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UCSD med school grad works on patient's weight loss.

Appetite everywhere

“I’ve decided I don’t want to keep losing weight,” she told me. - Image by Sarita Vendetta
“I’ve decided I don’t want to keep losing weight,” she told me.

Two years ago, Glenda weighed 342 pounds, and it was clear to me she needed more than advice to exercise and eat right. From the face covered with zits to the ankles swollen with arthritis, Glenda's body overflowed with consequences of poor eating habits One of her 42-year-old friends had just died of a heart attack, so she felt an urgent need to do something.

“What pill can you prescribe for me so I can lose weight?” She was posing a question thousands of people in this country ask doctors every working day.

Treating obesity Isn’t like treating high blood pressure. If someone comes into my office and our sphygmomanometer (blood-pressure cuff) measures a high reading at each visit despite whatever efforts the patient is making to exercise, reduce stress, and lose weight, I can choose from many anti-hypertensive medications. Based on factors including (but not limited to) ethnicity, sex, cholesterol level, desired side effects, and even mental illness,

I can choose an effective medication, or combination of medicines, most appropriate to the individual. Almost without exception, I can use prescription drugs to help a hypertensive patient control his or her blood pressure and continue to use them without causing other problems. The same is true for depression, which happens to be Glenda’s second major problem. But we do not have even one decent pharmacologic answer to obesity. Several drugs on the market can induce temporary weight loss, but none meet the criteria of proven long-term efficacy and safety that most physicians, myself included, require before prescribing medications for long-term use.

“There isn’t a pill like that which is safe for you,” I told Glenda. Gloom filled the room. Her round, chocolate-brown face and enormous slumping shoulders hung like an old, damp overcoat. I knew I had few options. Her Medi-Cal coverage (state- and federally funded insurance for the indigent) would not pay for any more visits to dieticians. She didn’t have money for dietary programs and barely had enough to buy healthy food. Her intermittent bouts with depression often made it difficult for her to get out of bed, which sabotaged her attempts at going to groups, such as Overeaters Anonymous.

I do my best work when I am able to put myself into my patient’s mind, body, and situation. As a young, thin, white family practitioner, I had some trouble assuming the character of a morbidly obese, black, poor, depressed woman who sometimes hallucinates that she is cutting off and eating chunks of her buttocks or vagina. It occurs to me now for the first time that some formal training in acting might help physicians do better at this, because I see many of us make recommendations to patients that are so out of touch with their realities that we cannot expect them to act on our advice. Glenda had intellectual resources we could use but little else.

I decided to try something I had never done before: I told her to keep a food diary and come in every week to show it to me. This tactic would never work for someone busy working, attending school, and/or raising a child, but Glenda’s long, empty days left her plenty of time to keep a detailed record.

I did not expect what followed. Her binges, in which she would eat a whole cake, a bag of donuts, a box of cookies, or a stack of fruit bars, stopped. She began to stuff herself with cereal, vegetables, and sugarless sweets. She dropped 18 pounds in the first month, which means her food intake for the month fell about 63,000 calories short of what she would have required to maintain her 342-pound starting weight. Most people weigh too little to generate a deficit that high in one month, which is why it’s impossible for most of us to lose 18 pounds of body fat in such a short time.

After her descent slowed down for a few weeks, I persuaded her to add daily walks to her diet plan, and this accelerated her progress. She registered over 300 pounds for the last time just after New Year’s Day 1997, four months into the diary experiment. About once a month, she added a few more blocks to her daily walk until she reached 30 blocks, where she stayed for six months before she went up to 34 blocks, the distance she has walked almost every day since. On June 11, she weighed in at 273 pounds. Her complexion had cleared, the swelling had long since departed from her ankles, and the folds of fat that used to hang like curtains from her waist and arms had shrunk to less than half their former size. The yeast and bacterial abscesses that used to establish temporary residences in her fatty folds could not do so anymore. For the past 18 months, her weight has fluctuated between 260 and 280 pounds.

