Several years ago, Mary, a young professional woman, came to see me for help in losing weight. She was about 40 pounds overweight, gained in large part because of the sedentary nature of her job; she endured a long commute that gave her little time to go to a gym or even jogging before or after work. A decreased calorie intake more compatible with her decreased level of physical activity and a health club opening in the office complex where she worked made weight loss relatively effortless.
A few weeks ago, she came to see me. I did not recognize her; she now weighed considerably more than 300 pounds. A perfect storm of family tragedies, job loss because of her firm’s bankruptcy, and two years of treatment for anxiety and depression with a medication known to cause weight gain had left her morbidly obese. Each time she went on a program such as Weight Watchers or dieting with calorie-controlled shakes, she lost 50 or so pounds, but gained them back as soon as she stopped the diet. She told me, “I am heavier than I have ever been, and I am still gaining weight.”
Bariatric surgery had been recommended but the stumbling block was the requirement to lose 30 pounds before she would be considered eligible. This is pretty standard procedure: The group caring for her prior to and following the surgery wanted to make sure that she would be able to stick to the rigorous diet plan she would have to follow for months after the surgery. She wanted me to help her lose the weight as I had many years earlier.
But now it was going to be so much harder. Mary was no longer a healthy young woman. Her obesity had spawned a cluster of health problems: type 2 diabetes, high cholesterol, high blood pressure, sleep apnea, chronic back and knee pain, and difficulty walking. And, she told me, she was horrified at the way she looked. “The doctors said not to worry about my weight gain. It was more important to get rid of my depression. But how can anyone not be depressed if they look in the mirror and see a fat body staring back at them? And now I can’t get a job! Sometimes I find part-time employment, but my weight makes it too hard for me to take any job that requires standing. And when I apply for a job that I know I can do, I don’t get hired, probably because employers don’t want to hire someone who is so fat.”
Isolation from not working, along with an extremely limited social life, contributed to her difficulty in losing weight. “I am alone all the time. Since I rarely work, I stay at home during the day, and I never go out at night or on weekends. No guy is going to date someone looking like me, and most of my girlfriends are married. I don’t know what to do. There aren’t any support groups to help people like me, who become obese on antidepressants and, as a result, have our lives fall apart.”
She was right.
Helping her lose weight now was not merely a matter of having her eat more salads, fewer pizza slices, and getting to the gym more often. Now losing weight meant dislodging her from the lifestyle self-imposed by her morbid obesity.
She already had a diet given to her by a clinical dietician and if she followed it, she would lose weight and her diabetes would be in control. But as she told me, she cheated after less than a week on the diet, and did not think she was capable of staying on it long enough to be eligible for bariatric surgery.
We discussed ways to make small changes in her life that might positively affect her weight loss. Her physical inertness from chronic back pain and fatigue from her medication had to be overcome. I urged her to move, even if it meant going from one chair to another, at least once an hour and to walk for five or ten minutes, twice a day. She knew from exercising years ago that physical activity would make her feel more, not less, energetic and perhaps even less depressed. And as she lost weight, walking, climbing stairs, and even getting up from a chair would become easier.
Volunteering seemed a good way of getting her out of the house and might generate a paid position, or at least recommendations that she could use in applying for a permanent job. Her acute loneliness on weekends might be diminished by volunteer activities that took place on Saturday and Sunday afternoons and early evenings. Educational workshops scheduled for weekends could also decrease her isolation, and she lived close to an adult education center that offered such courses.
We both knew that her progress in losing weight would not be without setbacks. Unraveling the complicated reasons for her weight gain cannot be undone by a few workshops or 10-minute walks. Progress would depend on resolving them with a therapist whom she was already seeing, a post-bariatric surgery body that was no longer a visual and physical liability, a job and, hopefully, a better social situation.
Mary may not be too fat to lose weight, but her situation demonstrates how hard it is for the morbidly obese to become thinner. It is a heroic undertaking.