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As a Neurologist I frequently see people who are overweight. They may need to lose weight in order to help medical conditions such as headache or to assist in mobilising following any kind of injury or illness process.
It is my opinion that more nonsense has been written about excess weight and how it happens than almost any other medical matter. This is matched only by the gobbledegook about how to lose it which has earned fortunes for those who have created their own special diets, treatments, additives, supplements, vitamins and varies besides a vast range of - ologies and – opathies that prefers to pull the wool over our eyes of the reality. The reason is pecuniary, that is how much money can be taken from the long-suffering public who yearn to be the perfect size of many near anorectic celebrities as featured in various colour magazines and popular press.
Perfect size does not mean perfect happiness and perfect diets that come in pill or bottle form are far from what we need. They all represent kidology or the science of ‘how not to take personal responsibility’. There are on this particular journey a number of facts and many fictions.
For many, weight loss has become like a maze with many turns and dead ends, when in fact it is a simple balance between energy expended and the energy consumed. If you eat more than you use on a daily basis you will increase weight. If you eat less than the body requires then you will lose weight. This is not rocket science. How can this simple fact be so blurred by those who should and in fact do know better? First we need to look at a few terms.
The basal metabolic index or BMI is a useful tool but nothing more than that. It shows simply if our weight is greater than it ought to be. This for each individual may be a fundamental question but at times there is no easy answer. To help overcome the uncertainty the BMI was devised. This measure requires knowledge of the weight in kilograms and then divided by our height in metres and centimetres squared (that is the height such as one metre, seventy centimetres multiplied by itself).
As an example if your weight is 80 kg, and your height 1.90 cm, then the BMI equals 80/3.6 which equals 31. Ideally a BMI should lie between 19 and 25.
I am aware that some superbly fit athletes with bulging muscles will have higher BMIs but they are the exception. To put it bluntly if your BMI is greater than 26 then you are overweight. If your BMI is greater than 30, welcome to obesity and if it is greater than 35, then it is morbidly obese.
I am not ‘fatist’, that is prejudiced against overweight people; in fact, very much the reverse. People make their own decisions in life over many issues. My role as a doctor and Neurologist is to respond to requests for help and advise as best as I can. If this advice is given and then either ignored or rejected, that is very much up to each individual. We all need to take responsibility for our own lives so what I do not want from my patients is the subsequent comment ‘no one told me’, when perhaps reflecting on an illness which is being compromised by excess weight.
Being overweight is a bit like not looking before you cross the road. If you do not look before you cross the road then you may not get hit by a car. Maybe the drivers will spot you and miss the target. Looking, however, increases the chance of not being hit. Having looked, however, you do not reduce the chance of being hit by a passing meteorite as you usually do not look up. I will explain this philosophy a little more later. A further example helps explain my views. In recent times, I saw an 85 year old man with a condition called a peripheral neuropathy; that is a disease causing damage to the peripheral nerves. His excessive use of alcohol was the mechanism by which the damage was being generated. I discussed this fully without any moral rectitude just as a matter of fact. The charming amiable single man told me that alcohol was his enjoyment in life. He had the benefit of a great life and could afford to pay for care when it was needed. He appreciated the time spent on diagnosis and what was the obvious advice but he would continue drinking as this suited him at this late stage in his life.
I am not a moral preacher raining fire and brimstone on my patients. I am an advisor. As long as any individual fully understands the situation that has been explained then it will be their own decision provided, of course, it does not harm other people.
Obesity is linked to many diseases and it shortens life. It also leads to reduced physical performance or a diminished psychological state and it does often reduce contribution to society as a whole. We now know that headache syndromes are more common in overweight people by a factor of between 5 and 10. Obese people are more likely to suffer fatigue and have diminished employment prospects. They are much more likely to suffer musculo-skeletal problems including backache. Diabetes, high blood pressure, heart disease, asthma, fatty liver and fat deposition elsewhere are all well known complications. Less well known is the predisposition to cataracts, leading to blindness, infections, venous thrombosis and pulmonary embolism and a much greater difficulty recovering from surgery required for other reasons. It also needs to be understood that doctors find it much more difficult often to make a diagnosis in individuals who are morbidly obese, particularly when there is abdominal pain.
