern ‘obesogenic’, or fattening, environment. The hard part, then, is not losing weight, but keeping it off. To succeed viii

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INTRODUCTION

at this, you will need ongoing support as well as the best and latest information on food, physical activity and other psychological issues associated with weight management. Doctors are the logical choice and the most accessible practitioners for this role. But doctors haven’t typically been trained in dealing with lifestyle-based causes of disease, or with diet, exercise and behaviour. However, because they represent some of the smartest and most dedicated professionals in the community, doctors are keen to learn how.

PROFESSOR TRIM’S: AN EVOLVING IDEA Like the GutBusters program from which it sprang, Becoming Gut Less involves many novel ideas. This is the workbook that goes with the Professor Trim’s men’s program and it contains most of the main ideas for the program. You won’t have seen or heard of some of these in any other weightcontrol program. They include: • measuring (waist) as well as weighing • eating more often, rather than less often • eating more!—particularly bread, cereals, fruits and vegetables • drinking alcohol if you like—but balancing it with trade-offs • concentrating on ‘energy density’—not kilojoules, or even fat • moving more, but not doing any exercise you don’t like • eating more spicy foods • never missing breakfast • not trying to stay warm all the time. As you read through the first part of the book, you might also be surprised to find out that: • a potbelly can cause you to lose a leg (through diabetes) • fat on the belly is different from other fat: more dangerous but easier to shift • men can usually lose weight more easily than women • snoring often comes from being too fat and can predict diabetes • dieting, fasting and missing meals can make you fat • exercising before breakfast can help you lose more fat • it’s not a ‘beer gut’, but a ‘beer and peanuts’ or a ‘beer and chips gut • some people are genetically prone to get fat and stay fat. ix

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GETTING THE FACTS Most of the recommendations you’ll find here are based on scientific information. Again, some are new and not yet part of mainstream weightcontrol lore. Where advice is based on experience rather than proven scientific facts, I’ll tell you that, give you reasons for the position I’m taking and leave the decision up to you. If you want more purely evidencebased facts, you can look at the National Clinical Guidelines for Weight Control and Obesity Management,2 or the Experts’ Weight Loss Guide,3 which preceded them. However, all the information in this, the patient’s guide, is based on these detailed sources—albeit in more user-friendly terms. The Becoming Gut Less book, which goes with the more detailed Becoming Gut Less program obtainable through your doctor, is divided into two sections: Part I looks at some of the theory behind the program. You’ll see from this why most traditional weight-control programs don’t work and why weight control for men is quite different from that for women. If you can’t wait to do something about your problem, the practical side of the program is covered in Part II. You can skip straight to this and come back to Part I later. The plan outlined in Part II is based on simple, scientific logic and has five main themes: 1. Changing habits that encourage overeating and lack of exercise 2. Eating differently but not necessarily less 3. Moving more, throughout the whole day 4. Plateaus, motivation and trading off and what to do when you stop losing 5. Getting extra help from medication, surgery or very low energy diets. More detail about the full PT program for men, and an application form, can be obtained from the Professor Trim website at www.professortrim.com. If you’re reading this, you probably have a chronic health problem— hyperadiposity (or too much fat). Just like people with asthma or hay fever or multiple sclerosis, the problem might go away, but there’s always the risk that it will come back, and obesity can come back with a vengeance. So it’s long-term maintenance of weight loss that we try to achieve through the PT program and not quick losses that will be shortterm ones. Remember these goals as we proceed to see how we can achieve them. x

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INTRODUCTION Reg had always avoided doctors. He believed, perhaps reasonably, that anyone who saw a doctor had to be sick. On a compulsory medical for a work promotion, however, he was advised that he was borderline diabetic, primarily because of his potbelly and lack of fitness. He was encouraged to join the GutBusters shared-care program with his doctor, and within three months he had lost his ‘gut’. He was also no longer borderline diabetic.

Calories or Kilojoules The traditional measure of ‘energy’ has been a ‘calorie’, which is the amount of heat energy required to raise the temperature of 1 g of water 1°C. As a calorie is a very small unit, we generally talk in term of 1000 calories, or a kilocalorie (written as 1 kcal). More recently, the metric measure of kilojoules is being used as a measure of energy: 1 kilojoule (written as kJ) = 4.2 kilocalories.

