Table of Contents
From Lessons 1 & 2 we acquired an understanding of our TDEE (total daily energy expenditure), how to calculate it, and also how to track calories if desired. In this lesson we will go over how to estimate what our caloric intake should be and how to adjust based on the progress we are making. To do this we first need to discuss how to set a target weight and how quickly one should attempt to gain or lose weight.
How to set a target weight
In many respects this is largely subjective; if you want to gain weight then go ahead and gain weight, and if you want to lose weight then go ahead and lose weight. You can always set a specific goal (ie, 200 pounds), get there, and then reassess to determine how to move forward. But what does the literature tell us about an ideal weight for optimal health?
Note: Both this section and the next regarding rates of weight gain/loss apply to adults only, not children. There are many additional considerations in childhood as children are actively growing and go through puberty at different rates & times. It’s even debatable if the standard definitions of overweight and obesity used in pediatrics are physiologically appropriate as increased metabolic risk can be seen at lower thresholds than currently used.(Kelly, 2020) While the same concepts in adults will apply to children, it is preferable to ask your child’s medical provider for guidance regarding target body weight and how quickly to attempt to get there. Alternatively, if children adopt healthier eating and exercise habits good progress will likely be made even without setting any specific goals.
Body mass index (“BMI”)
Many people are familiar with the concept of BMI. You take your weight in kilograms and divide by your height in meters squared (kg/m2). Click here for a calculator. This generates a number, and in adults this is classified as:
- BMI < 18.5 = underweight
- 18.5 < BMI < 25 = healthy weight
- 25 < BMI < 30 = overweight
- 30 < BMI = obese
Note: Where do these BMI thresholds come from? They are actually somewhat arbitrary(Kuczmarski, 2000; Komaroff, 2016):
- They initially came from the Metropolitan Life Insurance Company tables back in the 1940s & 1950s.
- In 1985 arbitrary cutoffs for an overweight BMI were set at 27.8 for men & 27.3 for women as these represented the 85th percentile of the BMI distribution for people aged 20-29 in the National Health and Nutrition Examination Survey (NHANES) II. Coincidentally these values correlated with the values representing minimal mortality outcomes.
- When the 2nd edition of the Dietary Guidelines for Americans (DGA) was published (also in 1985) they listed the highest desirable BMI for men at 25-26 and women at 24-25 without proposing a specific rationale.
- In the 3rd edition of the DGA (published in 1990) they adopted the BMI values of 25 for adults age 19-34 & 27 if >34 from the 1989 National Academy of Sciences report “Diet & Health: Implications for Reducing Chronic Disease Risk”. The reason for a higher BMI at an older age is due to observations that lower mortality was seen with increased body weight (BW) as age increases.
- in 1995 the World Health Organization used a newer meta-analysis indicating increased mortality at BMI < 18.5 & >30 to set a healthy range of 18.5-25. They acknowledged this was an arbitrary decision.
- The 4th edition of the Dietary Guidelines for Americans (published in 1995) went with this and defined a healthy BMI as 18.5-25, pre-obesity at a BMI of 25-29.9, class I obesity as BMI 30-34.9, class II obesity as BMI 35-39.9, and class III obesity as BMI 40+.
- In 1998 the NIH defined overweight as BMI of 25-29.9 and obesity as BMI ≥ 30.
- In 2000 the CDC used 5 nationally representative surveys (National Health Examination Surveys II & III in the 1960s, NHANES I & II in the 1970s, and NHANES III from 1988-1994) to make BMI growth curves for children in the US.
In 2000 The International Obesity Task Force similarly created childhood curves using data from 6 countries and decided to adjust the curves such that they passed through the cutoffs of 25 & 30 for overweight and obesity in adults. The most recent editions of the Dietary Guidelines for Americans move forward with this and define childhood overweight as a BMI ≥ the 85th percentile and childhood obesity as BMI ≥ the 95th percentile.
Can we be healthy at an elevated BMI?
A small percentage of people have relatively increased muscle mass, and this can elevate their BMI category. To my knowledge there is no evidence that increased muscle mass obtained through healthy means is harmful in any way.
