There comes a point in a long struggle with weight when the hardest part may no longer be hunger. It is the disappointment… You decide you are going to do better. You stop buying certain foods, start reading labels, order the salad when everyone else orders something you actually wanted, and perhaps replace lunch with a bowl of cottage cheese because it is high in protein and seems like the responsible thing to do. You get through the week feeling as though you have finally made some meaningful changes.
Then you step on the scale and see almost nothing. Maybe you lose a pound. Maybe the number does not move at all. Worse, perhaps it goes up.
That experience becomes very different when it happens once or twice compared with when it has been happening for years. After enough attempts, people can begin to interpret every unsuccessful diet as evidence about themselves. They assume they lacked discipline, did not want it badly enough, or somehow failed at something everyone else seems to understand.
Weight loss is certainly influenced by what and how much we eat, but the biology behind obesity and weight regulation is considerably more complicated than the old instruction to “eat less and move more.” Sleep, activity, medications, age, muscle mass, food environment, genetics and metabolic health can all affect the process.
For some people, insulin resistance is a particularly important part of that picture.
Insulin Resistance Can Exist Before Diabetes
Insulin helps the body manage glucose by signaling cells in muscle, fat and the liver to respond appropriately to the energy coming in. With insulin resistance, those cells do not respond to insulin as effectively as they should. The pancreas compensates by producing more insulin, sometimes successfully enough that blood glucose can remain outside the diabetic range for a considerable period of time.
That distinction matters because a person does not have to have diabetes to have insulin resistance. The National Institute of Diabetes and Digestive and Kidney Diseases recognizes insulin resistance and prediabetes as metabolic conditions that can precede type 2 diabetes, and excess body weight is closely associated with both. (NIDDK)
This is where seemingly sensible weight-loss advice can become frustrating.
Replacing a sandwich with cottage cheese may reduce calories or carbohydrate, depending on what was being eaten before. It may even be a very good choice. But if someone has substantial excess weight, significant insulin resistance, poor sleep, very little physical activity, years of dieting history and an overall eating pattern that continues to work against metabolic improvement, changing one lunch is unlikely to transform the situation.
The cottage cheese did not fail… The expectation placed on that one bowl was simply unrealistic.
“I’m Eating Better, So Why Isn’t This Working?”
This may be one of the most discouraging questions people ask themselves.
They really are eating better. The fast food is less frequent. Sugary drinks are gone. Portions may be smaller. There is more protein, fewer desserts and considerably more thought going into every meal than there used to be.
Yet weight loss can remain stubbornly slow.
A person with insulin resistance may also be dealing with higher circulating insulin levels as the pancreas works harder to maintain glucose control. At the same time, appetite, food availability, total energy intake, activity and individual metabolic responses continue to influence whether stored body fat is ultimately lost.
That is why I do not think it is helpful to reduce the entire discussion to one hormone or one food. Insulin matters. Calories matter. Food quality matters. Sleep and movement matter. The important question is how those pieces interact in the person who is actually trying to lose the weight.
Even modest weight loss can produce meaningful benefits. In people at high risk of developing type 2 diabetes, the landmark Diabetes Prevention Program found that losing approximately 5% to 7% of starting body weight together with increased physical activity substantially reduced progression to diabetes. (NIDDK)
Five percent may sound modest on paper. For someone who has been fighting for every pound, it may represent months of work.
That effort deserves more respect than another lecture about willpower.
Where a Ketogenic Diet May Fit
A ketogenic diet is one possible nutritional strategy for someone with obesity, prediabetes or insulin resistance, although it is not the only one and it is not appropriate for everyone.
The basic idea is straightforward. Carbohydrate intake is reduced enough that the body increases production of ketones and shifts more heavily toward fat-derived fuel. Because carbohydrate intake is substantially lower, the glucose and insulin demand associated with those foods is also reduced.