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PART I THE HOW AND WHY OF WEIGHT LOSS

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Chapter 1 WHY SHOULD MEN WORRY ABOUT THEIR WEIGHT?

FROM FITNESS TO FATNESS By the beginning of the first millennium of the modern era we humans hadn’t evolved beyond the day-to-day struggle of securing enough food for survival. As far as we can tell, this constant imperative meant that being overweight or obese was practically unheard of (except for the very rich, in whom fatness was a sign of wealth and status). It’s ironic, therefore, that as we move into the third millennium, we have evolved a weight problem for ourselves. According to the World Health Organisation (WHO), obesity is 3

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one of the four major pandemics (along with AIDS, heart disease and cancer) predicted for the 21st century. It’s no mystery how this has come about. Humans have always craved comfort. Throughout our (in evolutionary terms) brief but turbulent history we’ve struggled, with amazing success, to secure sufficient food while expending as little effort as possible. Considering everything we’ve done wrong, this is at least one area in which we have succeeded. The problem is that, as with most things in life, for every upside there’s a downside. The downside to technological advancement, which is not often recognised, is that those unreservedly living the good life will get fat. It’s inevitable, because fat was designed to help us save energy in the good times to get us through the bad times. The march of technology means that, at least in the western world, we’ve generally seen the back of the bad times— that is, in terms of the availability of high energy-dense food, and the need to be physically active to get it. In the early days, life was tough. Most men and women worked hard for a feed, and when they got one the energy it provided was quickly used up working for the next one. By the 1960s, for people in the affluent countries of the world, food was far more freely available for far less effort. Most people no longer had to work hard physically to make a living. Work became more sedentary and so did leisure. At the same time, there was a huge expansion in the food supply. Supermarkets expanded the number of foods available from around 600 to more than 10 000 different items. In some countries, even more foods are now available. Food was not only plentiful, but high in fat—a nutrient that, until recently in evolutionary terms, was relatively hard to come by. And as we know, you can eat less food in terms of volume but actually take in more fat and end up getting fatter.

TRENDS IN OBESITY As countries modernise, the pattern has typically been that adult women become overweight first. This is because women need to be able to survive the nine months of pregnancy in order for the human species to survive. So whenever there’s a surplus of energy in good times, women soak this up in case there are bad times around the corner. In terms of species survival, men are important for only one to two minutes—sometimes even less (or so I’m led to believe!). Therefore adult males get fat as the second phase of modernisation. After that comes overweight in adolescents, and then young children. 4

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North America, Australia and some parts of Europe are currently in the final phase of this process, with the majority of their populations now rapidly becoming overweight. Indeed, survey figures from the 2000 Australian Diabetes Survey1 have shown that 67% of Australian men and 53% of Australian women are now overweight or obese, based on height and weight measures. Where waist circumference is taken (as a better measure of the health risk of being overweight), 55% of males and 56% of females are overweight or obese. The growth in obesity as measured by Body Mass Index (BMI), which is a measure of height over weight (squared), is shown for Australian men and women over time in Figure 1.1. Figure 1.1: Changes in overweight and obesity (BMI>25) in Australia over time

BMI>25 60 % of pop

Males 50 40

Females

30 1980

1990

2000

Various surveys of schoolchildren have shown that the incidence of obesity in children has doubled in the past 20 years. For the first time, Type 2 diabetes, once called ‘late onset’ diabetes because it usually occurs later in life, is being seen in adolescents. Type 2 diabetes is strongly associated with obesity, particularly abdominal obesity and inactivity. The myths of the tough American cowboy, the bronzed Aussie surfer and the wiry English explorer are dead. Today we’re faced with a portly generation of fat, unfit, potbellied men who would get tired flying over the Kokoda trail, let alone walking it! 5