So many conditions or disorders are reversed or neutralised if weight reduction can be achieved. If you are unfortunate enough to have a disabling illness such as multiple sclerosis, stroke, neuropathy or any other neurological disease, then reducing weight will improve mobility. Pain and chronic pain are frequently seen in those who are overweight. Reducing weight allows more activity and distraction reducing the total pain load without even considering drugs.
Unfortunately obesity and a tendency towards it is almost certainly partly genetically determined. It is honed, however, by nurture or how we are brought up by our parents. We all know of, and maybe we are part of, fat families. This is as much due to a culture of high calorie food and little or no exercise as it is genetic. Is the combination of no exercise and watching soaps genetic? It may be but I would leave that discussion to geneticists. What is more important, is to do something about it.
Each of us knows usually who we are and how we can best achieve what is needed in our life. Sometimes, however, our insight is diminished and we need to be pointed in the right direction and then have our focus set on an appropriate goal.
With regard to weight reduction it is necessary to reduce calorie intake and increase exercise.
When we have it identified that our weight is too great and our exercise is too little, then there needs to be a plan and appropriate goals set. Those goals will depend on many factors but the plan should only have two headings;
1) less food and 2) more exercise. The challenge is how to achieve both and then continue the determination to maintain consistency in reaching the goal weight. Most people do know what weight they would like to achieve, but few in my experience have any idea of how long this should take and then even less idea about their goal for exercise.
I actually do have more sympathy and empathy for overweight people than these initial words suggest. I personally enjoy, no love, good food.
I frequently joke with my patients that ‘if it tastes good, it is bad’. We are literally bombarded with adverts for food from the earliest days. We have not lived if we have not had this week’s latest ice cream flavour or chocolate-coated biscuit. Healthy, vibrant smiling faces reach out from our TV screens telling us that ‘Snackowheat’ is the reason why our children are skipping in the country, the sun is shining and two adults arm in arm gaze into each other’s eyes with all the expectation of a perfect living experience. Maybe ‘Snackowheat’ or ‘Oat and Fibre’ will do that for you, but a healthy eating experience would probably mean not buying the manufactured food substance in the first place or better to eat the box jumping up and down on the contents.
‘The Daily Mail’ recently much to its credit, showed its readers what is the standard diet of our children over a year. I hope if you saw this picture you were as gobsmacked as I was. No wonder so many of us are and were fat children and destined to carry that with us into the future. We also then gift that eating experience in turn to our children’s children. Somehow we just have to change the way we live, reduce the amount of rubbish, high calorie food that is consumed and focus more on less calorie intake.
There is so much information available through your general practitioner, the internet, any library and every national publication about calorie counting and how many calories are in each item of food. Once there is insight; that is an awareness that change needs to happen, then the very first thing to do is to learn how much food weighs and how many calories are in each food substance you eat. A good quality kitchen scales is imperative, so that initially every item of food can be weighed. This is suggested not with a desire to obsessionality but more that people who do not have any idea about calories learn from their own experience.
It is imperative that anyone wishing to lose weight eats three meals a day. That includes breakfast, lunch and dinner. So often people think losing weight means missing breakfast. All that means is no fuel in the engine. Tiredness will follow in due course and there will be an increased appetite particularly for carbohydrate foods and that will lead in turn to greater calorie consumption. Breakfast needs to be like all meals involving what you enjoy. Half an ounce of cereal with low fat milk, a juice or preferred fruit in fruit juice but not syrup and low fat yoghurt. Tea or coffee, the former with lemon or black coffee if possible or alternatively with low fat or skimmed milk and a glass of water.
Lunch effectively needs 2 oz. of anything you like with green vegetables and one piece of fruit and drinks as above.
Dinner is 4 oz. of whatever you like together with vegetables without butter and salad. Two extra apples can be taken whenever you wish during the day. Knowing what 2 oz. or 4 oz. looks like is crucial, hence the importance of those good quality kitchen scales.
