When it comes to weight loss, what is your goal? Is it just so the scale will show a different number? Is it to get down to a certain weight and stay there? To be healthier? To fit into a certain outfit? To get off your medications? To avoid illness? Everyone’s goal is different, but to make the weight loss journey the most meaningful, it’s important to know why you are going through the trouble.
And what trouble it is! Weight loss and maintaining lost weight are almost impossible for so many people. When I tell people I struggle with my weight, many do not believe me. From an objective standpoint, when you look at numbers alone, you would say that I have never had a weight problem. My body mass index was never even close to the magic number 25. However, my weight got to be uncomfortably high for me, which is what finally triggered me to join Weight Watchers at 144 pounds. And, as you already know, I have been as low as 125-ish over the past 12 years that I have been a lifetime member of WW, but I set my goal at 135 and have pretty much been 133 – 135 most of the time. I have never had to pay for a WW meeting since I became Lifetime — once you are Lifetime, you only have to weigh in once a month, and you can be up to 2 pounds above goal before you have to pay for a meeting. Not that paying would be that much — it would be only 12.00 and you only have to pay that until you are back at goal, but it’s a matter of pride.
As I have gotten older, losing and keeping weight off is much more difficult. I used to be able to overeat significantly for a day, a week, or even two weeks, but take the gained weight off within a week. I lost all my pregnancy weight with all three kids within 4 months of delivery. If I binged all weekend, I might pay for it by restricting my eating during the week, but would be fine by Friday.
But now, a 2-pound holiday weight gain takes weeks to come off, and it doesn’t happen if I go back to “normal” baseline eating — I have to cut back by not having any alcohol, having only one carb serving at dinner, and sometimes eliminating my half cup of low-calorie ice cream for a few days. That zero PointsPlus fruit allowance at WW doesn’t work too well for me — I find that the weight goes up if I eat as much fruit “as I want,” which would mean about 8 pieces a day. I know, that’s a lot, but it’s really easy for me to eat that much fruit. So I limit myself to 3 – 4 servings of fruit a day. I had been enjoying a whole banana twice a day, but now I have only half a banana twice a day, and a piece of fruit at lunch and for a snack, and occasionally some more at dinner.
Understand, this is on maintenance. I really have to jump on any gain, even if it seems small, because there would be a cumulative, stacking effect if I ignored a 2 pound holiday weight gain — this has happened to me before, and I don’t want it to happen again. Basically, I have accepted and adjusted to the fact that if I want to keep my weight down below or at goal, I will never be able to eat everything and anything I want, because I am a bottomless pit. Not due to hunger, but just because I love to eat. The taste, the texture, the way it feels going down — the whole bit. Like, right now, I feel physically satisfied — I finished lunch about half an hour ago. But if I let myself, I could easily be tempted by more of anything, even fruit. I could easily eat all day long, even beyond fullness to stuffedness, because the desire to eat doesn’t have to be linked to hunger. But over the many, many years (since the age of 9, actually, when a relative told me, “you’ve put on quite a bit of weight, haven’t you? and even before that, when I noticed that my thighs were really chubby compared to those of my peers) that I have been weight-conscious, I have trained myself. So many times a week, I hear from my patients, “I know what I have to do, I just have to do it.” I know what I have to do, and I do it. In fact, that Nike catch-phrase, “Just Do It!” is my mantra when my alarm goes off at 5 a.m. and my whole being does not want to get out of that warm bed and go to the gym.
How do I do it? I have a million and one strategies, plans A, B, C, D, and down the alphabet. I leave myself no options. I refuse to buy bigger sized clothing. I avoid monotony. I surround myself with people who are supportive. I am extremely vain and really like looking good.
So what is the point of my going on and on about this? I am not bragging, and I know I am genetically lucky (although nowhere near as lucky as my Mom or my son, Woody, or my husby, cb, who pretty much stop eating when they are full and barely think twice about what they put in their mouths, never have and never will, and I am very, very jealous of them). The point is that even someone like me — a person who has never been overweight, who eats healthfully, who has always been physically fit and engaged in physical activity, who hates fast food and loves fruit and vegetables and “whole” foods, eats low-fat, good carbs, little junk food, no sweetened beverages — has to make keeping my weight where I want it to be one of my highest priorities. And even someone like me has to exert tremendous — mostly mental — effort to take off a few extra pounds.
So it must be a nightmare to try to lose weight when you have a lot more to lose. Things seem to be stacked against even the most motivated person. It is coming to light that people who are obese or morbidly obese who manage to get to a healthy weight require several hundred calories fewer a day to maintain that lower weight than those who have always been at that lower weight. People seem to have weight set points which are hard to change, so that when a person loses weight below the range of that set point, the body does everything it can to get back to the old, higher weight. People seem to be able to lose 5 – 10% of their weight relatively easily, and then the weight loss almost invariably stalls, and, even with continued effort, may inch back up. People get down to goal weight, and regain the lost weight plus more. Very few individuals seem to be able to take off and keep off large amounts of weight. Those who do have learned that they cannot let their guard down, ever.
