Tuesday, August 05, 2014

Having your health - what does that mean?

I've reached the age in life where each fact about personal health seems to be the start of a shaggy dog story.  Here's an example that provides no exception to the rule.

Let's begin with some good news.  A week ago I had some blood work done.  This was a little bit unusual, since I also had some blood work done two weeks before that.  In between I had a doctor visit.  That earlier blood test was because I had reduced my blood pressure meds to one pill a day, down from the previous two.  With my not drinking and trying to shed a few pounds, it didn't seem that I needed the two pills a day.  Indeed, I had asked whether I could go off the pills entirely.  The doctor suggested, instead, to go with that one pill and to monitor (and record) the blood pressure.  I did that for two weeks and the numbers were quite encouraging.  So that seemed to be working.  The blood test was done to see how everything else was doing.  The results sent out some red flags about my kidney function.  The doctor visit was scheduled to discuss possible responses.

We ended up deciding (really this was the doctor deciding and me providing enough background info to give some basis for the decision) to alter my regime of pain medication.  I had been taking over the counter stuff - the Walgreens generic alternative to Aleve, $19 and change for a massive bottle of 600 pills.  Mainly, I take pills twice a day, once in the morning with the first cup of coffee, and then again in the evening, usually near dinnertime.  I took pain pills at both times, three pills per.  This dosage was by my own design.  The goal was prophylactic treatment of the pain.  This way you couldn't distinguish between the treatment working or there really being no reason to take the pills in the first place.  But if there were more than incidental pain, then you knew the treatment wasn't working.  As far as pain goes, the regime seemed reasonably effective to me.

Yet the doctor thought this a bad approach because Naproxen, the active drug in Aleve, has a variety of pernicious side effects.  One of these is that it can cause an ulcer.  Another is that it can depress kidney function.  The doctor prescribed an alternative pain medication, Tramadol.  The dosage specified on the bottle is one or two pills every six hours.  The doc recommended to me at the office visit to stay on the low side of that, since Tramadol also has side effects, one of which is to make you drowsy.  So I followed the doc's advice, and then some.  The second blood test was to see how this new regime was working.  My results were normal in every category.  That certainly was good news. 

The thing is though, I didn't feel normal.  The Tramadol was making me quite constipated.  So I started to take less of it, to mute that particular consequence.  Then it occurred to me that I might have been a bit constipated even before starting with the Tramadol.  It's hard for me to tell.  I was eating substantially less than I had been before going on the diet.  I didn't know what the new normal felt like.  Fruits and vegetables had become a larger part of my overall diet, so I thought I was being sensible about things.  A couple of days after starting with the Tramadol, I added prunes to the mix, which may now have become a regular part of my diet, and I made a couple of other temporary adjustments that I would term, "treating the symptoms."  All of this made me a bit irritable.  Also, I was confused.  Was Tramadol really better than Naproxen for me?  I'm still trying to figure that out.

It's what happened next which really was the kicker.   Two or three weeks earlier I had surprised myself in a pleasant way.  My experience after walking for a while had been that there would be some pain in my lower back on the right side.  This was due to some combination of bone spurs and arthritis, which were first diagnosed back in fall 2009.  So I would take shorter walks only or do the walking on the treadmill, where I could use my arms on the handrail to help support my weight and thus put less stress on my lower back.  But because of our basement flooding, the exercise room became a temporary storage area and until that situation returned to where I could use the treadmill or the elliptical I'd have to get all my exercise by walking outside.  So I tried taking longer walks.  I was delighted to find that the the lower back didn't hurt at all.  (Other stuff, like my knees, still did but I could live with that.)  So I began taking longer walks as the regular routine, doing somewhere between an hour to 90 minutes.  My pace was certainly not earth shattering, 19 to 20 minutes per mile, and I would take a rest once or twice during the session, to adjust the Internet radio station I was listening to or to check email.  Even with these observations that the walking wasn't too strenuous, however, I felt good at the end of the session because I was tired from it.  Exercising to the point of fatigue is a good thing.  Doing less than that so as not too feel bad later may be prudent, but it is not very satisfying.  

