5 Steps to prevent Heart Disease

Thursday, June 30, 2016

Best drug to get off Insulin?

The two times I have gone on Insulin I have gained weight.
I remember in times past I was told Insulin does not cause weight gain by Endocrinologists.
While studying for my ABOM exam, Insulin was high on the list of drugs known to cause weight gain.

On 3-4-14 my Invokana(canagliflozin) switch  experience was very successful for me.

 I lost about 20 pounds during it while not changing my Atkins diet or increasing from my usual 20-40 minute walk a day. I went off Insulin.

Experts Agree Jardiance Reduces Cardiac Deaths  was in the news today:

"Late yesterday, expert advisors to the FDA voted by a margin of 12-11 that the diabetes drug Jardiance (emagliflozin) does indeed cut the risk of cardiovascular deaths for patients with type 2 diabetes who have a history of cardiovascular disease. The committee was unanimous in its agreement that the drug offers good cardiovascular safety. But the vote was much closer on the question of whether it clearly protects against cardiovascular deaths."

My endocrinologist put me on Invokana rather than the newer Jardiance   because it had already been used in Europe.  

"On July 4, 2011, the European Medicines Agency approved a paediatric investigation plan and granted both a deferral and a waiver for canagliflozin (EMEA-001030-PIP01-10) in accordance with EC Regulation No.1901/2006 of the European Parliament and of the Council.[15]
Canagliflozin was approved by the FDA on March 29, 2013, and became the first SGLT2 inhibitor in the United States.[16][17]

Dr. Sarah Halberg TED talk 18 minutes
Reversing Type 2 Diabetes Starts with Ignoring the Guidelines

Metformin and Victoza are two diabetic drugs that drug companies will pay for which also help obesity patients.

I started Qsymia on June 24, 2015:  241 lbs 152 glucose 0.8 glucose

  I have been able to taper off Actos without worsening Hgb A1c as I was losing another 20 pounds during the tapering period.

Actos taper

Actos 40 mg to  30 mg            9-6-15   236 lbs  117 glucose ketones 2.5
                          22.5 mg       9-21-15   237 lbs   139 glucose ketones 1.5
 Stopped Actos                     11-7-15    228 lbs   131 glucose ketones 1.6 

Tuesday, June 28, 2016

The ignored number in Tim Russert's post mortem

In 2008 did cardiologists calculate non-HDLc?

The link above shows two articles that talks about many tests that were done on Tim Russert but never does the following subtraction:

Total Cholesterol:           155
Subtract HDLc   :             37

Non-HDLcholesterol:    118

By the guidelines of that time (which are never referred to in the NYT article), he was not at goal. 

The secondary NCEP goal for non-HDLc was less than 100.

Update on Multiplier effect with using statins early in treating CVD.

My theory called The Multiplier effect 

has been touted by me since I described using it in my lipidology practice in my 2009 book titled
 The Tubby Theory Theory from Topeka.

Once again, Dr. Allan D. Sniderman has done more research re-validating the Tubby Theory and the Multiplier Effect in a research letter on May 18, 2016 in JAMA.

cardiologists did not know what a 
non-HDL cholesterol was?

Back then if a nuclear stress was normal, it was thought you were at low risk of getting a heart attack.
 Doctors  did not know about:
Glagov remodeling of arteries
In 2009 in Topeka I was getting non-HDLc, LDLp, CAC and CIMT on my patients.  
It's nice to see Dr. Sniderman talking about it now.


As with other models in treating chronic disease;
hypertension, HIV, diabetes use multiple drugs for more efficacy and
at lower doses to minimize the side effects for lifelong therapy.
The same is true to lower LDLp or apoB or non-HDLc.
In my medical practice before 2009 I was advising low dose simvastatin with 1,000 mg Endur-acin or Slo-niacin for less than $100 a year.  If treatment goal not met, to then add Zetia.

Now in 2016 we hopefully will soon have cheap generic Zetia, we do have cheap, safer atorvatstatin (Lipitor) and may soon have stronger, safer generic Crestor.

The multiplier effect of combining these drugs and giving them early before complex plaque lesions occur hopefully will reduce the 70% residual risk considerably.

