I recently watched a rerun of My 600 lb Life: Where Are They Now? featuring an update on one of Dr. Nowzaradan’s most challenging patients, James K. Like most of Dr. Nowzaradan’s patients, James grew up struggling with obesity and by the time he was in his ’30’s he was already over 500 lbs. That’s when a leg injury left him bed-bound and he has not walked since that injury. Unfortunately, being bed-bound has added to his weight gain and by the time we meet him in his initial episode, James estimates his weight at around 700 lbs. Speaking with James via computer, Dr. Nowzaradan gave him the basic diet he gives to all of his patients (1200 calories a day and no carbs) and advised him to begin losing weight immediately.
Getting to Houston to meet with Dr. Now was a struggle in itself as James needed a bariatric ambulance to take him from Kentucky to Texas and his insurance would not cover the cost. James’ father ended up financing the transportation, but once in Texas with his daughter and girlfriend Lisa, he continued to struggle with the diet. After four months in Kentucky, James arrived in Houston weighing 738 lbs. Dr. Now admitted him to the hospital to begin running tests and to put him on a controlled diet to get his weight down. Unfortunately, after losing over 100 lbs in the hospital, James moved to his apartment to continue losing on his own, but what followed was the beginning of a vicious cycle of weight gain followed by hospitalization and controlled weight loss only to regain again at home. Despite Dr. Now’s warnings regarding his deteriorating health, James and Lisa were unable to control his eating and he continued to gain weight. His constant gaining was followed by heart problems, kidney problems, and cellulitis infections in his legs. After one arrival at the hospital, James and Lisa are shocked to learn that he’s at 843 lbs.
From the outside, it’d be easy to say “what the heck is wrong with you two?!” but they were as mystified as Dr. Now was frustrated. Despite his repeated attempts to explain to them what they are doing wrong, they remained as confused and frustrated as Dr. Nowzaradan. Obviously, something was going wrong, but they could not understand what it was.
Quite simply, it was the food. I know you are thinking “no sh*t, Sherlock!” right now, but for James and Lisa, it really was mystifying. While they were obviously cheating on the diet more than they admitted, it wasn’t really the “cheat meals” that were causing the problems as much as it was all the other food he was also eating. While I obviously wasn’t there with them and only know what I saw on the tv, I’ve got a pretty good guess as to some of the stumbling blocks tripping them up: 1) nutritional ignorance; 2) portion distortion; and 3) cravings.
As a former Basic English instructor, I learned early on never to assume that people know “The Basics.” I remember going over a lesson on sentence construction, explaining how each sentence needs a subject consisting of a noun and a predicate consisting of a verb. When I casually asked “does anyone have any questions?” I was promptly asked “what’s a noun? Judging by the confused faces in the class, I gathered her question was echoed by most of my students. My carefully constructed lesson was pretty much wasted on them since I was essentially speaking gibberish!
I have a strong suspicion that this was part of the problem with James and Lisa. While it’s one thing to pass out a diet plan with recommended and/ or ‘forbidden’ foods listed on it, it’s another entirely to learn to read nutrition labels or simply to identify what other foods should be included on that list of ‘forbidden foods.’ I remember a very long time ago when my dad’s doctor advised him to lower his sugar intake and my mom complained about his eating bread. I asked “what does bread have to do with how much sugar he eats?” At the time, I had no idea that bread (a starchy carbohydrate) is metabolized like sugar in the body. In essence, a starchy carb like bread is viewed as a long string of sugars in the body. While it doesn’t look like sugar, technically our bodies turn it into sugar. It’s one thing to look at a slice of bread and think “starch” and see that one slice is allowed on the diet and it’s another thing to look at a bowl of brown rice and think it’s okay. If it’s not specifically mentioned on the diet plan, then where does that go? Is it allowed? Not allowed? For some people, it’s common sense but for others, it’s a mystery. While those of us who’ve spent a lifetime eating off one diet plan or another know what to do, for those who have never ventured into “Diet World,” it’s literally foreign territory. Having the doctor tell you “no carbs!” might as well have been “no finkerrupz!” for all the sense it makes to you. (Let’s not mention ‘total carbs’ vs ‘net carbs’!)