However, a much greater percentage of people have increased levels of BF, leading to a higher BMI category. This brings up the concept of “metabolically healthy overweight/obesity” (MHO). There is a subset of people with BMIs above the healthy range who do not have any metabolic abnormalities (ie, normal cholesterol, normal blood pressure, etc). However, even these individuals have a higher risk of poor health outcomes than metabolically healthy normal BMI individuals.(Magkos, 2019; Opio, 2020) Of note, both of these reviews cite data showing that when cardiorespiratory fitness is equivalent the “harmful” effects of MHO diminish greatly or even completely disappear. More research is needed but it is possible that with enough physical activity many of the harmful effects seen with MHO can be mitigated, though this is less likely when BMI > 40, and it is important to note that many individuals with MHO progress to metabolically unhealthy obesity.
Thus, it seems possible to at least temporarily be healthy at a higher BMI, assuming higher levels of cardiovascular fitness, but it’s not yet clear for how long this will persist and what the higher BMI threshold is for this to hold true.
The Obesity Paradox
In adults aged 65+, an “obesity paradox” has been observed, where individuals with BMI in the overweight or even the obese category live longer than those with BMI in the healthy weight category. There have been many studies showing this, with various explanations proposed.(Javed, 2020) One possible explanation is people losing weight with illness before death and then being classified in a lower BMI category than they had been in for most of their adult life. Another is that as we age our height decreases so our BMI is artificially elevated. A third is that extra BF is actually helpful in older age. However, a couple of recent analyses point to a separate cause, that being that elderly individuals with higher BMI also have more skeletal muscle, and this is what may be contributing to improved health.
In one cohort followed for >30 years increased longevity and quality of life correlated with increased skeletal muscle & decreased body fat percentage (“BF%”).(Jyväkorpi, 2020) In an analysis of NHANES data, separating BF% from appendicular skeletal muscle index (ASMI, total lean mass of the 4 extremities summed & divided by height squared) showed that in the elderly higher skeletal muscle mass was the principal reason for increased survival in individuals with overweight and obesity by BMI compared to normal weight.(Abramowitz, 2018) When normalizing for the ASMI there was actually similar survival in the normal & overweight BMI categories with a non-statistically significant advantage for normal weight.
Thus it is possible that higher skeletal muscle is driving the better health outcomes at higher BW as opposed to higher BF.
Does a healthy BMI guarantee healthy body composition?
As BMI itself does not describe the ratio of lean body mass (LBM) to BF, we need to consider if it’s possible to have high BF levels while also having a healthy range BMI. It turns out this is indeed possible. In the fitness world this is commonly referred to as “skinny fat”. In the literature this has been termed several things, including “overfat”, and it’s estimated that >20% of individuals with a normal BMI have an elevated BF%, both in adult populations and pediatric populations.(Maffetone, 2020; Javed, 2015). This means that just because someone has a BMI classified as healthy does not mean their BF% is healthy. While this is in part due to having too much BF, it can also be attributed in part due to a lack of LBM.
TIP: For individuals with a healthy BMI but elevated BF%, there are two primary options:
- you can diet to lose the excess BF; this is likely more warranted if your waist-to-height ratio is elevated (see below)
- you can attempt to maintain your current BW while undergoing a resistance training program and adopting healthier eating patterns. This will allow you to build skeletal muscle and lose BF at the same time (frequently termed “body recomposition” in the fitness world)
If your primary goal is to improve health then I generally do not recommend gaining weight if you already have significantly elevated BF levels.
How to determine if your body fat percentage (BF%) is elevated
Upper limits of healthy BF% are typically considered 25% for men and 32% for women(Jayawardena, 2020), though there is no true standard definition. This is in part due to the fact that different people carry BF in different places with different health implications.(Haczeyni, 2018; Luong, 2019)
There are several ways to estimate your BF%:
- Of the various anthropometric options (these are the ones that don’t require special equipment or cost money), a recent study in adults indicates the best may be the Department of Defense formula.(Tinsley, 2020) It should be noted that just because this was considered the best does not mean it is very accurate; it had an individual margin of error >5% (at times it was up to 10% off) and thus cannot be relied upon to provide accurate information. There are several other anthropometric measures that have been evaluated and show promise, but the overall body of literature at this time is too small for me to recommend any one of them over the rest.(Jayawardena, 2020)
- Another common and popular option is bioelectrical impedance analysis (BIA); scales can be purchased at a relatively low cost and then this can be used to track weight and estimate BF%. These should not be used by people with electronic implants and it’s not clear that it is safe to use while pregnant. Unfortunately these also tend to not be super accurate and in the above study the single-frequency type (the type one would purchase cheaply) had margins of error of ~5%.
