Insider is a mix of sources and references used in compiling
Stikky Weight Management, trivia, things we left out, and known errors

It also provides some insight to anyone interested in the thinking behind the Stikky method.

If you have a specific question you would like to see addressed here, email: insider1 (at) stikky.com.

You can find all the medical papers quoted here at PubMed, www.ncbi.nlm.nih.gov/entrez/query.fcgi. Abstracts are available free. The references given here are in the standard academic shorthand: "N Engl J Med 1998 Jan 1:338(1):2082-90" means "The New Journal of Medicine, January 1 1998, Volume 338, Issue number 1, pages 2082-90."

Photography. The first draft of the book used stock publicity photography of foods, but readers reported that it looked so good they felt hungry after reading. So we commissioned all new photography of the food as it really looks (shot and post-processed digitally). Some readers still reported feeling hungry, a reaction that may be partly conditioned. The book aims to begin countering that conditioning--your first thought may be "yum" but your second thought may be "uh-oh, 600 calories."

How to read this book: Many people read a lot about diet. More than any topic we have applied the Stikky method to, people hold very strong views about food. For instance, some test readers objected that 'aspartame causes cancer'. Simply stating the scientific evidence does not change these views. This paragraph was added in an effort to reduce this barrier to new information.

4: Two simple things you can do. (Didn't make it into the final version:) The French have a machine that can remove 10 pounds of ugly weight in a few seconds. They call it the guillotine.

4: The first is this: if you smoke, quit. In 1990 tobacco caused an estimated 400,000 deaths, diet and activity patterns 300,000, alcohol 100,000, microbial agents 90,000, toxic agents 60,000, firearms 35,000, sexual behavior 30,000, motor vehicles 25,000, and illicit use of drugs 20,000. See JM McGinnis, WH Foege, 1993, 'Actual causes of death in the United States' Journal of the American Medical Association 1993 Nov 10;270(18):2207-12.

5: Two-thirds of Americans are overweight. See the National Center for Health Statistics at www.cdc.gov/nchs/. This statistic is from KM Flegal et al, 2002, 'Prevalence and trends in obesity among US adults, 1999-2000' Journal of the American Medical Association 2002 Oct 9;288(14). The actual figures are 64.5% overweight, 30.5% obese; the 1976-80 study had 46.4% overweight, 15% obese. These chilling figures are the justification for calling overweight an epidemic. The projection for 2008 is an obesity rate of 39% in the US. In China the prevalence of overweight doubled in women and almost tripled in men from 1989 to 1997. See JO Hill, et al, 2003, 'Obesity and the environment: where do we go from here?' Science Feb 2003;Vol 299.

5: Contributes to 300,000 deaths each year. This figure has been widely reported as the stronger claim "300,000 Americans die each year from obesity" which is not supported by the original source DB Allison et al, 1999, 'Annual deaths attributable to obesity in the United States' Journal of the American Medical Association 1999 Oct 27;282(16):1530-8.

6: According to the official definition. Official statistics define overweight to be a Body Mass Index (BMI) of 25 or greater; obese is defined as BMI 30 or greater. BMI is weight in kilograms divided by the square of height in meters. When the BMI for overweight was originally defined it was set deliberately high to avoid categorizing more than half the population as overweight.

7: Twice as likely to die from… See WC Willet et al, 1999, 'Guidelines for healthy weight' N Engl J Med 1999 Aug 5:341(6) and J Stevens et al, 1998, 'The effect of age on the association between body-mass index and mortality' N Engl J Med 1998 Jan 1:338(1). As an alternative point of view, it has been pointed out that strictly speaking there is no direct evidence that losing weight will reverse the health risks--it may be that people who exhibit low mortality in these studies were never overweight in the first place. On this view, prevention of obesity may be more important than weight reduction. SeeJP Kassirer, M Angell, 1998, 'Losing weight-an ill-fated New Year's resolution' N Engl J Med 1998:338:52-54.

7: Shortens your life by three years. See A Peeters et al, 'Obesity in adulthood and its consequences for life expectancy: a life-table analysis' Annals of Internal Medicine 2003 Jan 7:138(1). The study found that 40-year-old female nonsmokers lost 3.3 years of life expectancy because of overweight, males lost 3.1 years. That's the equivalent of five weeks off each remaining year of life. For obese 40-year-olds the loss was 7.1 years for women and 5.8 years for men. Obese smokers fared worst of all, women losing 13.3 years and men 13.7.

