Pediatric Obesity

The patient (let’s call him Jake) had been referred to me by his local pediatrician. He was 17 years old and weighs 497 pounds. He came with his father who must have weighed at least 400 pounds.

There was a lot going on here and the family dynamics could be the subject of another blog entry. However, after they left, I couldn’t help reflecting. I’m 50 years old; did I ever know families like this when I grew up?

I remember the heaviest kid in our class when I was growing up. He was the target of endless abuse. His last name started with the same first five letters as mine; I tended to sit next to him because we were frequently assigned seating alphabetically. This included gym class, which meant that I had to sit next to him in the locker room. He was terribly ashamed of his body. I felt sorry for Larry, who was a gentle soul, and tried to act as if his corpulence didn’t exist, while many others would taunt him. I remember trying to avoid looking at his body while we undressed or showered in gym, both to save him further embarrassment but also because I was repelled by his rolls of fat.

For some reason, they once weighed us all in gym--publicly. I was 6’3” and 155 lbs., and Larry was 5’8” and 240 lbs. He was devastated because he hadn’t known how much he weighed.

Yet for all his corpulence, I believe Larry wouldn’t even stand out compared to what I see in adolescents today. 17% of our teenagers are obese. And to be considered an obese teenager you have to be pretty big. A child isn’t considered obese until he or she is above the 95th percentile for height and weight. Between the 85th and 95th percentile considers are classified as “overweight” and “at risk” for Obesity. Even by this incredibly lax standard, about 1 in 6 kids today is obese.

Furthermore, these kids already have the adult illnesses that accompany obesity. The rates of diabetes in children are at alarming levels. 10% of the kids in our country already have liver disease. Hypertension in kids is skyrocketing. It isn’t unusual for kids under 20 to be having heart attacks and strokes.

Despite all these health issues, the biggest issue still troubling these kids is what most bothered Larry--peer rejection. Despite the fact that they are now much more numerous, they still feel ostracized and very self conscious of their body image.

The biggest predictor of whether a child will become obese is if they have obese parents. Think of that the next time you evaluate your weight and health. Parents that make the time and effort to control their weight are the best role models for these children.

I last saw Larry over 10 years ago, at our 20th High School reunion. While he was still struggling with his weight he probably hadn’t gained more than 20 pounds since then. Meanwhile it was shocking to see how many of our classmates had overtaken him. I remember one of his worst tormentors, who was a small wiry kid. He now was a policeman somewhere in Florida and must have weighed 300 pounds. I remember the look on both of their faces when they greeted each other. Larry was too polite to say anything but one didn’t need to be psychic to know what he must have been thinking.

Gottlieb Lecture

Hey, Jill here again. I meant to post about this on my patient blog but kept forgetting to do so. So, since this hasn't been updated in a while, I thought I'd do it here.

Dr. Finegold gives a lecture at Gottlieb Hospital (and will be starting this at Prairie Stone as well) about the weight loss program. I was dragged into helping with this when one of our MAs couldn't make it because her daughter was getting married. I was prepared to hear everything I'd heard before and quite frankly to be bored out of my mind.

I was so very, very wrong. Now, understand that Dr. Finegold is indeed a man I've known all my life, and consider him to not be the most charismatic person I've ever been around. Despite that, he makes an excellent public speaker. I was truly inspired to renounce fast food (something I hold near and dear to my way of life) and to get to a frickin' gym and work out. I hate gyms and working out. But this lecture made me quit dragging my feet and contact the gym for a personal trainer, and I've been happier ever since. It actually scares me how well this talk worked.

He brings up some interesting points on how as a species we evolved to be a hunter/gatherer biology and how modern convience goes against this. We used to have to physically hunt our meat and live off of berries/roots/fruit/etc. We were lean, mean, low I.Q. machines. Culture wasn't at its height, but physically we were awesome. Technology and civilization has served to work against our natural physiology. Think about it: we no longer traverse the land on our own two feet but use cars to get places, even if it's five minutes away. Food is readily available in the supermarket, pre-killed (and packaged!) for us--or worse, we can get it "freshly prepared" in front of us in five minutes in a fast food line. Yet our biology is still rigged to the early days of hunting with sharpened sticks after lean deer or foxes or whatever-four-footed creature you could catch. Or fish. Or whatever. Anyway, he tells this better than I do. And with slides and pictures!

Next lecture is November 12th at Gottlieb Hospital. It should start at seven at night...though I'll double check that.

