Life Is A Struggle Against Bad Data

Over the past 6 months I’ve been asked a lot of “how did you do it?” and “what’s your secret?” type questions. These questions provoke a mixture of self consciousness, anxiety, and flattery in my brain, and I’ve generally been hesitant to answer for several reasons. The process of consistent habit change has several interconnected parts and for it to make sense I feel like you need to understand and see a lot of detail; consequently the answer gets long and feels complicated and I never really know how long of a conversation someone who asks these questions is looking to have. Also, as someone who has spent the majority of my life visibly overweight and been mocked for it as a kid I’m a little sensitive about discussing my body and habits. I figure it’s time to get over both of these concerns and write about my experience, thoughts, and plans.

For anyone looking for short answers that are also the truth.

The one word answer is: Noom. 

I downloaded the app for a variety of reasons (primarily because apparently I AM the target demo for NPR underwriters) and it clicked with where I was at the moment and has become a useful tool that fits with my own knowledge, beliefs, and style. It’s not magic, and I’m sure it’s not for everyone, but it works well for me. It offers a blend of data, coaching, and tracking that are convenient and easy to use.

The one sentence answer is: I eat food, not food-like substances, not too much, and mostly plants.

With the input from the Noom app and the ideas contained in James Clear’s Atomic Habits I’ve begun discovering ways of practicing the simple concepts laid out in Micahel Pollan’s In Defense of Food and David Kessler’s The End of Overeating.

The truth is I got lucky. I have accrued a bit of useful knowledge over the years and when the motivation hit I was able, with the aid of several tools, to bring the strands of motivation, efficacy, and knowledge together to conscientiously change a number of habits that aligned with my goals. 

The much longer version goes like this

How I got started

One day in March I stumbled upon a genuine reason to make changes in my lifestyle. If I ever get discouraged or wonder why I’m doing this I have a fall-back that offers a compelling reason to keep going. I’ve always thought of myself as a relatively fit and active person who happens to be very overweight. I bicycle, I hike and backpack, I climb mountains, I ski. Historically speaking being overweight has rarely prevented me from pursuing these activities I love. I have a good job, a wonderful family, and fulfilling relationships. Like most overweight people I felt angst about my body, and some chronic low level guilt and stress about the habits that created and perpetuated the situation, but by most accounts my weight was a fact of life, but didn’t have a significant negative impact on my quality of life. 

One of my favorite things about my life is that I live in a wonderful place where I can ski and mountain bike or play sand volleyball on the same day. No joke, I did this just last week. I am lucky to know other people who enjoy doing these activities with me. This year has strained the ability to engage in some of these activities collectively, but hasn’t completely ruined them. Sometimes I go out on my own to wander the deserts, canyons, and mountains near my home, but I am very lucky to almost always have a partner in crime when I want one. My wife is usually game, but she has her own interests and friends and isn’t always keen on dropping everything and heading up the mountain, but I have an ace up my sleeve. My dad. My dad is retired, lives about 5 miles from my house, and loves all these same activities, and can almost always be counted on to sign on for a trip just about anywhere I can throw at him. He’s nearly 70, and despite having a permanently broken left ankle keeps pace and passes me regularly on the trail. He still gets more hoots and whistles from on-lookers on the lift chairs while skiing than I do. It’s genuinely embarrassing to be me sometimes. However, some days he’s not up for skiing until they kick him off the lifts. Every once in awhile He’ll tap out at 3:45 instead of 4:00, and I enjoy a bit of pride at saying “I’ll just hit this one last run and meet you at the car”. A shallow victory indeed, but occasionally it was one way I could somehow be slightly better than the old man. Then in March near the end of a wonderful day with excellent snow my knees were bothering me and I said “I think I’ve had enough, I’ll head out after this run”. My dad was gracious and said he was ready to call it a day too, so we headed home. That night, reflecting on the day I realized this was an unacceptable trend. I am so very lucky to be able to hangout and do lots of fun things with my dad, and I hope to someday do the same with my kids, and the somewhat inevitable long-term consequences of obesity I know as a doctor came into sharp relief. Something needed to change. I wasn’t going to give up my favorite joint pounding hobbies. The laws of physics and health aren’t going to change. I had to change the only thing that I was willing to change: my weight. And so it began.

