Comment Corner: How Can You Lose Weight When You Can’t Lose Weight?

A while ago, a girl by the name of Sissy left the following comment after my “small steps” post (I’ve edited the text down somewhat):

Over the last two and a half to three years I've had two patellar dislocations and a meniscal tear (which I've had surgically repaired) all in the same knee. I am 238.4 lb (this morning) at 5'9", and I just turned seventeen. I saw your other post about losing weight to help knee pain, and I totally agree. In theory, it's an amazing cure. In reality, when I have tried it, I screw up and quit and start back up again.

When I was a lot younger, I used to do tae kwon do, play soccer, basketball, almost everything. Now I feel like I can't do anything because one day my knee is excellent and then next it's trying to commit suicide. I started Insanity (the workout program), and was following its nutrition guide. The first days I felt amazing. This past Thursday (getting closer to the end of my second week), both of my knees hurt so bad that I was afraid to get off my chair an hour after my workout because I felt like my knees were both about to dislocate or collapse.

You say to take small steps. Look...I just turned seventeen, I'm way overweight, I hate the way I look, I'm constantly uncomfortable, I'm extremely insecure, and I'm just sick and tired of this lifestyle, but no matter what I try to do about it, I can't finish what I started. I really do not know what to do. My doctors didn't sugarcoat anything. They told me to lose weight. But I need help. And quite honestly, I hate having to face that "taking small steps" is the solution. Can you suggest something or post a solution using me as an example, please?

Sissy sounds like a bright, thoughtful, self-aware ... and extremely frustrated teenager. She wants to lose weight. She wants her bad knee to get better. And she wants all that now -- or pretty soon anyway.

She joins a workout program called “Insanity.” If I were 5’ 9” and 238 lbs. and suffering from knee pain, I would look for a different program -- maybe one called “Sanity”? :) But I understand the “Insanity” appeal -- edgy moniker, the promise of fast results.

Truly, much is at stake here. Carrying a lot of extra weight is bad for anyone, but it’s really bad if you’ve got knee pain. I can’t be hopeful of Sissy finding a fast solution -- it takes time to expand to 238 lbs., and it’ll certainly take time going in the other direction. However, I don’t think the process has to be miserable.

Here are some thoughts I have (note: I’ve never had a challenging weight problem, I admit). Instead of organizing this by, “Do A and B and C,” I decided to take a more fun approach. Namely, I start out by asking, “What kind of person are you?”, then offer ideas based on that. Something different!

(1) Are you a social type?

Are you the one in your group of acquaintances with the most Facebook friends? Are you chatty and gregarious?

If so, try enlisting a support network to help you reach your weight goals. These people can be friends who can listen to you complain about your food frustrations or who can lend encouragement when the going gets tough.

(Note: This would be a special role, so I’d try to choose members of a support network wisely, and not make their duties too onerous. Or you might go from having 40 friends to four!)

(2) Are you a competitive type?

Do you like to win, even in situations when winning doesn’t (or shouldn’t) matter much?

Turn weight loss into a challenge. Compete against friends. Compete against yourself. Who can drop 20 lbs. by (insert date here)?

(Note: I would strongly suggest sensible, realistic goals. Crazy starvation diets -- or skipping meals you need to function properly, and alertly -- is dumb.)

(3) Are you a researcher type?

Are you more of a quiet, introspective person, who prefers reading and self-directed learning to clamorous discussion and debate?

Very well. You have an enemy: excess weight (and the bad food and high caloric intake that leads to excess weight). How to beat your enemy? Through research.

Learn how many calories are in common foods. Learn which kinds of calories. Learn about saturated vs. unsaturated fat. Learn which foods fill you up faster.

And don’t stop there! Study your own eating patterns. When are you most prone to overeating, or eating junk food? Use all this data to modify your eating behavior, and to beat your enemy.

(4) Are you a hobbyist type?

Are you someone who tends to get absorbed by hobbies, whether they’re collecting old glass medicine bottles or hanging out for hours and watching for different kinds of birds along migratory routes? If so, great. You’ve got a new hobby: cooking!

Now here’s the thing though: you’re going to be a cook who specializes in tasty, low-fat meals. You’re going to be someone who figures out how to saute spinach and sprinkle on a little grated cheese and just the right seasonings to make it taste like something off the menu of a 4-star French restaurant. That’s your goal anyway. Be creative. And have fun!

Note: Everyone loves a good cook, so don’t be surprised if your circle of friends expands. Who knows? You might get your own TV show (or get on a TV show anyway).

Okay, those are some of my ideas on losing weight.

But what if none of these works for you?