"Does My Insurance Cover This?"

Hey, Jill here again.



I get asked this question a lot. Half the calls made to the office are potential patients who won't consider coming in until they have this question answered. So I finally decided to post about it.



The answer is this:

It depends on your insurance plan. So there. Whatever your insurance, Blue Cross Blue Shield, Humana, Cigna, HMO, PPO, whatever--sometimes it's covered depending on what you're paying for.

So give them a call. The number is on your card somewhere. I know it is. All you have to do is muster the courage and patience to sit through the automated system until you talk to a real person. It's annoying, I realize that. That's part of life.

So does your insurance cover this? I don't know. But ask yourself this instead: "Can I afford to keep living the way I do now for much longer? Or will my health begin to deteriorate faster?"

Oh yeah, we don't take Public Aid. Everything else (HMO sites have to be Gottlieb West Town site 133) is acceptable. So you guys can relax about that, at least.

I will say most insurances do cover us, though. We have a small percentage of patients who aren't covered who never come back, but about 94% are.

So please, if you're going to call us, at least think of a creative way to phrase this question. I like creative thinkers. ^_^

I Can't Afford to Lose Weight Right Now

I was talking with Gloria, the manager of the Gottlieb Health and Fitness Center. GHFC partners with Chicago Weight Control in the near western Chicago suburbs. For the last two years we have had a highly successful comprehensive weight loss program. She was concerned about an alarming, if understandable, trend. Perhaps due to our current uncertain economic climate, people think that they cannot afford the program

Our program is called comprehensive because we attack the weight loss issue on every front. For three months people get:

• Appointments with physicians certified in weight loss medicine (bariatric medicine)
• They have their metabolism tested (indirect calorimetry)
• Two sets of blood chemistry
• A health club membership with 12 personal training sessions
• A meeting with a registered dietitian seven times
• Three group counseling sessions led by a professional psychologist.
  

The program does cost $2500, which initially seems like a lot of money. Insurances don’t cover it, although some of our patients have been able to get up to $600 back from their insurance companies.

I realize that $2500 sounds terribly expensive. However, let’s look at that a bit.

First off, what is the value of the services. The physician component, including the indirect calorimetry and the two sets of blood work, is worth about $1100. The 7 meetings with the dietitian are worth $600. The personal training is worth around $900. The health club membership is about another $500, and the three sessions with the psychologist are worth $300. That is roughly $3500 for $2500; it just isn’t possible for us to discount the service to any additional degree.

Secondly many of the patients are taking multiple medications. When they lose weight and no longer require these medicines, they are saving a fortune. Many patients can be on three medicines for diabetes, three for their blood pressure, one or more cholesterol medications, arthritis medications, etc. Even patients with insurance have costs for these medications. One of our patients who has lost more than 200 pounds states that in the past twelve months his savings on his insurance co-pays have already paid for the cost of the program.

The unfortunate truth is that being unhealthy is expensive. Not only are there medication expenses, but there are physician visits, medical equipment (wheelchairs, insulin pumps, walkers...the list goes on and on) that people have to pay for. Insurances are covering less and less of this, and as the economy falters, they will shift more of those costs to the patients.

From a financial planning perspective, one of the best investments that you can make is to protect your health. I would argue that money invested in our program will probably save you several times your initial investment. I would also argue that given the unreliability of every other investment vehicle out there, that if you need our program, investing in it is a lot more reliable investment than most other options.

All of the above is looking at this strictly from a financial planning standpoint. Finances alone are not the whole story. Can we put a price on being healthy enough to keep up with our grandchildren? Or being able to have children in the first place? How about living long enough to see our children raise their own children? At the risk of sounding like a Master Card commercial, there isn’t any price too high to pay for all of that.

I know that in times of great uncertainty, our program looks too steep. Honestly, I don’t think people can not afford our program. It is the best investment for both your health and finances that you could make.

The Number on the Scale Doesn't Mean What You Think it Does

Jill here. Just something I'd like to relate to those who read this.

We had a patient in recently (we'll call him Maverick to protect his identity) who was in for a check up. Maverick was looking much better in recent months than when I'd first met him. He was slimmer and definitely more buff. When he stepped onto the scale, he had gained almost five pounds in three weeks. When my dad saw that, his face was disappointed. I pointed out what I had noticed (Maverick was already in the room and my dad hadn't seen him) and that caused Dad to check his fat percentage. It was down by almost 10%.

