Weight Management Lessons I Learned on my Health Journey

Weight Management Lessons I Learned on my Health Journey
July 12, 2016 No Comments » Healthy Lifestyle Brian Fulton
My Journey

Maintaining one’s weight within a healthy target range can become increasingly difficult as we age. It would appear to be easier from some than for others. If you are one of those people whose body tends to pack on the pounds, then let me say that I truly empathize with your challenge on this issue. I am an unlikely figure to be writing on this topic, because I was not “reported” by friends as being overweight. However, you just cannot trust friends to be honest in this area for a multitude of reasons. Fortunately, doctors are more forthright in this matter, and my BMI clearly put me well into the overweight range during my fifties. I was perhaps fortunate in that my body simply tended to put only on about a pound per year as I reached my thirties. However, this put me well into the overweight range by the time I reached my late forties. At the age of fifty-eight, I became very interested in weight loss in the hope that it would not only allow me to lose weight, but also help tackle some of my health issues, which included elevated cholesterol and elevated blood pressure, for which had been treated with medication for several decades. I was showing some signs of classic heart disease. With a family history of heart disease and diabetes, I felt that my future was all but written in stone.

I began reading about weigh management and health, and one of the first concepts that I ran into was becoming more sugar-conscious. The first figure that impressed me was Robert Lustig. His You Tube video entitled, Sugar, The Bitter Truth is a one and a half hour long biochemistry lecture on the evils of sugar. In it, he convincingly communicates that fructose, when consumed in large enough quantities, can have similar effects on the body as alcohol. The metabolism of fructose is virtually identical to alcohol with the exception of the fact that fructose does not cross the blood-brain barrier, and therefore you do not get the “drunken” effects from fructose. If you are a sugar lover, this video may help get you off this “drug”. Sugar seemed an obvious demon given my diabetes history on both sides of my family, so when science and common sense merged, I embraced to concept of sugar as demon and began to lose some weight. The weight loss levelled out at less than ten pounds, and I was still overweight. Slightly disheartened, but still convinced that I should avoid simple sugars, I continued with this way of eating, but still kept looking for more answers.

Another loud voice in the anti-sugar field is Gary Taubes (author of Why We Get Fat and Good Calories, Bad Calories). Both of his books present a strong argument suggesting that the “low fat” approach is the reason for the current obesity epidemic in North America. Taubes proposes that low-carb solution. This is essentially a diet low in refined carbs and high in meat (and therefore fats). It is a modern version of the Atkins diet. Many people appear to have success with this diet, so I tried this approach. It did not last long. I could probably lose weight with this diet, because I just do not love meat enough to eat in this manner. I simply returned to sensible eating, and continued keeping sugar out of my diet as much as possible. It should be noted that I have since learned the flaws in Taubes’ argument and now understand that insulin resistance is linked to intracellular fats and blood fat, far more than it is to dietary sugar; therefore, any attempt to correct sugar/insulin issues by only reducing dietary sugar is bound to fail. This strategy pretty much describes the twentieth century mismanagement of diabetes. (*Note- If blood sugar is an issue for you, and you are either borderline or type II diabetic, a large body of science indicates the need to dramatically reduce dietary fats. The best book to read on this topic is Dr. Neal Barnard’s Program for Reversing Diabetes. Neal Barnard is President of the Physicians’ Committee for Responsible Medicine, and has conducted several clinical trials to back up this powerful approach.)

Anyway, my weight stayed about the same (which was still overweight), so I read and tried the both the South Beach Diet, as well as the Mayo Clinic diet. There are good aspects to each of these diets, but I didn’t see the results that I wanted to see, and none of these diets “clicked” with me. Eventually I watched the documentary Food Matters, and this led me to the documentary, Forks Over Knives. It would be an understatement to say that this movie was life changing for me. The very next day after viewing this movie I gave up meat, cheese, dairy and eggs. What I learned from this documentary was that most of my health problems from age 40 onward were a direct result of cardiovascular disease, and this disease process was reversible through diet. There is now a substantial amount of research showing that heart disease is caused by the North American diet, and it is reversible, and if not at least stoppable by changing one’s diet. I became deeply interested in the concept of nutritional healing, and it is from this journey that I have learned so many interesting things about what we put into our mouths. You do not have to become as committed as I have to plant-based eating to achieve weight loss; however, there is a lot of research suggesting that the further that you move toward a whole-food, plant-based diet, the less your chances will become of developing:

  • the most common cancers (colon, breast and prostate),
  • heart disease
  • diabetes
  • a host of other conditions collectively known as “diseases of affluence”


Additionally you will find weight management to be much easier on a plant-based diet. This diet is a high nutrient, low calorie diet, so it satiates your hunger drive, and gives your body all of the raw nutrients that it needs to keep you happy and healthy.


