Found And Lost, Part 3

 (The Digger's Waltz - Tommy Emmanuel)

A funny thing happened on the way to the dietician. 

Sentences you never thought you'd write, let me tell you.

Still, the dietician had an appointment that was running long, so my physician ended up taking me to see the shrink first.  There are, as it turns out, a whole host of monsters that can crawl out from under the bed when you start talking about weight loss.  The Bariatric Center had a guy for just such an occasion, a jolly little man with a last name that, at the time, I had absolutely no hope of pronouncing.

Like everyone else in that office, he had a huge smile on his face when I walked into his office.  At this point, I'd interface with a receptionist, a nurse, and a physician, and they'd all been sort of...happy.  Now there was this guy, and as I sat in yet another well-upholstered chair designed to accept my rotund ass, I started getting a little worried.

I was sitting in the middle of an office full of plainly spoken, realistic, honest, helpful medical professionals who seemed legitimately interested in helping me on my own terms.

"You look contemplative," he opened without preamble. 
"Yeah, I won't lie, this is...a little new for me."
"What, precisely?"
"All of this.  Doctors.  I don't go to see doctors, not unless something is wildly out of place.  I'm German, from a family of German farmers.  Practicality and stoicism are part of our religion."
"And yet you're here now.  Why is that?"
"...Because I'm broken.  I think."
"What makes you think you're broken?"

So I started over.  Again.  I laid it all out, and he sat there quietly with that infuriatingly pleasant, gentle, completely nonthreatening smile on his face and had the audacity to just ... listen.  Finally, after I'd run my mouth for close to 5 minutes, I stopped myself and blinked a few times.

I'd covered the bloodwork, the lack of weight loss, the food diary, the apnea, all of that.  Then I started rabbiting on about how the weight loss was supposed to work, and the science behind it, and how the Calorie was an absolute crap unit of measurement for this kind of thing, and why was I talking so much?!

"I think I know why you're so frustrated," He offered after I'd been silent for a moment.
"Oh?"
"You like facts.  You like data you can lean on.  They're reliable.  And right now, all of the facts you have don't appear to apply.  You're leaning on science, and it's not working.  And then you came here, to us, and we are admittedly not entirely sure why."
"Everyone keeps telling me I'm an edge case.  I'm the exception."
"That could have something to do with the fact that you're an edge case and an exception.  You represent a truly rare confluence of events.  Tell me, do you have a problem with how much you weigh right now?"
"Only that I don't think I should weigh this much.  That the data tells me I shouldn't.  I know how I got here in the first place, I just...don't know why I never left."
"So you're not concerned about your weight as long as you come by it honestly."
"More or less.  It doesn't really impact my life in any meaningful way.  I've apparently got bloodwork and other tests that prove that.  If I'm happy and I'm healthy, why should I want to lose weight?"
"That's a good question.  For what it's worth, we're not here to help you lose weight."
"That's...a very interesting statement."
"It bears the virtue of being an honest one.  If you're happy and you're healthy, we see no reason for you to lose weight.  All we want to do is help you figure out why you can't lose the weight.  Once we've done that, you can do whatever you wish.  Our goal is for you to be happy, not necessarily to be thin."

Then he asked me a series of control questions that were clearly designed to give him an indication about my current mental health.  After that, he closed his laptop.  "I think our dietician is ready to see you now."  We both stood up, shook hands, and started for the door.  I asked him if he wanted to see me again when I made my follow-up appointments with the other doctors.  He smiled and said that while he absolutely wanted to see me again, I didn't have to if I didn't want to.

Which...had the really bizarre effect of making me immediately want to talk to him again.

He led me down a hall to another office where yet another medical professional was waiting for me with a maddeningly genuine smile and another comfortable chair.  She closed the door after I entered, we both sat, and then she laughed a little. "Are you feeling okay?"  I thought about it for a moment and said, "I think that little man just shrank my head right in front of my nose, and I'm not entirely sure I didn't enjoy it."  

"He does that," she replied.  "Now, let's talk about your food intake and your calories, shall we?"

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The next hour or so passed in a blur of numbers and incredulity, but the take-away from the whole ordeal was surprisingly simple by the time the dietician was done pouring data into me.

The first thing she did was figure out both my Basal Metabolic Rate and my Total Daily Energy Expenditure.  My PCP got the BMR pretty darn close.  The dietician figured it at around 3,900 calories a day.  Then she dropped my TDE on me.  According to her -- and the internet agrees, so she must be right -- your TDE represents your BMR plus the number of calories you need to support any activity beyond the simple maintenance of homeostasis.  Get up in the morning? That burns calories.  Walk up and down the stairs?  Calories.  Drop a fat deuce after breakfast?