The other thing that happens is that people want quick results, which makes sense, because why put in all that work if you weigh 300 pounds and you are only going to lose .5 to 2 pounds a week? So they take drastic measures with diet and exercise, like SlimFast, or Atkins, or Optifast, or the Cabbage Soup Diet, and they get on the treadmill for three hours a day, seven days a week, and after a week or so of this, they may have lost 20 pounds, but they are irritable, light-headed, constipated, starving, and thinking about ice cream sundaes all day and dreaming about cheese steaks in their sleep. And then, someone brings chestnut doughnuts to work (I heard about these today from Jane and Michael Stern, on The Splendid Table) and they say, “I will just have one bite of one doughnut, just to see how it tastes, it won’t hurt me, I have been so perfect for so long. . .” and then it is all over. It is a bite, then a whole doughnut eaten very fast, then another, then McDonald’s or pizza for lunch because “I blew it, I may as well really enjoy myself,” and the backslide begins. They don’t even get back on track for dinner or the next day, because either they feel bloated from the binge, or they realize how much they have suffered over the past few weeks, and, if they are dumb enough to get on the scale the next day and are up 7 pounds (which cannot possibly be more than .25 pounds of real fat, and will probably mostly be gone the next day if they go back on track immediately), they figure, what’s the use, what was all that work for, all that suffering, and they give up. And because the body was in starvation mode, it requires fewer calories than ever, and the weight regain will likely end in a higher number on the scale than ever.
Where do I get this information? I did not make it up. These patterns have been described in the medical literature, and are being studied in top research centers. I have repeatedly read about these sorts of scenarios.
Also, I see this every single day in my internal medicine practice and in my bariatric practice. Obviously, I see it in my bariatric practice — numerous patients with BMI’s up to 80 — yes, 80! — most of whom have had experiences like those described above, and now they will need weight loss surgery to have any chance of achieving a semblance of a normal life.
Once you reach a certain weight, you have a very small chance of getting to a healthier weight without some sort of weight loss surgery, probably because of some of the metabolic and hormonal changes that take place as the BMI increases. Unfortunately, even weight loss surgery is no guarantee of a lifetime at a healthy weight — many who have the surgery who lose the necessary weight regain a substantial portion of the weight. For most, they are way better off than they would’ve been without the surgery, but for quite a few, ALL the weight plus comes back on. Sorting out and predicting who is more likely to have that happen is very difficult, but in some cases it is possible. There is a lot of controversy in the medical literature about how to predict good or bad post-surgical outcomes. Some researchers say there is no way to predict, and others have found an association between weight regain and certain pre-surgical eating behaviors.
I think it’s a mix. I think there are a lot of people who will not be able to lose significant weight in a sustainable way without surgery, but I also think that there must be an effort with lifestyle change, and that weight loss and improved health must be a priority in order for the surgery to have the optimal effect. Behavioral counseling alone is not that effective, it turns out, (although I think it helps some people) but cognitive-behavioral therapy (more specialized) is. Exercise helps keep weight off also, but the person must be willing to be persistent and consistent with physical activity. People must be willing to come in for regular follow-up visits after surgery, even if there is a lapse or a plateau in weight loss. The irony is, that although these instances can be so discouraging as to deter patients from making these follow up appointments, they are the very issues that should compel an individual to follow up asap.
Anecdotally, from what I see, I am pretty good at predicting who will do well and who will not after weight loss surgery. One problem is that after a year or so, when the weight loss slows, and begins to go back up, patients tend to not come back for help (as alluded to above), sometimes ever, so we don’t know what happens to them, or sometimes only after half the lost weight has been regained. The ones who do come in for help tell me they waited so long because they were embarrassed about the regain, or because they thought they could get back on track themselves.
So far, I have been pretty accurate, though, about the ones who will do poorly. These are folks who skip appointments, who do not keep food logs, or who keep inaccurate food logs, who look at the insurance requirement of six months of a medically supervised weight loss plan as just another hoop to jump through. The people who gain weight during the six months are usually those who put no effort into the program, and they do not do well in general. Many think the surgery is a quick fix, and if they could lose weight without surgery, they’d have done it already, but that is the wrong view to take. The point isn’t to lose a lot of weight before surgery, it is to work on lifestyle change so that it will be easier to adhere to dietary recommendations and exercise recommendations post-operatively. A person who weighs 350 pounds who sticks to a 1500 or 1800 calorie diet will definitely lose weight in six months.