Whole Food, Plant-Based Resources

If you want to learn more on the topic of whole food, plant-based eating, I suggest the aforementioned movie Forks Over Knives. If you have diabetic or blood sugar concerns, I recommend Dr. Neal Barnard’s Program for Reversing Diabetes. If you have heart or cardiovascular concerns, I recommend Dr. Esselstyn’s book Prevent and Reverse Heart Disease. If you are interested in dietary components to cancer then I highly recommend The China Study by T. Colin Campbell. I could not say enough about T. Colin Campbell. His lifetime of research on the topic of cancer and diet makes him America’s foremost expert on this topic. He is a living example of healthy eating, and he possesses a wealth of knowledge on the topic of diet as it relates to health. If you are concerned about weight loss and want to try the vegan, whole food approach I recommend looking at Dr. McDougall. John McDougall is a charismatic, outspoken physician who had a stroke in his early twenties. This event, coupled with other life events caused him to develop the Dr. McDougall’s Health and Medical Center. His website is a phenomenal resource on this subject, and his two books, The Starch Solution, and The McDougall Program for Maximum Weight Loss offer practical insights into co-managing health and weight. Thousands of people have lost weight and kept it off following his program, which requires no special foods or gimmicks or membership. It simply involves fruits and vegetables.


Weight Loss Help

I recognize that many people are not willing to take a plunge into whole food, plant-based eating, and would prefer to just get their feet wet by eating more plant-based foods, and that is fine! The more vegetables and fruit that you add to your diet, the less room you will have for processed foods, dairy, eggs and animal flesh. The more you move in the direction of whole food, plant-based eating, and the healthier you will become. This is partly because all plant-based foods are high in antioxidants, which help fight cancer and aging. It is also because of the high nutrient density of these foods. It is also because they have not had all of the nutrients processed out of them. As it turns out, your mother and grandmother, and her mother before her all know what was best for you; and this was that famous mantra, “eat your vegetables”.

Studies show that as people eat less meat, they lose more weight. Vegans on average are 40 pounds lighter than meat eating omnivores. Click on this link to view an excellent evidence-based video covering this topic at Nutritionfacts.org. Obesity is linked partly to meat consumption because of the fat content of meat. In one study that looked at a large population of individuals who ate different types of diets, they found the heaviest population was the omnivores (meat and plant eaters). The next lightest group was the flexitarians (those who ate meat occasionally), and then the vegetarians (these people still eat dairy and eggs). The group with the lowest body mass index were the vegans (plant-based eating only). The table below shows average Body Mass Index (BMI), Diabetes and Hypertension scores in these four populations. A BMI of 25 or higher is classed as being overweight (25% body fat or more). Notice the strong association of diabetes and blood pressure (hypertension) with BMI.

Looking at this study, you can see that the more meat and dairy that you remove from your diet, the more likely you are to keep weight off. Now, keep in mind that if one becomes a French fry and potato chip vegan who eats a lot of processed food, one cannot expect to achieve one’s weight loss or health goals. This weight loss rule applies to those individuals who eat in a healthful manner.

An excellent 2012 HBO four-part documentary entitled, Weight of the Nation, looks at many aspects of weight loss and offers some real insight into this complicated problem. I would highly recommend this documentary, which is now available for viewing on YouTube. Dr. Lustig is featured on the episode on sugar.


The Basics

I am now going to introduce you to some concepts for weight management/healthy eating that I have encountered in my health searches. Before we start down that road, here are the basics for a healthy diet that also help to address weight management goals. These common sense ideas also lead to improved health, and this should always be our ultimate goal. If we eat healthfully, our bodies will find their proper weight.

