I practice in the heart of California- must-be-thin- land (to be exact in Westwood, which in realtor terms is adjacent to Beverly Hills) and find that the majority of my patients who are over 40 and are not Pilate’s instructors complain that they are losing their flat stomachs and thin waists. I sympathize with their (and my) inability to wear those jeans that, when successfully closed, rise one centimeter above the pubic hairline.  (I also strongly advise women who cannot breath or whose abdomen is pushed into an unsightly overhang once the jeans are fastened to abstain and give said jeans to a pre-pubertal adolescent.)

Is the pouch of middle-ish age (I no longer know how to define middle as I get older) due to hormonal changes, menopause, the absence of hormones or hormone therapy? Probably not.  Most studies show that there is a change in fat distribution as we get older. In women it goes from the hips and thighs to the abdomen and the breasts. Add to this the fact that our metabolic rate diminishes by 5 % every decade, we are destined to lose the flat stomachs and hourglass figures we had as young women. Let’s just consider that 5%: if your food intake consisted of 2000 calories, 5% of that is 100 calories. If you add 100 calories to what you burn off each day you get an excess of 3000 calories a month. It takes 3500 calories to “construct” one more pound on your body. So let’s see…. one pound gained every 6 weeks comes out to 9 pounds a year. Simple physics and math take control; if your caloric intake remains unchanged, you don’t exercise more and live for 2 more decades, say from 30 to 50…you could now be at least 18 pounds heavier! And if much of that extra weight went around your waist…you now have to go up 2 sizes because of your waistband requirements. And to make matters worse, way worse, you and your expanded waist may now be medically overweight or if you have added much more than those daily 100 calories, obese.

One of the most important issues that all health care professionals have to address is how to prevent and treat obesity.  Unfortunately my patients, like the rest of the nation are succumbing to the overweight and obesity epidemic that will leave 1 in 3 adults in this life-ruining category (think diabetes, hypertension, cardiovascular disease, cancer and shortened life).

Our shrinking ability to be svelte has helped create a huge weight loss industry and hundreds of published (or pictured before and after) devotees to a myriad of diets. Most promote low carbohydrates or low fat. Then there is hefty marketing of weight loss foods, programs and non-approved weight loss supplements. Reality shows and web marketing sites reap huge financial benefits from the quest to lose weight. So what works?

I always thought that a low fat, Mediterranean type of diet was best for weight maintenance and health…. you know, lots of fruits, vegetables, non fat milk products, fish, olive oil and whole grain bread  (and in my case no red meat). And of course at least 30 minutes of exercise a day. I have to admit that I have remained fairly thin adhering to this type of nutrition. I  also stop eating when I am full, have no qualms about leaving portions on my plate and when possible make 2 meals out of one. I also don’t crave sweets (chocolate is not a sweet!)

But let’s get back to those diets. A recent study published in The New England Journal of Medicine gave one of the best long-term views of what works. They followed  811 overweight adults assigned to 1 of 4 diets for 2 years. The diets were similar in low caloric intake but reduced the amount of energy derived from fat, protein and carbohydrates respectively. (If you are interested, the different diets contained 20%, 15% and 65% fat, protein and carbs ; 20%, 25% and 55% , the third type was 55%, 40%, 15% and finally 40%, 25% and 35%).  The participants were also offered group and individual session for 2 years.

After 6 months all the participants had lost an average of 6 kg (13 pounds), which was 7% of their initial weight. They began to regain the weight at 12 months. Of the 80% of those that completed the trial at 2 years the average weight loss was 4kg ( about 9 pounds). Close to 15% had lost 10% of their initial body weight. Here’s the extraordinary finding: The type of diet (low fat, low carb or low protein) didn’t make a difference to success! Satiety, hunger, satisfaction with the diet and attendance at group sessions were similar for all diets. It was the attendance at the group sessions that seemed to make a difference…as much as of 0.2 kg (half a pound) weight loss for each session attended. Also all the diets improved lipids (blood fats) and fasting insulin levels (which constitute a diabetes risk). The authors then concluded the “reduced-calorie diets (coupled with regular sessions) caused meaningful weight loss independent of the ratio of fat, carbohydrate and protein.

So to reduce your weight (and as the pounds come off a little of that abdominal pouch may follow) reduce your caloric intake. Weight Watchers or similar programs that have frequent counseling and motivation sessions will help. My advice to many of my patients is to put what they normally place on their plates…. take a knife and remove 1/3 to 1/2 for next day consumption (or if necessary throw it into the garbage), eat the rest and exercise. The latter should include pushing the chair back from the table. We may not get into our old jeans but we don’t want to get into an early grave!