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.