I have a patient that is frustrated with her weigh progress and I seek input on what direction to take.  She is eating 1200 calories a day but could likely lose wt on more.  She refuses to eat more calories.  She is working out 2+hrs a day.
She is a 56 year old female, 67", 225 pounds, type 2 DM, HTN, dyslipidemia, hypothyroidism.
Here is a brief hx of visits:
(2/09) 241.5#

Newly dx DMx1 mo

Walking infrequently

Est Nutr Needs to promote wt loss (REE X 1.2)-500=1600 cal/d

(5/09) 232#
Making better food choices-turkey bacon, egg beaters, diet pop, vegs; 3 meals/d, occasional snack

Works in yard-mows 3 acres by hand

I used food models to demonstrate 1500 cals.  She said she never eats that much.  I thought she may eat less foods but more calories d/t svg sizes. 

Goals set: increase activity to 30 min/d  and use booklets to look up foods and track calorie intake
(8/09) 228#

Upset with only 4# wt loss past 3 months

Many medical problems over past 3 months-chest mass evaluated-benign, dental checkup, sleep study, started med for depression, no A/C in house for past 3 months

Still mowing but no activity regimen

Not counting calories but weighing foods

Goals set: Write exact amts of foods eaten and incorporate daily activity

(11/09) 225#

Using pedometer and increasing steps.  Food logs revealed 950-1000 cal/d on some days, others not recorded.  I suspected she is under-eating some days and over-eating others slowing metabolism.  I suggested 1500 cal/d but she refused and agreed to aim for 1200 cal/d.

Goals set: Con’t food logs; consistent calorie intake; increase steps

(2/10) 225#

Walking 2 miles 3xwk

Following 1200 cal meal plan found in a book but getting boring

Says 1200 cal seems like too much food

Showed her how to use meal plan to make own menus for variety

Encouraged daily activity

(5/10) 221#

Food logs reveal 1200 cal/d consistently

She has lost a total of 19.5# over the past 15 months.

My theory as to why she is not losing weight faster is that she is not taking in enough calories.  If she is truly working out 2hrs a day she should be able to lose wt on more than 1200 cal/d. 

Unfortunately, I don’t have a lot of experience with patients who are not losing wt fast enough.  I am usually just trying to motivate them to move.  So what do you think?  Should I convince her to eat more calories?  Or to continue to do what she is doing and she will eventually break through this “plateau”.   Or is strength training the key? 

Any and all input is appreciated.

MH

II think you are probably right that your patient is taking in too few calroies.  Let me explain my thinking.

I calculate her REE (or BMR) as 1600 calories.  She is now exercising basically every day (2hrs?), you probably should be using an activity factor (Harris Benedict) of 1.55 to 1.725.  Thus to just maintain she needs 2500-2760 calories.  If you drop 500 calories for a 1lb/week weight loss, then she should be eating 2000-2200 calories.  Instead, she is eating like 1200 calories, perhaps as much as a 1500 calorie deficit.  And that is perhaps conservative.

My thoughts.  She is stalled because her body thinks she is "starving" and has slowed down her metabolism.  This can be terribly disheartening to someone who is really trying.  And the worst part is that the best way to restart weight loss is to bring her back out of calorie restriction and let her body come out of starvation mode.

My suggestion.  I know it sounds bad and she may think it is wrong.  Bring her back to a calorie level needed to just maintain weight.  Set a "reasonable" exercise goal, cardio for an hour three times a week.  Then your idea of strength training is good, have here strength train on alternate days and leave on day for rest.  Recalculate her calorie needs based on this new activity level and ask her to spend one month just at a calorie level to "maintain" weight (i.e. no calorie deficit).  Then restart her on a 500 calorie deficit and see how she does.

If that also does not work, I have found that intermittent fasting works quite well on myself.  Severe calorie restriction over any extended period of time frankly gives me the "willies."   I don't think it is healthy.

I work with several people in a similar situation, and have found there's no easy answer. Sometimes people are eating more than they believe, even if they carefully measure out foods at meals - they may forget about beverages, or food grabbed on the run. It's incredibly difficult to accurately measure calorie intake.

You mention this person has hypothyroid along with other medical conditions. I always look to see if her thyroid is optinally controlled in these types of cases; often it's not.

I've also learned to look at purposeful physical activity AND movement throughout the day. Sometimes people are purposefully active for 1-2 hours per day, but then sedentary the rest of the day. They probably aren't expending enough calories on a daily basis to lose 1-2 pounds per week.

Thank you for the comments so far. 
I too think she may be taking in too few calories.  It will be a challenge to get her to eat more but that may be the best approach. 
I will further probe her regarding her intake to explore the option of calories she has forgotten to count.  That was always my thought...that she was likely taking in more calories than she thought.  To eat 1200 calories a day for months is a feat!  But she brings in food logs that she keeps on a daily basis. 
I will investigate some more.
MH

I know this subject was discussed back in 2010, but would like to start the conversation again if anyone is interested.  I have an 18 year old client who is type 1 diabetic and has been trying to loose weight to no avail.  Infact she is putting weight on.  She is on a high protein/low carbohydrate diet which has succeeded in maintaining good blood sugars, an HBA1c of 6.6, and dramatically reducing her insulin requirements.  Her  calorie intake is within 1,400 per day and she exercises 4 times a week, walking and resistance training.  She is sticking to 12 to 15oz protein a day, and 40 to 60grams of carbs.  Any recommendations as to what she should be doing now and why she isn't loosing weight?

Two hundred calories per day is not going to make that big of a difference.  Everyone has variance to that degree on a day to day basis.  (If she were eating 800 to 900 calories a day I would be more worried)  1200 calories is  reasonable for most women wanting to achieve wt loss.   The problem is metabolic.  There are issues with wt loss  other than just calorie intake:calorie burn.  Is she being kept at high therapeutic range with her thyroid replacement?  Some individual are still symptomatic in "mid-normal ranges".  Are her monthly cycles normal lengths?  Have we checked for cortisol levels (Cushing's) Recent studies are finding that as many as 10% of Type 2's may have undetected Cushing's.  Also bariatric and micro-biologic studies have identified several specific gut bacteria at higher levels in obese and overweight individuals that more efficiently extract nutrients and CALORIES.  Most people have some residual nutrient/calorie content in their stool, these individuals don't therefore that are getting higher nutrition at lower calorie intake.  There are plenty of cultures where the population lives very healthy at low calorie intake and do not have issues with obesity.  In fact studies have been published that indicate those with lower calorie intake generally live longer!  Increased calories will not rev the metabolism in someone who is active already.  The activity should be doing that.  I have mentioned and provided links on all these things in other discussions.  Please don't get stuck on "OPTIMAL" calorie intake.  That may not even be the issue. Look at the big picture meaning everyone, not just the person you have in your office.  Most people have some variance in calorie intake from day to day and don't have weight issues.  You keep trying to make it the persons fault for not eating the perfect calorie amount.  Most people with weight problems are working on it and try hard.  But you keep trying to make it their fault for not doing it perfectly according to your simple formulas.  Granted, most overweight individuals do need to change eating habits and do have success when they do.  But there are also a lot who won't have success with that.  That generally causes more harm to the individual who is really working hard when we insist on rigid perfection and continue to doubt their efforts and accuracy.   I observe and  know most people without weight problems eat more calories and have less awareness and more variance in their calorie intake but they just don't have weight issues.  Be realistic about that.  Sometimes we don't have all the answers and the answers are not always simple!  As those in the health-care professions we need to internalize that and recognize that when we find it.  We need to rethink how we will respond when we see it.  Please.  We don't know it all yet. 

Depends.  What is her current weight?  1400 calories may be too much of a restriction.  I liked Sonia's comments just before mine here.  We need to realize that there is no one right answer for all people.  My experience with the few people I have couseled that are actively trying to lose weight is that calories do matter, but the same calorie level for everyone is false.  I sometimes have patients that tend to fall into a 'feast or famine' rut.  They will be really good for a few days eating only 1000-1200 calories and then 'go on a bender' and eat 2000-2200. When in actuality they could probably lose weight if they maintained a steady intake of 1500-1700 calories a day (middle of the road).  I think the 'feast vs famine' is the problem.  They are confusing their metabolism, thereby slowing it down in the long run.  But 1500-1700 calories seems like too many calories in their view and it is sometimes a challenge to GET PEOPLE TO EAT when they are trying to lose weight.  I think this stems from the fact that a lot of people are clueless about calories.  1500 calories seems like a lot to a person weighing 250# that might be eating 1000 calories in one meal.  I am in the process of designing a study to look at people's perceptions of serving size and calories.  Can they identify the appropriate serving size when shown pictures of 4 different serving sizes of the same food?  Can they then identify how many calories are the in the serving size they chose to be the 'correct' size?  I can't wait to see what we find. 

Micki and Sonia thank you both so much for responding.  Her current weight is around 165lbs and she is 5' 6" tall.  Just to reiterate, she is Type 1 not Type 2, she is not on any thyroid medication (her thyroid levels are normal), her monthly cycles are 5 to 7 days and regular.  I absolutely agree that this is a rigid programme she has set for herself (having read Richard Bernstein).  I am trying to investigate all the other issues, as you say, other than calories in/calories out and to help her look at the bigger picture.  I am interested in the recent studies on Cushing's, and I am trying to investigate any other areas specific to Type 1's with regards problems with weight loss.  So good to be able to discuss ideas with such a wide group.  Any more of your thoughts gratefully received.

I calculate that at 18 years old, 5'6" and 165lbs, she has a BMR of 1600 calories.  If I conservatively give her a mid level of activity, she needs 2400 calories, practically as an active girl, she probably should have the highest activity level and needs about 3000 calories.  She is not eating enough.

If she claims to be following Bernstein, she is not eating enough fat.  She is eating like 30% protein, 20% carbs and 50% fat.  Bernstein would probably recommend that she up her fat intake, reduce her carbs and alter her protein intake to adjust her weight (she is eating high protein, up to 120 g/day).  Bernstein recommends that you target 50-70 g/day and adjust protein intake up or down to address weight issues.

Another problem she may be having is that if she is exercising aggressively four times a week and undereating, she may be unable to recover properly.  This can result in condition called overtraining, a slowing down of the metabolism, fatigue, elevated cortisol levels and becoming catabolic (burning lean body mass while accumulating bodyfat).

I agree.  I calculated very similar calorie recommendation based on the information I have.  I also agree re: the overtraining and possible slowing of metabolism.  I am too unfamiliar with the Dr. Bernstein diet to comment.  

Clarification.  My previous response was based on the original pt not the 18 yr old.  I didn't pick up on the fact that another pt case was brought into the conversation.  My Bad. 

I had a pt in past with this problem, without DM. She was in her early 60s and was swimming 2 hrs per day 6-7 days per week and consuming 1000 -1200 Cal per day. Through counseling and education, she agreed to increase her Calories to 1600 Calories per day and did start to lose about 0.5 to 1 pound a week.

Thankyou all.  Very interesting.  Do you think that muscle fatigue could also be a symptom of low calorie intake?

If a patient follows a starvation diet, they will deplete their glycogen stores and an obvious first symptom will be muscle fatigue.  Generally, having burned through the stores of glycogen, you will burn bodyfat, essentially going into ketosis.  You can do a blood test to confirm this.  At a certain point, continuation of a starvation diet will result in a catabolic condition where your muscles and organs start to lose protein and you lose muscle mass.  A reasonable description of this can be found on wiki.