When I first went into practice, over 20 years ago, all my patients were eating pretzels. Also Entenmann’s fat-free cake. And jelly beans.
It was the era of the low-fat craze, not to be confused with the low-carb crazes that preceded and followed it.
That my patients were not losing weight on these diets didn’t surprise me, not because of my vast knowledge of nutrition (about which physicians receive notoriously scant training), but because I wasn’t faring too well on them myself.
You see, dear reader, when it comes to dieting — to paraphrase the men’s hair commercial — I’m not only a professional, I’m also a member of the club.
I remember the precise moment I first decided to lose weight. I was 12½ and had lied to my parents about where I would be spending the evening: I said Susie’s. It was actually Teddy’s.
As I dressed for my clandestine outing, I gazed at a reflection of myself in a pair of purple striped hip-huggers and resolved to be thinner. I devised a diet that seemed sensible: 400 calories a day.
It didn’t take me too long to figure out that this was not enough to sustain a growing adolescent (or the average cocker spaniel, for that matter).
What took me decades to figure out, though, was that my impulse to diet had more to do with shame, specifically shame about desire (See above: Teddy) than with what I actually weighed — which wasn’t much.
If only things had remained so simple, or only just that complicated.
Like many other middle-aged women, I’d love to weigh now what I weighed when I first decided I was fat. And though I've never been more than a few pounds over what’s considered healthy, I long for the days when I could dismiss concerns about calories and fat grams as obsessions of a culture driven by unrealistic standards of female attractiveness.
But I can’t dismiss them. My coronary arteries have other ideas.
I would like to avoid the real health risks that come with excess weight, especially with the obesity to which I am genetically prone: cardiovascular disease, diabetes, arthritis, gall bladder disease; breast, uterine, and other cancers.
In a nation where two of three adults are overweight and one in three obese, in which half of all women and girls are dieting at any given time, my struggle with the scale is hardly unique. The added wrinkle (stretch mark?) is that in the past few years I have developed a clinical subspecialty in weight management.
It started in the late 1990s, when the combination of appetite-suppressant drugs known as Fen-Phen became available. Practically overnight, patients were calling the office for prescriptions.
By the time I had attended enough courses and conferences to become an expert of sorts, the “Fen’’ (fenfluramine) had been shown to cause heart problems and was pulled from the market. I had never had a chance to prescribe Fen-Phen, thankfully. My first public appearance as a diet doctor was on a radio show about a local woman who had died of cardiac arrest after taking the drugs to lose a few pounds before her wedding.
After the Fen-Phen debacle, I was tempted to abandon my professional interest in weight management. For one thing, the field seemed to be dominated by the search for ways to control appetite through drugs or surgery. But from my own and my patients’ experiences, I had never really believed that most people overeat because they’re hungry. It seemed to me that inability to manage uncomfortable emotions without food, plus the 24/7 availability of that “drug of choice” are more likely to produce weight gain than unbridled appetite.
The other reason I thought about giving up my professional interest in weight was shame. Yes, that word again, so inextricably embedded, it seems, in this subject. How could I counsel patients to adopt habits I had so much difficulty adopting myself?
The funny thing is, if I had been a diabetic counseling other diabetics, or an oncologist with cancer, my personal experience might be considered a plus. I have read countless successful medical school and internship application essays that tell of the candidates’ illnesses and disabilities, and about the extra empathy and commitment to patient care these conditions have given them.
But, unlike diabetes and cancer, weight issues are not clearly understood as medical. Though obesity is a major individual and public health problem, people become obese because of a mix of genetic, behavioral, environmental, and psychological reasons. And doctors and patients alike still often think an inability to maintain a lean body represents a lack of willpower, a moral failure.
Ultimately, I decided to follow the advice of doctor, writer, and longtime Crohn's disease patient Rachel Naomi Remen, who once observed, “It is our wounds that enable us to be compassionate with the wounds of others.”
With the help of a dietician, I started leading groups of patients with multiple risk factors for cardiovascular disease, including obesity. I talk about healthy cooking and pedometers and “good” cholesterol.
But I also talk about how hard it is for me, for anyone, to live in this fast-paced, drive-thru world without overeating, sometimes just to take a break.
When I acknowledge this, the members of my group invariably smile and nod in recognition. They are relieved. Some of that shame seems to dissolve once I’ve named our common demon.
Now we can strategize about packing lunches, climbing stairs, and meditating.
Now, together, we can move forward.
Dr. Suzanne Koven is a primary care
internist at Massachusetts General Hospital, and her book “Say Hello to a Better Body: Weight Loss and Fitness for Women Over 50” was released last week. Her column runs once a month. Read her blog on Boston.com/Health. She can be reached at firstname.lastname@example.org.