- Cheap body fat calipers can also be purchased but can lead to widely inaccurate results with inexperienced users; that said if you can use them consistently and simply compare the actual skinfold measurements directly you can track progress with them without even having to calculate BF%.
- While the above studies cater to adults, a recent review shows similar accuracy problems in children.(Orsso, 2020)
- More accurate options, such as a DEXA scan, cost more money.
Perhaps a simpler method to help determine if you have an elevated BF% is to simply calculate your waist-to-height ratio (WHR). Take you waist measurement as described on pages 52-53 here, and if this is greater than half of your height then that implies you are carrying excess abdominal BF. While not perfect, if this is the case it suggests losing weight may be beneficial as this is associated with negative health conditions.(Ashwell, 2020)
It should be clear from a health perspective there is no one perfect BW for any given person, rather there is a range across which similar health outcomes can be seen. In general I advise individuals with excess BF to lose the BF while also following a resistance training program to help maintain (or even build) their overall muscle mass. Most people in the obese category by BMI, and many people in the overweight category and with a WHR >0.5, will have excess BF. Beyond that it is really up to personal preference.
Rate of weight gain or loss
If an individual wants to gain or lose weight, it is helpful to know how quickly this can be safely and effectively done, as well as the risks of changing BW too rapidly.
Note: Some basic terminology:
- maintenance: consuming a number of calories equal to your TDEE, thus generally maintaining your current bodyweight
- surplus: consuming more calories than your TDEE, leading to weight gain over time
- deficit: consuming fewer calories than your TDEE, leading to weight loss over time
For people who want to gain weight
Note: This advice does not apply to people who are medically underweight (body mass index < 18.5) . If medically underweight I recommend discussing goals of weight gain with your medical provider; in general the desired rate of weight gain will be faster than what I discuss below.
The general goal is to gain LBM while minimizing BF gain. The rate at which we can gain new skeletal muscle and LBM is limited; if we gain beyond this rate the excess weight will accumulate as BF.
There are various recommendations for rate of weight gain. In many respects it depends on your current level of musculature; people with less muscle tend to be able to gain muscle more quickly as they are further from their genetic potential. One generic recommendation(Iraki, 2019) (written for bodybuilders in the off-season but applicable to anyone trying to build muscle) is to limit weight gain to:
- no more than 0.25-0.50% of one’s body weight weekly if a beginner to resistance training
- no more than 0.25% of one’s body weight weekly if more advanced
Tip: My recommendation is to eat as few calories as necessary to get stronger with resistance training over time, as strength gains correlate with skeletal muscle hypertrophy. Only a small surplus of a few hundred calories daily(Slater, 2019) is likely needed to maximize skeletal muscle hypertrophy. Thus, if one focuses on gaining strength without gaining too much BF skeletal muscle hypertrophy will occur. When strength gains stop then one can generally either change the resistance training program or increase calories by 100-200 kcal/day.
Anecdotally, many people will “bulk” (gain weight) quickly and think they are gaining a lot of muscle. Then when they eventually “cut” (lose weight), they look similar to how they did prior to bulking. This is because a lot of the weight they gained that they thought was muscle was actually water/glycogen/BF. Beyond the beginner stage (which can last several months to 1-2 years when training consistently) it takes time to build appreciable muscle; you are unlikely to see changes on a weekly basis (or even a monthly basis if you are more advanced).
So how do we tie this in to calculating one’s TDEE and tracking calories? You can calculate your TDEE, aim to eat this daily (knowing there is some margin of error), and increase your target by 100-200 kcal/day if progress with resistance training stalls. Alternatively, you can follow a good resistance training program while eating sufficient protein (discussed in Lesson 4) without tracking calories. If you stop making progress with the resistance training you can consider if you are not eating enough calories and increase food intake accordingly. If you are gaining weight too quickly (beyond the guideline above, or if you can tell your BF% is increasing) you can take certain things out of your diet or temporarily track calories to get back on course.