Physically, she has reached a new steady state, 70 pounds (20 percent) lighter with, for the most part, as healthy a diet as one who has so little income to spend on food can have and a regular exercise habit. Mentally, she has not changed much, and that is why she has not become any thinner than she is.

Most obese people have gone through periods of weight loss and gain. Glenda once lost 120 pounds, but when she was thin she hated the way men treated her, and therefore she does not ever want to be thin again. This creates an inner conflict, because part of her terrible self-esteem continues to be the notion that she is too fat. When she began this process she said she would be satisfied if she got down to 150 pounds. So she still hears powerful auditory hallucinations, voices in her head that call her a worthless fat slob. Sometimes the voices tell her to kill herself, and she has learned to check herself into the psychiatric hospital when her depressive psychosis reaches that point.

I treat depression every day in the office, but Glenda’s has such complexity and difficulty that I find it intimidating. Her hallucinations about eating herself show the power behind her feelings. It’s the perfect fantasy for her: by eating her own fat, she could binge and lose weight at the same time. Many psychiatrists have tried combinations of antipsychotic drugs and antidepressants to modify the intensity of her feelings, and the medicines do work to a point. Site’s a good example of the limits you run into when you treat the symptoms and not the disease. But realistically, how docs one address this conflict of wanting to be thin and not wanting to be thin? So far, we have a compromise: she lost 70 pounds.

Six weeks ago, I thought it was a good time to try for more. In maintaining her weight loss for 18 months, she had made herself a legitimate candidate for gastric stapling. This surgery reduces the stomach’s volume, which causes the patient to feel more full after eating less. This diminished appetite leads to weight loss as long as it is the appetite, and not habit or psychological dependence on food, that determines how much the patient eats. I asked Glenda to consider having the surgery.

One week later, I knew I had made a mistake. “I’ve decided I don’t want to keep losing weight,” she told me, forgetting that she hadn't lost any weight in a long time but was maintaining it. She had binged several times and put on three pounds because she didn’t want to be attractive, and although I had made some progress toward convincing her that she wasn’t yet thin, she was healthier than she had been in a long time, and she was not in danger of losing more weight; she had gained six more pounds since that visit.

Every week I work on her self-esteem. The fact that I, a man who she knows is busy, agree to see her every week helps. She has said to me many times that she expects me to give up on her, usually during visits where she has gained weight from the previous week. I can’t imagine giving up, but I do get frustrated, despite having learned not to depend on patients’ improvements for my own happiness and satisfaction. When taking care of challenging patients, one must appreciate every step forward and not be disappointed when things don’t go well. I’m much better at this now than I was earlier in my career when I had less confidence. I can now work on others’ self-esteem because I take better care of my own.

Still, it annoys me when she allows men to take advantage of her sexually. “He told me my thigh felt just like butter” was how she explained her latest encounter with a male friend, “and I let him take my clothes off."

“Did you want to have sex with him?”

“No.” But she allowed it; he did not have to use force, nor a condom. She doesn’t think enough of herself to stand up to a man, and I’m not sure she ever has said no with enough backbone to extricate herself from that kind of a situation. I think it would help her to role play that scenario, but she would need to do that with an expert, preferably a woman. An experienced female therapist would be a great asset to Glenda for this and many other reasons, but the only therapists we have for Medi-Cal patients are graduate students at U.C. Berkeley.

She has not explored this option recently, so I’ll suggest it the next time I see her; I could sure use the extra help for stuff like this.

I don’t think Glenda has any notion of what it’s like to have relationships with men on her terms. While walking down the street, she hallucinates about sexual encounters. “I see trees, telephone poles, and the papers on the street having sex with me,” she once told me. To me, this means she believes she’s at the world’s sexual mercy. Anyone or anything that wants to violate her can do so at any time. I allow myself to be optimistic about this problem because she once felt just as powerless about food. She now knows she can influence what goes into her mouth. I hope that next year I can say she has seized control of her sex life. Besides safeguarding her health and giving her a chance to have male friends, it will give her more room to lose weight.