The day after the second blood tests and after my long walk, my lower back started to hurt really badly.  After another day or so the pain migrated to the quadriceps in my right leg, but was equally intense.  I had taken a day off from walking.  That seemed to have no effect.  The pain was still there with a vengeance.  So was the constipation.

This was a time for a stiff upper lip.  I can do that if at the same time I see a way out.  But here I didn't sense a solution.  Instead, I had something like the opposite thought.  Both issues might end up  to be ongoing.  That prospect was sufficiently dismal that I started to feel sorry for myself.  After not drinking for more than five weeks, I asked my wife to buy me some Tanqueray on her way home from work (I knew she planned to get some wine for herself).  I had several stiff drinks that night.  I did likewise the following night, after which I went on a binge eating-wise.  I put on a couple of pounds just from that one episode.  The sole reason why I had stopped drinking was to prevent those binges from happening.  And the sole reason for the dieting was to lessen the arthritis pain.  Those reasons seemed to be losing force.

Yet even with the entire plan seemingly unraveling, I decided I didn't want to throw in the towel.  The pain had subsided some.  And it began to seem like my regime of prunes was bearing fruit (bad pun intended).  So on Friday I returned to the diet and no drinking.  On Saturday I took a moderate walk (about 40 minutes).  Yesterday I took a walk for an hour.  Perhaps the end goal is attainable, after all.  To mark that, yesterday morning I took 2 Tramadol pills, as there still was significant pain from the walk the day before.

* * * * *

I now want to change gears and move from talking about pain to talking about weight and what things I've learned since I started on the diet, about six weeks ago.

There are certain weights I hit at specific times in my life that I keep in my head, markers of where I've been that provide a record both of my sins and my accomplishments. These also speak to my self-image.

When I graduated from high school, spring 1972, I weighed 245 pounds.  In the winter during 10th grade I weighed approximately the same amount and was having some emotional issues at the time.  So, as part of my treatment, I went on a diet under doctor's supervision and aided by taking an appetite suppressant (amphetamine).  I lost about 40 pounds, which was terrific.  But it all came back in short order.

In between high school and college my sister and I made a western trip to see various National Parks.  I went on a diet then, unaided by drugs and without a doctor's care.  I lost about 15 pounds during those few weeks and after I returned home.  Again, the weight came back in short order.  Thereafter in college I put on about 20 more pounds.

I made a conscious decision to lose weight between undergrad and grad school, in the late spring and summer of 1976.  I averaged about a pound a day weight loss over almost two months.  I ended up around 210 pounds, what I'd be if I were at a normal weight for my height.  As extreme as that diet was, it worked in a way the previous diets did not.  The weight stayed off.  When I got married in June 1990, I was still at 210 pounds.  This is not to say the weight remained completely flat during the interim.  There were cycles with the weight typically higher in the winter than in the summer.  But there was no trend during those years.

Our first kid was born in August 1992.  Thereafter, the weight began to trend upward.  The initial reason was sleep deprivation.  A few years later I became an administrator and that encouraged a more sedentary lifestyle, because more of my work time was scheduled and it became harder to fit in time for exercise.  Then my knees started to go.  I had been a regular jogger.  It is amazing how regular exercise can offset sins from overeating.  But then it is no big surprise as to what happens once the regular exercise gets taken away from the daily routine.  I made a big mistake at the time by not finding something else to take its place, such as power walking, even if that weren't quite as vigorous.

The last big factor, and it was a doozy, was the work stress that accompanied being the Assistant CIO for Educational Technology.  This went well beyond being extremely busy.  From time to time I was getting beat up emotionally by the job.  I needed something to calm me down from all the stress.  Food and drink provided that comfort, though in retrospect it was merely a quick fix and not a healthy response to my situation.

