The first lines of information for diets are internet homepages, Google sidebars, blogs, and magazine racks in grocery store checkout lines. But when the diet goes wrong or weight loss stops, physicians become the next source of advice. Whether it is family members, friends, patients, or colleagues we are expected to have the answers on fitness and nutrition; however, there is a vast deficiency in nutritional education in medical school, leaving us unprepared to adequately advise patients on health and diet. 

As a competitive athlete, I’m keenly aware of how nutrition affects performance. Over the years, I’ve experimented with multiple diets and exercise regiments to maximize performance. While I don’t portend to be an expert on the subject, and especially not for high-performance athletes, I have acquired bits of knowledge that have proven useful in both clinical and personal interactions. Here are 5 Rules for Dieting of them that may be helpful to physicians and patients alike in discussing diet:
·        
1. The RIGHT diet is any one you can stick to. Now, I know this seems intuitive, but studies have shown that for the majority of diets, weight loss occurs primarily as a result of paying attention to the amount and types of food being eaten, rather than the actual make up of the diet. For many people, recommend a diet that is low-calorie and stresses the importance of fruits and vegetables.
·        
2. A calorie is a calorie. It’s true that the basis of weight loss is that we must burn more calories than we take in. It is important for people to calculate their basal metabolic rate (BMR; multiple calculators available online and not to be confused with body mass index, BMI) and then estimate their daily caloric needs. A typical diet should focus on a deficit of ~500 calories per day, leading to ~1 pound of weight loss per week. I prefer the approach of taking a strict BMR and then estimating daily activity rather than using a pre-set multiplier. 
 
3. Not all calories are equal. Unfortunately, there are some calories that are better than others. This reflects our choice of foods: a calorie from an apple or orange is better than that of a marshmallow because these foods contain important nutrients for your immune system, muscle rebuilding, and other bodily and metabolic functions. 

4. Eat More Protein. The cows of Chick-Fil-A may be on to something. Dieters should strive for protein to account for approximately 25-30% of their caloric intake. Multiple studies have shown that protein intake is associated with preventing muscle breakdown that sometimes occurs with caloric restriction due to utilization of amino acids in muscle as energy source over fat. Additionally, recent studies have shown that protein may play an even more important role in feeling satiated, a role previously thought to be driven by fat intake. When choosing protein, opt for lean meats like fish or poultry and limit intake of red meats to once weekly.  

5. Exercise is important. Exercise burns calories both during and after. A complete exercise routine should include both cardiovascular efforts where heart-rate becomes elevated (target HR for beginners should be 60-80% of the result of 220 – age), as well as strength work which will both promote muscle development and sustained elevated metabolism.

Obesity is a significant problem for America’s economy, health care, disease burden, and cultural perception abroad. Like treating smoking, a gambling addiction, or alcoholism, every step in a right direction; steps that improve weight and promote healthy lifestyles deserve our praise. Remind patients that weight loss often leads to increased energy and improved self-esteem, but don’t allow changes to go unacknowledged. Furthermore, when the changes stop is when we are needed most allay frustrations and instead, encourage maintenance of the healthy eating principles and continued exercise that were adopted during dieting. 

If you have any experience with these diets or specific questions, leave your questions below. For more information on specific diets and dieting practices, read on below.

Yesterday the New England Journal of Medicine published results of the PREDIMED study (Etruch et al. 2013), which examined the effects of an energy-unrestricted, Mediterranean diet, supplemented with either olive oil or nuts, against a low-fat diet on major cardiovascular events, including myocardial infarction, stroke or death by cardiovascular causes. Briefly, following 7447 persons since 2003 showed reduced events in those persons who followed either Mediterranean diet over those on the low-fat diet. 

In a 1997 article in the American Journal of Clinical Nutrition,
Barabara Haber traced the Mediterranean diet back to 1614 and an Italian named Giacomo Castelvetro who, unsuccessfully, promoted the consumption of olive oil, vegetables, fruits and limited animal products to the British in exchange for their rather bland, roasted meat-and-potatoes fare. In a parallel article to the PREDIMED study (Something New Under the Sun? Mediterranean Diet and Cardiovascular Health), Sarah Tracy notes that the Mediterranean diet is not a novel approach for Americans, having first been advocated by Ancel Keys in the 1950s and having recurrent appearances since promoting heart health and weight loss.

The virtue of the Mediterranean diet is that it is simple, based in the consumption of fresh vegetables and fruits, nuts, legumes, and cereals, simply prepared  and lightly dressed with olive oil, salts, and vinegars. The main sources of protein are fish and poultry with only rare consumption of red meat. And don’t forget the alcohol, the diet accounts for the occasional glass of wine or beer with meals, up to 5-7 per week with no more than two per day. The combination of fats, carbohydrates, and protein in itself is filling and limiting when built into a complete meal. 

Eat. Real Food. Not Too Much. These are the seven words I live by when it comes to diet. Eat because we have to; Real food is that which is simply prepared; and with portion control so that I never feel overly full. From salads to roasted vegetables to pasta sauces, I can count on one hand the number of ingredients used to prepare these dishes. I focus on creating a complete menu at every meal that consists largely of vegetables, a portion of protein, and some way to tie it all together as a pasta, stir-fry, or sandwich. I cook so that I can control preparation and portion size and I am constantly searching for healthier ways to prepare my favorite dishes. Yes, there are exceptions. I have my favorite marinades, salad dressings, and sweet treats that satisfy my palate. But these make up only a small portion of my overall intake 

Like the PREDIMED study and Giacommo, I am not innovative or novel in my approach. I have my own influences and study multiple recipes by chefs far more knowledgeable and skilled than myself. Furthermore, the PREDIMED study is not the answer to all of our questions on heart health and it did not even consider weight loss as an endpoint (although other studies have shown it to be beneficial in this area as well). The PREDIMED study does reaffirm the need for simple principles when dieting for health because living longer and healthier it is not just a food thing, it’s a lifestyle thing.