He was wheeled into the office by a young man, maybe his son, I’m not sure. He overflowed the oversized wheelchair, cradling his oxygen tank in his arms. He did not look comfortable. He did not smell good. He was able to struggle to his feet to step onto the scale: 250 kg (550 lbs)…
His diabetes is out of control. His blood pressure is high. He can barely walk. He is in his 30s and unlikely to see 40. He is not unique.
Mild to moderate obesity is a national health care crisis, affecting millions of people. Extreme obesity is also on the rise. Most people are not clear on just how obesity affects every aspect of someone’s life.
This man is going to die. The only chance at staying alive is radical weight loss. The risk of bariatric surgery is extreme–he has a good chance of dying perioperatively. He cannot get any preoperative workup to help reduce this risk–he doesn’t fit on the table for a stress test or cardiac catheterization; an ultrasound of the heart would be useless because the sound waves will barely penetrate his flesh. He has chronic skin infections in his folds of fat.
How many calories does he have to consume to maintain his weight? Probably about 20,000 a day, or about 10 times the amount you eat. How does he do it? Who brings him food?
The only way he stands a chance is for the whole family to become involved, perhaps an 12-step style intervention. He is not maintaining his weight by acting alone.
This man is going to die young. With obesity on the rise, we need a major public health initiative to save the lives of people like him, and to cut down on the enormous cost of this epidemic.
His son wheeled him back out of the clinic. They received advice on what to do to survive, but like many addicts, his chance of recovery isn’t clear. The clock is ticking, for him, and for millions of others.
September 7, 2007 at 8:26 pm
Tho I agree with you that a major public health initiative is the only thing that will stem the ‘obesity epidemic’, it certainly wouldn’t help this guy. You don’t get to 550# without some significant psychosocial dysfunction (and, as you pointed out, an equally dysfunctional accomplice) and more access to walking paths ain’t gonna cut it.
This degree of obesity is tragic. Do you have access to surgeons that would take him on? Your point about the preop clearance is something I had not considered before.
September 7, 2007 at 9:17 pm
There’s always a surgeon willing to cut. I’m certainly going to tell them how high risk it would be and try to disuade them. Might as well just shoot him in the head as operate. What he needs is some sort of inpatient program. Hmm, wonder if his medicaid will pay for it?
September 8, 2007 at 1:55 am
Yeah, but so far mainstream medicine’s idea of “obesity intervention” is to tell people to eat fewer calories and less fat. Funny, people have been eating less fat on average for the lats thirty years, if you believe the stats. Some have even adopted vegetarian diets. So where’s all the obesity coming from?
I’m obese too; I can still walk and even run, but my BMI’s in the thirties, mmkay? If I eat low-fat, here’s the kicker for you: I GAIN weight. That’s even if I drink diet soda rather than regular, since soda is a major source of calories for some people. I gained a lot of my present overweight, incidentally, by eating vegetarian.
This is what I was talking about in my other comment about mainstream medicine not always being scientific. Somebody along the way decided that eating fat makes you fat because… well… “everybody knows” you are what you eat. Oddly, the biology doesn’t match up. What is our primary source of fuel? Glucose. We already know that if we intake too much fuel we store the extra as fat. Well then it should be obvious that getting too much GLUCOSE is what makes us fat. Except it’s not, because most people’s brains short-circuit and substitute “calories” for “glucose.”
But a food’s caloric measurement only tells us the energy output from setting that food on fire. We don’t necessarily use protein and fat for fuel if we’re getting enough glycemic carbohydrates. So what’s the glitch here? Again, unscientific thinking. Instead of directly observing phenomena, which we’re perfectly capable of doing with this particular science, we’re indulging in leaps of logic instead. But it’s faulty logic, and it’s killing people.
And I’m kind of surprised at you, incidentally. You might not be able to do an ultrasound on a guy like this but you couldn’t have tested his lab values, maybe? It’s pretty difficult to get up to 550 pounds if there is nothing physically wrong with you. Thyroid? Fasting glucose with insulin levels (he’s sure to be severely hyperinsulinemic)? Something else? Not just judging him as morally inferior and sending him away? You’re his doctor. You should be giving him the info he needs to get well. If you’re not giving him all the info he needs, you’re doing him a disservice.
September 8, 2007 at 2:01 am
Just read it again and yeah, he’s diabetic (which I did read the first time, but I’m also not entirely awake). Now you’re going to go, “How’s he hyperinsulinemic? He’s diabetic!” He’s got stored body fat, hasn’t he? Someone who can’t make insulin isn’t going to store much fat either.
You’re going to roll your eyes at this but dude needs to be on a low-carb diet, and NOW. Most docs are going to look at his diet and figure he’s eating too much fat, but the truth is he’s getting too much starch and sugar, and it’s assaulting his glucose metabolism with deadly effect. He’s likely deficient in B vitamins and some minerals as a result, as well.
No, I’m *not* a doctor. But I can read, I know it takes B vitamins and some minerals to metabolize glucose, and that intaking refined carbs and sugars depletes those things. His insulin stays high because he never stops giving it something to metabolize, yet his body cannot respond to insulin effectively. So it’s better to not give the insulin anything to do, so his insulin levels can drop.
If he’s only eating meat and vegetables (the lower-starch the better) he’ll still get the nutrition he needs. It’s certainly no worse than bariatric surgery, which may well kill him and which doesn’t work for permanent weight loss for everyone who gets it anyway.
But… you wouldn’t do this for him, assuming he would even go along with it. Because it’s “quackery,” because it doesn’t fit standard medical leaps of logic. Right?
September 8, 2007 at 5:54 am
You are absolutely right about low fat diets not being THE answer to anything. More is being learned daily.
For an extreme case like this, it’s a matter of emergency reduction of caloric intake.
For most of us who have high BMIs (mine bounces between 28 and 32…not great), the answer is more complicated, and requires individual treatment. Proteins and fats tend to satisfy for longer, refined carbohydrates like corn syrup and sucrose tend to satisfy only briefly and cause spikes in insulin and glucogon levels.
Quite a bit is now known about nutritional medicine. Unfortunately, the basic idea that fewer calories is the only way to lose weight is still true, but the subtleties are important, and helpful when treating patients.
September 12, 2007 at 6:21 pm
Is the 20,000 calories bit hyperbole or a real estimate?
In some ways I’m scarily similar to your patient — mid 30s, about 550lb (yes, that shocked me too). In other ways, I don’t think I’m quite so far gone — I can walk a couple blocks and that’s improving; my blood pressure is good, with medication; my fasting glucose is normal.
I’ve been maintaining a food log over the past 6 weeks or so in prep for seeing a dietician in a couple weeks, and although I obviously eat considerably more than most people, I’m not seeing 20kC average. Of course, this is after some other behavior changes tryig to get things somewhat under control, and maybe it really was 20k before…
September 12, 2007 at 8:55 pm
You probably aren’t up to 20 K at this point if you are doing so much work. That’s usually at the end, when someone has really given up, and also they aren’t expending any calories when they get much bigger, like the 1000 lb folks, as opposed to people like you who are active. The patient is also about 5 ft or so, so the BMI is quite high.
There is always hope for obese folks, as long as they are willing to change and have access to the resources they need. A lot of the patients I see are quite poor and basically stuck between a rock and a hard place.
Thinking a little more, the amount of calories needed to maintain a particular wt is quite variable…the super obese (like the 6-900 lb folks) are prob up in the 20 K range. Keeping a food diary allows you to figure out where the extra calories are (even if it may seem obvious, it isn’t always.)