  I think this is important. I’ve been mocked both subtly and not so subtly about my weight, and like most humans, I don’t enjoy that sort of emotional pain. I’m also a doctor who has seen, up close and in a professional capacity, the long-term consequences of obesity. I also like to do physically demanding things. So there should never have been a lack of motivation, and yet for a long time if you discount the chronic angst I felt I have never been what I’d describe as highly motivated to lose weight or been “on a diet”. I’ve lost weight as a consequence of having more time to engage in my favorite activities, or as a result of other circumstances, but I’ve never really taken an aggressive, mindful, comprehensive look at my weight, nutrition, health, and eating habits with an eye to long-term change.  A key component for me is that I am not running away from something (shame, fear, lost opportunity), but moving toward something I very much want and enjoy both now and in the future. I want to bike and ski 30 years from now, but I also really enjoy doing those things now, so it’s a powerful, renewable motivator. I have no advice about how to identify that sort of motivating factor. Mine came without method and feels entirely circumstantial and serendipitous.

What I eat 

In order to lose weight you have to eat fewer calories than your body uses. There is no other way to do it. Increasing activity can increase caloric expenditure, but to achieve any real progress you must also reduce caloric intake consistently for a long time. I honestly feel like I’m the poster boy for the fact you can bicycle 100 miles per week and not really lose weight in the long term without dietary changes. Simply eating less of what I was already eating seemed doomed to failure. I don’t intentionally overeat, so the idea of reducing caloric intake consistently and permanently while eating the same food didn’t make sense. 

I had to find a way of eating that simultaneously met a few requirements.

1. Enjoyable – There’s no point in eating food you don’t enjoy – this means certain flavors and textures had to be present. Limiting intake of certain foods was an obvious necessity, but it couldn’t involve completely eliminating my favorite things like tacos, pizza, lasagna, and burgers. It also couldn’t be filled with exotic flavors, or all new textures (I’ve always been a picky eater)
2. Sustainable – I wish I were a good enough person to mean friendly to the planet (I hope to get there), but I mean it had to be something that I could actually do in the long-term. No purchasing special meals or kits. I can’t have to constantly make special requests or arrange for accommodations while traveling or moving beyond an environment I have substantial control over.
3. Family/ relationship friendly – My wife has an excellent relationship with food, and her body, and is an excellent cook of a variety of foods. I couldn’t force the entire household to give up certain meals or foods just to meet my plans. 
4. Not constantly hungry / not demanding superhuman self-control – I feel like I have an average capacity for self-control and ability to delay gratification, and while I was expecting to need to flex and further develop those skills on this journey I didn’t want to feel like I was constantly in a state of self-denial. Chronic self-denial felt like a sure fire way to quickly get to a breaking point and failure.

Surprisingly, meeting these requirements was easier than it sounds. About 12 years ago I read David Kessler’s The End of Overeating, and then about 10 years ago I read Michael Pollan’s In Defense of Food. In Defense of Food is a short book written in response to him being asked, “what should I eat?” while presenting his previous work The Omnivore’s Dilemma which I read about 15 years ago. I note how long ago I read these works to let you know these ideas have been percolating and marinating in my brain for a long time. Michael Pollan points out, and I don’t think anyone should underestimate the insanity of this situation, that he was being asked by adult humans in the 21st century what they should eat. There are over 7 BILLION humans on Earth. We dominate the planet. We have plumbed the depths of existence. We have gone to the moon, and unleashed terrible destructive forces, but for some reason adult members of our species don’t know what they should eat? Such a situation would spell doom for any other species. Surely, something has gone terribly wrong. He presents a bit of history, and factual information, and editorializes to a fair degree, but the takeaways make sense, and help a person see through much of the confusing claims we are bombarded with about food, human health, and nutrition.

