Being Fat is Hard

It is everywhere:  advertisements on television, statements by celebrities and politicians, regulations, school lunch programs, medical protocols.  Obesity is now a major public enemy.

I do not mean to diminish the significance of this issue.  There is no question, obesity is a serious health concern.  It has also increased, though not as much as advertised.  (The definition of obesity was changed, which automatically dramatically increased the numbers without anyone gaining any weight.)  At the same time, all of this attention acts as if obesity was an easily remedied problem, if people just understood they should not be fat. 

The reality is, there is not an overweight person, who wants to be fat.  Every overweight person knows they would look better, feel better and be healthier if they were not obese.   Every overweight individual has tried numerous times and all kinds of ways to lose weight.  If it was just a matter of telling people they should not be fat or government outlawing fast food and controlling what kids eat at school, there would not be an obesity issue in the first place.  Clearly, it is not a problem easily solved.

The cause of obesity is multifactorial.  First there is genetics.  There is no question that some individuals biology pushes them towards obesity.  Our bodies are somewhat of a black box.  By that I mean that science does not understand all that controls how our bodies handle the weight issue.  Why is it that two individuals can consume the same number of calories and do the same amount of exercise and have very different changes in their weight?  This does not mean an individual who tends towards overweight, cannot have a healthy body weight.  It just means they have to work much harder to achieve it.  Occasionally, there are fixable medical problems causing weight gain.  Though everyone hopes this to be their cause.  A fixable medical cause is very uncommon. There are also clearly life style factors, be it overeating or a sedentary activity level, that can produce obesity.

Once one gains excessive weight, it is anything but easy to lose.    We want  the “secret” diet or pill that will make the pounds melt away.  Advertisers know this as every form of media is full of “answers” for the obesity problem.  Some become so desperate, they resort to major surgery to fix it.  Why is overcoming obesity so difficult?

1)  The body’s biology is designed to prevent weight loss.  God designed us to survive in difficult situations, thus as the intake of calories goes down, the body holds onto them harder.  This is also why the first pounds come off relatively easy, but then it becomes harder to keep losing.

2)  Losing weight requires BOTH a reduction in calories consumed AND an increase in the burning of calories.  I find that most people try to lose weight by doing one or the other, but it requires both.

3)  Eating is one of the wonderful pleasures of life.  There is no question we have been given the capacity to enjoy our food.  Certainly there is nothing wrong with enjoying food, but without a doubt, that enjoyment makes it very difficult to resist putting too much food in our mouths.

4)  We have to keep eating.  When individuals struggle with addiction to tobacco, alcohol or drugs; we tell them they cannot just use them a little.  Smoking “just one” cigarette will quickly reignite the need for more.  Eating too much is no different.  Unfortunately, we have to eat, in order to survive, so we cannot completely remove food from our environment, which means the temptation to overeat is constantly in front of us.

5)  Few enjoy exercising. There are a few “weirdos” who enjoy exercising.  (Actually, I am jealous of those who enjoy physical exercise.)  However, most people do not enjoy exercising, but it still needs to be done.

6 )  The fight is never over.  It is relatively easy to get motivated to do hard things for a short period of time.  In the area of weight loss, the moment one relaxes , the weight starts to come back and often very rapidly.  While one cannot help but lose the intensity after a period of time, one can never consider the weight issue conquered.

Though very difficult,  I believe everyone is able to lose weight.  We are not plants.  Plants manufacture their own calories, but we do not.  If we consume fewer calories than we burn,  we WILL lose weight.  However,  it will not happen by wishing or good intentions or a burst of effort or because others harangue you. 

In order to lose weight you have to:

1)  Make up your mind YOU want to lose weight enough to be uncomfortable in order to accomplish it.  Write out a list of the beneficial things you will accomplish by losing weight and post it where you can review it when the going gets tough.  This is a long term project.

2)  Have realistic goals.  We all want to get down to what we weighed when we graduated from high school or college, but for most of us, that is just not realistic.  One is less likely to get discouraged and quit if you have small attainable goals, then a large difficult to attain goal.  Studies show that even a 10cpound weight loss can have a positive impact on your health.  Set a ten pound goal and then once one reaches it, celebrate and set a new ten pound goal and keep going.

3)  Reduce your portions.  It is not a matter of eating special food or even calorie counting. You do have to cut back on the amount of food you eat.  Do not refill your plate, even if it tastes soooo good.  Avoid sugared drinks.  It is astounding how many calories Americans drink.  Stay away from high calorie snacks.  Limit your eating out, as these meals have huge amounts of calories in them.  If you need help in this area, I think Weight Watchers is the best program in which to be involved.

4)  Schedule exercise.  Since most do not enjoy exercising, you will always find something else you would rather do and it just will not happen.  In order to be regular at exercising, you have to put exercising in your daily schedule.  Exercising adds muscles, so not only are you burning calories while you exercise, but muscles burn more calories than fat, even at rest you will burn more calories.

5)  Keep a constant check on your weight.  When you see that number go down, it is an encouragement to keep going.  When it does not, it should be a motivator to work harder.  Sometimes the number not getting smaller can be discouraging, but do not let that happen.  You are not looking for your weight to change on a daily basis, but a positive trend. 

6)  Do not give up.  Often the weight does not come down as one would hope, but do not quit.  If you are seriously watching what you are eating and exercising regularly, the worse that can happen is you stop gaining weight and you are stronger with more stamina.   In most cases you will slowly and steadily head towards your goal.