Well, there is what I would call the “nuclear option”: surgery. A procedure such as bariatric surgery can accomplish what a weak will cannot. But -- and it’s hard to overstate this -- surgery is a serious choice. Try everything else first. And then, be sure to consult with doctors and loved ones to make sure surgery really is your best option.

A True Story About the Limits of Surgical Effectiveness

Here’s the last of three straight posts related to surgery. No more for a while!

I never had any kind of surgery for my (now-healed) bad knees. Today, I’m very, very happy I didn’t. Surgery has an understandable allure -- the promise of returning our bodies to a perfect, pre-injury state. But the reality is rarely so simple.

That was underscored again by an article last year in Harvard Magazine called “The Cardiac Conundrum.”

If pressed to name two successful surgical procedures, one might come up with heart bypass surgery and the insertion of stents in clogged blood vessels. Both of these appear unambiguously beneficial. Yet a closer look reveals otherwise.

The article tells us the history of heart bypass surgery goes back to 1910. The patient, a dog, apparently didn’t survive. Success operating on humans came much later. By 1977, 100,000 bypass operations were being done each year.

That’s a big number, considering this is a major kind of surgery -- it’s not like removing someone’s tonsils. So, was it worth it?

A 1977 paper showed that most patients who underwent the procedure had no survival benefit over others who took medications. Other trials were done. Survival improved for a few patients with the most severe cases of coronary artery disease, but the rest just got relief of symptoms.

Was the surgery worthwhile if it usually didn’t extend the patient’s life?

Then along came the angioplasty in the 1980s. This operation too made sense: Open up clogged vessels using a tiny balloon. The problem: Plaques just reformed within weeks. So that led to the development of stents to keep the arteries open.

But the stents, as foreign objects, were actually found to promote clotting. So they were then coated with drugs.

Problem solved? Maybe not, if you look at the larger picture. A 2007 study showed that stents and drug therapy combined were no better than drug therapy alone for lowering the risk of a heart attack or improving survival odds during a seven-year follow-up period.

David S. Jones relates these histories of open heart surgery and angioplasty in his book Broken Hearts: The Tangled History of Cardiac Care. He argues that the prevalent explanation of what causes heart attacks -- coronary vessel blockages -- is mainly to blame for a misplaced faith, which still runs strong, in procedures such as the angioplasty. That “blocked vessel” perspective puts emphasis on highly visible plaques, when “smaller, often invisible lesions in the heart vessels are now understood to cause most heart attacks.”

Jones summarizes what needs to be done:

We need interventions, especially lifestyle changes or medications, that address the causes of atherosclerosis, and not just the largest plaques. And we need to accept that there are some large plaques that might not need intervention.

Obviously, I’ve chosen this “Cardiac Conundrum” story for its relevance to knee pain, and the dilemmas over whether or not to undergo surgery. In fact, the except above could be tweaked to read, “And we need to accept that there are some large cartilage defects that might not need intervention” -- and it would be just as true.

Does Knee Surgery Make You More Sensitive to Pain?

I just realized I have three straight posts (one more next week) that relate to surgery and knee pain. Then I'll give the subject a rest for a while, I promise. :)

Suppose you have two bad knees. You could be looking at a double whammy: first one knee operated on, then the other. If you are in such a situation, you may be consoling yourself by thinking, “Well, at least after the first operation, I’ll know what to expect, and the second will be easier.”

Not necessarily. In fact, the opposite may be the case.

Pain sensitivity in patients who undergo staged bilateral total knee arthroscopy (TKA) is greater after the second than the first operation, a study by South Korean researchers has found.

The study consisted of 30 patients with osteoarthritis in both knees who underwent total knee arthroscopies at a one-week interval (if this means, as it seems to, that only one week separated the surgeries, that’s important to keep in mind when interpreting the results). Self-reported pain was greater after the second operation than the first. When the knee was at rest, pain levels averaged 49.3 (using a visual analog scale) vs. 21.8. The difference was narrower, but still statistically significant, at “maximum knee flexion”: 83.7 vs. 74.3.

The amount of post-operation pain-relief medication that had to be administered supported the findings. After the second operation, patients received almost three times as much opiates.

What’s going on?

The speculation: “Surgical injury induces hyperalgesia [which simply means increased sensitivity to pain] via central sensitization.” The more detailed technical explanation: The hyperalgesia is probably caused by “neuroplasticity, or central sensitization, triggered by persistent nociceptive inputs from the first operated knee that alter sensory processing and sensitize subcortical structures.”

So: If surgery really does often beget further surgery -- as I believe -- these findings are unfortunate. They’re one more thing to ponder for patients thinking of going under the knife.