Better living through chemistry

Mother's little helper...

The dream, if we were all to be perfectly honest, is the ability to take a pill, eat whatever we want and be thin regardless.  This elusive dream drives a multi-million dollar market of everything from weird little crystals that you sprinkle on your food to prescription medications that are controlled substances. 

The options available over the counter alone are astounding:  Sensa, ketones, ephedra, caffeine, saffron extract, amino acids.  One thing is certain about all of these things - there is absolutely no clinical data to show that any of them work.  There is no data to show that in combination with diet and exercise your results are improved while taking them.  They are mainly a vehicle for creating very expensive urine.  Seriously, if any one of these was actually effective, there wouldn't be so many choices.  Everyone would just buy the one that works.

So what does work?  Right now there are a small selection of FDA approved prescription weight loss medications that are available in the US.  These and a few other prescription drugs that are for other diseases are the only proven adjuncts to weight loss in the US.   In order of their appearance on the market:

1. Phentermine:  half of the infamous phen/fen combo, this is the part that didn't cause mitral valve problems.  The original combo included the phentermine which is an appetite suppressant and fenfluramine which works by increasing serotonin.  The combo was very popular and relatively affective (doubled weight loss over 24 weeks!) while it was being taken.  Phentermine alone is still available and is effective, although not as effective as the combo.  It is a controlled substance due to it's similarity to amphetamine but has pretty low addictive potential. There are a handful of other "anorectics" available, although none seem as popular as phentermine.
2. Orlistat:  Otherwise known as Alli, this drug works by preventing absorption of fat in the intestines.  You take it with all your meals and it mixes with your food and blocks the enzyme that processes fats so they can't be taken up.  Ideally, used in combination with a low calorie diet, it can double your weight loss.  The caveat being that if your diet is too high in fat (>30%) you will have pretty bad side effects (diarrhea, incontinence)  and if it's too low in fat, it won't do anything for you.  BTW, the increased weight loss found in studies was at the prescription dose, not the OTC dose.
3. Qsymia:  The first new weight loss drug to be approved in more than a decade, this is actually a combination of 2 already-available drugs:  phenetermine and topiramate.  Yep, the same phentermine from above.  Topiramate has been long used as an anti-seizure medication and was noted during the use to have co-incidental weight loss.  We actually have little idea as to how it works, but it does.  It too is a controlled substance, based on the phentermine component.
4. Belviq:   Approved shortly after Qsymia, it has yet to be sent to market because it needs to "scheduled" by the DEA.  It is a new drug, locaserin, which works by stimulating serotonin receptors specific to appetite and satiety.  Since it is a new drug, the jury is still out on long term side effects.  As far as weight loss, it too seemed to double the amount of weight lost as compared to diet and exercise alone.

In addition to the above-mentioned pharmaceuticals, it's fairly common for other drugs to be used off-label for weight loss.  In particular, ADD/ADHD meds are well-known for their appetite suppression effects.  The most commonly used, the amphetamine class, includes adderall and dexedrine which were originally created for treatment of obesity.  Neither one is approved for that use now, but they are still widely used (and abused if you call taking someone else's prescription abuse) for that purpose.  In addition, some anti-depressants have been known to augment weight loss, although they may have the opposite effect if the person tends to eat little while they are depressed.  As long as treatment is carefully monitored by a physician, off-label use of prescriptions is common in the medical world and can be effective and safe in most cases.

So within the past 6 months we in the US have doubled our choices of drugs to help with weight loss.  As a weight loss professional, I see nothing wrong with giving these meds a try.  I think if you're otherwise healthy, they can help increase weight lost while participating in organized dieting (Weight Watchers, Jenny Craig).  What I hate to see is people using them while "trying to cut back" and then being upset when they can't maintain the weight loss after they go back to eating poorly.  This should really come as a surprise to no one.  Most people who have success with them need to keep using them long-term in order to maintain that success.  After all, you don't stop taking your blood pressure meds because they work.  You keep taking them.

The chance to cut is the chance to cure

Pressing the Reset Button

      I've been doing weight loss surgery since 2008.  When I first started, I actually didn't intend to do weight loss surgery.  I wanted to do additional training in laparoscopy and most laparoscopic fellowships included some (or LOTS of) Bariatric surgery.  I found a program that looked like it didn't have too much, applied and was accepted.  Once I started training, I realized that a good Bariatric surgeon is like a magnet.  Once word gets out, the inflow of patients is almost non-stop.  So, for better or worse, I did a LOT of bariatrics that year.