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GENDER DIFFERENCES You probably thought that weight gain and loss work the same for males and females. You were wrong! In reality, the two genders are like different species when it comes to gaining and losing weight. Women—at least in their reproductive years—tend to store fat around their hips and buttocks. Men store it around the waist—hence the male potbelly or beer gut. Male abdominal fat is easier to gain and lose. In scientific terms it’s more lipolytic; it passes from the fat cells around the waist into the bloodstream to be used as energy in the muscles more readily than does fat around the hips and buttocks. The downside of this is that because it circulates in the bloodstream, it can do more damage, by blocking the arteries the way mud blocks a hose. So abdominal fat is much more dangerous than the more benign gluteal fat of women. According to the swings and roundabouts principle, though, the big payback for men comes later in life when mother nature deserts the female of the species after menopause, but continues to allow men their reproductive rights into their twilight years! In women, the trend of increasing fatness might have been hidden to some extent by clothing manufacturers. For example, the average women’s dress sizes have increased a size and a half over the past 20 years. Cunningly, manufacturers have kept the old size numbers while increasing their measurements. So a size 12 in Australia, the ‘average’ size that used to fit women with waists of 85 cm and hips of 95 cm, is now 6 cm bigger in both places. You could be excused for thinking that a program that went by the name GutBusters was for older men with the traditional beer belly. Over the twelve years the program operated, however, the average age of the men involved decreased progressively, with the youngest being 14 years of age. (The oldest was 91, and confessed to wanting to lose weight because he claimed to ‘look crook in a swimming costume’.)

Young women often manage to stay slim—sometimes too thin for good health. It’s only when they reach their forties and fifties that a significant number of these women start to get too fat. For men, the picture is different. They start to get fat in their twenties and by their mid-thirties the potbelly is firmly in place. More than 50% of all Australian men in their late thirties are overweight or obese. Among women of the same age, more are underweight than overweight in Australia, although this is not the case in some other countries. The irony is that young women, many of whom are already thin, make the most effort to lose weight. Men tend to ignore their excess flesh. Why should this be so? And why worry anyway? 6

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DOES SIZE MATTER AFTER ALL? There are two common beliefs among men. These are that: 1. Size doesn’t matter 2. I don’t have a problem anyway! Unfortunately, both are groundless. In the first place, size does matter. But it’s the size of a man’s waist that is important. If this is over 100 cm (measured at the navel), the risk of losing a leg, a kidney or your eyesight (through diabetes) or having a heart attack and leaving your family prematurely is increased dramatically. Worse still, this size waistline can affect your energy levels, cause snoring and lead to diminished bedroom athleticism . . . among other things. Second, if you think you don’t have a problem, try this little test. Write down your current trouser size (in centimetres). Now, remember what it was when you were twenty? If your current size is more than about 3 cm larger than your size at twenty, you have got a problem. Gradual increases in waist size after late adolescence are now regarded as just as bad as always having been overweight. In fact, the bigger the increase and the more weight cycling between gain and loss, the greater the likely health risk.

THE M AND M SYNDROME There are a number of problems associated with being overweight and, particularly, with increased abdominal fatness or a potbelly. As shown in Table 1.1, these ill effects can be of two types: first there are metabolic, or internal, problems, for example high cholesterol, high blood pressure and diabetes, which are caused by the disruption of normal physiology by excess fatness. Second, there are mechanical problems, such as sore knees, a sore back, breathing difficulties and fatigue, which result simply from carrying around excess weight for 24 hours a day. Dr Andrew Binns, a prominent general practitioner from Lismore in New South Wales, refers to this as the M and M syndrome. It describes the mechanical problems that come with the better-known metabolic syndrome—a cluster of risk factors known to be associated with increased weight and to lead to more serious disease risks such as diabetes, heart disease, stroke and even some forms of cancer.

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Table 1.1 The M and M syndrome: metabolic and mechanical problems associated with being overweight Risk

Metabolic problems

Mechanical problems

Greatly increased • Type 2 diabetes (3+ times greater than • Gall bladder disease for someone lean) • Hypertension • Dyslipidaemia • Insulin resistance

• • • • •

Sleep apnoea Breathlessness Asthma Social isolation/depression Daytime sleepiness/fatigue

Moderately increased • Coronary heart disease (2–3 times greater) • Stroke • Gout

• • • •

Osteo-arthritis Respiratory disease Hernia Psychological problems

Slightly increased (1–2 times greater)

• • • • •

Varicose veins Musculo-skeletal problems Bad back Stress incontinence Oedema/cellulitis