While some of you are rolling your eyes, let me remind you that we all start somewhere different when we begin this diet journey and even though a nutritionist may have been sent out to help James and Lisa learn more about food overall, not all nutritionists and/ or dieticians are created equal. I remember my own dietician basically giving me a list of rules to follow (again regarding carbs) without ever asking me if I knew what a carbohydrate was! However, as a reader and an information-gatherer in general, when I started asking questions about nutrition, I decided that the internet (though convenient) wasn’t comprehensive enough for me and I went off to the bookstore and came home with Nutrition for Dummies. ( Nutrition for Dummies ) I am a big fan of the Dummies books because they assume you know nothing about the topic, so you can start at your own level. I also realize that some people are offended when you suggest these books to them (“she called me a dummy!”) Frankly, I have a large library of Dummies books because in my opinion, there’s a whole lotta stuff I don’t know crap about and pretending that I know more than I do is the only thing that really makes me a Dummy!
There’s also another pitfall that catches most people unawares: “I thought I knew what I was doing but I really didn’t!” This was my error when I was teaching sentence construction: I thought I was giving my students The Basics but it turned out it wasn’t basic enough! In short, I thought I knew where to start but I didn’t! Hospitals have also learned this lesson the hard way. When patients arrive for a procedure, they make the patient explain to the nurse what’s going to happen to them. This is the best way of making sure the patient understands what is really going to happen! I am sure James and Lisa thought he was following the diet and only cheating a little bit, when in fact, he was probably cheating more than he wanted to admit and also eating foods that weren’t on the diet although they thought that they were.
Then there is the whole issue of portion size. This is one of the reasons I recommend a food scale in the beginning at least (Ozeri Food Scale). When someone is used to eating a slice of cake that weighs in at a half-pound or a sandwich the size of a loaf of bread, they usually have no idea what an actual ‘portion’ looks like. The idea that a sandwich consists of two regular slices of bread, 2 oz of meat and maybe one ounce of cheese is a real shock. A hamburger patty really isn’t supposed to be one-third of a pound or more; it’s supposed to be about 3 oz! The same thing with a chicken breast or a piece of steak– about 3-4 oz is a ‘serving size.’ The general rule of thumb is that your protein is supposed to be about the size of a deck of cards or the palm of your hand, not the size of your head!
It’s easy to jeer at someone weighing 700 -plus pounds who clearly doesn’t understand why he weighs so much, but the truth is that a lot of us are in the same boat. The only difference is that while James can’t understand why he’s still over 700 lbs, we can’t figure out why we still can’t lose these same twenty pounds we’ve been trying to lose since college. It’s usually that Terrible Trio I mentioned above: a combination of nutritional ignorance, portion distortion and cravings. We think we are eating healthier foods in the right amounts but until we do a little investigating, we may not realize that while sweet potatoes and brown rice are better for us than white potatoes and white rice, they still have a lot of carbs and starch in them. We also think that a serving is one whole sweet potato no matter the size or that we can eat twice as much brown rice as white rice. The truth is while we are eating healthier, we may not be eating healthy enough to lose the weight we want.
Cravings are another story entirely. Everyone who’s tried to lose weight has fallen victim to this one, some of us more often than others. It really doesn’t matter what the craving is for, either. Whether it’s chocolate, bread, nuts or even something healthy like a salad, if we eat too much of it, it’s not good for us. If it’s something not on our ‘recommended foods’ list, it only adds to the problem. While it’s not usually a disaster when we give in to the cravings, we don’t often realize that giving in prolongs the problem. In short, if you ‘indulge’ once a week, you begin to expect that indulgence and when you try to skip it after repeatedly giving in, it only makes it harder to resist. For someone like James, who’s probably never resisted a temptation, the cravings can be unbearably difficult. For someone like Lisa who is used to giving him what he wants, the response is probably close to automatic: he wants it? he gets it.
Making the changes James and Lisa need to make to lose weight and improve his health likely requires more adjustments and education than they anticipated. It means a complete restructuring of their home life and habits. It not only means throwing out all the foods not on the diet, it means re-learning how to eat, how to buy food that’s healthy and how to think about what we eat. Like most of us, James thought he could out-exercise his cheating and bad food choices, but we all know we’d be jogging all day to ‘cancel out’ that burger and fries lunch or the pie or whatever ‘indulgence’ we had. Losing weight permanently takes significant changes and these need to be permanent if our weight loss is to stay permanent. That means re-thinking what’s normally on the menu and what’s not, what a real portion size is and what’s too much, and whether that slice of carrot cake is really worth it. It means keeping an open mind about The Basics and even changing those Basics if need be. It’s not an easy adjustment to make but when your quality of life depends on it, are you really going to trade that for carrot cake?