    It turns out that it was for better.  I discovered that, despite my inclination going into it, that I really liked bariatric surgery.  I've been varying degrees of fat for most of my life (100 in the 4th grade, 180 in the 8th grade, 170 in college) and it was so rewarding to see people regain their life after losing their weight.  What I hadn't realized prior to fellowship was that the pre-conceived notions that made me think it wasn't a worthy pursuit as a career are the same ones that keep people who need the surgery from getting it.  They are also the same notions that make the nay-sayers say "Nay". 

    We've all heard it:

"You're just taking the easy way out."

"You just need to eat better and exercise more"

"Well, if you ate this way before you had the surgery, you wouldn't have had to have the surgery."

    None of these are even close to the mark.  Anyone who has ever had bariatric surgery can tell you that there is nothing "easy" about it.  It's usually a 6 month or greater slog through nutritionist, psychologist, medical "weight loss" and insurance purgatory  before you can even be considered.  This is followed by preoperative evaluations, weeks of nothing but proteins shakes, moderately painful major abdominal surgery and lets not forget, more weeks of protein shakes.  The culmination of this process is carefully tracking everything you eat for at least the next few months, relearning how to eat (or rather unlearning all the terrible habits you have) and finally getting an organized exercise habit in place.  If you are vigilant, during the first 12 months, you lose about 75% of your excess weight. 

   

    Then, the real work begins.  From year 1 to year five, you have to prove that you actually made the changes and can sustain the new habits and lifestyle.  If you didn't/can't, you regain the weight.  I have seen many patients who have had bariatric surgery 3, 5, or 10 years ago who are now the same weight they were before they started or more.  There is a 25% failure rate and I assure you it has nothing to do with what I did while I was in there, and EVERYTHING to do with what the patient did with it after the fact.

  Speaking of failure rates, the failure rate of traditional treatment - diet and exercise - is 95%.  No, that's not a typo.  Only 5 % of people can lose significant weight and successfully keep it off.  So, while it's a noble idea that moving more and eating less can have the same effect as me and my knife, reality shows this not to be the case.  I'll take the 25% failure rate over the 95% one any day.

    We've all dieted.  It sucks.  It's slow.  It's aggravating.  And, as I showed in the math post, the metabolic numbers do not work in our favor.  Most of us have no real trouble maintaining our weight (be it normal or elevated) because living on 2100 calories a day is not really too bad.  To expect people to eat like they've had bariatric surgery when they haven't is just cruel.  The trick is to not get overweight/obese in the first place.  Only, we figure that out when it's too late. 

    So here's where bariatric surgery comes in.  It's like hitting a reset button.  You have your surgery, you have one year to make the behavioral and psychological changes needed to live a healthier life.  You have one year relatively free of your grehlin and leptin monsters to relearn what real hunger feels like.  You have one year to find something fun to do that involves moving your body again.  You have one year to shed your 100 lb backpack and remember what it feels like (or maybe learn for the first time) to not be carrying around that baggage.  And at the end of the year, if you've done all that, you get a chance to try to eat like a normal human being, and maintain your new healthier weight.  2100 calories a day, just like all your skinny friends always did while you were dieting all those years.

  Data right now says that only 1% of Americans eligible (based on obesity criteria) have actually had bariatric surgery.  That means there are a lot of people out there who may benefit from pressing the reset button.  Food for thought...

Baby Step #2

Establish eating patterns that set you up for success!

On Wednesday, 1/9, we looked at the myths about when/how we should eat.  Using this data, along with a few other recent studies, my advice would be to start altering your eating patterns as follows:

1. Eat 2-3 meals per day, no more, no less.  You teach your body when to secrete grehlin, the "hunger" hormone.  If you graze, it will learn to secrete it all day long and your appetite will torture you.
2. Eat when you are hungry, not when the clock says to.  Don't force yourself to eat breakfast because it's breakfast time.  And don't wait until noon to eat lunch if you're hungry at 10 am.
3. Do not "snack" between meals unless absolutely necessary (going to chew your arm off hungry).  See above about grehlin
4. When you "snack", eat protein.  Greek yogurt, deli turkey, low-fat cheese stick.  Protein slows stomach emptying and almost all proteins are associated with a small amount of fat which causes a leptin surge, making you feel satisfied.  The lack of carbs in the snack also stabilizes your blood sugar, keeping your energy level steady and depressing appetite overall.
5. FYI, a "snack" by definition of the Bariatric surgeon in never more than 150 calories.  If you are trying to lose weight, most of your meals will average 300-500 calories, so a snack should not be 275 calories.
6. "Close" your kitchen after the dinner meal.  Once the table is cleaned off, no more eating until you wake in the morning.  All the studies on obesity and eating patterns show a repetitive pattern of escalating calories throughout the day.  IE, no breakfast, moderate lunch, huge dinner then snacking in the evening.  Some even reveal frequent waking to eat.  This is the one correlation between timing and obesity that is consistently found.  STOP.
7. No eating in front of electronics, EVER. Computer, TV, ipad, iphone.  Try focusing on your meal and the company instead.  Eating in front of entertainment or distractions leads to mindless eating, overeating and decreased satisfaction.  Instead try having a conversation, putting your utensils down between bites and savoring the food and the company.
8. Do not eat out unless you absolutely have to and then only if you know in advance what you are ordering and how many calories its going to cost you.  You have little knowledge and even less control about what you are being served.  Cooking methods are horrific, involving large amounts of fats, added salt, MSG, corn syrup and sugar (especially in chain restaurants.)  Portions are always 2-3 times more than anyone should eat (after all people want to get their money's worth!)
9. When you think you are hungry, drink first.  Thirst often masquerades as hunger.  Drink 8-12 oz of any zero calorie liquid and wait half an hour.  If you're still hungry, you have permission to eat.  Better yet, add a dose of Metamucil to that liquid and lose weight faster.  Studies show that people who take powder fiber supplements lose more weight, more quickly when dieting.  It likely serves to decrease appetite, increase speed at which you fill up and also improves colon health which is ALL good news.
10. KNOW WHAT YOU ARE EATING!  This is probably the easiest and hardest for many people to follow.  If you are eating packaged foods, you have to learn to read labels like a detective.  That's why it's so hard.  So the easiest way to comply is to start eating more simple and natural foods.  Know how many calories are in an egg, what the real serving size is for meats (a deck of cards), how many grams of protein are in your favorite yogurt.  Break out your measuring cups and quit guessing.  And keep a food journal.  You'll be shocked at how inaccurate your guesstimates have been.

Next up:  Bariatric Surgery - Gastric Bypass 101

You are WHEN you eat

“There are three types of lies -- lies, damn lies, and statistics.”
― Benjamin Disraeli

So, in my last post I made reference to the myth of "starvation mode" as it is propagated by the nutrition police.  Today we are going to talk about 3 popular myths about how you "should" eat, where they came from and why they are TOTALLY wrong and are making Americans fatter, not healthier.

Myth number one:  If you eat "too few" calories, your body will go into "starvation mode" and you will not be able to lose weight.
This has been cited so many times, it's hard to figure out where it came from.  Looking through the science, one thing that stands out about this myth is that it is true for the underweight athlete.  Unfortunately, studies consistently show that this effect is not applicable to the overweight or even the normal weight:
Reduced skeletal muscle mitochondrial respiration and improved glucose metabolism in nondiabetic obese women during a very low calorie dietary intervention leading to rapid weight loss

This study in particular looked at 32 year old women kept on a 550 calorie diet for 53 days.  What they found is that they lost 11% of their body weight with no change in their mitochondrial citrate synthase activity (a marker for metabolism.) No starvation mode. But, GREAT weight loss! :)

Myth B:  You have to eat every 2 hours to keep your metabolism "up"

This one first took life in the 1999 book by Bill Phillips, Body for Life.  However, there was no scientific data referenced in the book to support the notion.  As this review paper states, the "thermic effect" of eating food (increased metabolism in response to eating)  is only 10% of the actual calories consumed.
Energy Metabolism and Obesity

It seems sort of silly to think that burning an extra 30 calories somehow justifies eating an extra 300!

 Even now, nutritionists who continue to recommend this eating style, do so not because it increases metabolic rate, but because of the ill-gotten notion that frequent eating of small meals should lead to overall less calories consumed.  However, studies have shown that it actually does the opposite.  In general, the best was found to be 2-4 REAL MEALS per day.  More than 4, you'll overeat calories, less than 2 and your likely to be so hungry when you eat that you'll make poor food choices.