• • • • • • • •

Cancer (breast, endometrial, colon, and others) Reproductive abnormalities Impaired fertility Polycystic ovaries Skin complications Cataract

TO SLEEP, PERCHANCE TO SNORE You might be surprised to know that having a potbelly can make you snore more! This is because the tongue is one of the first parts of a man’s body (along with the belly) to get fat. Once it does it can block your air passage, or pharynx, during sleep so that you sound like a lumberjack’s mate. It might drive your sleeping partner to distraction in the process. Snoring is part of a sleeping problem known as ‘obstructive sleep apnoea’ (OSA), which is common among overweight men. OSA involves suboptimal breathing at night, which can mean your body doesn’t get the oxygen it needs to keep you healthy. Your heart might have to work harder and this could push up your blood pressure. Because you run a very real risk of dying from lack of oxygen, your brain (one part of your body that, fortunately, is still working) will wake you up in brief spurts to get you breathing again. You might not be aware of it, but these little intervals of 8

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disturbed sleep that snorers snuffle and grumble through can happen hundreds of times a night. And you wonder why you’re tired during the day! Fat men who are heavy snorers often think they’re great sleepers. They say they never suffer insomnia. And, of course, they’re right. They suffer from the opposite—hypersomnia, or the need for too much sleep. Because they wake unconsciously so often during the night, they’re asleep at their desks or at the wheel of their car or truck during the day while their body tries to make up for the disturbances at night. ‘Men rarely come to see a doctor about their weight or other non-medical problems,’ says Dr Andrew Binns. ‘When you do see them, however, such as through a program like Professor Trim’s, you can have an enormous impact. They find it much easier to lose weight than women, and can frustrate their partners by how easy it is for them.’

BEING FAT IS A PAIN IN THE . . . Backache is another problem for the fat-bellied man. The reason is fairly obvious. Try hanging a heavy bag on a stick of willow and see what happens to the stick. The trouble is that when the human spine bends, it doesn’t snap back like willow. It can pull on or pinch nerves and muscles that are designed to hold it upright. The only solution is to take the pressure off by getting rid of some of the weight. A similar thing happens to the knees. As major joints between the gut and the ankle, they have to take a lot of the weight, especially in the flexed position, when climbing stairs or walking up hills. The greater the bend in the knee, the greater the multiplication of the load it has to carry. And any self-respecting knee can only take so much. For some men this is selfdiagnosed as ‘arthritis’, which can cause them to reduce their activity level, supposedly to reduce the pain. This, in turn, can cause an even greater weight increase and even more knee pain, so it’s exactly the wrong thing to do! It’s the same with the feet: having extra weight forcing down on the two pads responsible for keeping the body upright is a bit like what would happen to two raisins on sticks expected to hold up a pumpkin. If the feet are enclosed in ‘non-breathing’ leather shoes and heavy woollen socks, they are likely to overheat and perspire. With no way to cool themselves the feet can develop rashes and skin problems. 9

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Many fat people suffer from skin problems that they don’t relate to their excess flesh. Underneath that fold of fat so characteristic of an overhanging gut in a man, it can get hot and damp—a perfect breeding ground for lots of micro-organisms. Intertrigo is a type of eczema that can form under this fat layer, causing itching and rashes. The sex problems associated with having a potbelly hardly bear mentioning. It might be worth pointing out, though, that testosterone, the male hormone associated with ‘friskiness’, decreases with increases in belly size. So if your night sport activities are suffering, it could just be your girth size that’s doing it. In any case, even if it’s only from your partner’s point of view, getting rid of a belly is not going to be a disadvantage.