Calories.  In my case, a lot of calories.  I ship a lot of freight out on the ol' porcelain rail, people.  This isn't that kind of a story though, so...

Turns out, my TDE?  4,550 calories.

On one hand, I laughed out loud when she told me the number.  On the other, I sort of shook my head in disbelief.  After all, 4,550 calories is what I had to consume on a regular basis to get to my weight and stay there.  That alone was sobering.  The fact that I'd done that for so long and was still reasonably healthy was...

What was it my PCP said about me not really understanding how lucky I was? Yeeeeah.

That still left the problem of weight loss though, and it also added an entirely new problem to the mix. 

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"Two problems, actually," the dietician added after a moment.  "This is actually sort of unusual now that I stop to think about it."
"...That has pretty much been my mantra since I started this whole process."
"So, that whole calorie deficit we talked about?  The reason why you want to shoot for around ten to fifteen percent is because if you create any more of a deficit, your body starts to think there's no longer a stable source of food around, and it begins hoarding fuel.  In this case, fat."
"You are...trying to imply that because I'm eating so much less than my massive body thinks it requires, it thinks I'm starving?"
"More or less."
"Please do not say that I need to eat more to lose weight.  I'm asking nicely.  That would be the cherry on top of an already very weird day."
"Well...we could do it that way, but I think we both know that's not really an ideal choice."
"Gosh, I'm...glad we agree on that.  So the deficit is the first problem, but you said I had two."
"Yeeeeah, about that.  This is kind of interesting when you stop to consider all of the moving parts. See, your apnea has most likely been effecting more than just your beauty sleep..."

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Remember that bit about how if you spend enough time being oxygen deprived that it starts to screw with everything?

Yeah.

The physician, the psychologist, and the dietician couldn't put their finger on exactly what was keeping me from losing weight, but they had a working theory that was too good to ignore. It also sort of explained how I got so fat to begin with.

Yes, I realize that my eating 4,550 calories day in and day out is how I got fat, but what compelled me to do that?  I love food as much as the next person, but 4,500 calories is a lot of food, people.  Why was I eating so much?  

The working theory from the bariatric specialists is that I was so exhausted from lack of sleep that my body had gone into survival mode and was trying to augment my flagging energy reserves any way it possibly could.  You certainly get energy from sleep, but you also get energy from food.  The brain isn't stupid, so it did the only thing it could think to do.  It started demanding more food.  I'm a guy that already likes a nosh, and I spend time with family and friends that also really enjoy a nosh.  It was a perfect recipe, no pun intended.

Now, let me be perfectly clear here: I made the choice.  I did this to myself.  I ate the food.  Even in my sleep-deprived state, I was not so lacking in will power that I couldn't put the fork down.  I chose.  I just had absolutely no incentive to stop.  Eating food felt good.  Turns out, there was a reason.

Even constant eating wasn't the last piece of the puzzle though.

See, I didn't really cook much in 2019.  Unless it said 'KRAFT' on the side of the box, I didn't have much experience with it.  I wasn't inept in the kitchen, I just...didn't have the patience for it.  I wanted my food to be faster and more convenient.

I think you can see where this is going.  No?

Fast + Convenient = More fast food.  More pre-packaged food.  More sodium.  More sugar.  More carbs.

Now we finally get to that last puzzle piece.

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"So, let's go over what we know so far, shall we?"  The dietician began ticking fingers off.

1. Now that you're using your CPAP, you're not exhausted.  That's a good thing, and it explains why you're no longer consuming so much food.  Your body simply doesn't need to get that much energy from nutrition anymore.  You're actually recovering energy from sleep.  Unfortunately, you've created such a large calorie deficit for yourself that your body now thinks you're starving, which means it's holding onto its fatty reserves.

2. You eat less food now, but what you do eat is still not awesome.  Generic weight loss math deals in calories, but a calorie isn't really a great unit of measurement when it comes to nutrition.  A calorie is a unit of measurement in chemistry.  It has to do with how much heat or energy a unit of a particular substance puts off when it's burned.  Where it breaks down is this conception that all calories are created equal.  They're not.  It's not just about creating a calorie deficit, it's about making sure that the calories you do take in contain the appropriate nutrients that your body needs to leverage them properly.  

Then she smiled at me and held a third finger up.  "Here's the part where I tell you why I don't think you're losing weight."