It is remarkable that there are so many diet books being produced and ever more tips about eating good food. Of course, a good dietician or nutritionist will assist. Whether or not cinnamon, red pepper, melon, soya sauce, carrot juice, calcium, red meat, pomegranates, green tea, chilli, spinach, lentils, walnuts, rape seed, starflower, olive oil, tomatoes, pineapple, lupin seeds, paprika and linoleic acid really help ‘the metabolism’ is something that science still has to prove for certain. It also depends on each individual. None of the above will do any harm so all of those items would be worth including in a ‘normal’ diet.
Over the years I have heard a whole series of comments both socially and from patients. I hope I can encourage those reading not to use them.
‘Fat turns into muscle and muscle weighs more than fat’.
‘You can only lose 1 lb. a week’.
‘I have a slow metabolism’.
‘I am fat because all my family are fat’.
‘I put on weight with my underactive thyroid or diabetes’.
‘I cannot lose weight since going on thyroid hormone’.
‘I have wheat intolerance’.
‘I have metabolic syndrome’.
‘I have polycystic ovaries’.
‘I retain a lot of fluid’.
‘I have big and heavy bones’.
‘If I lose 1 lb. a week, it will stay off’.
‘I put on weight after ……..’
‘I eat next to nothing and I can’t lose weight’.
‘I am allergic to the 21st century’. (Was 20th century).
‘I have candidiasis’.
‘I have chronic fatigue syndrome’.
All of these are euphemisms for ‘I eat too much, and I exercise too little’.
This section has been written together with Andrew Howell who is a graduate physiotherapist, elite athlete and personal trainer. Not only is he a superb physiotherapist and in particular, sports physiotherapist, he has to look after his own body in order to perform at the highest level of athletics.
He recognises that he has been given attributes that enable him to have good physical performance but even he has to work exceptionally hard at pushing his body to the limit of performance. His diet equally has to involve the right amount of high quality natural food or he will not be able to perform.
If our top sportsmen and sportswomen perform better with appropriate diet then how much more important is it for those of us who are just normal to eat healthily.
With regard to exercise it is vital to set the right exercise goal for each individual.
Each of us needs to have an exercise programme tailored to need. This is even more important if you have a physical illness such as multiple sclerosis, stroke or Parkinson’s disease. It is worse recognising, however, that you can be disabled and unfit in the setting of your disability or you can be disabled with functional handicap and as fit as you can be. The same principles apply whether you are fully able bodied or not. If you can get the psychological state right your physical condition will improve rapidly and weight will reduce. If the mental state is poor or challenged, then sensible eating and even more so, sensible exercise will be much more difficult.
Remember even the very best sportsmen do not perform well when the psychological state is impaired. If there are issues in life and for many at the moment that probably means nearly all of us, then trying to work out the best strategy to look after your own needs and push to one side the negative issues will help. That is a topic for another time and discussion.
We know from the newspapers just how much our footballers and cricketers, for instance, suffer convolutions in their physical performance depending on what is happening in their emotional and social life. If the emotional state is so vital for the fittest people in the world, just think once more how important it must be for the rest of us.
Not many of us can run a mile in four minutes or two miles in eight minutes. How about the twenty-six miles of a marathon in just over two hours? Knowing our own physical limits makes these figures seem all the more remarkable. I am quite fit and yet I can hardly run thirteen miles per hour for one minute, let alone two hours. I advise everyone of whatever age or fitness to see if they can walk two miles in thirty minutes. To do this they can measure one mile in their car, walk back to their home, turn around and go back to the car. If you are able to do two miles in thirty minutes, then this is a baseline that is a minimum fitness level. It is an entry card to do more activity, as discussed below. If you cannot do this, then all you need do is walk more quickly each day bit by bit until you can achieve the goal. It is worth trying to walk two miles in thirty minutes, talking to someone else throughout the walk and seeing exactly how unfit you are.
Having identified that exercise is a crucial part of weight loss regimes, Andrew would advise that a personal trainer is particularly helpful in giving a positive mental state. They will also set short and long term goals. This in turn will give you a point of focus, lift your mood and motivate each week particularly if your targets are met. The targets have to be realistic but challenging.