INTRODUCING MELVIN Health is, of course, related to longevity. So will getting healthier help you live longer? Or will it just feel longer? To explain this, we need to meet Melvin, our new kid on the PT block. Melvin stands for ‘Maximum Extended Lifespan, proVided you’re Interested and not too Naughty’. As you might have gathered, this is not a strictly scientific concept. But it will serve to answer the question posed above. Let me explain. How long you live on this earth (barring unexpected accidents or the taking of one’s own life) is determined primarily by your genes. The best measure is usually how long your parents, grandparents and other family members stick it out. However, this is only a general indication. Our lives can be shortened or lengthened by how we live them. And this is where Melvin comes in. In the current environment (few major life-threatening infectious diseases to contend with—AIDS, of course, being an exception), our potential to spend more time on terra firma can be increased by remaining healthy. Staying lean is one way to do this. Obviously, not being overly stressed, eating the right foods (and not overeating), not smoking and keeping active are other ways, but these are all part of keeping your weight down anyway. So getting rid of your gut can help extend your ‘Melvin’. Instead of dropping off the twig at 60 as your father’s genes might have dictated, you might stick around till 70, 80 or even 90 by being interested (which you obviously are, since you’re reading this book)—and not too naughty! Having a long Melvin is one thing. But what’s the point of living to a ripe old age if you’re hospitalised or bed-bound and can’t make the most of those extra years? It’s life in your years you want, not years in your life. So 10

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you can have a HAPPY Melvin (where HAPPY stands for Healthy, Active, Potent, Productive and Youthful) or you can have a SAD Melvin (where SAD stands for Sick And Decrepit). The aim of the Becoming Gut Less program is to give you a long and happy Melvin. The rest of this book is designed to show you how to do this.

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Chapter 2 JUST WHAT IS FAT ANYWAY?

You’re probably familiar by now with two types of fat: there’s the fat in food and there’s the fat on our bodies. What’s the difference? And what is fat anyway? There’s little difference between the fat we eat in foods and the fat we store in our bodies. Plants store fat as oils, animals usually in a more solid form, like the fat on a piece of steak. Plant fats (oils) are usually less saturated with hydrogen (hence their liquid form at room temperature) and are often seen as more healthy than the more saturated animal fats. However, all fats have the same energy value (9 kilocalories per gram), and to all intents and purposes should have the same effect on body weight. As we will see, some recent research is beginning to question this but, for the moment, reducing all fats in food is regarded as one of the best ways to reduce all fat on the body. 12

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JUST WHAT IS FAT ANYWAY?

To answer our second question, fat is a form of energy that is stored in the body. Its main function is as a source of fuel, so we can say it’s like a pile of firewood that’s built up over the summer to be used to provide heat during the winter. Fat is stored in special fat cells, which are similar to other body cells except for a small pool, or reservoir, of fat, as shown in Figure 2.1. Figure 2.1: Fat cell cell wall cell nucleus

lipid (fat) pool

protoplasm

FAT AND FAT CELLS The fat cell then is the equivalent of the woodheap in which firewood is stored. But in the case of fat, it’s not all stored in one place. There are literally billions of fat cells all over the body, each of which stores only about 0.0005 of a micron of fat. Now a micron is only a very small amount, but multiply 0.0005 by over 50 billion (the number of fat cells in the average non-overweight person) and you can see that even someone of normal weight can store 20–25 kg of fat. At 9 kcals of energy per gram, and given that an average 80 kg man would require around 2000 kcals a day to survive—even lying in bed—this would provide enough energy for that man to live for 60 to 90 days without food. So fat is a very effective form of fuel. It also has other functions in the body, such as carrying certain vitamins and minerals around the body and making hormones. But our focus here is its function as a reserve source of fuel. The lipid pool in the fat cell increases or decreases in size depending on how much energy we use up staying alive and moving around and how much energy we take in from what we eat and drink. If there’s more energy coming in than is being used up—in other words the woodcutter is supplying more each day than is burned up in the fire each night—we get a build-up in the woodpile or in overall fat. Which of the many ‘clumps’ that make up the 50 billion fat cells receives this extra fat is determined by a number of factors, including genetics, gender and race. Men, for example, 13

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BECOMING GUT LESS Because fat is such a good source of fuel, it enables us to survive for long periods without food. Castaways, for example, with only a moderate amount of body fat (say 20 kg or 20 000 g) would have 20 000 x 9 kcals = 180 000 kcals of energy to help them survive. At a low rate of energy use (around 2000 kcals a day) this would allow such a person to survive for 90 or so days without food (provided they have water). On the other hand, the body can store only about 2000 kcals of carbohydrate, ensuring only approximately one day’s survival without food.

store reserve energy as fat around the waist, whereas women store it around the hips and buttocks. A potbelly is nothing more than a huge mass of swollen fat cells. If you cut off all the white fatty bits on a big pile of T-bone steaks, put them in a plastic bag and tie them around your middle, you’d have a similar lump of fat. Horrible thought, isn’t it?