The question is this: how can you explain weight gain in this kind of patient? I see patients who have to be put on a very low calorie liquid diet prior to surgery in order to get the weight down to 400 pounds. The risk of surgery is greater the higher above 400 pounds you go. The surgeons like to keep the risk as low as possible — they are not asking for miracles, just to get the weight to that level, and this sort of pre-surgical weight loss seems also to make the liver smaller and easier to manipulate during surgery. So this is the one occasion in which I recommend this type of extreme regimen, almost always at the end of the six-month attempt at lifestyle change. The powdered shakes are provided to the patient, and each shake has 35 grams of protein. The instructions are to drink 3 shakes a day and pretty much unlimited (non-starchy) veggies. The patients are instructed to come in weekly for follow up, and if they are on insulin, I work with them to adjust their doses. Many people lose large quantities of weight in no time. But there are actually some who gain weight or do not lose a pound. These people claim they are following the plan “to a T.” No deviation. No lapse. “Just the three shakes a day, like you told me. I am doing exactly what you told me to do.” And week after week, the weight does not change.
The diet is about 700 calories a day. It is virtually impossible not to lose weight on that number of calories a day, but the patients are so adamant that I want to give them the benefit of the doubt: that for some reason, although for 6 weeks they have 100% followed the liquid diet regimen, the weight has gone up 5 pounds.
I wonder what the reader thinks of this. Has anyone out there honestly had the experience of being on 700 calories a day and over a week not lost weight? If so, I want to hear your story. I am just so baffled. Why would a person come to see me if they did not genuinely want my help? I think people want me to lose the weight for them, as in, “You’re the doctor, do something for me.” They think just coming in for an appointment is effort enough. In addition to counseling, and managing medical co-morbidities of obesity, I do prescribe weight loss medications in appropriate settings. They are absolutely not for everyone, but in some cases, they can help a lot.
This question carries over to my regular practice in internal medicine. Recently, I saw three patients with concerns about their weight. Each person had come to me to help with weight loss, but none had or were willing to make the changes that would result in weight loss.
One was a bariatric patient with weight regain. The reasons for the regain were obvious to her and to me. She said, “I know what I have to do.”
Another was someone who has lost some weight. This person is not a candidate for weight loss surgery. She has lost on the average of less than two pounds a month, which is less than half a pound a week, although in the past 3 months, her weight has been stable. She brings in a food log every time, and has made almost no changes in her eating since last year. I asked her whether she thought she was getting anything out of her visits with me, since I do see her quite frequently and there’s been so little change. She told me, “I don’t always agree with what you tell me.” This is pretty clear, since she has done virtually nothing I have recommended. However, she claims to want to lose weight, and to still want to come in regularly. I asked her to think about how I could help her more.
A third person said, “This is the year I am taking care of me,” and went on to share that “I need to do something about my weight.” Her weight had been going up steadily over the last few years. She told me that in the past 5 years, she had gained about 50 pounds. The last time she was successful with weight loss, she hadn’t made any eating changes, but had exercised a lot — walked around the track for several hours a couple of days a week, at least. Now, she was doing no exercise at all. She didn’t think her eating habits were too good, because “I eat too little.” What she meant by that was that she often ate on the run, or in her car, because her job required her to go from place to place unpredictably. She would go to McDonald’s, because it was convenient, although she knew that wasn’t a good idea. She would snack on junk food. She was too tired to prepare healthful meals at night. When I suggested bringing non-perishable, healthier options with her in the car, she made a face. “I’ve tried that. But then I look at it and say, ‘I don’t want that today,’ and then I go to McDonald’s, because I really like McDonald’s.” When I suggested she try moving more since that’s what helped her in the past, she told me she had gotten some exercise tapes to use at home, which she did occasionally. She didn’t see having any time for more exercise than that. My attempt at motivational interviewing completely flopped — although she had come in stating she really wanted to do something about her healt and her weight, she was willing to make zero changes in her lifestyle which might promote weight loss.
The main thing about weight loss is that it is not going to happen by itself. If you make no changes, it is not going to happen. One saying at WW is, “If you keep doing what you’ve always done, you’ll get what you’ve always got.” The person who wants to lose weight has to recognize that it is not going to be easy and that it is going to take dogged persistence. Not giving up is key. Not suffering is also key. The goal is important, but the journey is just as important. I said that I had to constantly think about my weight, but that doesn’t mean I am miserable. On the contrary — I like my lifestyle and the way I feel. The struggle is more mental and emotional, because I am battling my demons all the time, not because I am undereating.
It is a burden and boring sometimes, but I try to make it interesting by changing the kinds of exercise routines I do, and trying new foods and new recipes. I can’t say I enjoy preparing my lunches the night before, but I love having the lunch all prepared in the morning when I am set to go off to the office. I can’t say I like getting up at 5, but I do love the way I feel after a workout. I may wish I could snack constantly on a bag of pretzels, but I prefer to have a piece of fruit, fit into all my clothes season after season, and have lots of energy. Weight management is definitely a trade-off. To do it successfully, you have to make it as appealing as possible, and you should never be “on a diet.”