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“I’ve decided I don’t want to keep losing weight,” she told me. - Image by Sarita Vendetta
“I’ve decided I don’t want to keep losing weight,” she told me.

Two years ago, Glenda weighed 342 pounds, and it was clear to me she needed more than advice to exercise and eat right. From the face covered with zits to the ankles swollen with arthritis, Glenda's body overflowed with consequences of poor eating habits One of her 42-year-old friends had just died of a heart attack, so she felt an urgent need to do something.

“What pill can you prescribe for me so I can lose weight?” She was posing a question thousands of people in this country ask doctors every working day.

Treating obesity Isn’t like treating high blood pressure. If someone comes into my office and our sphygmomanometer (blood-pressure cuff) measures a high reading at each visit despite whatever efforts the patient is making to exercise, reduce stress, and lose weight, I can choose from many anti-hypertensive medications. Based on factors including (but not limited to) ethnicity, sex, cholesterol level, desired side effects, and even mental illness,

I can choose an effective medication, or combination of medicines, most appropriate to the individual. Almost without exception, I can use prescription drugs to help a hypertensive patient control his or her blood pressure and continue to use them without causing other problems. The same is true for depression, which happens to be Glenda’s second major problem. But we do not have even one decent pharmacologic answer to obesity. Several drugs on the market can induce temporary weight loss, but none meet the criteria of proven long-term efficacy and safety that most physicians, myself included, require before prescribing medications for long-term use.

“There isn’t a pill like that which is safe for you,” I told Glenda. Gloom filled the room. Her round, chocolate-brown face and enormous slumping shoulders hung like an old, damp overcoat. I knew I had few options. Her Medi-Cal coverage (state- and federally funded insurance for the indigent) would not pay for any more visits to dieticians. She didn’t have money for dietary programs and barely had enough to buy healthy food. Her intermittent bouts with depression often made it difficult for her to get out of bed, which sabotaged her attempts at going to groups, such as Overeaters Anonymous.

I do my best work when I am able to put myself into my patient’s mind, body, and situation. As a young, thin, white family practitioner, I had some trouble assuming the character of a morbidly obese, black, poor, depressed woman who sometimes hallucinates that she is cutting off and eating chunks of her buttocks or vagina. It occurs to me now for the first time that some formal training in acting might help physicians do better at this, because I see many of us make recommendations to patients that are so out of touch with their realities that we cannot expect them to act on our advice. Glenda had intellectual resources we could use but little else.

I decided to try something I had never done before: I told her to keep a food diary and come in every week to show it to me. This tactic would never work for someone busy working, attending school, and/or raising a child, but Glenda’s long, empty days left her plenty of time to keep a detailed record.

I did not expect what followed. Her binges, in which she would eat a whole cake, a bag of donuts, a box of cookies, or a stack of fruit bars, stopped. She began to stuff herself with cereal, vegetables, and sugarless sweets. She dropped 18 pounds in the first month, which means her food intake for the month fell about 63,000 calories short of what she would have required to maintain her 342-pound starting weight. Most people weigh too little to generate a deficit that high in one month, which is why it’s impossible for most of us to lose 18 pounds of body fat in such a short time.

After her descent slowed down for a few weeks, I persuaded her to add daily walks to her diet plan, and this accelerated her progress. She registered over 300 pounds for the last time just after New Year’s Day 1997, four months into the diary experiment. About once a month, she added a few more blocks to her daily walk until she reached 30 blocks, where she stayed for six months before she went up to 34 blocks, the distance she has walked almost every day since. On June 11, she weighed in at 273 pounds. Her complexion had cleared, the swelling had long since departed from her ankles, and the folds of fat that used to hang like curtains from her waist and arms had shrunk to less than half their former size. The yeast and bacterial abscesses that used to establish temporary residences in her fatty folds could not do so anymore. For the past 18 months, her weight has fluctuated between 260 and 280 pounds.