FAT LOCATION Where you store fat most readily is also affected by individual factors. Genes, for example, help determine your size and shape. You also inherit the ability to gain or lose fat easily. Obesity can run in families (more on this later). Sometimes it runs in families who all eat and drink too much. In other cases, obesity runs in families because their genes mean they don’t burn up excess energy easily. So it’s difficult to say where you are going to put on fat most when you gain, and lose it from most when you lose. One thing we do know, however, is that you will most likely lose it first from the last place you put it on. So while for most men this is the stomach, some might lose it from their neck, chest, buttocks or legs before it comes off their stomach. If you are one of these men, don’t despair. It will eventually come off the waist, it might just take longer to happen for you. In the meantime, you’re losing extra weight, in the form of fat, anyway. If the tape measure doesn’t pick this up, the scales should, as we’ll see in Chapter 3.

FAT AND PHYSIOLOGY When most of today’s doctors did their university training, they learned very little about fat. This is because fat was not regarded as very important, except in its role of energy reserve. Muscle and other tissue was thought to be more important, because it was much more metabolically active. 14

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FAQs about FAT • Why is fat so easy to get but so hard to lose? Because, in evolutionary terms, it was vital to be able to store fat for survival in times of need. Therefore the metabolic ‘brakes’ are much lighter on weight gain than on weight loss. • Why am I finding it harder to lose weight as I get older? Because your metabolism slows gradually with age. This means you probably need to eat less and/or do more to stay the same weight and, since you are getting older, you most likely aren’t doing this. • Why do women find it easier to gain weight and harder to lose it than men? The answer lies in the different physiology of male and female fat. This is probably because, in terms of survival, larger energy reserves are more important for women to enable them to survive the nine months of pregnancy and thus ensure the survival of the human race. • What is a ‘healthy’ amount of body fat? In men, the healthy range is 12–24% of body mass as fat. In women, the figure is 15–35%. This can be measured using scales. These are now available for the home, using bio-impedance analysis (BIA). A simpler cut-off point to use is a waist circumference of 100 cm for men and 90 cm for women. • Why can’t I just take a drug to lose weight? While there are some drugs that can aid in weight loss, these only slightly increase the benefits that come from lifestyle changes and, indeed, don’t work unless lifestyle changes (regarding food and exercise, in particular) occur. To work, these drugs also need to be taken for life. • Is exercise or diet best for weight loss? It’s always easier to reduce kilocalories in the short term using diet. However, in the long term, the people who are leanest are those who have a regular exercise routine. Having said that, some people’s weight problem is caused mostly by diet, whereas for others it’s mainly inactivity.

In the past decade, however, fat has taken on a whole new importance. In fact, the medical speciality of endocrinology, which is based on the study of hormones and their effects on health, now includes fat as an endocrine organ, along with the thyroid, the adrenals, the sex organs and other endocrine glands. 15

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We now talk of the ‘fat organ’. This means that fat cells can secrete chemicals (we now know of over 30) that send messages to other organs in the body. The hormone leptin, for example, which was discovered in 1994, communicates to the part of the brain associated with hunger that we have, or have not had, enough to eat. This then changes our level of hunger. A newly discovered hormone, gherlin, is produced in the gut and also seems to have an effect on hunger levels. We now also know that fat cells receive messages, which they act on in various ways. They are what is known as parocrine and exocrine organs, which receive messages from other nearby cells or other parts of the body. So the fat cell is much more active than was once thought and future endocrinologists are likely to be studying fat cells as much as the adrenal glands or the thyroid.