 

Midwife Legislation in SC

Legislation has been proposed in SC that would severely restrict and possibly eliminate the option for out of hospital birth in South Carolina.  http://www.supportscmidwives.com  The following letter is what I have written in support of the certified midwives.

To Our Legislators:

 

Re: H3731

 

I am a family physician practicing in Greer, SC.  I have been delivering babies for more than 25 years.  When I started my practice in Greer in 2005, I was approached by one of the certified midwives and asked to see their patients as needed and to be available for phone consultation when the need arose.  I was initially hesitant because I had heard all of the horror stories and been told how these unqualified ladies were endangering moms and babies with their poor quality care.  At that time most of the traditional obstetrical community had frozen them out, but their popularity among patients was growing so cooperating physicians were badly needed.  The attitude of most obstetricians was that if they refused to cooperate, the certified midwives would go away.  However, because the midwives were filling a need their practices were increasing in size.  For those who claimed they were giving the cold shoulder because they were concerned about quality, I did not understand how making access to traditional care more difficult improved the quality of care for those women using the certified midwives.

 

I decided to make myself available to the certified midwives and their patients.  In working with these ladies I have found, quite contrary to my prior perception, that they are well educated in pregnancy and birth.  They are compassionate providers of quality care and they know their limits and when they need help.  They are not bungling, hicks killing moms and babies.  Just because their training process is based on an apprenticeship model, rather than the college model, does not make them untrained.

 

There is no evidence based data that shows these providers of maternity care are dangerous practitioners.  Studies such as this http://www.bmj.com/content/330/7505/1416   in the British Medical Journal have shown otherwise.  While I am sure that those championing this bill will site anecdotal cases, the reality is the only cases  that most practitioners see are the challenging ones, which gives a false impression as to the risk associated with birthing with a certified midwife.  The average practitioner does not see the hundreds upon hundreds of good outcomes.  The NICUs across the state are full of babies whose mothers were cared for by obstetricians.  Every doctor providing obstetrical care has fetal demises, life threatening postpartum hemorrhages, postpartum infections.  There is even the occasional maternal death.  Does this mean obstetricians should be regulated out of existence?  More likely it means that the certified midwives are being judged by a tougher standard than the obstetricians.  If the obstetricians are so much better at providing care to pregnant women, why do they have a cesarean section rate that exceeds 30%, while the midwives have a rate significantly under 10%.  Maybe the obstetricians have something to learn from the midwives?

 

What is really happening is that the certified nurse midwives are providing an alternative for women from the highly medicalized environment of birthing in a hospital.  This option is being chosen by an ever increasing number of women and the obstetricians do not like the competition.  It is amazing that in the Upstate, where even nurse midwives were resisted for many years, all of a sudden they have opened a nurse midwife practice.  Over the last year the Greenville Health System has begun changing their practices so that they are promoting breastfeeding, immediate bonding between mother and infant and a more natural approach to birth.  The certified nurse midwives have been providing this kind of care for many years, while they have been seriously criticized for doing so.  Now all of a sudden traditional medical care is acting like they discovered it and its benefits.

 

The proposed legislation would effectively eliminate these providers of care for pregnant women.  This would be harmful for all parties:

 

1)   Our political leaders should be working to promote freedom and choice for the citizens of South Carolina.  If the certified midwives are regulated out of existence, freedom has been diminished and choice has been eliminated.

2)  It is being argued this regulation is needed to protect women from unsafe practitioners.  However, other than out of context anecdotal stories, it has not been proven the way things are currently being done is harming women.  One thing is sure, because it is happening in other states, if these practitioners go out of business, not all of their clients will go to the hospital.  The elimination of these practitioners will dramatically increase the number of unattended births or births attended by individuals who have no means to easily access the medical system.  If you want to increase the number of injured and dead moms and babies, this legislation will do it.

3)  The American way is the free market and competition, because it makes all parties provide better and less costly services.  The elimination of this option for women will diminish this needed pressure on the hospital systems to provide the best possible care for all patients.  As I mentioned above, we have seen the positive influence these providers have had on obstetrical care in the Upstate.  Do you really want to go back to the way things were?

4)  Today all policy makers are struggling to find means of providing lower cost, quality medical care.  These practitioners are providing quality obstetrical care for a fraction of the cost of traditional, hospital based care.  You should be looking for ways to promote their care, rather than eliminate it.

5)  A significant number of the women who use the certified midwives do so because they cannot afford hospital based obstetrical care.  What are these families supposed to do if this is no longer an option?

 

What is the REAL objective of this legislation?  If the real objective is to eliminate certified midwives, than this legislation will accomplish that goal. The obstetricians will NOT in any way assist them in carrying out their mission.  Several times I have personally been threatened, that I will lose my ability to practice obstetrics as a result of the assistance I provide to them.  You can be sure, the obstetricians will not provide direct assistance to them.

 

On the other hand, if the real goal is to provide the best quality care possible for the pregnant women of this state, than we need to increase the voluntary corroboration between the traditional obstetrical world and the out of hospital midwives.  Both groups have things they can learn from the other.  Joint conferences where real people talk to each other and cases are reviewed will do much more to improve everyone’s view of the other and improve care than will increasing the regulatory straight jacket.

 

One of the major criticisms of the midwives is they wait too long to get help.  Is it any wonder this happens when they meet with such hostility when they try to get help.  The fix to this is to provide easy, friendly access to obstetricians and hospitals.   In our local area this approach has already proven to be very helpful.  It should be expanded and carried out in other areas.

 

I applaud the legislators desire to have safe medical care in our state.  I contend this legislation will not accomplish that, so it should not be enacted.

 

Keith Stafford, MD

Greer, SC