Thursday, May 23, 2013

My Lonely Journey from Almost Obese to Almost Healthy

We Americans are fat.

We were able to hide it for awhile under our loose fitting dresses and Hawaiian shirts, but now it’s staring us in the face.  One-third of American adults are obese, and obesity among children has risen from 5 to 18 percent in the last 30 years.  Almost no one looks good from behind anymore. 

The costs and consequences involved with this new obesity epidemic are much more serious than just those related to the additional fabric needed to cover us.  Type 2 diabetes, which we used to call adult onset diabetes when I was in medical school, is now occurring in childhood.  The estimated medical costs related to obesity-related illnesses were nearly 21% of our annual medical expenditures in 2005.  Many of these costs are covered by Medicaid and Medicare, two important programs that are under attack because of their high price tags.  The U.S. military has a smaller pool of potential recruits because so many in the pool are too large.  Airlines are now charging many of us for two tickets or forcing us to move up to business class if we can’t fit into a seat with the arms down and an extension seat belt.  Hospitals are renting and buying extra-wide wheelchairs and big sturdy beds as well as training attendants on safer ways to move obese patients.

But that’s all part of the “big” picture (sorry!).  Let me get closer to home.

I've known for a long time that I needed to lose weight.  I tried to fool myself into believing that I hid it well, but I've been in the official “overweight” category for most of the last 20 years.  I’d usually slim down some in the summer, when I’d get more exercise outdoors, but it always came back in the winter.

I've also had a persistent sense of guilt, since I've felt I should be a healthy “role model” for my department, and because I was getting closer and closer to falling over the “obese” line on the BMI (body mass index) chart.  Then I was hit with a “perfect fat storm.”

Three events poured the truth onto me.  The first was a conference I attended which was all about how health care workers should model healthy lifestyles.  The second was when I tried to buy some new jeans at an outlet store.  I told my wife I couldn't find any that I liked, and she said, “ You've got to try them in a larger size.”  She was right.

The third event was sitting by a hotel swimming pool.  As I sat sucking in my stomach and comparing myself with the young people who were swimming and tanning, I decided I either had to buy some large gold-chain necklaces and a tiny pair of Speedos® or lose weight.

I decided to lose weight.

No, really.  I meant it this time.

I’d played around with diets and exercise programs before, as most Americans have, but this time I was serious!

Unfortunately, there are thousands of diets, and programs, and surgeries, and medical devices out there that guarantee weight loss results.  It is very confusing even for someone trained in medicine.  And while I’m sure many of these plans meet the needs of certain individuals, I didn't want to spend any of my own money, my insurance wouldn't pay for surgery, and I’m skeptical of most “guaranteed” programs.  So I decided to make up my own weight loss plan.  Here is my five-step-lose-weight-and-get-back-into-shape plan:

            1.  I would set a goal weight;
            2.  I would weigh myself every day;
            3.  I would eat breakfast every morning;
            4.  I would count calories, and;
            5.  I would increase my physical activity.

Setting a Goal Weight

This is one of the things that the U.S. Preventive Services Task Force has found to be included in most effective weight loss programs.

The definitions of “obesity,” “overweight,” and “healthy weight,” are tied to something known as the body mass index, or BMI.  The BMI is an admittedly inappropriate way of gauging an individual’s body fat, and was invented by a European (Adolphe Quetelet) using metric measurements and high-level mathematics like square roots to confuse and bewilder Americans while still being able to prove that we are fat.  As you can see from the table below, a BMI above 30 is considered obese, a BMI between 25 and 29.9 is considered overweight, and a BMI between 19 and 24.9 is considered healthy.  (Evidently in Europe there are some people with BMIs below 19, who are considered underweight, but this condition is so rare in the U.S. (outside of Hollywood and New York) as to be irrelevant.)

My weight loss journey began on the precipice of obesity at 216 pounds (BMI of 29.3).  Not wanting to be too aggressive or presumptuous, I set my goal weight at 185 pounds (BMI of 25.1).  (See arrow in table below.)  It was like taking a leap over the overweight category from the edge of obesity to the doorway of normality.

Weighing Every Morning

This is a point of some controversy in the weight loss community.  Weighing every day has been shown to decrease the amount of weight regained after weight loss, and the U.S Preventive Services Task Force has found that effective weight loss programs often include active self-monitoring, which could include frequent weigh-ins.

Daily weighing also has been shown to have potential negative effects, such as unhealthy eating habits or discouragement leading to abandoning the program.  Daily weight can fluctuate for many reasons that are not related to body fat.  The item most often implicated is water retention, but a scale can’t differentiate between fat, bone, blood, muscle, water in tissue, water in the bladder, or stool moving through the intestines.  Fluctuations of one or two pounds are common, and it is difficult to retain or “burn off” 7000 calories a day, which is what 2 pounds of fat would represent.  Some suggest not weighing at all, and just keeping track of your measurements.  I, however, enjoyed the daily weigh-ins, and found them motivating.

Eating Breakfast

Numerous studies have shown that eating breakfast is important both in losing weight and in keeping it off.  The National Weight Control Registry, made up of individuals who have lost 30 pounds or more and have kept it off for at least a year, shows that most  (78%) of them eat breakfast every day, and almost 90% of them eat breakfast at least five days a week.  It has long been taught that while skipping breakfast may seem like a good way to cut down on calories, breakfast skippers quite often more than make up the difference by nibbling throughout the day or binging at lunch or dinner.    However, two randomized controlled trials that studied this issue showed no difference in weight loss between those who did or did not eat breakfast.  Still, it seemed like a good way to get a good start on the day, so part of my plan was to eat a small, but healthy breakfast every day.