Human bodies and societies have thrived under a wide variety of conditions with a broad array of diets. There appears to be a glaring exception in the modern world, the diet rich foods processed to maximally appeal to human taste buds the western world, embraced most fully in the US, adopted over the past 70 years. He makes what I find to be a compelling case that we have overestimated our ability to quantify the value of food and its role in human life and health. Consequently we have drawn incorrect conclusions from data of questionable value and this hubris combined with the profits available to those able to sell food-like substances using claims based on these conclusions has resulted in some very undesirable, some might say disastrous, consequences. 

His prescription is simple: Eat food, not too much, and mostly plants. He has several rules defining food, but it often boils down to the concept of: if your great grandmother wouldn’t recognize it, it might not be food. Basically do what, hopefully, some matron in your life always told you: Eat your vegetables. 

I’ve always been a picky eater, and for reasons of flavor, texture, and obstinance I have generally been very bad at doing this. Over the last 9 months with a little creativity, trial and error, and persistence I have become better at it, and now find that I very much enjoy fruits and vegetables more than I have historically. All tastes are acquired tastes. Some are easier to acquire than others. I typically eat 5-6 servings of vegetables, and 5-6 servings of fruit most days. I eat a lot of leafy greens, carrots, broccoli, apples, bananas, peaches, oranges and grapes with a smattering of squash, green beans, cauliflower, and radishes, and I found I actually enjoy it.

There is a concept Pollan hits on briefly in his book that I overlooked 10 years ago, but that the Noom app hits very early on. Caloric density. While human health is very complicated and whether or not there is an “ideal” balance of vitamins, minerals, other micronutrients, and lipid or carbohydrate types is hotly debated and constantly changing, there are some immutable laws, and a bit of fairly well understood human physiology at play. The energy stored in a food is not mysterious, it is quantifiable, and dictated by fundamental laws of matter. The major sources of energy in the human diet comes from carbohydrates (sugars and starches), lipids (fats), and proteins, the famous “macros”. There’s a lot of debate about which ones are “good for you” and if there’s an ideal ratio of these 3. I am of the opinion that such discussions and debates are kind of silly and irrelevant. Hopefully the rationale for my opinion will become obvious as I work through this. I mention them now because there are established facts about them that have bearing on hunger, satiety, and therefore weight loss. 

Before I move forward there is one more macromolecular component often left out of these discussions and that is cellulose (no not the fat on the legs and abdomen infamously feared in the 1990s), but the long strands of carbohydrates used to provide physical strength and structure in plants (they don’t have bony skeletons). We know cellulose by another name and that is fiber. Interestingly the human digestive tract doesn’t have the ability to break down these carbohydrates into usable fuel so even though there is plenty of chemical energy stored in fiber it generally passes right through us. There is some discussion of fibers being fermented by bacteria with the byproducts translating into human energy so there may be some caloric value, but it is generally low. Finally, there is the complex interplay of physical displacement, and neuro-hormonal regulation between gut and brain that regulate hunger and satiety. I’m not going to pretend to fully understand all the complex relationships between ghrelin, leptin, cck, insulin, and all the other regulators of human feeding, but basically you need a certain amount of calories and bulk volume to shift the balance from hungry to satisfied. That balance I’m sure is a little different for us all, and can likely be shifted and manipulated in a number of ways, but the bottom line is you need a certain amount of food, and energy, and that the ratio of macros eaten does have some obvious consequences for weight loss here.

Food type	Caloric Density	Ability to induce satiety
Carbohydrate	~4 Cal/gram	lower
Fat	~9 Cal/gram	lower
Protein	~4 Cal/gram	higher
Fiber	~0 Cal/gram	lower

I used vague terms of higher and lower to describe “ability to induce satiety” because these are to a certain degree subjective, and I don’t think a real numerical “ranking” would reflect any real high quality data or knowledge.

If you think about this information you start to see why basically any diet that “works” achieves its results. “Low carb” diets like keto, paleo, Atkins etc. keep caloric intake down by shifting towards foods that result in higher satiety. You feel full and hopefully eat fewer calories and therefore lose weight. There’s no magical metabolic switch induced by the diet itself, your body naturally burns fat to supply the extra calories needed to run your body and when the body burns fat it transports the energy via ketones and thus the highly prized “ketosis” arises as a simple fact of the situation not because you’ve eaten fat (the body can assemble glucose and glycogen from fat when needed). It isn’t magic, its basic biochemistry.  Vegan and vegetarian diets remove a lot of fats by eliminating animal products and the fats, carbs, and proteins eaten often come along with a generous fiber component. Fewer calories consumed makes it easier to run a caloric deficit and weight loss occurs. Again it’s not rocket science. It’s biochemistry. 

