Overweight patients are not necessarily lazy

My nurse practitioner was pleased to see me at my annual physical this year. “So how does it feel to be 20 pounds lighter?”

“It feels terrible,” I replied.

Allow me to explain.

Weight has been an issue my entire life. Raised on a standard Midwest diet of complex carbohydrates and the best processed delicacies that government assistance could buy, I spent most of my childhood socially segregated by my peer group due to my appearance.

At the age of 13, I was abruptly stricken with an illness and lost over 10 percent of my body weight. When I returned to school, it became clear to me that the way that you look changes your circumstances in a remarkable way. Nothing tastes as good as skinny feels, so it goes. With the help of a few nutrition books, I learned how to count calories and plan an exercise regimen.

Driven by motivations common to teenagers, I realized at 16 that no calorie count is as effective as zero. And I dieted (starved) my way to 148 pounds, my lowest weight at my current height of 5 feet, 9 inches. With a little bit of help from my brother’s weight bench, an emerging surge of testosterone and a shift to a more permissive but vegetarian diet (a decision based on the views of a girl I wanted to date), I filled out the shoulders of my discount polo shirts at 170 pounds before graduating high school.

The freshman 15 was an understatement for me. My ensuing yo-yo looked something like this: 170 earns a pretty girlfriend, fast food job results in a weight of 205, back down to 180 after a break-up, then to 235 when studying becomes more important, graduate school poverty equals 185 and a new pretty girlfriend, etc. In short, being thin was either associated with recently being discarded by a woman, being near death, or praying an ATM would let me exceed my credit limit to afford my next meal.

When I started medical school (205 pounds), I realized that mine was the path to diabetes like my brother before me. I eliminated all sugared beverages and coupled medical school studying with an unhealthy elliptical trainer obsession. The driving force now was not my appearance but creeping triglycerides and liver enzymes. What happens to many of us when we eat too much is that the liver accumulates fat which damages the cells and causes inflammation. There is no treatment for this other than diet modification, and fatty liver disease is rapidly becoming the most common source of liver failure in the United States.

My medical school graduation present to myself was abdominal liposuction which, while only responsible for about 10 pounds, removed a few childhood deposits that would never go away otherwise. It remains today the best money I ever spent.

Old cycles die hard. And while liposuction does remove fat cells under the skin, the body merely finds other cells for storage. I can’t help to wonder if this redistribution may be partly responsible for my sleep apnea and hypertension. My physical last year was a wake-up call, so I recently went back to the faithful trick of calorie counting. Most fad diets yield temporary benefits by draining carbohydrate stores (carbohydrates weigh more than fat), but long term success is only achievable by eating less than you burn. In my experience, fad diets fail because they are either too strict to adhere to or because the body learns how to adapt to the change.

As I ran the numbers, I averaged about 2500 Calories and 45 minutes of cardiovascular exercise a day last year with heavy weight training three times a week. I remembered my younger successes well, and I should be lighter. Alas, aging is a harsh reality. I must exercise more and eat less to achieve the same success. What I found, however, is that my body wants those 2500 calories or else my hypothalamus will make me go looking for it. For many, that threshold may be more like 1500, or it may be 3500.

When presented with an unhealthy food item, I have long found that the average weight person will take a small amount in moderation, the anorexic will shun it altogether out of fear, and the large individual will take more. Obesity is thus in some part caused by choice, but these choices are mediated by internal drives. My lesson from dieting is that most overweight people are not heavy because they are lazy. They are heavy because they need more food to not feel hungry anymore.

To breakthrough and achieve weight loss for the sake of my liver and my blood pressure, I must restrict myself in ways that are no longer comfortable. At the very minute that I am writing this, I just waved off a complimentary in-flight meal because I have already hit my calorie maximum for the day, and the only thing keeping me from wrestling the dinner from the lady sitting next to me is that she is pregnant. (That was a joke.)

I have very few vices in life. I don’t drink. I’ve never smoked. I haven’t had a candy bar, pastry, or dessert in years. I am a one-woman kind of guy. There is no food in my home. My lone addiction is the diet form of a popular yellow soda that I now restrict due to caffeine content. The one thing that has never failed in brightening my day for as long as I can recall is a turkey sandwich. I can’t eat it as often because of the bread. A former favorite dinner of mine, an “organic” burrito, has been stripped down to a salad bowl with soybean meat. I should at least get a discount.

Getting back to my original thesis, my nurse practitioner was not expecting my response. Food restriction has cost me some of my patience and most of my joyful disposition. I think I may have inadvertently given someone a death stare the other day when she said that I looked better.

When given a choice between eating healthier and taking a couple of pills, most Americans prefer the medical solution, and I can completely empathize. Unfortunately for me, however, there is no magic pill. I can’t get the diabolical fat out of my liver unless I say no to food that I like and for some reason my body thinks it needs.

For anyone out there struggling with food, hang in there, and please consult a professional before making drastic changes. For primary care providers, do discuss barriers to diet success and make nutrition a focus of care, but do it in a compassionate way. Overweight patients are not necessarily lazy. They’re just hungry when others aren’t.

Cory Michael is a radiologist.

Image credit: Shutterstock.com

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