8: A good target weight. These figures correspond to a BMI of 22, a widely used improvement over the official number of 25. In fact, some medical professionals also consider 22 too high. A lower limit for healthy weight is more controversial. Reports of higher death rates amongst very thin people turned out to be confusing cause and effect: very ill people, such as those suffering from cancer, are thin and have higher mortality. Studies of BMIs down to 17 have found a straight-line connection between lower weight and lower risk of death. Unhelpfully, US and World Health Organization guidelines continue to suggest that a BMI below 18.5 is unhealthy.

8: The same for men and women. Of course, specific disease risks are different for men and women, overweight men are at greater risk of coronary heart disease, women of diabetes. But the total risk at each BMI is close enough not to warrant separate targets. See WC Willet et al, 1999, 'Guidelines for healthy weight' N Engl J Med 1999 Aug 5:341(6).

10: As well as health benefits. (Didn't make it to final version:) One study showed that slimmer people earn more and are more likely to be married. The study concluded that weight loss improves earning and marry-ability. But the causal arrow could just as easily point in the other direction: perhaps people in higher-paying jobs run around more, for instance. For the original study see B Harper, 2000, 'Beauty, statute and the labour market: a British cohort study' Oxford Bulletin of Economics and Statistics 2000 Dec:62:773-802.

11: You have to want to lose it. You need both the skill and the will to achieve a change. This book is mostly about skill but it also uses recent findings from psychology to create motivation. See www.stikky.com/sub/motivatingreaders.html.

14: Your body converts food into fuel. Not all the calories in food you eat are absorbed by your body. Energy derived from food is stored with an efficiency of at least 50% for nearly everyone and much greater than 50% for most people. See JO Hill et al, 2003, 'Obesity and the Environment: Where Do We Go from Here?' Science Feb 2003;Vol 299.

27: Bodies burn less energy as they get older. Primarily due to less exercise, see RE van Pelt et al, 2001, 'Age-related decline in RMR in physically active men: relation to exercise volume and energy intake' Am J Physiol Endocrinol Metab 2001 Sept:382(3) at http://ajpendo.physiology.org/cgi/content/full/281/3/E633.

28: Four times higher than overweight teenagers. CL Ogden et al, 2002, 'Prevalence and trends in overweight among US children and adolescents' Journal of the American Medical Association 2002 Oct 9;288(14).

29: Big Mac and large Coke. These are McDonald's own figures. See www.mcdonalds.com/usa/eat/nutrition_info.html.

32: Temporary result. Around 20% of overweight people are able to lose 10% or more of their weight and keep it off for at least a year according to RR Wing and JO Hill, 2001, 'Successful weight loss maintenance' Annual Review of Nutrition 2001 Jul:21:323-341.

40: 150 again. To be precise (see comment on page 42, below): Sprite has 140 calories, Seven-Up has 160, and Mountain Dew 170.

42: Also 150. Dieticians who reviewed the manuscript pointed out that some calorie values given are not totally accurate. A 5-ounce glass of wine, for example, is closer to 100 calories than 150. This overlooks the point that people don't know how many fluid ounces of wine are in their glass (and the point that it's quite likely to be more than five). More importantly, we intentionally simplified the calorie counts for common foods, rounding them to make them easier to remember. The changes are insignificant compared to the amount an average person takes in daily and so do not detract from a reader's ability to make appropriate diet decisions. Readers interested in greater accuracy could, of course, consult the detailed table at the back of the book.

48: Aspartame, which dozens of studies have found to be safe. See page 232. Aspartame discussion on the Internet has become a case study in misinformation. So much so that the FDA was moved to state its case for approving sweeteners in full. See www.fda.gov/fdac/features/1999/699_sugar.html. Online activists became excited all over again when the European Union decided to re-open the case on aspartame in 2002. The conclusion was the same as before: aspartame is safe (the full report is at http://europa.eu.int/comm/food/fs/sc/scf/out155_en.pdf).

49: Tastes can be acquired. One study tracked down 23 pairs of identical twins with one twin obese and the other lean. The obese subjects were found to have three times the preference for fatty foods compared to their lean twin. Since this differing preference cannot be genetic (identical twins have identical genes) it must have been acquired. The study is A Rissanen et al, 2002, 'Acquired preference especially for dietary fat and obesity: a study of weight-discordant monozygotic twin paris' Int J Obes Relat Metab Disord 2002 Jul:26(7):973-7.