You can also see how and why it would be easy to eat too many calories: eat foods high in carbohydrates and fat and low in fiber and protein (sugary beverages, candy anyone?) and you could eat too many calories without feeling “full”. These attributes: high sugar, high fat, high caloric density, and low fiber make a food very tasty and palatable, and appealing. The mammalian brain is evolved to love these things. Historically they were scarce in the environment and so it made sense to eat them aggressively when available. Smart humans have figured out how to manufacture them plentifully, and put them into inexpensive food-like products. We haven’t yet mastered the art of making actual plants into high fat, high sugar, low fiber products. My first year of medical school a lecturer said “the cause of obesity is obvious: there’s too many delicious foods, too widely available to pass up”. The solution is also obvious, but not simple: re-arrange your personal environment and habits to make it easy to enjoy low caloric density foods and there’s a better chance you eat fewer calories.

There’s an added bonus here. Fiber is fibrous (shocking right?). It demands that you chew. Chewing takes time. Neurohormonal signaling is slower than pure neurologic impulse transmission. Translation: there is a lag between your stomach being full and your brain realizing it. If you’ve ever eaten until you felt full, and then felt “stuffed” or overly full 30 minutes later you have experienced this reality. I am convinced the problem we face as Americans encountering all the splendidly delicious foods at our disposal is that many of the most palatable/tasty foods that satisfy mammalian craving for previously difficult to obtain fat and salt is that we can quickly consume 1000 Calories in minutes without trying too hard and before our body has a chance to register “full” because we don’t have to chew very much because so many tasty foods are high in sugars and fats and low on fiber. Furthermore we’re capable of feeling hungry again shortly after because the volume of food was actually low, due to the high caloric density of the food. Historically humans faced the problem of caloric scarcity so there was little to no chance of consistently surpassing needed calories before these signals worked. That is not true anymore. Gorillas spend something like 14 hrs per day foraging for the calories they need. Why? Their diet is not calorically dense and very high in fiber. Humans can consume 2000 Calories sitting in a padded booth in minutes during a single meal handed to them by a waiter. No matter what your stance on organic evolution is it seems clear 21st century humans face very different challenges compared to most animals on planet Earth in terms of obtaining the energy needed to live.

Food manufacturers (Think about those two words being in close proximity for a moment) have realized this and tried putting fiber or other indigestible polysaccharides into food-like products to reduce caloric density (Fiber One bars anyone?), but that either destroys the palatability that made the foods desirable and hurts sales, or leads to osmotic retention of water in the stool, or fermentation in the lower GI tract both of which lead to undesirable consequences (ever read Amazon reviews of sugar free gummies?).

This brings me back to my requirements. Throughout human history people all over the world found a wide variety of ways of balancing the demands of calories to sustain life with foods that were easily available in their environment, that lead to many delicious culinary creations that we still enjoy. I am trying to do the same. It turns out you can get away with eating a lot of fruits and vegetables without consuming all that many calories and still enjoy tacos, pizza, and burgers in moderation. Food is good for you and you should eat it. Cut out things that aren’t actually food and there’s lots of variety to enjoy. 

 I attribute my success to the fact that by replacing high fat, high carbohydrate, high caloric density foods with lots of fresh fruits and vegetables I feel full and eat fewer calories. Overall the volume of food I eat is the same or greater so the mechanical expansion of my stomach occurs, and I still get plenty of protein, fat, and carbohydrates from things like sandwiches, chicken, steak, fish, lasagna,and tacos, but because I have also eaten a lot of leafy greens, carrots, broccoli, grapes etc. I eat less of the more calorically dense foods, and the net effect is that I eat foods I enjoy, while also consuming fewer calories, and I’m not starving. I eat food, not food like-substances, not too much, and mostly plants.