  • Drink lots of water
  • Eat a minimum of processed food
  • Eat more fresh fruits and vegetables
  • Include some raw (uncooked) vegetables in your diet
  • Eat less sugar, less salt and less fat
  • Do more food prep at home where ingredients can be controlled. (Interestingly, even though low income is a substantial health risk factor, low income people who cook at home actually have better health outcomes than wealthy people who dine out once per day.) Controlling your ingredients allows you to better control your weight.


I am not going to cover weight loss tips. There are many excellent weight loss suggestions available and if you want to learn some of these ideas, I suggest that you use the search term “weight loss tips”. You will find lots of tips and tricks on the internet to help you with weight loss. With all of that being said, I want to introduce you to some other broad concepts that I have found very useful in determining what to eat, why my cravings exist, and what to do about them. I have gathered a lot of information here (sorry), so I suggest that you read at your leisure when you have the time. A lot of this information has been covered in my Fulton Massage Therapy Facebook posts over the last few years. If you are on Facebook, I recommend that you “like” my page. I post two or three times per week and provide helpful, evidence-based information to help you become a healthier you.

Losing weight and keeping it off, as you know, is extremely difficult. At the risk of sounding negative, most people will fail in this pursuit. The average person who loses weight tends to put it back on again. So, if one is going to go down a road that causes most people to fail, it would make sense to understand key concepts about why this happens, so that you don’t fall prey to the common traps. To begin with, it is advisable to abandon the idea of a diet, and embrace the concept of a “way of eating”. This means that the changes that you make are permanent, not temporary. I would suggest that you abandon the idea of a diet and embrace the concept of a permanent “way of eating”. This is one of the keys to keeping the weight off. Other key concepts to grasp include:

  • Calorie density
  • Nutrient Density
  • Satiety
  • The pleasure trap (aka the motivational triad)
  • Salt-oil-sugar (SOS) awareness
  • Habituation (aka neural adaptation)
  • Hunger/need/desire for variety
  • Movement/Exercise


I am going to explain each of these concepts and give you links to videos and websites with more information.


1)    Calorie Density

When trying to lose weight, some people try to eat less food. This is bound to fail because you will eventually be hungry, and no one can live this way for any extended period. The trick is to eat foods of lower calorie density, and eat until you are no longer hungry. (Note that eating until one is no longer hungry is very different from eating until one is “full”, or eating until one cannot eat any more. Then we are indeed talking about overeating. This is a different matter from walking around hungry.)

Of all of the concepts described here, calorie density is probably the most important concept to understand. Calorie density is typically described in calories per pound. While no one sits down to eat a pound of anything. The pound is simply used as a standard by which to compare one food against another. To give one example of calorie density, many people will tell you that olive oil is healthy, when in fact vegetables oils (just like animal fats) are the most calorie dense foods on the planet. One full can of coke has about the same number of calories as a mere tablespoon of olive oil! As well, the nutrient density (a concept that we will look at next) of both of these foods is extremely low.

Calorie Density Graph Guide

Unref CC= unrefined complex carbohydrates such as brown rice, whole grain pasta and whole wheat breads.

Ref CC = refined complex carbohydrates such a white rice, pasta and breads that are not 100% whole wheat.

*Note the high caloric density of oils (olive oil, vegetable oil or any oil). Food cannot get more calorically dense than oil. Oils all undermine weight loss. Sugar, which is not on this chart, has a caloric density of 1755 calories per pound.

*Note that junk food, snack food, nuts, oils and many cereals have a caloric load that is even higher than pure sugar. There is only one way that a food could have a higher caloric load than pure sugar, and that is if it contains oils or fats.


If you want a quick introduction to this concept from an excellent, entertaining public speaker then I suggest that you watch Jeff Novick’s short talk on this topic at https://www.youtube.com/watch?v=9gTLpTq1nQk

Calorie density is a key concept to grasp. One example of failure to grasp this concept is eating a salad at a fast food outlet that has the same calorie count as a hamburger or cheeseburger (not a joke). You get a lot of nutritional benefit from eating the vegetables in this type of salad, but you will also be eating a lot of calories. (The calorie density of greens is extremely low, but the calorie density of oil is 2 ½ times the density of table sugar! Likewise, the calorie density of cheese is extremely high; so if you put oil and cheese, nuts and seeds on your salad, the calorie count will likely undermine your weight loss goals.)

