I recently gave a lecture on weight control to a group of family practice residents. I began the early morning talk by telling them how much my patients hated doctors and had been hurt by them. We didn’t even need coffee to wake up these young doctors after that comment. They were angry and shocked. A few were not surprised, and felt it was a necessary evil that resulted from doing their job. They argued that it was their required role to instruct the patient about their health, and that nobody liked being told that they were fat. These residents felt it was their duty to identify health problems and prescribe medication and counsel lifestyle changes.

I chuckled inside because they had fallen into the common trap that ensnared many health professionals who work with weight control. Without realizing it, they had assumed that the patient’s lifestyle was the problem, and had automatically initiated treatment because the person was overweight. I quickly pointed out that they had been guilty of recommending treatment without proper diagnosis. They had assumed that the patient’s lifestyle was the problem without truly knowing what the person ate. They had also ignored that fact that differences in energy expenditure may explain the problem, and had not even included that option in their thinking. Eager to learn, the residents started to ask questions about how energy expenditure is measured, how costly is it to the patient, all the usual questions that a physician might want to ask. I described the two methods of measuring energy expenditure. The most accurate is an evaluation using gas exchange technology with a metabolic cart. It is the auto emission test for the human engine. Similar to analyzing the gases in a car’s exhaust, the oxygen and carbon dioxide content of human breath is measured at rest. The patient merely breathes into a snorkel for 15-20′ and their breathing is analyzed. I said that this method is the most accurate but costs $150-$200. A second method to measure energy expenditure is by determining the person’s weight changes in response to following a fixed calorie level diet. This method was outlined in my book, THE BURN RATE DIET. While not nearly as accurate as gas exchange, it is low cost and provides a reasonable estimate. I mentioned that the problem is that it takes several weeks and is susceptible to fluid changes that mask the true loss of body fat and alter the validity of the scale readings.

The discussion quickly turned to answering questions about how this information is used to diagnose and treat weight control. I explained that the energy expenditure allows me to compare the patient’s results to other people their same age and sex. This comparison would determine if their metabolism is normal at this body weight. If it is in the normal range, then it would mean that regular eating, not overeating, would create the current weight. Overeating would then not be the explanation for their weight problem since their current weight would be their natural weight, the weight you weigh if you eat like the average person.

The second significant outcome would be that it would allow me to predict the drop in energy requirements that would accompany any weight loss. The person’s ideal or goal weight would be selected based on the level of calorie restriction that the person could tolerate. It would define the degree of weight change that could reasonably be expected from the patient and avoid imposing arbitrary and restrictive weight goals that would be a prescription for failure.

Thirdly, I can use the predicted energy requirements at this reasonable goal weight to construct a nutritional plan that is the ideal for the patient to follow for optimum appetite control. Their body burn rate could be matched to the burn rates of food over the time intervals between meals. The resulting appetite control would be essential to enable the patient to live on the least amount of calories to achieve the lowest possible weight.

At the completion of this lively exchange, the Director of Family Practice Residency Program at Frankford Hospital, Dr. Robert Danoff, said that I had described a new “vital sign” that needed to be recognized in order to help the patients. He said that this vital sign is no different that blood pressure or heart rate and needed to be tracked throughout the patient’s life. Without this information, it would be difficult for any health professional to help any patient with their weight control. I could not have agreed more.