Counting Calories

This is another complicated and controversial issue.  Expert advice ranges from counting everything to counting nothing.  But I figured that I wanted to lose my fat, and if each pound of fat equals 3,500 calories, the simplest way to approach it was to cut 500 calories out of my usual diet every day, or increase my exercise to burn off 500 more calories every day so I would lose one pound every week.  Unfortunately, it isn't quite that simple.  With weight loss we usually lose some fat, some muscle mass, and some water, so as we lose weight we need to adjust our caloric intake to account for all of that to get to our desired weight. 

I found that counting calories also helped keep me from falling into the “that’s a toxic food” trap.  There are many diets these days that focus on only one part of the food we eat, such as carbohydrates or proteins, and treat them almost like poisons.  By counting my calories and reading the labels on foods, I was able to pretty much stay within the nutritional limits that many experts consider healthy.  (This is probably the area of most disagreement.  Many “experts” feel we Americans get way too many carbohydrates and not enough protein.  I tend to agree with the dietary guidelines for Americans recommended jointly by the U.S. Departments of Agriculture and Health and Human Services.)  I found that my weekly intake was almost always in the range of about 60% carbohydrates, 10% proteins and 30% fat, which is within the U. S. Health and Human Services dietary guidelines (See graph below: Carbohydrates 45 – 65% (blue grid lines); Proteins 10 – 35% (yellow grid lines); Fat 20 – 35% (pink grid lines)).  Reading labels also helped me keep track of total fats, saturated fats, cholesterol, fiber and sodium, all of which are important players in a healthy diet. 

Increasing Physical Activity

I don’t mind exercising, but I hate jogging.

I have never reached a “runner’s high.”  Even when training for a marathon.

Some have said that the jogging craze has probably been the worst thing that ever happened to physical fitness for the average American – since so many of us have found jogging to be so miserable that we totally gave up on physical activity of any kind!

But it is true that:  1) you almost never see a fat runner, and 2) it is almost impossible to lose weight without increasing your physical activity.

I knew I would have to increase my physical activity if I was going to be successful in my weight-loss program, and since I didn't want to jog, I didn't want to buy a lot of expensive equipment, swimming is too much hassle for me and it’s hard to find time in the day during the week to ride my bike, I decided to walk. 

I began to walk every night in my 5-year old running shoes and regular clothes.  I began walking a mile, but soon found that I was up to 3 miles, then 4, and eventually 5-6 miles every night.  I learned, however, that I couldn't just saunter around town if I wanted to burn calories.  I had to push myself.  I started out at about 3.5 miles per hour, and gradually worked up to about 4.7 miles per hour, which almost doubled the calories I expended every night!


Amazingly, I began to lose weight!

Disappointingly, no one seemed to notice!

It wasn't until I had lost over 10 pounds that anyone asked me if I was losing weight, and the majority of folks didn't say anything until I had lost about 20 pounds.  By then most of them were saying I was looking better.  I bought that new pair of jeans and began going shirtless whenever I could!

Eventually I lost about 35 pounds and around 5 inches of waist, and have been able to keep my weight between 180 and 185 pounds now for over 9 months.  I've learned, however, that this 5-step plan has to be a lifelong plan.  Whenever I start feeling smug, and start slacking off on any of the steps, my weight starts heading back toward the overweight category.

Conclusions, Tricks and Suggestions

In conclusion, there are three main points I’d like to make:

1) It’s hard work losing weight!

Although I've been rather flippant in an attempt to make this more interesting, there were many times when I wanted that piece of key lime pie or crème brûlée and many nights I really didn't feel like getting out in the stormy weather to walk. It was especially discouraging when I was losing weight and no one seemed to notice! A couple of things that really helped me, and made this more like a game, were some apps for my smart phone that my son showed me. I used the Lose It! app to keep track of my weight and my calorie count every day, as it has a large list of foods, calories and nutritional values both for eating at home and for eating at many popular restaurants. The Map My Ride app uses GPS to track your work out, whether you’re riding a bicycle, walking, running or doing numerous other activities, and estimates your caloric expenditures. Both of these apps are free, and both of them have more deluxe programs that you can purchase if you wish. There are also many other similar apps available that you can experiment with to see which ones work best for you. Using the data from these, I've estimated that about two-thirds to three-fourths of my weight loss was from cutting back on food, and the rest was from the exercise.

2) It’s got to be a lifelong change of lifestyle!

As I mentioned above, you can’t lose weight down to your goal, and then go back to your usual way of living in the past. It has to be a permanent change of lifestyle. There are still times when I want that piece of pie, or I don’t want to go out exercising, and I have to remind myself about my goals and priorities. (This is not to say that I can’t ever have another piece of key lime pie! It just means that if I do have the pie, I can’t have some other food items, or I’m going to have to walk a few extra miles tonight. That’s one of the benefits of tracking calories and exercise with the apps.) I also understand that not everyone has a smart phone or a safe place to walk. While the apps may make it more fun, there are still ways of tracking calories and exercise without them. And if you don’t live in a neighborhood where you feel safe walking at night, you’ll have to creatively find other forms of exercise that you can do during the day. I personally don’t believe you can lose and keep weight off without lifestyle changes that impact both food intake and physical activity.

3) It’s worth it!

Although I've used myself and my journey as an example, it really is not all about me! While I do feel better, and the compliments, and movie offers and autograph requests are flattering, the two things that have made this all worthwhile are the fact that it has inspired other family members and co-workers to begin losing weight and it’s something my son said to me after the recent funeral of one of my classmates who died suddenly of a massive stroke. “Thanks, Dad,” he said, “For losing weight and taking better care of yourself."

Dr. Johnson still walks almost every night and continues to keep track of his calories and his weight. He has been an inspiration for many at JCPH who are taking steps toward a healthier lifestyle.