While there are start-up costs in terms of redesigning your habits and environment, and buying fresh foods is a bit more time and dollar consuming than buying some other types of foods, after a few weeks I found it actually ended up being cheaper, and easier than how I was living. As I’ve said before I have acquired a “taste” for a broader variety of fresh fruits and vegetables than I ever have before while not entirely eliminating foods I really like. Enjoyable = win. With a bit of meal planning in the week especially focused on breakfast and lunch where historically I’ve been on my own, and not benefited from Stacy’s efforts in the kitchen I am able to acquire the necessary foods to sustain these changes without having to order kits, or boxes at a big mark-up. Sustainable = win. Because I am not “on a diet” and I am striving to make lifelong, sustainable changes, where the events of a single day aren’t throwing-off some questionably invoked, tenuously achieved biochemical state I feel like I can eat just about anything for a given meal so I don’t have to assert some “dietary veto” while visiting friends or family, or in family meal planning. Relationship friendly = win. Because I am generally eating a higher volume of lower caloric density foods I eat plenty of foods I enjoy, and this allows me to not feel like I’m constantly in a state of self-deprivation so I don’t feel like I’ve somehow “willed myself” to constantly stay “good” for 9 months. I crave and then enjoy grapes, apples, peaches, and even the aroma and taste of hot oatmeal and raw broccoli. I feel like I am harnessing my knowledge and skills to change my habits and create a sustainable approach to living and eating that has yielded good results that doesn’t need to change significantly once I reach my target weight. Non self-denial = win. Win, win, win, win. Michael Scott approved. 

How I actually do it  

We all know that a person can know the facts of a situation, and still lack the ability to navigate the situation successfully. Assessing your own behavior, motivations, emotions, and habits is notoriously difficult, and not something I feel like I have anything approaching expertise in discussing. I do know a few things: our lives are ruled by habits. We may not want to believe or accept it, but in my experience this is true to an impressive degree. Archimedes once said something like “I can lift the world with a large enough lever”. While impractical the concept is true. Humans really like the story of sudden and miraculous transformation. While photos taken months apart may give this impression I don’t feel like what has happened this year is like displacing my world with a giant lever. I’ve found my journey to be far more like turning a tightly threaded bolt. My favorite way of dealing with tightly threaded bolts is a ratcheting socket wrench. The wrench provides leverage to amplify my strength and turn the bolt with less effort. The socket provides a snug fit so I don’t constantly have to reposition the wrench and I spend less mental effort on getting and keeping it in position. The ratchet allows me to perform the action required to turn the bolt, repetitively in the area of highest strength, comfort, and speed. It’s an engine for harnessing my strengths while simultaneously offsetting my weaknesses and impediments. Technically it’s not as efficient compared to the imaginary situation where I have tough, dextrous, strong-as-hell fingers that could just grasp and turn the bolt, but it works, and is an incredibly popular tool for many of these reasons. I feel good, intentionally constructed habits are like a socket wrench. There’s a conscious decision to use the tool, a bit of fiddling up front to get the positioning and sizing locked in, but once started the repetitive motion maximizes comfort, amplifies applied effort, and minimizes cognitive load. 

Stepping back a bit I realized early on that over many years I had developed lots of habits, very few of which were consciously chosen by me, and my eating habits created the body I had. The idea of temporarily adopting a “diet” to lose weight without addressing the systems and habits that got me to where I was seemed like a fool’s errand. I may be light-hearted on the outside, but I am no fool, I am prideful, I love to win, and I hate failure. It may come off as a bit snippy, but whenever people ask me “what diet are you doing?” I answer “I’m not on a diet, because diets don’t work, I’m consciously undertaking several lifestyle modifications”. If you don’t like your outcomes you need to examine your systems, and systems are built on habits. I knew all this, but hadn’t ever taken the time to think about how a person consciously chooses or changes habits. I downloaded James Clear’s Atomic Habits sometime last year, but didn’t bother to give it a listen until May of this year. In some ways the insight and advice he offers are super obvious, but that’s just how life is sometimes. To be honest I am still working on this business of habit building, but I have found the awareness of my own habits has helped me make some very important changes.