As I mentioned, calorie density is generally expressed in calories per pound. No one eats a pound of broccoli, or a pound of cheese. The unit is just used as a convention for comparing one food to another. Research has shown that people can eat freely of foods that are 300 calories per pound or less and not gain weight. People can consume relatively large portions of foods that are between 300 and 800 calories per pound and still lose or maintain their weight depending on their individual activity levels and metabolism. The intake of foods with a calorie density of 800-1,800 should be limited, as these foods can contribute to weight gain and interfere with efforts to lose weight. Additionally, the intake of foods over 1,800 calories per pound should be extremely limited, as these foods can very easily contribute to weight gain and obesity and can also greatly interfere with efforts to lose weight. See the tables above and below to give you an understanding of the calorie density of different foods.

A 2007 report from the American Cancer Institute and the World Cancer Research Fund recommended lowering the average calorie density of the American diet to 567 calories per pound. One can easily do this by following the above principles of calorie density, which allows us to eat freely of unrefined, unprocessed fruits, veggies, starchy veggies, intact whole grains and legumes without the addition of salt, sugar and/or fat/oil.

The tables provided above do not show meat, and the range is broad, but here are some examples of the calorie density of a few of the healthiest cuts of meats. I have also included salmon, which is admittedly one of the fattier fish available. If you are going to eat fish, consider a lower fat fish than salmon. Note that these numbers assume healthy cooking (no added fats or oils in the cooking process).

  • There are 798 calories in 1 pound of Lean Ground Beef (advertised as 90% lean / 10% fat). The actual calorie breakdown of this product is 51% fat, and 49% protein. *Note that while lean ground beef is advertised as 10% fat, the nutritional breakdown reveals that it is actually 51% fat!
  • There are 694 calories in 1 pound of Chicken Light Meat with the skin removed (Broilers or Fryers, Roasted, Cooked). Calorie breakdown: 24% fat, 76% protein.
  • There are 653 calories in 1 pound of Pork Chops (Top Loin, Boneless). Calorie breakdown: 37% fat, 63% protein.
  • There are 830 calories in 1 pound of Farmed Atlantic Salmon. Calorie breakdown: 53% fat, 47% protein.

Note that while the caloric density of meat is actually not too bad, the fat percentage by weight is of concern, even when cooked healthfully (and with skin removed in the case of chicken).  However with the sauces and oils that are added in most cooking, and the fat that exists in many cuts of meat, the commonly touted figure for cooked meat is 1000 calories per pound. Note that the caloric density of most pasta, white rice and white breads is higher than the caloric density of meats.

Here is another helpful way to view calorie density. This website has pictures of several different foods. Each picture has 200 calories of a given food: http://www.dailymail.co.uk/news/article-2280846/Revealed-What-200-calories-looks-like-different-foods–results-surprising.html

Here is a link to an article on this topic http://www.forksoverknives.com/the-calorie-density-approach-to-nutrition-and-lifelong-weight-management/?utm_medium=email&utm_source=Newsletter062612

Here is another article on this topic http://www.sciencedaily.com/releases/2007/06/070608093819.htm


2)   Nutrient density

While not critical to dieting, nutrient density is an important health concept. Interestingly enough it typically has an inverse relationship with calorie density in most foods. In other words, foods that are low in caloric density typically have high nutrient density, and vice versa. So as you switch to vegetables, not only do they fill your stomach while also being much less fattening; they also pack way more nutrients than a similar weight of high density foods. You may have heard the term Superfoods. These are foods with high nutrient density but low caloric density.

*Note in this chart to your right that even vanilla ice cream contains four times as many nutrients per gram than olive oil. Despite what marketing you encounter and what people tell you; olive oil (or any oil for that matter) is not healthy eating, and it has a very high caloric penalty. If you like olive oil, then eat unsalted olives. The same holds true for any other oil. Eat the whole food, not the oil.

*note- In the table provided, the superfood kale was given an arbitrary benchmark score of 1000. This is because of all foods tested at that time; kale had the highest nutrient density. All other scores show how any given food measures up to kale.