56: 250. To be precise: Snickers has 280 calories, Reeses (both cups) 240, Twix 285, 3 Musketeers 212, Kit Kat 236, Butterfinger 216.

61: Save around 100 calories. Grande latte with whole milk is 270 calories; grande latte non-fat milk is 160; tall latte non-fat milk is 120. Data from Tufts University Health & Nutrition Newsletter, http://healthletter.tufts.edu, August 2002, based on Starbucks' own figures.

62: Serving sizes have grown larger. Portion sizes increased between 1977 and 1996 for all food categories, inside and outside the home, except pizza (SJ Nielsen, BM Popkin, 2003, 'Patterns and trends in food portion sizes, 1977-1998' Journal of the American Medical Association 2003 Jan 22:289(4):450-453). The largest portions (and greatest increase) was at fast food establishments. See 'Contribution of expanding portion sizes to the US obesity epidemic', New York University, at http://www.nyu.edu/education/nutrition/PDFS/young-nestle.pdf.

87: Cynics might say. To be fair, many serving sizes are set by law in the Nutrition Labeling and Education Act of 1990 (though food manufacturing lobbyists have been known to influence lawmakers).

88: Nutrient Facts labels. The official dietary reference intakes (DRIs, which replaced the old RDAs) are printed on Nutrition Facts labels in simplified form. If you want to know the exact recommended amount of just about anything for someone of your age and sex, consult the Institute of Medicine's tables in PDF format at www.iom.edu/project.asp?id=4574.

120: You'll be losing around a pound a week. One of the team working on the book lost 16 pounds in 16 weeks by making lower-calorie substitutions, achieving his target on schedule. After another 9 weeks, he found he had lost a further 9 pounds and so had to reverse some substitutions to stabilize his weight!

128: Helps fill you up for minimal calories. An excellent book that develops this idea into a full dietary plan is The Volumetrics Weight-Control Plan by Barbara Rolls and Robert Barnett.

130: Can only be talking about surgery. Of course, someone who consumes on average 4,000 calories a day could lose 8 pounds a week if they starved themselves. If they also started exercising 2,000 more calories a day than they did before, they would lose a further 4 pounds a week. Our research did not turn up anyone who had done this.

132: Read a book for an hour. The CDC provides a table at www.cdc.gov/nccdphp/dnpa/physical/measuring/met.htm showing how much energy you burn at dozens of different activities. Burn rate is measured in metabolic equivalents (METs). When you are at rest (eg, reading a book) a 150lb person burns 1 MET, which is equal to 1.2kcal per minute (a kcal is the proper term for what is popularly referred to as a calorie).

134: Gym membership is not the way. Exercise also builds muscle, which burns more energy, even when you are at rest, than fat. However, it is tough to build enough muscle to produce more than a marginal benefit, and it atrophies fast.

135: Being just a bit fit. This is a good example of how some of the most important findings are recent. See, for instance, JE Manson, FB Hu, et al, 1999, 'A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women' N Engl J Med 1999 Aug 26:341(9):650-8.

137: 30 minutes of brisk walking five times a week. Women in the Boston Nurse's Health Study who walked this amount were 35% less likely to have a heart attack (see the Manson, Hu study quoted in the note for page 135). Regular vigorous exercise (greater than 6 MET, see the note for page 132) was associated with no better risk reduction. Persuading people to increase 'lifestyle activities' such as walking is, though, proving difficult. The book uses photographs specially created to serve as triggers. We found in testing that people faced with a choice of stairs or escalator remembered the advice in the book and (sometimes) took the stairs.

138: Out of breath. 'Brisk' is defined as 3mph. Some people use the 'talk-sing' test: if you can sing while you exercise, you are not working hard enough; if you can talk but not sing, you are exercising at the recommended rate; if you cannot talk, you are working harder than you need for fitness (but, of course, the harder you work, the more calories you burn).

138: Two-thirds of Americans don't. Data from 1997-98. The full report is available at the CDC National Center for Health Statistics, www.cdc.gov/nchs/releases/02news/physical_activity.htm.