Research continues to examine how much of the benefit comes from carbohydrate restriction itself, ketosis, weight loss, reduced calorie intake or a combination of those factors. Recent clinical research in adults with obesity and prediabetes has shown that calorie-restricted ketogenic diets can reduce body weight, fasting insulin and HOMA-IR, a commonly used measure associated with insulin resistance. (PubMed)
That does not make keto a metabolic loophole.
If somebody consumes more energy than their body requires indefinitely, being in ketosis does not make the laws of physiology disappear. Nor does a ketogenic diet automatically outperform every other well-constructed approach over the long term.
What it can do for some people is dramatically change the structure of the diet. Bread, pasta, sweets, many snack foods and other major carbohydrate sources are sharply reduced. Protein and fat become more prominent, and some people find that their appetite and cravings become easier to manage as a result.
Other people find the diet restrictive, socially difficult or simply unpleasant.
That is useful information too… A nutritional plan has to survive contact with real life.
The best diet is not the one that sounds most impressive when somebody explains the science. It is the one that improves the person’s health and can still be followed after the excitement of starting it has worn off.
What the Ketone Pee Stick Can — and Cannot — Tell You
Urine ketone strips have one significant advantage: they are cheap, simple and immediate.
For somebody new to carbohydrate restriction, seeing the strip change color can be encouraging because it provides evidence that ketones are being produced and excreted. There is something psychologically useful about having feedback that does not come from the bathroom scale.
But a urine strip should not become another object of obsession.
Urine strips primarily detect acetoacetate being excreted through the urine. They do not directly measure beta-hydroxybutyrate, the predominant circulating ketone that is usually measured when more precise information about ketosis is wanted. Research comparing urine strips with blood measurements has found that urine testing can miss mild nutritional ketosis, particularly at the levels commonly encountered in dietary ketosis. (PubMed)
So I see urine strips as a potentially useful feedback tool, especially early in a ketogenic eating plan, rather than a scorecard.
A darker strip does not mean somebody had a better day. A lighter strip does not prove the diet failed. Hydration, timing and the body’s changing use of ketones can all influence what appears in urine.
If accurate measurement of ketosis is actually important, blood beta-hydroxybutyrate testing provides better information.
There is also an important safety distinction here. Nutritional ketosis in a person without diabetes is not the same thing as diabetic ketoacidosis, which is a dangerous medical condition most commonly associated with diabetes. Anyone with diabetes, significant kidney or liver disease, pregnancy, certain medications or other substantial medical concerns should discuss major carbohydrate restriction with the appropriate healthcare professional rather than treating a ketogenic diet as a do-it-yourself experiment.
The Part Nobody Sees
Weight loss has a public side and a very private one. The public part is obvious. Clothes fit differently. People comment. Someone asks what diet you are on. Friends notice when you order differently at dinner.
The private side is what happens at 7:00 in the morning when you are standing on the scale before anyone else is awake.
It is deciding whether you are allowed to feel good about yesterday based on the number that appears beneath your feet. It is trying not to compare yourself with somebody who claims they lost 20 pounds simply by giving up soda. It is wondering whether everyone at the restaurant notices what the overweight person ordered, even though almost certainly nobody is paying as much attention as you imagine.
Repeated dieting can turn ordinary food decisions into moral judgments remarkably quickly.
A piece of cake becomes evidence of weakness. A good week becomes evidence of discipline. Weight goes down and you were “good.” It goes up and somehow you were “bad.”
Food was never supposed to have that much authority over a person’s opinion of themselves. Neither was a bathroom scale. It’s just a tool. It doesn’t determine who you are as a person.
And Then Comes the Advice
People struggling with their weight receive an astonishing amount of unsolicited expertise.
- Have you tried walking?
- Have you tried cutting out bread?
- Have you considered eating smaller portions?
- And my all time favorite – Maybe you just need more discipline.
After years of trying, those comments stop sounding helpful because the person hearing them has often already tried all of it. Sometimes repeatedly.
There may have been periods when the weight came off, followed by periods when it returned. Life changed. Work became more demanding. An injury reduced activity. Sleep deteriorated. Stress increased. Family habits changed. Medications entered the picture. Menopause, aging or other physiological changes altered what had previously worked.