Many of us are not gym enthusiasts and often will find the thought of going to a gym a struggle or even generate fear. All the more so if there is a thought that only muscle bound Adonises and Madonnas are going to be working there.
Going to a gym, however, can be a rewarding experience. If you know what to do, then great camaraderie can be built with other people. The key is to push yourself but maintain a healthy, social life style as well in order to prevent boredom.
There will be weeks when you do not meet the targets that are set. This is normal; do not fret as the body does find ways to hold on to water and the results may not show on the scales. With perseverance and consistency, however, the weight will come off and significantly so. If you cheat, you cheat yourself. You do not cheat anyone else. A week of exercise whatever it is reflects one more week of increased fitness compared to where you were.
Andrew with his clientele advises setting up a calorie data base or diary at the same time as increasing the exercise according to diet. In the same way an exercise diet is also helpful as it enables a clear idea of how much is being achieved and what improvements are occurring on a week by week basis.
There is evidence that regular exercising does change the metabolism. It is also a truism that the less food you eat then the less food you will seem to eat as the body gets used to having the right amount of food. That tends to go hand in hand with the similar comments about exercise.
Pairing up with another person who is overweight tends to lead to better results when working with a gym buddy. Few of us have the ability to eat and prepare meals together but that can occur if there are two people within the same household such as a husband and wife, or a friend who can share the journey. Each person helps the other through the low moments and provide encouragement. Once again the social environment lends itself to enjoyment and enjoyment enhances mood which reduces calorie intake and makes exercise easier to maintain.
We both find that individuals who once disliked exercise at first slowly begin enjoying the work, particularly as it gets harder and they see the results. People are particularly encouraged when they suddenly find that they can climb two flights of stairs and hold a conversation at the top without getting short of breath.
Some people will have joint problems and this does require very specialist help to make sure that impact exercises are limited but other exercises are substituted. Even if there is a broken limb there are still three other limbs that can be adequately exercised whilst the damaged limb recovers. Perhaps it is not obvious outside medical practice, but those who do keep fit during a limb injury recover much faster once they can get back to full fitness.
Training programmes consist of two types of training in order to enhance fitness and burn calories. First it is necessary to build lean muscle mass and secondly cardiovascular training where the heart rate needs to exceed 80% of each individual’s maximum rate. The key is to maintain the highest possible heart rate whilst continuing with any circuit training or weight based exercise. It is the skill of a personal trainer to know the limits of their clients. It is vital not to give up because of exhaustion but to maintain a high enough heart rate to burn calories as efficiently as possible. This is the minimum expectation from a trainer along with a programme which is tailored to your specific levels of fitness and need.
Ideally photographs at the start of a programme from the front and the side enable progress to be seen. With pictures taken every month physical changes can be observed and will be remarkably rewarding. As weight comes off make sure there is a reward; a healthy weekend away or a trip to the theatre. Buying a dream item of clothing as a target to try on after a six month period is also worthwhile. This helps maintain motivation and will reinforce motivation on this continuing and life changing journey.
With an increased exercise and training programme soft tissue injury may occur. If this happens, do not panic but then work with a physiotherapist and/or personal trainer to maintain exercise that allows healing but maintains calorie usage.
Remember with exercise never give up and it is never too late to start. The right time to begin is now. Seek help. Personal trainers and therapists do not just make a living out of helping. In our experience they really want to help as much as possible but you need to engage with them.
The TV programme ‘The Biggest Loser’ is remarkable and inspirational. People who are truly large people, some vast, volunteer to spend either two months (UK) or four months (US or Australia) in a house away from their family and friends. They work with personal trainers. They have to look after their own diet but they are given specific advice and there is no fad diet or food supplements. The weight loss achieved by these people is simply staggering. People lose half of their body weight in the four month period and all they are doing is increasing their exercise, working with a personal trainer, and reducing their calorie intake. Do we need to say more.
Dr Michael Gross MA MD FRCP MEWI
Andrew Howell B.Sc. MCSP