The upshot is that the upward trend in my weight continued unabated for the next fourteen years.  Then I received a warning shot that things had to change.  I had a serious fall, ripping all the tendons above my left knee, leaving me unable to walk and requiring surgical repair.  At the time I weighed well over 300 pounds.  During my recovery I lost some weight to get me to around 285, which is where the weight plateaued for almost four years.  Then I had a colonoscopy, my birthday present for turning 55, and took off another 10 pounds after that.  My weight again plateaued in the mid 270s until the start of the current regime.  I began the current diet weighing 273.

Yesterday morning I was 255 at the daily weighing, which I take soon after getting up, immediately after getting my blood pressure.  So I have been averaging about three pounds lost peer week, but the time pattern has been more like a period of loss followed by another period of plateau, then another period of loss, etc.  I am not quite sure why it's been that way, but noting that outcome serves as a useful point to launch my other observations. 

During my doctor's visit the doctor strongly encouraged me to use this time of weight loss as a way to change lifetime patterns and habits toward a more healthy way of doing things.  In other words, the goal is not just to take the weight off.  It is just as important to keep it off afterwards.  No surprise there. And in theory everyone would agree with this goal.  So, as I understand, it is generally viewed as better to shed the pounds slowly but to keep at it until the desired end weight is attained.  What I did when I was 21 was too rapid, in this view.  The more amazing thing then is that the weight didn't bounce back up immediately thereafter.

There is no risk now of me losing at the rate of a pound a day.  I'm not sure whether the weight would come off that quickly even if I went on a diet of only water and nutritional supplements.  My metabolism is different now.  It has slowed down substantially as compared to when I was 21.  My capacity for exercise is much less, quite apart from the arthritis pain.  And now I can't maintain for extended periods where I feel very hungry and try to divert my attention from thinking about that, say by watching some junkie show on TV.  I could do that at 21.  Now  I need to be reasonably functional while this diet is going on, to prepare my class for the fall, to write other blog posts on topics unrelated to dieting, to do some household tasks, and to enjoy more demanding diversions, such as reading the biographical novel about Van Gogh that I'm currently engaged in.

There is a risk at the other extreme, say of losing at a rate of one or two pounds per week, or losing weight even more slowly, especially if there are periods of plateau as part of the process.  One significant motivator in sustaining while on the diet is seeing progress.  Then you know, "it's working." If it doesn't seem to be working you start to contemplate taking a more drastic approach.  So there is some tradeoff in going fast enough that it seems noticeable and going slow enough that the results can be sustained.  I've bounced a bit on this and haven't yet found the ideal point.  For the same reason, quite apart form the issue of immediate pain, there has been some bouncing on how much exercise I do.  The need to see results drives more extreme behavior.  The fear with doing this is that the extreme behavior soon becomes the new normal and after making progress with that for a while the plateau phase returns, ultimately demanding even more extreme behavior. 

Apart from noting that progress is being made, what other factors contribute to staying on the diet?  I did a bit of reading on this and was intrigued by this piece from WebMD on planning your diet and your exercise.  In particular, I was struck by this paragraph.

"It is very difficult to lose weight and keep it off - and people who succeed must have discipline," says James O. Hill, PhD, the Registry's co-founder and director of the Center for Human Nutrition at the University of Colorado Health Sciences Center. "People who are most successful plan their day to ensure that they stick to their eating plan and get regular physical activity. It takes effort to be successful in long-term weight management."

The author of that quote is obviously extremely knowledgeable about nutrition and to the extent that his use of the world "discipline" refers to proper eating and getting sufficient exercise, then I'd agree with what he says.  But if he's talking about the psychology behind going on a diet, I'd say he has it all wrong.  Below are my views on the matter.  To the extent that these views make sense, they may constitute the most important part of this piece for others who are contemplating going on a diet to promote their own health.

1.  What is it that you want to eat?  Can you learn to want only those things that are healthful for you and to not want those things you shouldn't be eating? 