Muscle is denser than fat and will weigh more. I have to tell patients this all the time when I weigh them. They'll have worked out, lifting weights, toning muscle, jogging, biking, whatever, and then gain weight. They get upset over this, but it turns out that their fat percentage is always down and they look much better than they had previously. But the number the scale shows always disappoints them. The number isn't always that important--what's important is that they're taking care of themselves and not turning their muscle and organs into fat.

Not everyone believes me though. They just want to weigh less. It's not about being healthy to some, it's about being thin. Baaaaaaaaaaaaaaaaaaaad idea. First goal should always be about being healthy. 10 overweight is better than underweight. If you get sick, this helps protect you. There's a little more cushion to break falls, run into corners, get hit by flying objects, etc. so nothing actually gets broken. And if it's all muscle, then that's even better. Except you might bruise more.

Anyway, that's all I have to say for now. Take care. Oh yeah, read my own blog. It's linked off to the left there. ^_^

Do I Really Have To Excercise?

The new patient (let’s call her Nancy) was not in any way unusual. She was fifty years-old and a life-long dieter. Five feet three inches tall, 189 pounds. Her body mass index (BMI), which is a persons' height divided by the square of their weight, was 32.

Normal BMIs are between 20 and 25. Between 25 and 30 is considered medically overweight, and obesity is defined as starting at a BMI of 30. 35 is the second stage of obesity. Morbid obesity (or as it is now politically correct to say, “extreme obesity”) begins with a BMI of 40. This last segment is the most rapidly growing segment of the
obesity epidemic.

Keep in mind that two thirds of the adults in this country are now either overweight or obese. I’ve come to think of a BMI of 32, while unhealthy, as garden variety obesity.

There was one thing about Nancy, however, that immediately jumped out, and that was her percentage of body fat. Our scale has a device called impedance plethmography, which means that it measures body fat percentage. A normal body fat percentage for a woman is less than 25% fat. Nancy was 52%. We routinely see patients with that degree of body fat, but usually they have BMIs that are much higher like over 40. I’m used to seeing a body fat in the 35 to 40% range for a BMI like Nancy.

I reviewed the nutritional history that we ask patients to fill out. It showed that she had lost and regained weight more times than she could count.

I asked her if she exercised regularly, either at the present time or in years past. She admitted that she had never exercised. Each time that she had lost weight in the past she had really deprived herself of food until she couldn’t stand it, then went back to her old ways and the weight rapidly returned.

Nancy’s body fat was so high because when she was starving herself to lose weight, she was losing a lot of that weight as protein, and when she was regaining it, and she was regaining it as fat. The protein that she was losing was coming out of her muscles and her internal organs (heart, liver, brain, etc); when she regained the weight those areas were filling up with fat.

Her subsequent physical exam and laboratory reports confirmed this. Her exam was really striking in her thighs. Both of her thighs had an hourglass shape; they tapered in at the middle and bowed out on both ends with squishy jelly-like material that was probably muscle completely interlaced with fat. Her blood work showed elevated liver enzymes, which is usually a sign of fat infiltrating the liver; a subsequent ultrasound of the liver confirmed this.

In short, Nancy was only modestly obese, but she was remarkably unfit and unhealthy.

A dirty little secret is that we can all lose weight without exercising. If we limit our calories to less than our bare needs, our bodies start breaking down tissues to supply the required energy, starting with our protein-laden muscles and organs. (Muscle can burn fat, but also weighs more on the scale.)

What people don’t tend to realize is that among other beneficial things exercise does, it preserves lean body mass. In other words, the weight you lose will be fat--which is the stuff we want to lose--and our muscles and internal organs will be preserved.

I love to exercise myself. I do it early in the morning and it lowers my stress levels for the rest of the day. I become much more tolerable to be around. If I don’t get a chance to do it, I get really crabby. My wife, kids, and my coworkers don’t want any part of me.

One of my kids is also pretty unbearable unless he is doing something physical, but my daughter, Jill, who also blogs here, hates to exercise unless properly motivated. Regrettably for those who hate to do it, it is pretty essential.

I always tell patients that I don’t have a pill labeled exercise. Even Bariatric Surgery patients are expected to exercise.

How much exercise should we do? And what type? That will be the subject of a future blog. The short answer--anything is better than nothing at all.

Does Bariatric Surgery Turn You into a Sex Maniac?