Here is a web article on the topic of nutrient density. http://www.peertrainer.com/diet/nutrient_density.html

Here is a website with lots of information on caloric density and nutrient density: http://www.theranchmalibu.com/blog/?p=1037


3)   Satiety

People tend to eat the same weight of food each day (3 – 5 lbs. depending upon the person). We tend to eat till we are full, and then (hopefully) we stop eating. One quick method to fail at dieting is to try to eat less food. This will generally not work, unless the individual was previously binge eating. Generally you need to plan on eating until you are just full (i.e. don’t stuff yourself). If you are full, then stretch sensors in your stomach tell your brain that you are full; curbing your need to snack. If you are not full, then you will be feeling hungry, and this is a recipe for diet failure. The way to lose weight then lies in eating a normal amount of food, but to eat foods of lower calorie density, rather than trying to just eat less of foods with high caloric density. The graphic of the human stomach illustrates the connection between satiety, calorie density and weight loss.

Remember as stated earlier that eating until one is no longer hungry is satiety. This is very different from eating until one is full, or eating until one cannot eat any more. Then we are indeed talking about overeating. This is a different matter from walking around hungry.


4)   The Pleasure Trap

The pleasure trap is a motivational triad that guides not just us, but all animals on the planet. This concept, put forth by research psychologist Doug Lisle is a well accepted behavioural principle. Here is a link to a video on this topic: https://www.youtube.com/watch?v=xAdqLB6bTuQ . This talk is a bit long, but his take on weight issues is quite interesting. The motivational triad that guides all animal behaviour on the planet involves:

  • Pain avoidance
  • Pleasure-seeking behaviour
  • Energy conservation (minimum effort for maximum results).

The pleasure trap explains why we are so drawn to fats, sugars and salts. Our brains are hardwired to seek out these compounds in foods because they are essential to our survival, and they were typically in low concentration in the natural environment. Times have changed from the plains of Africa, where our forefathers had to forage for food. Now we can eat unlimited amounts of any of these compounds. The pleasure trap also explains why when we switch to a healthy diet, most of us fail. Rather than doing a poor job of explaining this, I suggest that you check out his video.


5) Habituation (aka Neural Adaptation of Taste Buds)

Habituation is a concept that you are already aware of. You have undoubtedly experienced this with cologne or aftershave that you or someone else was wearing. When you were first exposed to the scent you noticed it. Twenty minutes later it appears to you that the scent has worn off when in fact it hasn’t, because your brain has habituated to the smell. The same phenomenon occurs with mild pain levels, noise, and taste. This is why you will encounter people with very strong perfumes. They think that it is not that strong because they have habituated to the scent. The same thing happens with our taste buds. The good news is that we can adapt to lower levels of salt sugar and fats and food can taste just as good, but it actually takes several weeks for this to happen. If you watch Doug Lisle’s talk, he covers neural adaptation in his pleasure trap talk. Neural adaptation happens in phase III and phase V of the pleasure trap.


6) SOS Awareness – (Salt-Oil-Sugar)

It is the pleasure trap that hooks us on salt, sugar and fats, but as you can see from the calorie density scale, oils and fats need to be largely removed from our diets if we are trying to lose weight, or to keep weight off. Don’t worry about not getting enough fats. You will easily get enough fats in your diet in the foods that you eat (even if you were to eat only vegetables) without adding more fats.

Pure sugar needs to be avoided due to its caloric density, but also because of its links to diabetes, premature aging and cancer. In its pure form it is extremely detrimental to long-term health, and should be removed from our diets as much as possible.

This leaves salt. Salt, like sugar and oil is essential for life, but you do not need to add it to food. If you eat out in restaurants or eat processed food then you are unquestionably eating levels of salt that are high enough to be impacting on your health in a negative manner. Salt is the cheapest way to make food taste good, since it acts as a flavour enhancer. The problem is that salt elevates blood pressure (hypertension) which is a major factor in strokes, heart failure and heart attacks.  There is also increasing evidence of a link between high salt intake and stomach cancer, osteoporosis, obesity, kidney stones, kidney disease and vascular dementia and water retention.

Once you become nutritionally awakened, you will realize that cannot control fat, sugar and salt when dining out of your own home. These refined food constituents are all put in food to stimulate the pleasure centres. The only solution is to find those few restaurants that are SOS friendly or to seriously curb dining out. Note also that because of taste, restaurants rarely serve whole foods; so you will generally find they serve white rice, pasta that is not whole grain, and at best 30% whole wheat bread. You have to begin to equate white bread, white rice, and pasta to an image of sugar if you want to actually eat in a healthful manner.