My wife keeps a lot of junk food in the house - ice cream, a variety of different sorts of chips, and sometimes other sweets (double stuffed Oreos, for example).  She views these things as a kind of reward after a long day's work.  She too has a stressful job and puts her all into it.  So she deserves her rewards, especially given that she is not overweight and the health issues for her are different than they are for me.

Should I be jealous of her and what she eats as reward?  If I am jealous, then resisting those foods, like resisting any temptation, requires willpower.  But if I'm not jealous and these are not the foods I would choose if I were free to have anything I want, then not eating them doesn't require discipline.  It requires noting that jealousy is not a good motive to drive what it is that you do want to eat. Indeed, having a mental picture of what foods you think you like may may also be wrong, because it is apt to confound childhood pleasures with what gives pleasure now.  There may be many foods that you viewed as treats as a child (think of marshmallows, for example) that wouldn't give any pleasure at all as an adult. Resisting eating such foods should not be hard at all.

On the flip side of this, there may be certain foods that you do really like but that are only available on a seasonal basis.  Earlier this summer I bought some nectarines for my breakfast as a healthier and less caloric alternative to the bananas that I had been having in my yogurt.  I really liked the nectarines.  They were extremely flavorful.  But I suspect they won't be around after the summer or that those nectarines which are available then will have far less taste.  What happens at that point?  Do I go back to the bananas?

2.  Do you plan for what happens next when you go off the diet or do you ignore that question and simply hope it never happens? 

If being on a diet requires discipline, then going off the diet means you've failed with your discipline.  The next step in the chain of thinking is then to administer some punishment for the failure.  But in the twisted way many of us think, particularly those of us with a diminished self-image from years and years of being overweight, the punishment might very well come in the form of going off the diet even more.  After all, if the goal is to lose weight, that sort of punishment takes you further from the goal, which is what any good punishment should do.  But with this sort of reasoning, before too long you are off the diet altogether which, sad to say, is the story with way too many diets.

It would be far better to forgive and forget and get on with the business of the diet as soon after the departure as possible.  How can you forgive yourself for such transgressions?  In my way of thinking, the only way to do that is to not make a big deal of them at the time.  Know they will happen occasionally.  With that expectation at hand, discipline may not be all that it is cracked up to be.  A gentle temperament that allows the person to forgive and forget would then be far more important than having the discipline to avoid ever making a transgression.

3.  What about "cheats" as alternatives to discipline.  Should those be encouraged or should they be avoided?

One sort of cheat that many people recommend, including the authors of the book Nudge, is to avoid having tempting food in the house.  In other words, amplify your personal resolve by increasing the economic cost (in time or money) of getting foods that you would otherwise find tempting.

I used to subscribe to this view wholeheartedly.  It was absolutely essential as a practice for me to not gain weight once I started graduate school.  But it has been less important during this most recent diet.  There is still some gin left in that Tanqueray bottle.  Yet I've not been tempted to drink it the last few nights.  It's been enough for me to say to myself that I didn't want a drink.  Likewise, I don't want the ice cream my wife bought, even though I used to be unable to resist once I knew that it was there.  It's not that my force of will is greater now.  It's just that the ice cream doesn't interest me at the moment.

Yet there is a different sort of cheat that I've practiced regularly.  I've used it to manage the time after dinner, to avoid going for seconds (or thirds), and to resist other sorts of snacking.  I've known for quite a while that this is the part of the day when I'm most vulnerable to temptation.  What I've done is to take medication I would take anyway and that causes me to be drowsy, now both Benadryl and Tramadol.  The only adjustment is to take it earlier than I would have done had I not been on the diet.  I then go to sleep earlier as a consequence.  This shortens the time when I'm most vulnerable to overindulging.  The approach has worked pretty well, to date, though I'm a pretty boring fellow in the evenings these days.