Insulin resistance started developing somewhere along the way as well. When all of those pieces are compressed into “you just need to eat less,” the person can understandably conclude that nobody is actually listening. It is a fact that once you get to a certain level of Insulin Resistance, this is the answer to those unsolicated inquiries…
- Have you tried walking? No, because my blood sugar drops, and I get tired and sleepy before the beneficial effects of walking kick in.
- Have you tried cutting out bread? I can cut out every morsel of food possible, but two minutes later, my brain signals that I’m so hungry I want to rip your face off just to get some food in me.
- Have you considered eating smaller portions? Refer to the above.
- Maybe you just need more discipline. – I am exercizing all levels of discipline not kick you in the shins right now.
You Didn’t Get Fat Alone. Why Should You Be Expected to Succeed Alone?
I know the word fat makes some people uncomfortable.
Sometimes we have become so careful about discussing weight that the conversation becomes almost meaningless. Obesity is a medical issue, but it is also something people experience every day in mirrors, photographs, airplane seats, clothing stores, restaurants and doctor’s offices.
So I want to make this point plainly.
You didn’t get fat alone… You didn’t get fat in one month… However, that does not mean somebody else is responsible for your weight. It means weight develops inside a life, and nobody lives one of those alone. It means you’re not gonna lose all the weight in one month either.
Your family helped establish how you ate before you were old enough to understand nutrition. Food manufacturers influenced what was convenient and affordable. Work determined how many hours you sat. Friends and family were part of birthdays, vacations, restaurants and holidays. Injuries may have changed how much you could move. Stress changed your appetite. Sleep changed your hunger. Biology contributed its own rules.
Perhaps insulin resistance eventually became part of the equation too.
Given all of that… why are people expected to solve the entire problem privately, armed with a bathroom scale and another promise that Monday will be different?
They should not be.
There Is a Difference Between Help and Judgment
Dr. John DeMaio has a background in clinical nutrition in addition to his work as a chiropractor, and nutrition discussions at DeMaio Family Chiropractic & Physical Therapy are not intended to replace the role of a patient’s physician, endocrinologist or other appropriate healthcare provider.
They can, however, be part of a broader conversation about health.
That may include looking more carefully at eating habits, discussing carbohydrate intake, understanding insulin resistance, deciding whether a particular nutritional strategy is realistic, addressing movement limitations that make exercise difficult, or recognizing when laboratory testing and medical management need to become part of the discussion.
Sometimes the most useful thing a healthcare professional can do is stop assuming that the person sitting across from them has never heard of vegetables.
Most people who have struggled with obesity for years know quite a bit about dieting.
What they may not have is a plan that actually fits their metabolism, health, daily life and history… along with someone willing to help them adjust that plan when real life inevitably gets in the way.
You Are Not Alone… and You Should Not Be
There is no shame in needing help with weight loss.
There should also be no expectation that a person battling significant obesity or insulin resistance has to prove something by doing it alone.
Some people may respond well to a ketogenic approach. Others may do better with a less restrictive lower-carbohydrate plan, a Mediterranean-style diet, structured calorie reduction or another evidence-based strategy. Some may need medical treatment in addition to lifestyle changes. The right answer depends on the individual, and it may change as that person’s health changes.
What should not change is the understanding that repeated difficulty losing weight does not automatically mean repeated failure of character.
If you have been losing the same weight, regaining it and starting over for years, perhaps the next attempt should involve more than another diet.
Understand what your body is dealing with.
Get appropriate medical information.
Build a strategy you can actually live with.
And have somebody in your corner.
Because you are not alone in this challenge… and you should not be alone while trying to overcome it.
With care,
Dr. John DeMaio, D.C., CNS
A Chiropractor in Bowie & Gambrills, Maryland
For appointments, call or text my office at:
Gambrills – (410) 721-2222
Bowie – (301) 262-4545