As you can see when you look at the typical North American diet that we have all gone seriously off the rails. If you try and eat healthy you will be regarded as a health freak. This is because 61% of Canadians are now overweight (having a BMI of 25 or over). This means that the majority of us are overweight, so of course you will be in the minority if you choose a healthy lifestyle with healthy eating habits.


7) The Hunger for Variety

Every animal on the planet has an inbuilt hunger for variety. The survival dynamic at play here is that the organism is more likely to get a broader complement of nutrients if it eats a variety of foods. You are also less likely to experience the negative effects of build-up of toxic trace substances that exist in many foods sources if you eat a variety of foods. The hunger for variety could be viewed as a natural extension of neural adaptation. After we eat a food item, our taste buds habituate to it and we yearn for something different. The hunger for variety is a powerful, helpful instinct that helps to round out our diets with more balanced nutrition. It is a good thing. We just need to keep this drive in mind when planning our new diets. If the new diet is too restrictive, it will fail in the end. However, this principle actually works quite well as a short-term weight loss method. These diets have you eat specific foods with little variety. For example if you have a one-dish meal, you will eat until you are full. At this point, you will stop eating if not presented with new, different food. As a result, you eat less with this method of weight loss. A permanent/long-term diet needs to have many healthy options for you to eat though. If it doesn’t include a healthy variety of options, you will definitely seek out and find variety, but it is not likely to be a healthy option.


8) Movement/Exercise

Sorry, but we can’t get through this topic before mentioning exercise at least once. Exercise alone is a very difficult way to lose weight because you simply cannot outrun your mouth, and this is the reasons that I have left this topic to the end. There are hundreds of reasons to exercise. Exercise affects not just our physical health, but also our emotional and mental health. Exercise can also help us maintain a healthy weight by temporarily raising our metabolic rate. The challenge is that exercise often also increases our appetite, so it is important to eat low calorie food and not go for the quick fat fix after your workout. In one health eating group that I belong to I did a poll to see how often people included regular exercise (defined at 30 minutes of exercise four times per week). I was surprised to find that 75% of people exercised regularly, even though 99% of the discussions of this group centre on food.

The type of exercise that appears to yield the best bang for the buck is “interval exercise” or fartlek. Exercise intervals involve short burst of high intensity exercise that are maintained for about 40 seconds to one minute in duration. You then return to your target heart rate until you recover. After you have recovered, you do a short burst again. A thirty-minute workout might include six or more of these high intensity bursts. You can incorporate intervals into just about any type of cardio exercise. Interval training has been shown to rev up our metabolism, causing our bodies to burn fat hours after our workout, improving fat mobilization and utilization.  This is where big gains are made in weight loss over traditional aerobic training.

It is Interesting to note that as a fuel, carbohydrates tend to increase metabolic rate, whereas fats and protein appear to have opposite effects. Fruits and vegetables are largely carbohydrates, so it should be no surprise to find that vegetarians tend to have higher resting metabolic rates than non-vegetarians. The metabolism of vegans and vegetarians appears to be increased by a factor of be 11% versus non-vegetarians. One of the reasons for this is that there is an enzyme known as Carnitine Palmitoyl Transferase (CPT). This enzyme shovels the fat that we eat into the furnaces in our cells. The more active CPT is- the more fat we burn. CPT appears to be significantly upregulated in vegetarians, boosted by a factor of 60%. So, in conclusion, exercise, combined with carbohydrates as a primary fuel help to raise one’s metabolic rate, which will aid in weight loss.


In Conclusion

I hope that you find some of the information in this article to be helpful. Falling off of the wagon is something I, and all humans all do extremely well. I continually use the information listed here help pick myself up and climb back on to the health wagon after I fall off. I constantly find the need to remind myself of my health goals, and my strategies. The intent here is not to preach, or to hold myself out as an expert on this topic. More than 50% of our population battles with weight, so clearly it is not an easy or simple issue. It is only because I have found my own struggle so difficult and because have found these concepts so helpful in my own journey that I have shared them with you. I hope that you find some benefit in the information provided.

Regards- Brian


Legal Waiver- This site does not provide medical information. Before making changes to your diet, consult your primary care provider.


About The Author
Brian Fulton Brian Fulton has been a Massage Therapist in Ontario Canada since 1999. His approach toward health and the human body is broad and holistic in nature. Brian is also the author of The Placebo Effect in Manual Therapy: Improving Clinical Outcomes (available on Amazon)