Sunday, June 26, 2016

Biggest news about Biggest loser

The Big News:

Reduced metabolism persist for 6 yrs 

Reduced obese regain weight because of billions of shrunken fats cells that never disappear.  This is like a sponge that is ready to put on fat for the survival of the human.
Thus even at a low calorie diet these fat cells will take on fat.
Only a sub-starvation diet diet can maintain weight loss in the reduced obese.
 This is how 10,000 people have done it at National Weight Control Registry.

This article from Market Watch tells the story of two winners of biggest loser from 2011 who have maintained their weight loss for 5 years.

Excerpt from Emma Court article:

‘What you’re dealing with’
"For “The Biggest Loser” contestants who regained much of the weight, the May 2 study found that their metabolism — slowed from weight loss — remained “suppressed at that same average level as at the end of the weight loss competition.”

This is the really big scientific news. 
 When studying for the American Board of Obesity Medicine that I passed in December 2015,  the lectures I attended in preparation for the exam showed different slides with different opinions as to the length of time on metabolic suppression. 
Indeed I questioned Frank Greenway about his chapter in the text Handbook of Obesity by Bray on adaptive thermogenesis. 
He wrote back and said the chapter was written before the data on The Biggest Loser came out. 
 He corrected this in 2015 with:  Frank Greenway review

Again from Emma Court article:

"But in fact, the Obesity study concluded that, despite contestants’ weight regain, they were “overall quite successful at long-term weight loss compared with other lifestyle interventions.”

"Like Ward and Curlee, the authors concluded that weight loss wasn’t impossible.
Rather, they said, “long-term weight loss requires vigilant combat against persistent metabolic adaptation that acts to proportionally counter ongoing efforts to reduce body weight.”

Commentary on final paragraph
“Weight loss wasn’t impossible”
Kevin Hall et al

Millions of people know they can lose weight, they just can’t maintain the weight loss.

“Long-term weight loss requires vigilant combat against persistent metabolic adaptation”
Kevin Hall et all

Very true but if diet and exercise are the only tools in your toolbox 90% of your patients will not accomplish it. 

The two ladies in the Biggest Loser who maintained their weight loss are not typical patients.

Case One
Ward 40 years old

Quoted from Emma Court's article: 

“For Ward, who’s 40 and lives in New York City, that means what she eats is “maybe not the normal amount of calories a normal 150-pound woman would eat.”
She works within that by eating like a nutritionist’s favorite client — think lean protein, fruit and vegetables — and avoiding simple carbohydrates.
When she does indulge, it feels more decadent than it used to in her pre-TV show days, when it was a far more common and less savored event, she said.

Not to mention, she’s a spin instructor, so she works out a lot — as many as three times in one day.”

Case Two
Curlee 37 years old

“But does fitness have to become your day job to maintain weight loss? That hasn’t been the case for Curlee, 37, who lives in Nashville, Tenn., and does corporate communications for HCA Healthcare HCA.
Though much of her job involves planning wellness programs for HCA, Curlee said that, like most people, she still spends most of her day sitting at a desk.

That means going to the gym at lunchtime, for example, and other kinds of life changes, said Curlee, who is married to a personal trainer.

“When I work, my metabolism does,” she said.

“When I exercise, feed my body what it needs to be fed, when I’m eating 75% to 80% clean, my body does respond. It’s a hard lesson to put in every day... and it doesn’t mean I never have a cheat meal or veer off. I just don’t veer off nearly as much as I used to.”
I agree that diet and exercise has worked for these two ladies just as I believe diet and exercise alone work for the people in the NWCR. 
I suspect these ladies are at less than a net of 1,000 calories a day. 
The rest of the story for Emma Court is to follow this ladies for a few days in their diet and exercise and try to keep up. with normal Leptin levels.
I know I couldn't do it without tremendous effort and suffering. 
To offer this false hope to the rest of society without the help of diet medicine to fight the effect of low Leptin is blind to the science of the disease of Chronic Obesity.  

I analyze Emma Courts excellent article here:
 The rest of the story on Court's article

Thursday, June 23, 2016

Obamacare is gutting Medicare

My response to the NY POST article 

This is a special time for this article to come out as there are other recent pertinent articles

1- My response to NY Post article

2- MSNBC on GOP plan to replace Obamacare

3- Forbes article on GOP plan to replace Obamacare

4- Vox article on Health Care Costs

5- 2014 article on whether ACA affects Medicare

From Sarah Kliff's Vox article:

The US is spending trillions less than expected on health care — and uninsured rates are at an all-time low

Updated by on June 21, 2016, 4:30 p.m. ET

The United States is spending trillions — yes, trillions — less on health care than government forecasters expected when Obamacare passed in 2010.
Back then, the Center for Medicare and Medicaid Services estimated that the United States would spend $23.7 trillion on health care between 2014 and 2019.
But the forecasting agency has regularly and repeatedly revised spending estimates downward over the past six years.
 In 2015, it estimated that health care would cost the United States $2.6 trillion less over that same five-year period, a new analysis from the Urban Institute and the Robert Wood Johnson Foundation shows.

"It’s a pretty significant reduction, and really across all types of spending," says John Holahan, a fellow at the Urban Institute and co-author of the new report.
This isn’t to say that the health care law caused health costs to grow slower than expected. The authors of the report make it clear that while the Affordable Care Act may have played some role, it is far from the main contributor.
Rather, the figures show that the Affordable Care Act hasn’t exploded the federal budget, as critics charge. 
 Quite the opposite — health costs have risen modestly as the uninsured rate has dropped to the lowest level on record.

Medicare alone has cost $455 billion less than expected

One remarkable fact about the lower-than-expected health costs is that they stretch across the entire health care sector. Medicare spending has come in lower than expected:

A bit of this has to do with lower-than-expected health insurance enrollment.
Medicaid, for example, has millions fewer enrollees than CMS initially expected — a product of the Supreme Court making the program’s expansion optional in 2011.
But this isn’t the case everywhere: Medicare, for example, is expected to have 700,000 additional enrollees in 2019 for $96 billion less. 

Think about that for a moment: Medicare will be spending less money to cover more people.

This has everything to do with the fact that per-person costs of health care are dropping.

 Forecasters now expect Medicare to spend $12,527 per person in 2019 — significantly less than their estimate of $13,990 in 2010.

One reason health spending is lower: Obamacare cut Medicare prices

The health care law significantly reduced certain Medicare payments.

 It also created dozens of new programs that pay hospitals based on the quality of care they provide, not just the quantity.

CMS knew all of this when it forecast health spending in 2010.

 But it didn’t know how exactly the changes would play out — whether hospitals, for example, would sign up for the pay-for-value programs or if they would change the trajectory of health spending. 

Much to health wonks’ frustrations, some forecasting agencies refused to estimate any savings from these programs. 
At the time, they were just too unknown.
Now there’s at least some evidence that a handful of these programs are working to reduce costs. 
Hospital readmissions, for example, have fallen sharply since Medicare began penalizing providers for those unnecessary repeat visits.

Less health spending is good news for budgets — not so much for consumers

Budgeteers will likely cheer the slower health cost growth.

 Less spending on health care means more money for the government to spend on other things like education or infrastructure.

But for individual consumers, slower health spending likely doesn’t feel cheaper at all. 

In fact, it probably feels more expensive: One big way private insurers have held down costs is by asking consumers to pay a larger and larger chunk of their medical bills.

Deductibles and copays have steadily grown over the past decade.

 Separate research shows that patients use less health care when they have to pay more. 

Sometimes they cut out unnecessary care — but patients will also skimp on the care they need, too.

Tuesday, June 21, 2016

Is Yo-Yo dieting bad for you or is it excess number of fat cells?

Yo-yo dieting theory vs. Sponge Theory

as cause of easy weight regain in reduced obese.

Yo- Yo dieting is bad for you?

Below is from NEJM, link above

Frank Greenway writes about the new science validated in
The Biggest Loser experiment
excerpt below:

This is where Biggest Loser Experiment was published:

Abstract of Biggest Loser Experiment below


1-  Body Mass Index:48.7 ± 10.1 kg/m2

2-  Weight 144.9 ± 39.4 kg, and

3---Body Fat 49 ± 6% (mean ± SD)

During the first phase of the competition when the contestants were isolated in a boot camp environment,
the average rate of weight loss was 0.4 ± 0.1 kg/d and
 decreased to 0.19 ± 0.1 kg/d after returning home.

Total weight loss was 58.2 ± 26 kg with 
81.6 ± 8.4% coming from body fat. 

The computer simulations closely matched these data and calculated that average energy intake decreased by 65% during the first phase to 1300 kcal/d while participating in 3.1 h/d of vigorous exercise. 

After returning home, energy intake increased to 1900 kcal/d and vigorous exercise decreased to 1.1 h/d.

Simulation of diet alone resulted in 34 kg of weight loss with 65% coming from body fat,
whereas exercise alone resulted in a loss of 27 kg with 102% from fat.

"The Biggest Loser combined vigorous exercise with dietary restriction causing the participants to lose fat and preserve more lean tissue."

"The reduction in metabolic rate is proportional to the drop in Leptin and Leptin is correlated with the drop in body fat. " 

Monday, June 20, 2016

If you write a Weight Loss Diet Book you must address LOOK AHEAD

Above is from page 54 of Always Hungry by David Ludwig M.D.

To my surprise, Dr. Louis J Aronne did not refer to the LOOK AHEAD trial in his book The Change Your Biology Diet.  Ironically, unlike Dr. Ludwig, he does not rely only on diet on exercise to treat obesity.  He also has medications and surgery in his toolbox.

Here is the data every weight loss diet book should present.
It is the best that a 10 year diet and exercise program could produce.

 However,  I don't know any weight loss diet book that has this graph published in it.   After 10 years of work and suffering a 2.5% improvement over the control is the best that can be achieved?

This shows the waterfall effect of the treated group.  39.3% did maintain >10% weight loss and that is great. 

However, the control group had 17.2% > 10% weight loss after 8 years.
Remember, half of the people in the National Weight Control Registry maintain their weight loss on their own.

This speaker still manages to put a positive spin on  LOOK AHEAD

In April 2015 when the lecture in the video above was given, the 

10 year LOOK AHEAD data 

was available:
Quote from the NEJM paper:
"Weight loss was greater in the intervention group than the control group throughout
(8.6% vs. 0.7% at 1 year;
 6.0% vs. 3.5% at study end)."  (2.5% difference)


The False Hope of Diet, Exercise, Medication and Surgery below:

It's all about adaptive thermogenesis.  The shrunken fat cells don't disappear.  The low Leptin level eventually causes the body to regain weight.  30% of bariatric surgery patients regain all their weight after 10 years.  

Even gastric bypass surgery has a waterfall results, with some patients gaining weight. 

In Sponge syndrome with billions of shrunken fat cells causing weight regain after 6-9 months of weight loss because of Leptin deficiency.

This low level of Leptin cannot be treated with one maneuver.  If you look at this flow sheet you will realize why. 

Many different pathways are involved.  Thus ultimately, the treatment of the reduced obese low level of Leptin will be 

Saturday, June 18, 2016

Indication for adding a second diet medication

This slide comes from the Obesity Medicine Certification Review Course for the ABOM exam given in Washington D.C. in December 2015.
The slide belongs to Harold Bays MD and was shown during his Pharmacotherapy lecture.

Best new Diet Books?

Always Hungry by David Ludwig 

Is a great diet book if you want to go on a low carbohydrate high fat diet that is not as restrictive as Atkins.  It allows more low glycemic carbohydrates as you progress in the diet. (nutritional ketosis does not seem to play a role?)  It believes this will reprogram your fat cells.  Of course it doesn't reduce the number of your fat cells. Sadly, Ludwig has no discussion of the other tools in the toolbox:  diet medications and bariatric surgery.

The Change Your Biology Diet
 by Louis J Aronne MD

Is also a great diet book if you want to go on a low carbohydrate high fat diet that is not as restrictive as Atkins. (nutritional ketosis does not seem to play a role?) It also seems Dr Aronne thinks he will out think Leptin with high intensity exercise in the reduced obese.  There is a real difference from Dr. Ludwig in this passage on pages 249-250: 

Dr Aronne also goes into a detailed discussion about the surgical solution for severe obesity in chapter 12.

The Sponge Theory 
I however have a very different approach based on the number of fat cells that never go away even after liposuction.  They eventually come back. 

I learned from both Dr Ludwig and Dr Aronne but I have 
personal experience 
that diet and exercise ultimately fail the reduced obese to maintain weight loss.  
I learned this very early from Gina Kolata's book Re-Thinking Thin and this 1 minute 40 second video.

This idea of the reduced obese regaining weight despite more exercise and strict diet was validated recently in  
NYT article by Gina Kolata- The Biggest Loser

 Thus I must offer my Bon Vivant diet.  
You can't fix the shrunken fat cells with diet or exercise.
It's all about the new drugs.
4 simple points 

How to treat adaptive thermogenesis in the reduced obese. 


Wednesday, June 15, 2016

For the Reduced Obese it is not a sick fat cell, it is a shruken fat cell.

The main challenge in the Obesity Epidemic is to help the people who have lost weight maintain that weight loss.

I learned a major lesson when I watched:
HBO Weight Loss Nation 1 min 40 second video

It is clear to me that fat cells become sick, especially in the apple shaped obese.

However, it is also clear to me that insulin resistance is often reversible when there is weight loss.  Thus the fat cell is not sick it is shrunken. 

It has lost it's fat and subsequently the body has a Leptin deficiency. 

Strange, since the body did not have this Leptin deficiency when it was at this lower weight before. 

The younger body did not have all these billions of extra fat cells that will now never go away. 

These are not sick fat cells, on the contrary, these fat cells are very capable of doing their job.  Storing fat to get ready for the next famine. 

In Always Hungry by Dr. David Ludwig he writes: 


I don't believe low glycemic diet will change the nature of a shrunken fat cell that is deficient in Leptin. 
Dr Aronne in The Change Your Biology Diet offers this approach:

Then he suggests that intense exercise may be the key:

Diet and Exercise have failed to helped the majority of the reduced obese because of the billions of fats cells that remain after weight loss. 
These Leptin deficient fat cells cause the body and the brain to regain weight at low calorie diet and high exercise.

I call this:

The Sponge Theory

How to treat adaptive thermogenesis in the reduced obese

Sunday, June 12, 2016

Fascinating discussion over trial that happened 4 years ago

Low carb diet reduces metabolism less than low fat diet link

David Ludwig vs Kevin Hall  6-7-16

Persistent metabolic adaptation 6 years after “The Biggest Loser” competition Kevin Hall May 2016


Metabolic adaptation persists over time and is likely a proportional, but incomplete, response to contemporaneous efforts to reduce body weight."

 The Biggest Loser NYT article by Gina Kolata 2016

"Danny Cahill

46, speaker, author, land surveyor and musician, Broken Arrow, Okla.
Weight Before show, 430 pounds; at finale, 191 pounds; now, 295 pounds
Metabolic Rate Now burns 800 fewer calories a day than would be expected for a man his size."
“It is frightening and amazing,” said Dr. Hall, an expert on metabolism at the National Institute of Diabetes and Digestive and Kidney Diseases, which is part of the National Institutes of Health. “I am just blown away.”
It has to do with resting metabolism, which determines how many calories a person burns when at rest. When the show began, the contestants, though hugely overweight, had normal metabolisms for their size, meaning they were burning a normal number of calories for people of their weight. When it ended, their metabolisms had slowed radically and their bodies were not burning enough calories to maintain their thinner sizes."

“We eat about 900,000 to a million calories a year, and burn them all except those annoying 3,000 to 5,000 calories that result in an average annual weight gain of about one to two pounds,” he said. “These very small differences between intake and output average out to only about 10 to 20 calories per day — less than one Starburst candy — but the cumulative consequences over time can be devastating.”
“It is not clear whether this small imbalance and the resultant weight gain that most of us experience as we age are the consequences of changes in lifestyle, the environment or just the biology of aging,” Dr. Rosenbaum added.

The effects of small imbalances between calories eaten and calories burned are more pronounced when people deliberately lose weight, Dr. Hall said. Yes, there are signals to regain weight, but he wondered how many extra calories people were driven to eat. He found a way to figure that out.
He analyzed data from a clinical trial in which people took a diabetes drug, canagliflozin, that makes them spill 360 calories a day into their urine, or took a placebo. The drug has no known effect on the brain, and the person does not realize those calories are being spilled. Those taking the drug gradually lost weight. But for every five pounds they lost, they were, without realizing it, eating an additional 200 calories a day.
Those extra calories, Dr. Hall said, were a bigger driver of weight regained than the slowing of the metabolism. And, he added, if people fought the urge to eat those calories, they would be hungry. “Unless they continue to fight it constantly, they will regain the weight,” he said.
All this does not mean that modest weight loss is hopeless, experts say. Individuals respond differently to diet manipulations — low-carbohydrate or low-calorie diets, for example — and to exercise and weight-loss drugs, among other interventions.
But Dr. Ludwig said that simply cutting calories was not the answer. “There are no doubt exceptional individuals who can ignore primal biological signals and maintain weight loss for the long term by restricting calories,” he said, but he added that “for most people, the combination of incessant hunger and slowing metabolism is a recipe for weight regain — explaining why so few individuals can maintain weight loss for more than a few months.”
Dr. Rosenbaum agreed. “The difficulty in keeping weight off reflects biology, not a pathological lack of willpower affecting two-thirds of the U.S.A.,” he said.
Mr. Cahill knows that now. And with his report from Dr. Hall’s group showing just how much his metabolism had slowed, he stopped blaming himself for his weight gain.
“That shame that was on my shoulders went off,” he said.