NOT IF YOU’RE FAT, BUT WHERE As we have seen, fat cells around the abdomen in men are different from those on the hips, buttocks and thighs of women. Abdominal fat cells are generally bigger and more active than fat cells elsewhere in the body. This means they inject fat into the bloodstream more readily when the body needs it and they take fat more readily from the blood and store it when there is more than the body needs to power muscles. Even more dangerous are fat stores known as visceral fat. Visceral fat is stored around the internal organs of the trunk, for example the stomach, liver, kidneys and intestines. Visceral fat has been shown to be several times more active than either gluteal (around the hips) fat or subcutaneous (under the skin) abdominal fat. This means it is released into the bloodstream even faster than other fats and is potentially even more dangerous. A bigger problem is that visceral fat is not obvious in the way, say, a potbelly is. However, it generally, although not always, correlates with abdominal fat. Like abdominal fat, it’s usually much easier to shift than female-type gluteal fat, but sometimes genetic and ethnic factors make it particularly intractable. The bad news is that fat-bellied men can have lots of extra fat lurking in their bloodstream. Hence, in large part, the increased risk of heart disease, diabetes, gallstones, high blood cholesterol and high blood pressure. (Indeed, the relative risk of contracting diabetes for an obese man can be up to 40 times that of someone of normal weight. In obese women, the risk is even higher, at up to 90 times.) This also explains why the potbellied man is generally unfit and unable to . . . well, do things. No fat-bellied man needs to be told that he can no longer move the way he could before he 16

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began to look like a Christmas stocking half-full of melons. A kilogram of fat needs around 29 km of plumbing (blood vessels) to feed it. And because fat, unlike muscle, is not very active tissue, supplying this dead load with nutrients puts an extra strain on the main organ of the body—the heart. Imagine pumping air into a flat bicycle tyre with a foot pump. Now imagine doing the same with a flat tractor or truck tyre. The extra work your foot has to do is equivalent to the extra load on a heart that has to pump blood around an oversized body. If the muscles in the foot are weak, they will cramp, seize up and stop you from pumping. Similarly, if the muscles in the heart are weak, they too will seize up. It’s important to realise that you don’t have to be fat all over to be at risk. In fact, the lean man with a gut shaped like an apple is more at risk than the fat man without a gut but with big hips, who is shaped like a pear, or even the man who is big all over—shaped like the box the fruit comes in!

FAT IN YOUR GENES If your gene pool doesn’t have a shallow end, it’s certainly true that you might find it harder to slim down than someone with ‘lean genes’. That doesn’t mean, however, that slimming down is impossible. Fat genes are not like the genes for fair hair or blue eyes; they don’t mean that being fat is inevitable. They do mean that in the right circumstances—the wrong kind of food and not enough exercise—it will be easier for someone with ‘fat’ genes to put on fat than someone from a leaner background. So let’s not kid ourselves: it might be a little more difficult if you picked the wrong parents. But, remember, irrespective of your genes, we now live in an obesogenic (fattening) environment. Everything in modern society is designed to make things easier for us. But all this ease can also make us fat. It might not be as good as a gene test, but you can gain an idea of your genetic liabilities from the following test. If your particular weight problem is a potbelly, it’s more than likely that your major problem is not inherited fat but your lifestyle: what you eat and drink and how much you move. An imbalance in food, drink and exercise will give you the apple or android shape—a bit like a pregnant telephone pole. The man who is genetically fat is usually fat all over, with an ovoid or box shape. This problem is usually apparent early in life. However, there are some accurate yet simple ways to determine whether or not you actually have a problem, which we’ll look at in Chapter 4. 17

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Testing your genes Answer the following four questions to see if you can blame genetics for your body weight. For measurement purposes here, the term ‘overweight’ means having a Body Mass Index or BMI* over 25, ‘obese’ means a BMI over 30 and ‘very obese’ a BMI over 40. *BMI = weight (in kg) divided by height (in metres)2 1. As far as you know, were either or both of your parents obese or very obese for most of their lives? Neither/Don’t know/No Yes, one parent Yes, both parents

Obese 0 7 14

Very obese 0 14 28

2. Do you have any members of your immediate family who have been obese for most of their lives? Score 2 points for every obese member of your immediate family, up to a maximum of 10 points. 3. How would you describe the average BMI of your siblings? BMI 30) 6

Very obese (>40) 12

4. When did you first become overweight and/or obese? Never Before age 10 Before age 20 Before age 30

Overweight 0 20 10 5

Obese 0 30 20 10

Scores: