America's No. 1 Health Problem -- Overweight but Undernourished
An expert's advice on shedding unwanted fat: An interview with Dr. Anthony Conte
by Richard A. Passwater, Ph.D.
You know it for a fact -- Americans are overweight but undernourished. Obesity is a major health problem increasing the risk in almost one out of every three Americans for heart disease, cancer, diabetes mellitus, high blood pressure, stroke, gout, gall bladder disease, osteoarthritis, some forms of cancer, sleep apnea, etc. [1,2] There is even good evidence that "calorie restriction" can lead to better health and longer life in laboratory animals.  The health care costs to this country of the morbidity related to obesity were estimated at $39 billion in 1986, and about $30 billion a year is spent in the U. S. in efforts to lose or control body weight. [4,5]
Countless educators have tried to convince Americans that all they have to do is to eat a "balanced diet" (pray tell what that might be) and reduce their calories. But these educators don't live in the real world. They ignore the fact that the average American eats too much junk and not enough whole foods. They ignore the fact that the average American eats too much fat and calories, and can't stop eating at the suggested limit. Every time an "expert" comes out with a new theory, another "expert" proves it wrong. As Dr. F. Xavier Pi-Sunyer editorialized in the Journal of the American Medical Society, "Decreasing food intake and increasing activity seems an easy formula, yet it is proving extremely difficult to implement." 
What is needed is to have an experienced educator -- one who has successfully worked with overweight, underfed Americans and understands what is needed to help them reach their desired weight in the real everyday world -- tell us what works. So, I have called upon Anthony Conte M.D., a leading bariatric physician, to give us good practical time-tested and real-person-tested advice.
Passwater: Every one "knows" how to control their weight. Every day "experts" tell us to avoid fats and exercise more, and we will have no weight problem. However, studies show that a greater percentage of Americans are obese. Are Americans ignoring the advice, or is the advice wrong?
Conte: The answer is "YES" to both questions. For the past 30 years, every patient of mine has come to the office anxious to go on a diet to lose weight. To all of them, I have said: "I don't want you to do either." Although most people talk about losing weight, they are not really interested in losing muscles, bones, and vital organ tissues.--the components of lean body mass (LBM); they are interested in losing body fat only. After all, it is the excess fat that jeopardizes our health and detracts from our appearance. Have you ever heard anybody complain that their muscles were too heavy? Fewer and fewer Americans will ignore our advice if our message is loud and clear: "Dieting without exercise can result in the loss of a substantial amount of LBM as well as body fat resulting in detrimental changes in body composition. Don't be a slave to the scale! Loss of inches means a loss of fat and a gain of valuable LBM. The bathroom scale carries little weight when it comes to assessing your fitness level.
Passwater: Just how serious is the problem? Is the percentage really increasing and what harm is it to be obese or overweight?
Conte: Obesity has ranked high on the list of national health problems and personal health concerns for most of the 20th century. Today, more than a third of all adults are obese, 32 million women and 26 million men and the numbers are increasing dramatically, up 31 percent in the last decade. On any given day, half of all American women and a quarter of the men are dieting. A report in the Journal of American Medical Association called obesity an "orphan disease." Despite obesity being responsible for so much suffering and socioeconomic damage, neither the medical establishment nor the pharmaceutical industry have been willing to adopt it. An unfortunate and unjustified snobbery toward obesity and its treatment exists in many places out there in the American jungle. Some State medical boards allow physicians to prescribe appetite depressants for a maximum of 12 weeks out of the year regardless of successful management and benefits to the obese patient. Physicians need effective and safe medications for obesity. While developing these new drugs, pharmaceutical firms, scientists and health professionals must recognize that herbal medicine should be considered as an equal partner and not an adversary.
The harm to good health--our most precious possession--is so great that the Center for Science in the Public Interest has started a National Campaign to Reduce Obesity and has called for the administration to convene an obesity summit to focus on treatment and prevention of obesity through good nutrition, physical activity and more research.
C. Everett Koop, M.D., a former surgeon general, is working with Hillary Clinton on an obesity prevention program, "Shape Up America." Of course, the American Society of Bariatric Physicians (ASBP) through research, continuing education and exchange of information has encouraged excellence in the practice of Bariatrics for 45 years.
Passwater: Well, you have been concerned with this for over 30 years. You have been a bariatrics physician, you have published in The Bariatrician and other obesity-related journals, you have tested drugs and diets, and have been a pioneer in Bariatrics. What kindled your interest in this field?
Conte: As an Anesthesiologist from 1954-1963, I was keenly aware of the greater risk presented by the obese patient to me , the surgical, and the recovery teams. But, I also recognized that controlling obesity was clearly a physician's responsibility--a medical specialty worthy of any physician's interest and challenge.
At that time, I definitely agreed with a New Jersey physician, Dr. Henry A Davidson, who in 1962 predicted correctly that "If we doctors don't do the job, everybody and his brother (diet faddists, physical culturists, cosmetologists, gymnasts , dance instructors, masseurs, non-medical nutritionists, and a spectrum of crackpots) is going to get in on the act of controlling obesity promoting a variety of fancies."
Right now, I want to say that my quest for a better alternative weight loss enhancer started over 15 years ago when my wife Jo, a Registered Nurse and nutritionist, "forced" me (a physician) to read some of your books and booklets on Chromium Picolinate and selenium to name but two.
Passwater: Another study has added support to the concept that we have a "set point" for our body weight. What are your observations? Can we alter this "set point?"
Conte: The "set point" theory, developed in the past 12 years or so, suggests that each of us has a natural tendency to acquire and hold a certain quantity of fat, you can think of your own SET POINT as the weight you maintain, give or take a few pounds; when you aren't thinking about it, the weight you return to after an unsuccessful diet. The set point, according to some experts, appears to be determined by the brain and the hypothalamus; how it works is still a mystery, but it fights our efforts to lose significant amount of fat. When we cut calories by going on a diet, the body cuts down on the number of calories burned after a few days of adaptation. This can ruin all our attempts to lose weight. My belief is that we can bypass the set point mechanism and lose body fat by increasing our physical activity above a certain level through different aerobic exercises (the way athletes do) daily.
In highly resistant cases of set points or "previous weight levels" or "plateaus, I have successfully recommended one or two "Unifood" days a week; either the fruit or the protein method: examples, one apple every two hours until six apples are eaten; or two ounces (after it has been cooked) chicken breasts, every 2 hours until six portions are consumed. Remember: "unifood" means only one food that day, not a combination of different fruits and or different proteins. Of course a minimum of 64 ounces of water (two quarts or about eight glasses -- "typical" drinking glasses hold eight-to-ten plus ounces) per day is also recommended.
Passwater: Why is water so important in a fat-reduction program?
Conte: There is a vital connection between drinking water and fat loss. Eight glasses or more of water daily keeps fat away! Incredible as it may seem, water is quite possibly the single-most important factor in losing weight and keeping it off. I call water the only true "magic potion" for permanent weight loss. Here is why;
Passwater: Dieters should keep in mind, that they normally receive a large portion of their daily water needs through their food, which can be seventy-to-ninety percent water. During dieting, the food intake is reduced and thus, the person is not getting their normal supply of water let alone the extra water they need to flush out the metabolic by-products. This results in a "hidden hunger" in dieters as the body is craving food, not for its calorie content, but for its water content.
The water is especially needed to keep the skin healthy. If the body can't get rid of the by-products from metabolizing stored body fat via kidney excretion, the skin is called upon to help excrete these by-products. People often overlook the role of the skin in excreting toxins. Water is not only a "magic potion" for fat-loss, it is a "magic-cosmetic" for the skin.
Why does each additional pound of fat lose become harder to achieve?
Conte: For many years we have been told that 3,500 calories is the equivalent of one pound of body fat. And, if we reduce our daily calorie intake by 500 calories, in a week we would lose a pound. Of course, this is a simplification and hardly takes in consideration any of the multiple factors responsible for obesity. But even if it were true, it would mean to me that a person would have to constantly be reducing his or her calorie intake as his or her body weight is reduced. A 180 pound person cannot simply reduce their daily caloric intake by 500 calories and expect to constantly lose a pound a week.
First of all, that person may have been gaining two or three pounds a week, and a reduction in food intake might only slow the rate of fat gain. But even if the person were in weight-calorie equilibrium, a 180 pound person could not simply cut their present calorie intake by 500 calories a day and continue to lose a pound a week until they weigh only 105 pounds.
A certain portion of our calorie intake goes to support our resting energy expenditure (also called basal metabolism) -- the needs of every cell in every tissue. The resting energy expenditure (REE) correlates better to lean body mass than to total body weight, but there is some correlation to both. As examples, the RDA lists REE reference values for a 128 pound person as 1,350 calories and for a 154 pound person as 1,750 calories. These two figures average about 11 calories per pound just to provide the REE.
When we have more body weight, we need more calories just to maintain this body weight. If we could lose a pound a week by reducing our daily calorie intake by 500 calories, eventually we reach a body weight that is just right for maintaining that weight.
Let's go back to my example with a 180 pound person. Let's say that this 180 pound person needs 11 calories a pound per day to maintain their REE weight and because this person has a sedentary lifestyle, only 5 calories per pound is needed for a total of 16 calories per pound every day to maintain their body weight. (The RDA teaches that a person with very light activity needs the REE times 1.5) Thus, our 180 pound person needs 2,880 calories a day to maintain his or her present weight. To lose a pound of body-weight a week according to conventional wisdom, this person would need to reduce his or her calorie intake to 2,380 calories per day. Assuming that there is no decrease in metabolic rate -- that is the calorie level that would maintain the weight of this person at 149 pounds.
As the person approaches the weight that will be supported by a given calorie intake, the difference between actual body weight and that weight maintained by a given caloric intake becomes smaller and thus, the rate of weight loss becomes less.
When this person eventually reaches 149 pounds -- the weight supported by the 2,380 calorie diet -- the person must then cut his or her diet by another 500 calories to get back to the theoretical one pound per week rate that would again hold only for the first few pounds of weight loss. At 1,880 calories per day, the person, according to theory, could eventually expect to reach 118 pounds, if the person could remain on the 1,880 calorie a day diet long enough -- which is a 35 percent reduction in calories from the original 2,880 calorie intake.
But there is also evidence that as we lose weight, our body involves a starvation protective measure and slows our metabolic rate! There are other things that we can do that can increase our metabolic rate in spite of the fact that we are losing fat. This is part of the "set point" theory.
Yes, fat-loss, especially those last few pounds, becomes harder. However, with a successful plan that takes these factors into account, you can be successful too without counting calories. With good habits, good nutrition and a good attitude, you can lose the fat you want, without counting calories. We can turn today's good habits into tomorrow's rewards.
Passwater: "Yo-yo" dieting -- Is this harmful or not? Some people feel as if they are losing and gaining the same ten or twenty pounds over and over again. First we were told to diet as necessary to keep our weight down. Then we were warned to avoid constant ups and downs in body weight. Recently a report suggested that it might be better to keep taking the weight gains off to try to stay near our desirable weight. It seems that if someone were to lose twenty-five pounds and not fully regain them for two years, then that would be two years in which that person would be at lower risk for high blood pressure, etc. Should we avoid dieting because we might gain it back in yo-yo fashion, or should we diet and try to keep it off?
Conte: In my opinion, the jury is still out on the harmful effects of yo-yo dieting. Unfortunately, patients and doctors alike don't seem to be able to get away from the word "dieting." I prefer "planned nutrition" or "smart choice eating."
Selection of an appropriate "Nutri-plan" should consider the individual's lifestyle, eating patterns, and health needs.
The most effective and nutritionally sound nutri-plan combines the following fundamentals:
Like your Nutri-plan, the selection of an appropriate physical fitness exercise program must consider your lifestyle and health needs.
The major problem with many weight control programs is that rewards are expressed only in terms of weight loss. Losing weight does not automatically bestow the skill of maintaining it. Proper eating habits as well as other lifestyle changes, once installed must be automatically maintained.
Passwater: Is there an ideal reducing diet that works for everyone?
Conte: Absolutely NO!
Passwater: Is there any hope for the "genetically" gross obese--those who must lose 100 pounds just to be considered fat?
Conte: In weight control, as in everything we do in life, success if based on 85% attitude and 15 percent ability. Success is there for all of those who want it, plan for it, and take action to achieve it.
In my own Bariatric practice, I have several patients who have lost 100 pounds or more--My star patient is a young man who went from 448 pounds to 254 pounds in exactly one year. I am sure my fellow Bariatricians have similar successful cases. Surgical intervention has helped many grossly obese patients. Studies in Charlotte, NC, show that a combination of phentermine and fenfluramine is helping many morbidly obese patients. The FDA has granted a license to MIT to market Dexfenfluramine in the USA (more effective, fewer side effects). But, let me repeat once again: don't treat the scale, don't treat the disease who has the patient but the patient who has the disease. Examples of good medical care and what can be done to give hope to these genetically obese people are many.
I am looking at the Pittsburgh Post Gazette April 16, 1995, at pictures and story of participants in eating disorders group therapy sessions at St. Francis Medical Center in Pittsburgh--very, very encouraging to say the least.
Passwater: What do you recommend for taking off excess body fat?
Conte: Obesity is a chronic genetic, metabolic neural, hormonal disease. It is influenced by emotional, social economic factors interacting with each other and finally becomes a learned disorder. In other words, obesity is a heterogeneous disorder with multiple etiologies or causes, and hence multiple risk factors must be identified by history, laboratory data, and physical examination prior to establishing an individualized treatment.
An intelligent weight-loss program involves: Attitude - Nutri-Plan - Exercise and medications as necessary. These are the four magic keys to successful weight control. Understanding from the very beginning the difference between weight loss and fat loss, between diet and nutrition, and between being thin and being healthy. This understanding is a logical and important step in developing and maintaining a positive mental attitude for the long haul.
Because losing excess body fat is a gradual process, it favors a calm, collected approach rather than a frenetic "lose it now" mentality. You have to develop a less rigid lifestyle, one that reduces the need to consciously control what you eat.
Passwater: Are there supplements that help?
Conte: Yes. It is ludicrous to assume that every case of obesity can and must be treated without the judicious use of medications. I am referring not only to appetite depressants and diuretics. There are many obese individuals who need digestive enzymes, lipolytic agents (choline, inositol), metabolic correctors and nutritional supplements.
I am always emphasizing the difference between therapeutic doses and supplemental doses to my patients. All of them receive a one-a-day multiple vitamin/mineral (total formula). I believe that vitamins act as co-enzymes and are the catalytic agents or activators of all body activities and make them happen quickly and accurately. However, I am not a vitamaniac!
I am also a firm believer in the new age of alternative medicine, which is rapidly catching on because the public is fed up with surgery, drugs, and quick fixes.
Specifically, I am talking about the use of (-) Hydroxycitric acid, [HCA], the extract from Garcinia cambogia that grows in Asia, primarily in Southern India, and chromium picolinate.
Passwater: Have you tested these in a clinical trial? Are there any adverse effects or any conditions that preclude their use?
Conte: Yes, I have conducted three clinical studies on obese subjects using these non-drug, all natural weight-loss enhancers as well as using them in my private bariatric practice.
In an eight-week double blind study in 1991, the active ingredients group lost an average of 11.1 pounds per person while the placebo group lost an average of 4.2 pounds per person. The article describing this study was published in The Bariatrician in 1991.  The Bariatrician is the official medical journal of the American Society of Bariatric Physicians -- an international organization of physicians that seeks to encourage excellence in the practice of bariatrics through research, continuing education and exchange of information. This study was the first study done anywhere on humans (utilizing available pre-clinical research data developed with the aid of animal studies) on (-)HCA (extract of Garcinia cambogia) and chromium picolinate.
The 1993 study, a consumer study with no placebos and no exclusions because of associated medical conditions and therapies, but otherwise identical to the 1991 study, confirmed the effectiveness and safety of the original study: subjects lost an average of 11.4 pounds per person in eight weeks. In 1994, we did another consumer study identical to the 1993 study except for an additional laboratory procedure: detection of plasma chromium levels before and after the eight-week duration. The latter two studies were published in part in abstract form at the 35th Annual Meeting of the American College of Nutrition in 1994 and also in the booklet "Citrin: A revolutionary, herbal approach to weight management. [8-10]
The average weight loss was almost 11 pounds per person in eight weeks.
Passwater: How much should they take? Any side reactions? What rate of weight loss should people expect by using this approach?
Conte: The synergistic effects of (-) HCA and chromium picolinate, namely reduction in appetite and cravings for sweets while reducing fat formation and storage, and keeping insulin levels in check, have helped my patients lose excessive body fat and improve their health. HCA and chromium picolinate when taken as directed, that is, one capsule of 500 milligrams of Garcinia Cambogia [standardized to 250 mg of the calcium salt of (-) hydroxycitrate] and 100 micrograms of chromium three times a day, approximately one half-hour before meals is safe and effective. I have seen no side reactions to discontinue the treatment and they do not interfere with other medications.
Keep in mind the smart choice eating: a low-fat, low-sugar, low-sodium version of three meals per day, and a sensible daily exercise program.
Patients should drink a minimum of 64 ounces of water per day, which is essential to kidney and liver metabolic functions. Water intake overcomes the problems of water retention, helps to maintain normal body temperature and proper muscle tone; helps to rid the body of waste, relieves constipation and is a key to fat metabolism and storage.
A weight loss of l-2 pounds per week is achievable with this regimen.
Passwater: How should they measure their progress? Daily or weekly weigh ins? Tape measure? Calipers? Pinch test? Bioelectrical Impedance Analysis? Ultrasonic? Infrared?
Conte: Different strokes for different folks. My personal preferences:
Passwater: Should dieters set goals?
Conte: Of course. We set materialistic and idealistic goals for everything we do in our life day in day out
My Weight Loss/Time Management System clearly identifies the total weight loss desired, the immediate goal (weight loss/week), the intermediate goal (50% of desired weight loss and size, and estimated date) and finally the long-range goal (Fit for Life--Reach and Maintain-Final Weight-Final Size-Estimated date). Asking patients to set goals without setting goals for myself is counterproductive and stupid. Therefore, I use these unifying principles as the physician in charge:
Passwater: How does one know their ideal weight?
Conte: I don't believe there is such a thing as ideal weight or ideal blood pressure, pulse, blood sugar, etc. etc.
I rather think desirable weight according to age, sex, and frame is more appropriate--But, again, even this weight must be considered in the panorama of good health, lifestyle, achievability, and reasonable ability to maintain it.
Passwater: How does the dieter stabilize and maintain the desired weight?
Conte: Self monitoring is the key to success. This includes a self-designed nutritional plan of three meals a day, drinking at least 64 ounces of water daily and a sensible exercise program. Many causes or risks have been identified for the 3 stages or phases of "dieting:" Lapse - Relapse - Collapse - and they are enjoyment of food, food exposure, lack of interest, negative feelings, such as depression, stress, major life changes, job problems, conflicts, illness, socializing, traveling, and "testing oneself." But, the basic underlying causes: No structural eating plan or exercise; No self monitoring or record keeping.
Therefore, to avoid what I call the three Dreadful D's: Disappointment, Discouragement, and Disillusionment -- a dieter must automatically maintain the once installed proper eating habits and exercise as well as other lifestyle changes.
Passwater: When should dieters be under the direction of a physician? When should dieters be under the care of a bariatric physician?