The above is a great article in NYT by Gina Kolata.  I hope she tells us the rest of the story about the reduction of metabolism in the reduced obese and if low carbohydrate vs. low fat vs. high intensity exercise can prevent it.

 The above is from page 134 of The Tubby Traveler from Topeka when I took issue with Dr. Hall's calculation of 300 calories a day in the energy gap of the reduced obese.  I wrote my book in 2011.
 I used Michael Rosenbaum and Rudolph Liebel's research that people who lose 8-10% of their weight reduced the amount of calories burned during movement by 42%.  Thus instead of needing to walk 3 extra miles a day, my calculation came to an extra 5-6 miles a day.
The people in NWCR walk an hour a day.  3-4 miles a day?  However, if scale goes up they walk more and watch calories more carefully.  At 1500 calorie a day diet I suspect they already are 300 calorie below Dr. Hall's calculated energy gap. 
Subsequently with the Greatest Loser Data my viewpoint has been validated.

NYT Journalist wars

How to treat decreased metabolism of the Biggest Loser

Saturday, June 11, 2016

Exercise intensity to muscle failure still does not make shrunken fat cells disappear

NYT article 7-16 Light weight's as good as heavy

Another Gretchen article 

"The other volunteers began the lighter routine. Their weights were set at between 30 and 50 percent of each man’s one-repetition maximum, and he lifted them as many as 25 times, until the muscles were exhausted.
All of the volunteers performed three sets of their various lifts four times per week for 12 weeks."
"Instead, the key to getting stronger for these men, Dr. Phillips and his colleagues decided, was to grow tired.
The volunteers in both groups had to attain almost total muscular fatigue in order to increase their muscles’ size and strength.
That finding suggests, Dr. Phillips says, that there is something about the cellular mechanisms jump-started in muscle tissue by exhaustion that enables you to develop arms like the first lady’s."

Article on losing weight but gaining muscle

"The other 20 volunteers began a diet that mimicked that of the first group, except that theirs swapped the protein and fat ratios, so that 35 percent of their calories came from protein and 15 percent from fat. (50% carbs)
Over all, their protein intake was about three times the recommended dietary allowance for most people."


Our results showed that, during a marked energy deficit, (weight loss diet diet)
consumption of a diet containing 2.4 g protein · kg(-1) · d(-1) was more effective than
consumption of a diet containing 1.2 g protein · kg(-1) · d(-1)
in promoting increases in LBM (Lean body Mass) and losses of fat mass when combined with a high volume of resistance and anaerobic exercise."

 Trial on High Protein High intensity exercise 2016

Link to Gretchen article above.

I did a similar experiment myself while on Atkins and in nutritional ketosis.
I did not lose weight but I gained muscle.

6 weeks of data in nutritional ketosis and weight lifting

Unlike the experiment described by Gretchen I was satiated by the ad libitum Adkins diet.  I also did not do high intensity exercise.   I could tell my muscle tone and definition was much improved.

I thus went on Qsymia.  I stopped the weight lifting and decreased my exercise to walking 1-2 miles a day.  I simply ate less with the diet medication and began losing weight without the pain described in the Gretchen trial.   I quickly lost the muscle tone I gained.  That is mostly water in the muscle to my knowledge?

I quoted Utimate Fitness by Gina Kolata  in my book The Tubby Traveler from Topeka:

Dr. Louis J Aronne in The Change Your Biology Diet book page 224 talks about high intensity exercise program.

I have great respect for Dr. Aronne.  Perhaps this will be the way people can avoid a great reduction in their exercise metabolism by maintaining muscle mass.  I however believe that the billions of shrunken fat cells remain and that the disease of Leptin deficiency (The Sponge Syndrome) will prevent all those muscles to maintain weight loss in the reduced obese in all but the few.