Physically, she has reached a new steady state, 70 pounds (20 percent) lighter with, for the most part, as healthy a diet as one who has so little income to spend on food can have and a regular exercise habit. Mentally, she has not changed much, and that is why she has not become any thinner than she is.

Most obese people have gone through periods of weight loss and gain. Glenda once lost 120 pounds, but when she was thin she hated the way men treated her, and therefore she does not ever want to be thin again. This creates an inner conflict, because part of her terrible self-esteem continues to be the notion that she is too fat. When she began this process she said she would be satisfied if she got down to 150 pounds. So she still hears powerful auditory hallucinations, voices in her head that call her a worthless fat slob. Sometimes the voices tell her to kill herself, and she has learned to check herself into the psychiatric hospital when her depressive psychosis reaches that point.

I treat depression every day in the office, but Glenda’s has such complexity and difficulty that I find it intimidating. Her hallucinations about eating herself show the power behind her feelings. It’s the perfect fantasy for her: by eating her own fat, she could binge and lose weight at the same time. Many psychiatrists have tried combinations of antipsychotic drugs and antidepressants to modify the intensity of her feelings, and the medicines do work to a point. Site’s a good example of the limits you run into when you treat the symptoms and not the disease. But realistically, how docs one address this conflict of wanting to be thin and not wanting to be thin? So far, we have a compromise: she lost 70 pounds.

Six weeks ago, I thought it was a good time to try for more. In maintaining her weight loss for 18 months, she had made herself a legitimate candidate for gastric stapling. This surgery reduces the stomach’s volume, which causes the patient to feel more full after eating less. This diminished appetite leads to weight loss as long as it is the appetite, and not habit or psychological dependence on food, that determines how much the patient eats. I asked Glenda to consider having the surgery.

One week later, I knew I had made a mistake. “I’ve decided I don’t want to keep losing weight,” she told me, forgetting that she hadn't lost any weight in a long time but was maintaining it. She had binged several times and put on three pounds because she didn’t want to be attractive, and although I had made some progress toward convincing her that she wasn’t yet thin, she was healthier than she had been in a long time, and she was not in danger of losing more weight; she had gained six more pounds since that visit.

Every week I work on her self-esteem. The fact that I, a man who she knows is busy, agree to see her every week helps. She has said to me many times that she expects me to give up on her, usually during visits where she has gained weight from the previous week. I can’t imagine giving up, but I do get frustrated, despite having learned not to depend on patients’ improvements for my own happiness and satisfaction. When taking care of challenging patients, one must appreciate every step forward and not be disappointed when things don’t go well. I’m much better at this now than I was earlier in my career when I had less confidence. I can now work on others’ self-esteem because I take better care of my own.

Still, it annoys me when she allows men to take advantage of her sexually. “He told me my thigh felt just like butter” was how she explained her latest encounter with a male friend, “and I let him take my clothes off."

“Did you want to have sex with him?”

“No.” But she allowed it; he did not have to use force, nor a condom. She doesn’t think enough of herself to stand up to a man, and I’m not sure she ever has said no with enough backbone to extricate herself from that kind of a situation. I think it would help her to role play that scenario, but she would need to do that with an expert, preferably a woman. An experienced female therapist would be a great asset to Glenda for this and many other reasons, but the only therapists we have for Medi-Cal patients are graduate students at U.C. Berkeley.

She has not explored this option recently, so I’ll suggest it the next time I see her; I could sure use the extra help for stuff like this.

I don’t think Glenda has any notion of what it’s like to have relationships with men on her terms. While walking down the street, she hallucinates about sexual encounters. “I see trees, telephone poles, and the papers on the street having sex with me,” she once told me. To me, this means she believes she’s at the world’s sexual mercy. Anyone or anything that wants to violate her can do so at any time. I allow myself to be optimistic about this problem because she once felt just as powerless about food. She now knows she can influence what goes into her mouth. I hope that next year I can say she has seized control of her sex life. Besides safeguarding her health and giving her a chance to have male friends, it will give her more room to lose weight.

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