Myth iii:  Breakfast is the most important meal of the day
All meals are equally important.  The key is to eat well and with thought, when you are hungry.  I have lots of patients who tell me they have to force themselves to eat breakfast because the nutritionist says its the most important meal of the day.  If you aren't hungry, you shouldn't be forcing yourself to eat.
As long as you are eating 2-4 reasonable meals per day, you will be fine if one of them is not breakfast. I routinely skip breakfast, eat lunch at 10:00 (I'm up at 5:30 so this really is lunch for me) then am not hungry until 6:00 pm.  There is nothing wrong with eating when you are hungry and not by the clock.

These are all variations on the same toxic theme that seems to present itself repeatedly, wolf in sheep's clothing as it is.  It instructs us to eat more - more often, more meals, more calories - regardless of how we feel or what we know about how much we've consumed so far.  It sings the sweet, false promise that somehow, ingesting more calories will result in weight loss.  It seeks to disavow us of the laws of physics as we know them.  The conservation of mass, E=mc2 doesn't really exist in the land of these myths.  But Einstein was right, if you don't put it in your mouth, it can't end up on your rear!

See you Friday for Baby Step #2

Barbie says "Math is hard!"

Weight Loss Math - the bane of my existence.

 

Don't get me wrong.  I married a math major. I can add large sums in my head.  I am a multiplication wiz.  I know my change before the neanderthal clerk can get the computer to spell it out for them.  I was raised before calculators were allowed within a 2 mile radius of schools.

It's not math itself that is the problem, it's the information that this particular branch of math conveys.  Weight loss math's main downfall is this conclusion that it forces one to arrive at:  It is possible for an obese adult to maintain their weight on VERY little food.  And it takes A LOT of exercise to lose weight without changing what/how you eat. And we are not given this information by any reliable source.  I didn't learn it in high school health class.  They didn't teach it in physiology class at Muhlenberg.  I didn't get it in med school, residency or fellowship.  I figured it out on my own, after spending many years picking over diets, studies and textbooks.

Here are a few numbers to keep in mind when trying to figure out where your weight loss efforts are going amiss:

One pound of fat = 3500 calories

Basal metabolic rate of the average middle aged female =  1272 calories per day
(based on the Katch-McArdle equation)

Maintenance calorie needs for average middle-aged female = 2100 calories per day
(from the American Cancer Society: Calorie Counter Calculator )

(the difference between these 2 is that BMR is if you are lying in bed all day, maintenance calories are if you get out of bed and go about life)

Number of calories you need to eliminate per day if you wish to lose 1 lb per week = 500 calories

Number of calories you need to eliminate per day to lose 2.5 lb per week = 1250 calories

Number of calories burned by running = 105 calories per mile

Number of calories burned by walking =  74 calories per mile

(these are both from the 2004 Syracuse university study showing that we are  overestimating the amount of calories used in exercise:  Energy expenditure of walking and running )

Number of hours needed walking on the treadmill to lose one pound = 12 hours
(based on a 4 mph pace)

So if you eat only 850 calories a day or walk at a fast pace for 24 hours per week you can reasonably expect that in an entire month of that behavior, you will have lost 10 lbs.  That's just flat out depressing.  However, the good news is that if all you want to do is maintain your current weight, you can eat 2100 calories a day and do absolutely no exercise and you should be ok.

Before you start arguing with me that you aren't sedentary or that you walk at a 4.2 mph pace, not 4.0 mph, remember that these numbers are all estimations.  If your goal is to lose weight then you have nothing to gain by manipulating these numbers to suit your circumstances.  None of my patients have ever come to me and said, "I'm burning more calories than your data assumes and now I'm losing too much weight so I think we should adjust my calorie intake up."  Any fudging you do on the front end of these calculations only worsens the impact of the cheating/fudging you do on the back end.  And lets face it, we all slip at times. 

And just FYI, that whole "starvation mode" metabolism thing is utter bull.  I'll address that in a future post, but suffice to say that no overweight or obese person will go into "starvation mode" on a low calorie diet.  There are no studies to support it and I've seen first hand that it just doesn't happen.  I put all my bariatric surgery patients on a 600 calorie per day diet for 2-4 weeks before surgery and while they are purely miserable, if they adhere they lose around 5-8 pounds per week. 