For people who want to lose weight
The general goal is to lose BF while maintaining (or even gaining) LBM.
If people lose weight too rapidly they put themselves at risk of medical complications (ie, developing gallstones). Additionally, faster weight loss increases the risk of losing LBM making it harder to keep the weight off long term.(Dulloo, 2018) It is harder to maintain a faster rate of weight loss as the body undergoes compensatory mechanisms to fight this. These include decreases in leptin/thyroid/insulin/satiety hormones, increases in cortisol/ghrelin hormones, and alterations in sympathetic nervous system activity. Collectively this increases adaptive thermogenesis & hunger, making dieting more difficult.(MacLean, 2017; Müller, 2013)
Note: Technically not all of adipose tissue is actually fat. When we lose fat we lose some of the non-fat mass associated with the adipose tissue. It’s unclear how variable this is between individuals but it’s estimated that ~15% of adipose tissue is actually not fat.(Abe, 2019) While this fact may be of interest for individuals who are losing large amounts of weight and attempting to track changes in LBM via sophisticated means (ie, a DEXA scan), practically speaking this is not an important thing to consider.
So how quickly should one lose weight? The literature is sparse regarding interventions in large groups of people with effective exercise and dietary components testing the impact of variable rates of weight loss on outcomes. A recent review indicated no significant differences with weight loss rates up to almost 1% body weight weekly in dietary interventions without exercise components.(Turicchi, 2019) As following a proper resistance training program will further aid in maintaining or gaining LBM while losing BF, I feel aiming for up to 1% body weight loss weekly is a safe metric to shoot for.
Example: Let’s see how we can attempt to lose weight keeping in mind all of the above. A 200 pound person with a TDEE of 2,500 kcal/day wants to lose 1% BW weekly. 1% of 200 is 2 pounds, requiring a 7,000 kcal weekly deficit, or 1,000 kcal/day. Thus, they aim to eat 1,500 kcal/day. Knowing their BMR, TEF, and NEAT will decrease, they estimate this to sum to 300 kcal/day. Therefore they start exercising enough to burn an estimated 300 kcal/day to make up for this difference. This maintains their TDEE at 2,500 kcal/day with a 1,000 kcal/day deficit. Part of their exercise is resistance training to attempt to maintain their LBM and have the weight loss come from BF.
Over the first few days they lose 4 pounds of water/salt/glycogen (see below). Over the next 4 weeks they lose 7-8 pounds, meeting the 1% body weight loss per week goal. Now that the new body weight is less (~188 pounds), there is more adaptive thermogenesis, so their TDEE decreases further. As this continues to occur at some point they will no longer be losing 1% body weight weekly. They can proceed with a slower rate of weight loss or choose a combination of eating fewer calories and increasing exercise to maintain the needed deficit for 1% loss per week. As discussed in later lessons a minimum level of nutrition is needed to maintain good health, so at some point calories cannot safely be reduced further and any increase in the deficit should come from increased exercise.
Ok, so that seems straightforward, but what if we have a lot of water weight fluctuations so it’s hard to know how quickly we are losing weight? What if we don’t want to track calories and thus cannot easily adjust the total amount we are consuming? First lets go over how to track weight changes and monitor progress, and then we will go over a strategy to do this without tracking calories.
How to track progress
- Use a scale. I recommend weighing yourself every morning after using the bathroom and calculating a 7 day rolling average. So weigh yourself Monday – Sunday and calculate the average. Then next Monday, weigh yourself, get rid of the first Monday weight, and calculate the new average. Track how this changes over time. I recommend doing this because water weight can fluctuate daily depending on physical activity and what you eat. Of note, as women go through their menstrual cycle water weight can fluctuate a lot. Thus, depending on how big of an issue this is, women may need to compare 7 day averages from cycle to cycle (ie, the 7 day average on the 3rd day of this cycle compared to the 7 day average of the 3rd day of the last cycle) to confidently track progress. Libra (android) and Happy Scale (iphone) are apps that can be used for this. An example done in Excel is shown below.
