At 6’3″ and 282 pounds, Mr. JB, a retired factory worker, had many classic complications of obesity when he presented to our weight control program. He had undergone angioplasty several times and had bypass surgery in 1996. He was on terazosin hydrochloride (Hytrin) at 5 mg per day and trandalopril at 2 mg per day for hypertension. He was on 500 mg per day of metformin and 10 mg of glipizide to control his diabetes, which was diagnosed in 1988, and he was taking aspirin daily for coronary/stroke prevention.
Mr. JB had hypercholesterolemia and had undergone gallstone surgery in 1994. He also had arthritis in the knees and had undergone surgery earlier that year for a ruptured disk. He reported many symptoms of sleep apnea – loud snoring at night, sleepiness in the daytime and his wife’s observation that he sometimes stopped breathing during his sleep. Sleep apnea is often caused or aggravated by obesity; when the neck muscles relax, airways can be constricted by fatty tissue.
With a body mass index of 35, Mr. JB obviously needed to lose weight to control his diabetes, coronary disease and other medical problems, and he had a major success factor on his side – a sincere desire to change his habits and improve his health.
This patient’s social and family history yielded no additional contributory factors; his mother died in a car accident at age 50, and there was no significant family history of diabetes, high blood pressure or heart disease. He did not smoke or drink alcohol, and he walked one to two miles per day.
On physical exam, the patient’s blood pressure was 140/76. His pulse was 80 and regular. He tended to breathe noisily and with some difficulty, and he had a resting tachycardia. The exam was remarkable only for an S4 gallop on auscultation, 1+ pitting edema of his extremities and decreased pedal pulses, indicating his diabetes may have been affecting circulation to his extremities or that the same disease that affected his coronary arteries also affected the vessels in his leg. Fundoscopic exam revealed an occasional exudate consistent with background diabetic retinopathy.
Mr. JB and I had a long discussion, and he felt that a goal weight of 220 pounds was attainable. He agreed to restrict his caloric intake to 1,100 to 1,200 calories per day, using a diet of nutritionally balanced supplements and one daily meal, and he began keeping careful records of foods and beverages consumed.
One important precaution for this particular patient was to take him off the glipizide, which controls diabetes by stimulating insulin production. Because Mr. JB was eating less, continuing the glipizide would have put him at a much higher risk for hypoglycemia, which would not only be dangerous to his heart but also counterproductive to his effort to lose weight; if his blood glucose dropped, his urge to eat might become uncontrollable.
Mr. JB also began attending behavior modification classes, a vital part of our program at UAMS. The classes give our patients additional information about sticking to a calorie budget and reinforce what they have already learned from their physicians. Patients also benefit from the additional support and are more likely to stick to a plan if they are closely followed.
Mr. JB began to see results right away, with a five-pound weight loss the first week. He continued to lose weight fairly steadily, and five months later he had lost about 45 pounds. At 10 months, he had lost a total of nearly 50 pounds.
In addition to the obvious benefits of enhanced self esteem and healthier eating habits, this patient is enjoying some very important, perhaps life-saving, health benefits. His blood pressure is now maintained with lower doses of terazosin and trandalopril. His fasting blood glucose was reduced from 211 to 119 even though his medications for diabetes (metformin and glipizide) were discontinued. If he continues to maintain his weight loss, he may not need to take medications for his diabetes. His cholesterol is greatly reduced. Prior to starting the UAMS weight control program, his cholesterol was 255 and his triglyceride was 478. More recently, his lipids were greatly improved, with a cholesterol of 149 and a triglyceride of 128.
In addition, he is sleeping much better, feeling refreshed in the morning. His wife is also sleeping better since his snoring is reduced.
While severely limiting caloric intake can be dangerous for patients who are trying to do it “on their own,” this patient’s experience illustrates that fairly rapid weight loss can be safely and effectively achieved with a physician’s help through careful monitoring along with guidance in selecting foods and/or diet supplements. Some patients may also benefit from carefully selected medications, such as sibutramine (Meridia), or orlistat (Xenical), but these medications should be accompanied by behavior modification.
However, even patients who need to lose just a few pounds can benefit from UAMS’s weight loss program. In fact, some of our patients are not overweight but just want to improve their eating habits to maintain good health.
Almost anyone can benefit from a healthy diet and exercise program. Most people are surprised to find that they have vastly underestimated their caloric intake and overestimated their physical activity. Also, many people overestimate or underestimate their weight problem. The body mass index can be useful in determining whether a person’s weight falls within a healthy range.
While a few stubborn and vexing pounds may not be the serious problem that our society makes them out to be, true obesity is a critical and costly health problem in the U.S. Some studies have indicated that more than half of Americans are overweight. Often, seriously overweight people spend much of their lives struggling to lose weight, jumping from one fad diet or new remedy to another without ever achieving lasting success. The problem isn’t necessarily a lack of motivation; they may have simply been misguided by mixed messages in the media or friends and family full of good intentions and bad advice. An effective diet and exercise program coupled with professional behavior modification can make all the difference for these patients – to their weight, health, self esteem and quality of life.