I was surprised when I walked into the exam room to see my next patient. Her chart identified her as a new patient, although her name was vaguely familiar. I realized why when I saw Susan (not her real name) waiting for me on the exam table. She was a pharmaceutical salesperson (we call them “Drug Reps”) who had only recently started calling on me. About two weeks ago her company had hired me as a speaker to promote one of their (non weight loss) drugs that I prescribe in my general practice. The meeting was held in a private dining room of a trendy restaurant. Very few physicians showed up and there was a lot of time to kill with me chatting with the reps from this company. Naturally a lot of the conversation centered around weight loss, since that is my specialty .

Susan met me for the first time at that meeting. She was about thirty years-old, very articulate and intelligent. She had an attractive face and she appeared to be just a smidge over ideal weight. I remember thinking that her interest in weight loss seemed out of proportion to her own situation, but that is not common, especially with women.

She was very tense and tearful, totally at odds with the very professional and relaxed appearing woman that I had chatted with recently. “Can you take Wellbutrin and Phentermine together?” she blurted out, choking back tears. “Does Wellbutrin cause you to act crazy?”

I should explain here that Wellbutrin is anti-depressant, the only anti-depressant that doesn’t cause weight gain (and may cause a small weight loss). Phentremine is an appetite suppressant that I commonly prescribe.

This was an unusual way to start a physician/patient relationship, to say the least. I asked her to back up and explain why she wanted to know, and also why she was so upset.

Her story was hair-raising. It seems that immediately after my meeting with her, her husband and her own parents had had her committed for a few days to a psychiatric hospital. She had just gotten out before our visit.

After the birth of her daughter, now aged eight, her husband had stopped having sexual relations with her. She ate out of depression and her rate ballooned to almost 300 pounds. Unable to lose the weight, she had bariatric surgery and went down to 150.

Then it got interesting. She began to participate in Internet groups looking for sexual partners. After a few months she let herself be filmed having sex with three men simultaneously. As what happens every time something like this occurs someone who knew her and her family saw these pictures and alerted her family.

She had been placed on Wellbutrin a few months prior to the surgery for depression and her family was trying to blame this drug for her behavior. She had regained 15 pounds during her week in the Psych hospital, wanted to take Phentermine and continue her Wellbutrin (thus her opening question to me).

Her story interested me even more than it normally would because of a few other patients that I have seen recently. Another one had had bariatric surgery in Ohio, had moved to Chicago and wanted me to follow her. She had asked for an HIV test and in the course of counseling her, she let slip that since she had lost weight in surgery she was participating in orgies (her husband also participated--at least this time it was a family activity).

Another patient was seeing me because her husband had had bariatric surgery and was losing weight rapidly and she wanted to lose some weight non surgically. On her third visit she was crying because two nights before she had caught him on the Internet entering his info into E-harmony. She proceeded to divorce him.

The psychiatric literature is replete with articles about patients who after bariatric surgery become addicted to alcohol, cocaine and other drugs, or compulsive gamblers. The speculation by the various authors is that some obese people tend to engage in compulsive behaviors (such as overeating). When they can no longer overeat because of the surgery, they find other outlets for their compulsions.

I have to say that after many years of helping people lose weight non-surgically I haven’t seen that kind of problem in my patients. Perhaps because these people have to work at it, and as part of that they wind up examining what makes themselves tick, and they learn how to deal with their compulsions rationally. The patients who go for surgery tend not to be to introspective: they want the quick fix and they don’t really want to examine their lives and make changes. I’m not going to pretend that I have all the answers. However, I do think examining the question is very interesting...

New Blog to Start...

We're starting a new blog that'll be like a sister-blog to this one. It'll be written by me (sorry folks) about my experiences of going through the weight loss program. It's guarenteed to be somewhat snarky at the least, so if you like that sort of thing check it out. It's on the list of blogs on the side of this very page. ^_^

If you don't know who "me" is, I'm Jill, the receptionist at the Hoffman Estates office. I work in the Elmwood Park office Monday mornings as well, though any of the patients who remember me are scary-good at remembering tiny details and may want to look into becoming detectives for a living. Or something. I'm also Dr. Finegold's daughter, so when he asks (nicely) that I do something I really have no reason to say "no". So...here we are. I'll go update the other blog now.

Are You a Real Doctor Too?

I love it when I hear patients say: “I didn’t keep my appointment with you last week doctor because I was sick.” Or when they describe their other medical problems and I start making comments, if they say “Are you a real doctor, just like my doctor?”