7 Day Rolling Average Example
- Body part measurements. A change in weight on the scale won’t tell you if you are gaining or losing LBM or BF. Measurements help you do this. I recommend measuring once a week (ie, every Sunday), in the morning after using the bathroom. For males measuring the waist is useful. For females measuring the waist and additionally at the widest portion of the hips is useful. You can measure additional spots (ie, neck, arms, thighs) if desired. In general, BF decreases or increases when waist/hip measurements decrease or increase, respectively. This is very helpful to help determine if the weight being gained or lost is due to LBM vs BF. Additionally, for women with water retention issues due to the menstrual cycle, if the scale is moving in the wrong direction but your measurements are going in the right direction, you can be confident you are doing well even if the scale is not showing it acutely.
TIP: Of note, it is crucial you perform measurements the same way each time. For example, to measure the waist you can stand straight, relax your stomach (don’t suck it in), put the tape measure around your waist at the belly button and make sure it is level, breathe out, and then pull the tape measure so it is slightly snug. It doesn’t matter too much how you do it as long as you are consistent over time. Consistency is key. To see the official way to perform a waist circumference measurement, look at pages 52-53 here. Pick whatever method you think will be easiest to stick to and stay consistent.
Additionally, for those attempting to gain muscle measuring arm and thigh circumferences can be helpful. Beware though that if you lose fat and gain muscle at the same time the measurements will capture both of these processes so they should not be relied upon in isolation. A combination of metrics to track progress is most insightful.
- Pictures. I recommend taking pictures when you start dieting (to gain or lose weight), and periodically take new ones with the same poses and lighting. This can help motivate you and provide another method to track progress. I would take pictures no more frequently than every 2 weeks. Every 4 weeks is probably better for being able to see real changes, especially when it comes to muscle gain.
- Exercise numbers. In general, maintaining strength while losing weight indicates LBM is being maintained. If you gain weight without gaining strength, that’s a sign you are probably gaining excess BF. If you are losing weight and start to lose strength this would be a good time to reevaluate if you need to slow down the rate of weight loss (by increasing calories), increase protein intake (discussed in Lesson 4), or alter your resistance training program.
TIP: The first week of dieting can yield water weight changes of several pounds. This is because when you decrease calories and increase exercise you use up glycogen (a molecule the body uses to store glucose), and 1 gram of glycogen is stored in the body with at least 3 grams of water.(Murray, 2018) Changes in sodium intake also impact water retention especially in the first few days of dietary changes. Therefore, weight fluctuations the first week do not indicate actual changes in BF.
After the first week I recommend tracking your weight daily for 2 weeks and taking measurements each week. If after these 2 weeks (not including the first week) you are gaining or losing weight at the appropriate pace and the measurements are good, keep doing what you are doing. If your weight is not changing at the desired rate, adjust accordingly. As examples, if you want to lose 1.5 pounds per week and are only losing 0.5 pounds per week, then decrease your calories by 500 kcal/day (or increase activity accordingly). If you want to lose 1.5 pounds per week but lost 2 pounds the last week, increase your calories by 250 per day. Then adjust further after another 2 weeks of measurements.
For those who do not wish to track calories, you can still track your overall progress as described above and adjust accordingly. If you’re not losing weight quickly enough, try to eat smaller portions of the same foods, cut out a food item that has a significant number of calories, do more physical activity, or adjust in some other way that makes sense to you. Then get right back to tracking your progress and make further adjustments as necessary. If these strategies do not work you can always temporarily track calories to get back on track.
After these first three lessons you should now have a basic understanding of the interplay between TDEE & caloric intake, how to estimate TDEE, how to use this estimate to start the dieting process, how to set a healthy goal BW, and how to track progress and adjust caloric intake over time as indicated. As long as you are objectively and consistently tracking progress, you can attempt almost any dieting or lifestyle strategy that suits you and adjust as needed.
With this general understanding of calories, it is time to start discussing where these calories come from. In the following 3 lessons we will go over the 3 basic macronutrients: protein, carbohydrate, and fat.
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