3. The body's metabolism is an engine that is designed to run most efficiently on a particular type of fuel: Protein.  Your bloodwork shows us that your metabolism is not broken, per se.  Instead, I think your body has gotten so used to the influx of high fat foods that it has stopped looking at protein as its primary energy source and has instead started to look at fat.  It now believes that fat is what is most precious.  Unfortunately, it also believes you're starving, so it's hoarding your fat.

I blinked really slowly at her.  She grinned back.  "The fix is easy.  You're not a vegetarian, are you?"

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With some few exceptions, matter that is safe and nutritious for humans to consume can be broken down into three main macronutrient categories:

- Fat
- Carbohydrates
- Protein

When you hear health-conscious people talking about their 'Macros', they're talking about the ratio of fat to carb to protein in the meals they take in each day.  There are as many articles as there are stars in the sky talking about what people believe the best macro ratios are for weight loss, but the generally held knowledge is that a normal diet for a reasonably healthy person should contain around 45% Carbs, around 35% fats, and 20% protein.  Depending on what you want to do with your health, you can modify those ratios to suit your goals, provided your doctor has no issues with it.

Now, we inject some math into this.

One gram of protein equals around 4 calories.
One gram of carbs also equals around 4 calories.
One gram of fat, however, equals around 9 calories.

As a hypothetical, if the FDA wants the average person to eat 2,000 calories a day and you're using the macro percentages I mention above -- 45, 35, and 20 -- that comes out to 900 calories from carbs, 700 calories from fat, and 400 calories from protein.  Add those calories up, and you should get 2,000.

And that, as it turns out, is how you calculate macros.  With this information, we went back and looked at my food diary.  Sure enough, my macros were completely shot, containing much higher amounts of fat and carbs, and far less protein.

This is where we get back to the net result of that first series of appointments with the bariatric specialists.

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"We need to teach your body to burn protein as its main energy source again," the dietician said.  "That means making sure that whenever it goes looking for energy of any kind, there's ample quantities of the best energy source it could possibly want.  You need to eat more meat."

I began laughing gleefully at that point, and the dietician quickly raised her hands.

"Hold on!  I don't mean that you should go home and eat a pound of bacon at every meal.  The trick here is to eat as much lean protein as you can, within reason.  That means chicken, preferably white meat.  That means lean beef.  That means fish.  Pork is...pretty much horrible from a fat and sodium standpoint, so try not to lean on it too hard."

Then she reached into one of her desk drawers and, I shit you not, pulled out a completely prepared plate of food.  My laughter escalated at that point because why in the world should anything else about this appointment be normal?  Girlfriend just pulled a plate of food out of her drawer.

----------

After I managed to calm myself, I realized that it was a plate full of plastic food, and...I confess, I was a little disappointed. 

We proceeded to have a very animated conversation about how my goal should be to fill half of my plate at each meal with a protein of some kind.  The remaining half should be divided itself in half.  One quarter should, ideally, be a vegetable of some kind, preferably green.  The other half?

She didn't really care what the other half was.  

Then, because she knew who she was talking to, she explained things using numbers.

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"If you're concerned about portions, let me make this easier for you."  She tucked the plate of food away into her desk again -- another sentence I never thought I'd be typing -- and leaned back in her chair.  "I want you to prioritize the consumption of between 80 and 100 grams of protein each day.  No less than 60.  That's around 30 grams of protein per meal."  She spread her hands. "I don't care what you eat after that.  Ideally, I'd love to see you eat something green and/or fibrous in addition to your protein, but if you get that 30 grams of protein in before you get anything else down the hatch, I'll be perfectly happy.  Let's start there."

"Let me...be sure that I heard you correctly.  You want me to eat 30 grams of protein at each meal, which I can make meat as long as it's reasonably lean meat and only occasionally involves bacon."  I raised an eyebrow.  "And after that...I can eat twinkies?"

The dietician leaned forward in her chair then and did something really scary.  She looked me in the eye, smiled really widely, and said, "Yep."

And that was more or less the way that first doctor's appointment went.

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My bariatric physician met me while I was checking out and asked me how my visit with the dietician went.  I told her that I generally didn't care for doctors, but that I also applauded their attempt to sooth my anxiety by basically giving me cart blanch to eat meat and junk food.

At this, my physician laughed, checked my digital chart, and said, "You have absolutely no idea how much lean meat 30 grams of protein is, do you?"  She shook my hand once more and turned to walk away. "She doesn't care what you eat after the meat because you won't be able to eat much after that other than a light salad.  See you in a month."