I guess I can’t blame patients for their confusion. Most physicians who deal with weight loss--and there aren’t that many of them--do nothing else. Dr. Elhag and I are somewhat unique in that we have kind of a dual practice. We are primary care physicians who have done extra training in weight loss medicine. We still practice primary care internal medicine.

I know that we are all specialized these days, and perhaps patients like the idea of seeing a doctor who does nothing but weight loss medicine all of the time. However, from my standpoint, I think that primary care physicians are the best physicians capable of dealing with weight loss issues.

First of all, we see all the complications that come from obesity. I first became interested in this because for many years I’ve been treating people for diabetes, coronary artery disease, sleep apnea, hypertension, breast, prostate, and uterine cancers, back pain, knee and hip arthritis, infertility, and many of weight related illnesses. You get tired of treating each problem independently with a plethora of medications. Eventually you’d like to treat the root cause of all these problems and make them go away.

We also get to see the side effects of many medications prescribed by other physicians. I don’t know how many psychiatrists that I’ve had to inform that our mutual patient has gained fifty pounds because of the medications that that doctor has used, only to have the shrink deny that their medication was the culprit. Now there is an increased awareness of this in the psychiatric community but it took years. The same can be said for estrogen replacement therapy, many blood pressure medications, seizure medications, and a host of others. As PCPs we are aware of what medications can cause these problems, what may perhaps be a better alternative, and how to coordinate these issues.

Another issue is how to deal with the favorable effects of weight loss. For example, diabetics on insulin make dramatic improvements in their blood sugar with small amounts of weight loss. Since as PCPs we prescribe diabetic medications constantly, it is easy for us to advise the patient what to do as they lose weight. The same can be said for the cholesterol and blood pressure medications.

Many times I’ve had a patient in for their routine weight loss checkup with a bad cold, or asthma attack, or some other acute problem. It is both gratifying and amusing to have them realize that we aren’t just “weight loss doctors” when we treat that other problem as well.
Our weight impacts our entire health. I think that primary care physicians are in the best position to deal with that whole person.

Shakes, Bars, and Less Expensive Groceries. Oh My!

Jill was telling me a story the other day. It was about a patient of ours who had started the weight loss program as a less-than-enthusiastic participant. She had tried Weight Watchers, Jenny Craig, and every fad diet under the sun and ended up gaining weight in some instances. She'd just about had it with even trying to lose weight.

She'd come in for a free consult two months ago and asked a lot of questions with little hope in her voice. After conducting an IC on her we saw that her metabolism was actually normal which did little to make her happy. When I had Jill show her the supplements she had heaved a weary sigh and glumly bought three items (two sets of protein bars and one set of strawberry shakes; this should last any patient for two weeks).

When I was with another patient about a month later this lady stepped in to be weighed. We let our patients use our scale all the time at no cost as long as someone is here to input the data. It sends an elecetric current through the human body through the feet at a current so low you can't even feel it. The current bounces off of fat and muscle which have different densities and tell the doctor and patient how much of either substance is contributing to the number the scale reads for their weight. With diet and exercise a patient might not lose weight because what was once fat is now muscle (which weighs more), but the muscle burns fat and is in fact much healthier.

Anyway, the patient had stepped in to hop on the scale to see what, if anything, had happened. It turns out she had lost almost ten pounds in about three weeks, a healthy weight loss, and was feeling more energentic than she had in years. She quickly bought ten supplement and meal replacement items with a big smile on her face.

While on I'm on vacation, Jill is still in the office selling supplements. The patient stopped back in to be weighed (this is now almost two months after her initial visit) and lost nearly ten more pounds. Jill said she was having trouble understanding her because she was so excited that she was talking in a constant stream. The patient bought nearly twenty items, and when Jill questioned it she said this:

"I've lost so much weight and am so happy just by having a bar or two a day and walking around more that even my husband started sneaking my bars. I just figured I'd buy more. We've stopped buying as much stuff at the grocerey store because we're not as hungry with these bars around now!"

Jill says that the patient says she currently saves almost three hundred dollars on groceries now. I was floored, and can't wait to congratulate her on her next appointment. All this without the appetite suppresent too!

Patient Plateau

Before I walk into the exam room where my patient is waiting for me I grab the chart and look at the weight slip the scale printed up. My staff is instructed to put little symbols next to the patient's weight. A smiley face indicates weight loss, frowny faces are weight gain, and an indifferent face (flat line) means no change. Jill, my receptionist who weighed this patient, had drawn a frowny face with two big tears rolling down its cheeks.