Ultimately, you may ask, "What am I supposed to do with all this math?"  The answer is simple;  whatever you want.  You may use it to decide that you need to ramp up the intensity, duration or frequency of your exercise.  You may use it to decide that you need to start carving calories out of your life.  You may use it to decide that it's hopeless and give up the ghost entirely (I hope not, cuz it isn't hopeless, I promise)  But at least you've got the information in it's distilled form.  My hope is that it will motivate you to do both of the first two and find that it actually does make a difference knowing the math.

New week, new information.  Keep up your food journaling and keep track of the numbers - you may be surprised!

Coming Wednesday:  HOW to eat...really.

Baby Step #1

What is the biggest waste of calories?

Anything in the liquid state.

Before you start defending natural fruit juice, milk, protein shakes, energy drinks, or alcohol, hear me out.

This blog is primarily focused on weight loss.  Not "healthy eating", not bariatric surgery, and certainly not telling people what they want to hear (I'm really bad at that in general!) And when it comes to losing weight, the first thing I tell all my patients (pre-op, post-op and no op) is to never let anything pass your lips that contains calories in a liquid form. 

Water is nice, if that's your thing.  It's not mine.  Diet Coke or any other diet soda works, as does Crystal Light or any artificially sweetened drink mix.  Iced tea or hot, sweetened with Splenda, Equal, Sweet n Low.  Black coffee with the same (no you may not have a mocha-latte-chino with whipped cream!)  Fruit 2 O, Vitamin Water Zero, Perrier or Peligrino.  You're getting the picture by now I think.  In reality, many of these do have a few calories per 8 oz serving, so I generally set the limit at 6 calories or less per serving.  If you've had bariatric surgery, you may want to avoid the bubbles as they can be quite painful.  Having said that, I know many post-op patients that indulge and either never have trouble, or have learned how to overcome their issues with carbonation.

Now, to address the haters among you who are decrying the absence of that wonderful substance, milk, from the above list.  Milk, to be blunt, stinks. Cows milk, just like human milk (which I guarantee, none of you are champing at the bit to drink) is meant to add weight to baby cows.  It was never designed to be consumed by weaned adult humans.  Not even by un-weaned child humans.  Name me one other animal on earth that routinely ingests milk after it is weaned from it's mother....nope, none.  Now name me one other animal on earth that drinks the lactation products of another species... right.

Milk is not naturally full of anything we need.  In fact, our milk is fortified with Vitamin D, Vitamin A (if it's fat free, since the Vitamin A leaves the milk with the fat) and often calcium and protein.  Of course, all this fortification is still not enough to provide us with the amounts we actually need.  This study in particular refuted the idea that drinking milk would protect us against bone loss: 

Milk, Dietary Calcium, and Bone Fractures in Women

Most of us really should be on a multivitamin, Calcium and Vitamin D anyway.  So why waste the calories.

I prescribe protein shakes to my patients on a daily basis.  Used the right way, they have been a fantastic tool in the weight loss game and I couldn't do my job without them.  Their near-ubiquitous availability means many people are on the protein shake band wagon.  The problem occurs when overweight people start using them as a beverage.  I love protein, don't get me wrong.  I think it's the one thing we all need to make sure we're getting enough of daily.  But if you are overweight, you need to use the protein shake as a REPLACEMENT for something - not a supplement.  In other words, if you don't normally eat breakfast and decide to start doing protein shakes for breakfast, you have just added 200 calories to your day for no good reason.  Bad idea. If you normally eat a pack of Donut Gems for breakfast and decide to switch to protein shakes, you just saved yourself 200 calories and added about 9 grams of protein to your day.  Overall a win.  Of note, all protein shakes chosen should be at least 15 grams of protein, less than 200 calories and less than 10 grams of sugars per serving.

As for fruit juice - you might as well have a Coke.  Studies have repeatedly shown that there is a clear association between juice consumption and obesity among children.  There really is no benefit to drinking juice, besides that it tastes nice!  Even though there are some small amount of vitamins present in some (not all) natural fruit juices, it is still not enough to provide us with the amounts we actually need.  This abstract is from a very recent article confirming, once again, that fruit juices contribute to obesity:

http://www.mdconsult.com/das/citation/body/393171468-5/jorg=journal&source=MI&sp=25740299&sid=1394451125/N/25740299/1.html?issn=0090-0036

Most of us really should be on a multivitamin, Calcium and Vitamin D anyway.  So why waste the calories.  (BTW, that repetition was not accidental.)