139: Several opportunities every day. Other exercise ideas: a walking meeting, get a dog (or walk someone else's dog), walk while your kids play sport, walk while you talk on the phone, avoid drive-through restaurants, at work walk to a different floor to use the restroom or copy machine.

141: Three items to take upstairs. This photograph was taken outside someone's New York apartment. Someone pointed out that leaving full boxes outside an apartment may not be good advice so, to make the photograph look like the inside of an apartment, the table and lamp in the background were added in Photoshop.

145: A famous study. The Lyon Diet. See M deLongeril et al, 1999, 'Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease' Lancet 1999:343: 1454-59 and M deLongeril et al 'Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon diet heart study' Circulation 1999:779-85 for which the full text is available free at http://circ.ahajournals.org/cgi/content/full/99/6/779.

148: Not all fat is bad fat. Unfortunately, this message has been twisted by some (notably the New York Times in 'What if it's all been a big fat lie?' by Gary Taubes, July 7, 2002, available for a fee at www.nytimes.com) into 'no fat is bad fat', which madness was of course seized upon by Atkins activists.

148: Saturated fat is also bad. There is an excellent article on sat fat, trans fat, and n-3 fats (in fish oil) in the Center for Science in the Public Interest's newsletter at www.cspinet.org/nah/07_02/fats.pdf.

148: Proven clogger of arteries. So why is there a recommended daily value for saturated fat on food labels? The Institute of Medicine (who make the recommendations) argue that, though sat fat is a proven health risk, eating none of it at all is "neither possible nor advisable," a somewhat odd combination. This is because fat sources available today are mixes of good and bad (unsaturated and saturated) fats. Avoiding them altogether would be dangerous since some good fats are essential. The problem is that most people read the daily value as a Recommended Daily Allowance (it isn't; no RDA is set for sat fat) and so the label seems to endorse sat fat.

153: The muffin on the left. Data from www.dunkindonuts.com/nutrition/.

163: Trans fat. For a wonderful consumer action site on trans fat, see www.bantransfat.com.

163: Institute of Medicine. See the Dietary Reference Intakes available from www.nap.edu.

165: From 2006. Why so long? Labels don't take so long to change, of course. The logic appears to be to give food manufacturers a chance to replace trans fat in their products.

169: Fish once a week. See, for instance, K He et al, 2002, 'Fish consumption and risk of stroke in men' Journal of the American Medical Association 2002 Dec 25:288(24):3130-6.

170: Fiber. One recent study in young adults found that dietary fiber was a better predictor of cardiovascular disease risk factors than saturated fat consumption (D S Ludwig et al, 1999, 'Dietary fiber, weight gain, and cardiovascular disease risk factors in young adults' Journal of the American Medical Association 1999 Oct 27;282(16):1539-46) though this could be because people who eat fiber have other good nutrition habits. Recent studies have cast doubt on the old claim that fiber helps prevent colon cancer but reports of this seem to have led some people to conclude that fiber is not beneficial at all.

179: Folic acid. See Next Steps.

182: Top 10 foods in terms of calories. The Continuing Survey of Food Intakes by Individuals is available from the USDA on CD at www.barc.usda.gov/bhnrc/foodsurvey/home.htm. The table on this page represents new analysis of this data by Laurence Holt Books.

198: To lose weight you need to reduce calories, not fat. As an example of the widespread confusion that remains on this uncontroversial point, a leading cookery book, published in 1998 by the BBC, recommends potatoes as follows: "Fat has now emerged as the number one culprit and the major cause of being overweight. This means that large portions of potatoes (without fat) are nutritious, healthy, high in energy-giving carbohydrate and low in calories…and the single most important source of vitamin C in our diet" (Delia's How to Cook by Delia Smith). The writer seems to be under the impression that energy and calories are different things. Getting your dietary advice from a cookery book is, of course, not recommended. Incidentally, orange, grapefruit, and other fruit drinks account for four times as much vitamin C in the American diet as potatoes (AF Subar et al, 1998, 'Dietary sources of nutrients among US adults, 1989 to 1991' Journal of the American Dietetic Association 1998 May:98(6)).

200: Atkins. One of the first scientific trials of a low-carbohydrate diet, though small-scale, found that Atkins adherents lost more weight in the first six months of dieting but did no better than other dieters after a year. Unfortunately, the comparison was with another flawed regime: a low-fat diet rather than simple calorie restriction. The study is: G D Foster et al, 2003, 'A Randomized Trial of a Low-Carbohydrate Diet for Obesity' N Engl J Med 2003 May 22;348:2082-90.

224: Very recent. In particular, genes cannot be solely responsible for the recent upsurge in obesity--the gene pool has barely changed in the last 50 years.

226: The real you. An example of intrinsic motivation, which has been found to be more powerful than extrinsic motivation (rewards, peer pressure). See www.stikky.com/sub/motivatingreaders.html.

229: Accuracy of body fat monitors. VJ Tyrrell et al, 2001, 'Foot-to-foot bioelectrical impedance analysis: a valuable tool for the measurement of body composition in children' Int J Obes Relat Metab Disord 2001 Feb;25(2):273-8. Accuracy is best if you (i) use the monitor first thing in the morning, (ii) avoid alcohol for the previous 48 hours, and (iii) you are not menstruating.

230: Waist circumference and health risk. S Zhu et al, 2002, 'Waist circumference and obesity-associated risk factors among whites in the third National Health and Nutrition Examination Survey: clinical action thresholds' Am J Clin Nutr 2002;76:743-9.

230: Vigorous exercise carries a very small increased risk of sudden death. CM Albert et al, 2000, 'Triggering of sudden death from cardiac causes by vigorous exertion' N Engl J Med 2000 Nov 9;343(19):1355-61.

231: Specific foods. Everything in this section is based on at least two reports from reputable sources. If a specific reference isn't given, the main source was one of: Walter Willett, Eat, Drink, and Be Healthy, MEDLINEplus, or WebMD.

232: Artificial sweeteners are safe. See the note on page 48, above.

232: Aspirin and heart disease. TA Pearson et al, 2002, 'AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update' Circulation 106: 388-391.

232: Calcium, study on immobile people. A LeBlanc et al, 1995, 'Calcium absorption, endogenous excretion, and endocrine changes during and after long-term bed rest' Bone 16:301S-304S.

232: Calcium and hip fractures. W Willett, 2001, Eat, Drink, and be Healthy, p142, Simon & Schuster.

232: Calcium and prostate and ovarian cancer. W Willett, 2001, Eat, Drink, and be Healthy, pp145-6, Simon & Schuster.

232: Calcium not a 'superstar nutrient'. Institute of Medicine, 1999, Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, pp89-90.

232: Cholesterol. 'The Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP III)' is available at www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm.

233: Glycemic index. See D S Ludwig, 2002, 'The glycemic index: physiological mechanisms relating to obesity, diabetes, and cardiovascular disease' Journal of the American Medical Association 2002 May 8;287(18)2414-23.

233: Sodium can lower blood pressure. The DASH Eating Plan, which trials showed resulted in lower blood pressure, is at www.nhlbi.nih.gov/health/public/heart/hbp/dash/.

233: N-3 fatty acid. The study mentioned here is R Marchioli et al, 2002, 'Early protection against sudden death by n-3 polyunsaturated fatty acids after myocardial infarction' Circulation 2002;105;1897. Note that participants in the study did not change their n-6 intake, contrary to the theory put forward in Artemis Simopoulos and Jo Robinson's book, The Omega Diet.

233: Nuts. F B Hu and M J Stampfer, 1999, 'Nut consumptions and risk of coronary heart disease: a review of epidemiological evidence' Curr Atheroscler Rep 1999 Nov;1(3):204-9.

233: Vitamins. See WC Willett and M J Stampfer, 2001, 'What vitamins should I be taking, doctor?' N Engl J Med 2001 Dec 20;345(25):1819-24.

234: Water. See, for example, A C Grandjean et al, 2003, 'The effect on hydration of two diets, one with and one without plain water', J Am Coll Nutr 2003 Apr;22(2):165-73.

America's 200 Most Commonly Eaten Foods. This table is based on new analysis performed by us with help from the USDA on The Continuing Survey of Food Intakes by Individuals. The source data is available from the USDA on CD at www.barc.usda.gov/bhnrc/foodsurvey/home.htm. Food rankings are problematic since they depend heavily on the food groupings chosen. For instance, should all milks be grouped together (ranking very high) or separately (ranking lower)? Previous rankings have disaggregated foods such as pizza and burgers into their constituents. Instead, we tried to group foods according to how they are common perceived and purchased.