A few habits I’ve adopted that make up my systems

A mentor from my years in Residency, Fran Johnson, told me several times “Life is a struggle against bad data” she was speaking in the context of caring for the chronically and critically ill, but her words are true in many other situations. I collect data to measure progress and capture feedback, but more than that the act of measurement keeps my mind focused on the system inputs.

I weigh myself every morning – sometimes it’s higher, sometimes it’s lower, but no matter what I ate the previous day, no matter if I think it’s going to be “good” or “bad” news I step on the scale and record the number.

I record what I eat – Everything. Generally within minutes of eating. It is really difficult to honestly record everything you eat and also consistently eat far too much. Today’s calorie tracking tools make it easy and also provide instant feedback about the relationship between foods consumed, calories eaten, how your body feels, hunger, and satiety. I am looking for an app that allows me to create my own surveys on these subjects and collect that data. If anyone knows of one I’d be much obliged.

I record my activity – I am a firm believer one cannot exercise one’s way out of obesity. It may be immodest to say again, but I feel like I’m the poster child for the fact you can cycle 100 miles per week, or mountain bike 20 miles every weekend, or swim 1 mile daily and still be obese. I won’t delve into the different definitions of overweight, the limitations of BMI, metabolic health etc. but I have done all those things for extended periods of time and never changed weight significantly or in a sustained way. However, recording activity gives a bit of insight into activity levels in the long run, and there’s some name for the concept that when you measure a thing it moves in the direction you want it to go in. I won’t look it up, but it’s well documented.

A few other habits

I plan my meals – The thing about fresh fruits and vegetables is that they spoil, so you have to consciously eat them when available, and buy them constantly. This is expensive, but my budget shows that it’s cheaper than eating outside the home with any regularity (which I was doing before this whole business started). I have to plan around what we have or get what I need. Without a plan it is easy to fall back into old habits. Thankfully new habits are forming and becoming defaults, but one doesn’t undo 35 years of bad habits in a few weeks or months.

I eat with intention – I strive to differentiate true hunger from boredom, cravings, and stress responses. I ask myself, “are you actually hungry or are you feeling something and your historic response to this stimulus is to interpret it as hunger?” Food can be comforting, and that’s fine, but I’m trying to be aware of when and why this is occurring and I’m trying to use alternative coping mechanisms instead of food.

I eat slower – I try to enjoy what I eat more than I once did. Sometimes I consciously enjoy a flavor. Sometimes I count how many times I chew. Sometimes I even put my fork down and see what I’m feeling in the middle of a meal. It’s part of eating with intention, but by slowing down it allows for this sort of conscious reflection and enjoyment while also allowing the aforementioned neurohormonal signaling mechanisms to work.

I exercise regularly –  When the weather is nice I ride my mountain bike ~5 miles per day, or swim a mile in the morning. With the onset of winter I’ve turned to a combination of walking/running about 4 miles. I do a bit more on the weekends, but nothing impressive or extreme. I have a strength training regimen that takes about an hour that I do 2x/week. This simple, not very aggressive combination has yielded some impressive results in terms of capabilities, and noticeable physical changes.

I try to get good sleep – again, nothing extravagant. I shoot for a solid 7 hrs nightly, and sleep in a bit more on weekends.

I hope that one day I can set aside such rigorous data collection, and get to the point where these practices are second nature and become the “ruts” my wheels fall-back into whenever disruptions occur. The truth is I’m not yet at the weight I want to be, and I suspect there will be months and years of slowly backing off the conscious efforts, but as of now I think the motivation, approach, and practices I’ve enjoyed in the past 9 months are healthy on multiple levels, make sense, and the results are difficult to argue with at this point.

I could go on and on, but that’s how I’ve done, am doing, and hope to continue to “do it”. No secrets. No gimmicks. A few insights into biology, the modern world, and the human mind coupled with what I feel is a healthy motivating factor. If you have questions, concerns, or thoughts I’d be happy to connect and discuss, but I think I’ve created and stood on this soap box long enough.