With regard to "sports" drinks, I am left scratching my head.  Maybe it's because our education system is so crappy when it comes to health related information.  Maybe it's because the language used in marketing is designed to confuse and obfuscate.  But when I see my morbidly obese patients or friends drinking energy drinks, I have to ask "Do you know what "energy" they are referring to?"  Energy, my friends, equals calories.  Why anyone who is trying to lose weight would intentionally down 20 ounces of "energy" is beyond me.  If the label said "Fat Rear", would you drink it?   Yes, you sweated when you walked to your far off parking spot at the mall.  OK, maybe you even spent an hour doing Zumba or riding bike.  But seriously, the only people who need an "energy drink" are underweight extreme athletes.  Ran a full marathon, go ahead, have one.  Ran a 5k?  Have a Diet Coke.

Now, to my saddest statement.  If you are truly serious about losing weight, you should not be drinking any booze.  I know, it stings, really I do.  But in addition to the empty calories (9 per gram, about the same as fat), it has other issues.  First, alcohol increases appetite. The last thing most of us need is an increased appetite, it's hard enough to behave with the one we started with.  Secondly, it decreases inhibition which also means in makes us much more likely to cheat or eat things we otherwise wouldn't.  Jenny Craig or Nutrisystem (I can't remember which) referred to this as the "tipsy taster".  If you need to take the edge off, you'd be better off with a massage, a Xanax or a joint (but only if you live in CO, and only if you can control yourself with the munchies.)  And seriously, if you find that you really can't stop drinking until you've reached your goal weight or are close to it, then you likely have some issues that need to be sorted out that are just as important as your weight, if not more so.

So Baby Step #1 is to eliminate all liquid calories from your life starting today.  Give it a whirl for at least a few weeks to decide whether it's a tolerable way of life for you.  Studies say that if you do something for 60 days straight, it becomes a habit.  And dropping a few hundred calories a day is probably a habit we could all use.

Coming Monday:  Weight loss mathematics! 

Have a great weekend!

Bobby, your Daddy died of dehydration...

I Hate Water!

At work, I have always had to rely on the mutli-disciplinary approach to patient care.  If this is executed in the correct way, the patient gets superior care and I get to offload work I'm not really interested in.  For instance, a GI/Nutrition or Internist can deal with adjusting meds, checking labs, making sure blood pressure is ok, etc.  A PA can do band adjustments and routine pre-ops.  And a nutritionist can modify the diet, help overcome issues with intolerance and can be the early warning for potential problems.

But you'll see that if my "para-professionals" and I aren't on the same page, it can really wreak havoc in this setting.

A perfect example of this is the Nutritionists' insistence that patients drink at least 48 fluid ounces of water per day.  There is a prevaling belief in American society in particular that everyone must drink 8, eight ounces glasses of water each day and that coffee, soda and alcohol don't count.  WRONG.  

No scientific studies were found in support of 8 x 8. Rather, surveys of food and fluid intake on thousands of adults of both genders, analyses of which have been published in peer-reviewed journals, strongly suggest that such large amounts are not needed because the surveyed persons were presumably healthy and certainly not overtly ill. This conclusion is supported by published studies showing that caffeinated drinks (and, to a lesser extent, mild alcoholic beverages like beer in moderation) may indeed be counted toward the daily total, as well as by the large body of published experiments that attest to the precision and effectiveness of the osmoregulatory system for maintaining water balance. It is to be emphasized that the conclusion is limited to healthy adults in a temper- ate climate leading a largely sedentary existence, precisely the popula- tion and conditions that the “at least” in 8 x 8 refers to. 

 Here's the full article in case you're interested:

http://ajpregu.physiology.org/content/283/5/R993.full.pdf

So the take-home message is this:  Drink what you want, when you want, as much or little as you want.  If you are thirsty, drink more.  If your pee is darker than a lemon, drink more. If you are trying to lose weight, drink nothing with calories - it's a waste of calories.  And yes, your Diet Coke and black coffee count toward your daily water totals!

And just FYI, I haven't consumed anything but Diet Coke and Crystal Light for years, and I'm still alive! Just sayin'...