Conte: "Going to a physician-supervised program, where the physician doesn't know what he or she is doing is perhaps a great misrepresentation because you think you are getting safe monitoring, when in essence you are not." This is a direct quote from Dr. C. Wayne Callaway, an Associate Clinical Professor at George Washington University, at a recent hearing on investigation of the diet industry in Washington, D.C., and chaired by Representative Ron Wyden of Oregon.
Strategies for losing weight may or may not work, but before individuals adopt any of the programs for the purpose of losing weight and maintain their weight loss over extended periods, they should be aware of the pitfalls of managing his or her own diet. Navigating through your diet sets an uneven course; only an experienced Bariatric Physician can be your "trusted pilot" and help you steer clear of rough waters.
Medical guidance is especially needed in Diagnosis-Related Obesity, including that associated with arthritis, hypertension, diabetes, cardiovascular diseases, and pregnancy. Short-term weight loss is just an illusion.
Passwater: Any words of encouragement or advice you wish to leave our readers with?
Passwater: You certainly understand the problems people have in losing fat, and you offer excellent advice and motivation. We are glad you switched from anesthesiology. Why did you chose to become a physician in the first place?
Conte: Perhaps it was destined! It came about sort of accidentally. I was in the ninth grade at school, back in 1938 and I was running out of time to do a term paper about "What I want to be and why." I had no idea of what to write about . I ran into the library just before it closed and explain my problem to the librarian. She suggested that I consider thinking about becoming a doctor. I opened the encyclopedia to "medicine" and began taking notes. When I went home and thought about it, it was only a dream. I guess the adrenaline was really flowing and I put my heart into writing the best I could. My teacher was so moved (s)he brought my paper to the attention of the principal. The principal called my future high school principal and the two of them planned my curriculum for my remaining years. Previously I was tracked for another school where I could learn something practical like carpentry. My family was not of the economic status to even consider advanced schooling such as college or medical school. The word spread in our small western Pennsylvania town and I received a lot of encouragement. I couldn't let them down.
As they say, "the rest is history." My family and friends made sacrifices and helped me in numerous ways to reach what had not ever been my goal before that term paper: Becoming a doctor. I knew the financial hardships my family went through. It was shortly after the "great" depression. My father worked on the Pennsylvania Railroad. My brother, an attorney, and I have been very fortunate and appreciative of being raised in this country by our caring parents. I hope I have not disappointed my family and my supporting friends.
Passwater: That's destiny! Thank you Dr. Conte for sharing your wisdom with us.
1. Increasing prevalence of overweight among US adults: the National Health and Nutrition Examination Surveys, 1960-1991 Kuczmarski, R. J., et al. J. Amer. Med. Assoc. 272:205-11 (1994)
2. Medical hazards of obesity Pi-Sunyer, F. X. Ann. Intern. Med. 119:655-60 (1993)
3. Chromium Picolinate: The Longevity Factor Passwater, Richard A. Keats Publ. Corp., New Canaan, CT., (1993)
4. Economic costs of obesity. Colditz, G. A. Amer. J. Clin. Nutr. 55:503S-507S (1992)
5. Hearing before the Subcommittee on Regulation, Business Opportunities and Energy of the U. S. House of Representatives Committee on Small Business. Testimony of Janet D. Steiger, Chairman, Federal Trade Commission (March 26, 1990).
6. The fattening of America. Pi-Sunyer, F. X. J. Amer. Med. Assoc. 272 (July 20, 1994)
7. A non-prescription alternative in weight reduction therapy. Conte, A. A. The Bariatrician (Summer 1993)
8. The Allendale Study. Conte, A. A. In: Citrin: A revolutionary, Herbal Approach to Weight Management, Rosen, R., et al., eds., New Editions Publ., Burlingame, CA. (1994)
9. The Hilton Head Study II: Citrin 75 Conte, A. A. In: Citrin: A Revolutionary, Herbal Approach to Weight Management, Rosen, R., et al., eds., New Editions Publ., Burlingame, CA. (1994)
10. The effects of (-) Hydroxycitrate and chromium (GTF) on obesity. Conte, A. A. Abstract 60, 35th Annual Meeting Amer. Coll. Nutr., Atlanta, (Oct 1994)
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