The patient had only gained one pound in a whole month, so I was puzzled: why such a big deal? After all, this patient had lost forty pounds since joining our practice and was able to stop taking the blood pressure and diabetes meds that she had been on when she started. From my perspective she was a real success story.

When I walked into the room, I discovered that the patient didn't see it at all. Arlene had started at 200 lbs., was down to 160 lbs., but in the last four months had lost only two pounds. She was angry because she wanted to weigh 140 lbs. and it didn't seem like she would ever get there.

"I just don't understand. I'm doing the same amount of exercise and I haven't really changed the way that I eat much, but I'm at a plateau."

This is the part that frustrates everyone who is trying to lose weight. You can have success and then it just seems to stop. Even bariatric surgery patients hit a plateau.

Let's look at why that occurs. As I mentioned in my last blog, we do metabolism testing in our practice. Now, when Arlene started she weighed 200 lbs., which is about 90 kilograms. The equation for predicting the RMR of a woman is to multiply her weight in kg by 24 and then take 90% of that number. That's about 1960 calories for Arlene. When we measured her metabolism she was exactly 2,000 calories (10 calories/pound).

Arlene followed a 1200 calorie/day meal replacement diet and began walking four miles/day and lost the forty pounds. However, at her new weight of 160 lbs. her RMR is 1570 calories. We repeated her metabolism test and she was 1580.

This means in order to keep losing weight, Arlene now has to account for over 400 calories that she didn't have to account for before. Simply put, since there is less of her she now needs less calories to stay baseline.

Arlene has to now eighter increase her exercise to account for those calories (walk six miles a day?) or eat 400 calories less than she had been before. Neither option looked particularly attractive but that's the way it goes.

In her case we tried adjusting one of her meds and we got her to increase her activities in daily life--parking farther away at work/shopping mall, not using elevators but stairs instead, using a bike instead of walking, etc.

She lost another seven pounds in her next two appointments and is happy to see some progress. It's become easier for her to remain enthusiastic about the program again.

Metabolism

  The new patient sat there looking at me with a facial expression that was a mixture of frustration and bemusement.

   "I really don't eat that much" she said.  "I don't know why I have trouble keeping my weight down."

   We ask patients to provide us with food diaries.  For breakfast she had written yogurt.  Lunch was a salad, and dinner was a boneless skinless chicken breast with vegetables.  No snacks or alcohol were listed.

   This patient is a sister of another patient who had lost 80 pounds in less than a year.  I knew that the sister was a reliable person, but I figured this new lady must be lying through her teeth.

She was 42 years old, weighed 357 pounds, and was seeing a fertility specialist who told her that her chances of ovulating were greatly enhanced if she lost weight.

   I tried to probe without letting on that I didn't believe her.  "Is this a sample of the way that you have recently been eating?  Perhaps you have only been seriously dieting for only a few weeks and prior to that you took in more calories?"

   She looked annoyed.  "No doctor, I've been trying to lose weight my whole life.  I'm not that

hungry, but I just can't seem to lose anything."

   She admitted that she didn't exercise, but continued to insist that her intake was not excessive.  On her history form, she stated that she had been in Weight watchers for 20 weeks, was placed on a 20 point/day diet (1000 calories) and lost only two pounds.

   An individual's Resting Metabolic Rate (RMR) is how many calories someone needs to consume to either not gain or lose weight, assuming that they sat in one place all day and did

not move.  There are equations to predict the RMR, and her predicted RMR was close to 3000

calories.  If her metabolism was normal, she should have lost plenty of weight on a 1000 calorie diet.

   That turned out to be a big "if".  In our office, we can measure peoples metabolism with a piece of technology called an Indirect Calorimeter.  It is a machine that you breathe into for about 10 minutes.

   Most of our patients think their metabolisms must be slow, but when we measure most of them they aren't.  A careful diet history will usually reveal that people are taking in many more

calories than they suspect.

   Not this woman.  When we measured her her RMR turned out to be just over 1000 calories a day, or almost one third what it should have been.  No wonder she couldn't lose weight.  I should not have doubted her.

   She took some comfort in knowing that her metabolism is slow.  She is going to be a tough patient to treat, but as long as she is willing to be patient and work at it, she will do well.

   Everyone is different.  We all have different metabolisms, and having a tool t measure it is a great asset in customizing a weight loss plan.