Now I want to buttress the point by arguing that this sort of cheating makes perfectly good sense as part of a long term strategy.  There are two further points to make.  One is that managing how you react to temptation is not simply throwing a switch - before you were indulgent, after you were disciplined.  Over time you can get better at being disciplined, particularly if you also get better at learning what sort of temptation is there for the right reason and those other sort of things that become easier to resist because as it turns out you really didn't want them.  If there is learning-by-doing of this sort, then early on it makes sense to provide an assist with a cheat.  The cheat will become less necessary over time.  The cheat allows early success to feed on itself.  The other point is that the cheat itself can become permanent.  In my case that would mean either having dinner later or going to sleep earlier.  That latter seems a likelihood, quite apart from the dieting.  If that's true, moving to it now isn't really a cheat, is it?

The next observation is about the fixation which I now have with the dieting.  I view such fixation as unhealthy.  Yet I think it is unavoidable, particularly early on, especially if you have the sort of history with weight that I've had.  So the question is whether you can wean yourself off of being so fixated before too long.  It is evident to me that as long as I've got the physical pain issue to deal with and the constipation too, both of which engender their own sort of fixation, then I'll be fixated with the dieting as well.  The fixation with the dieting is manifest by weighing myself multiple times a day, which is completely silly but which I've been doing right along.  It also comes into play when fishing for complements of the sort, "gee, you've lost weight" and then being disappointed when a friend doesn't seem to have noticed.

The question is how to get past this early, fixation stage.  In giving my proposed answer, let me assume that the pain and constipation issues get resolved, each on their own accord.  If I remain fixated with dieting beyond that point, it will be only the dieting itself which sustains the fixation. 

I do get fixated on things, as a matter of practice.  It is a personal strength, at least in some cases.  When my mind is grappling with some issue, I can't let go of it until I've done my complete analysis and then have gotten the word out about the analysis.  It is why I like to write blog posts.  I know enough about myself to not try to short circuit the process prematurely.  That will not work.  I won't be able to let go of the old issue.  And I won't be able to devote my full attention to the next one.  This is true even if some "objective voice" tells me the old issue isn't worth the effort.  Having gotten my hooks into thinking about the issue, I vote nay on the proposition put forward by the objective voice.   Instead, I trust my blogging habit to allow me to move onto something else in due course.

Indeed, that gives one real reason for writing the current post.  I'm trying to get the fixation out of my system as soon as I can.  Earlier, I had thought about writing a book to chronicle the dieting while giving an ongoing commentary in the process.  But I've decided quite recently to abandon this project, as sticking to it surely would extend the fixation beyond where it is necessary.  My health is more important than my creative efforts.  Beyond that, I surely will need other projects to grab my attention, so the time that would have been spent worrying about the dieting can be spent more profitably on something else. In the past there has been no shortage of such projects.  Something interesting usually emerges in short order.

Let me close this section with one more observation, this time I hope in the humorous/frivolous category.  As my weight trended upward I kept some of the clothes that I used to wear but that had become too small on me.  Over the years my wife has nagged me to throw these things out, but I've insisted on keeping them.  Now they serve a a kind of subliminal motivation to stick with the diet.  I have khakis and button down shirts.  For the pants, there are some with waistlines going as high as 52" and others as low as 40", with 2" increments between sizes (though across different vendors there is no consistency in how big a certain purported waistline actually is).  To these various clothes I have some mental model of the weight needed to cross the threshold to the next smaller size.  Last week I crossed such a threshold.  It is its own sort of reward.  Each time you can fit into smaller clothes, you feel as if you've accomplished something.

But there's been a surprise along with the accomplishment.  The weight at which the threshold was crossed was lower than I thought it would be.  Either my current scale is giving me the benefit of the doubt more than the previous scale did or more of my body mass is now clustered near the waistline, where it previously was distributed more elsewhere.  Assuming the latter is the true explanation, I wonder if it is a consequence generally as one ages.  For example, I definitely use my arms less than I used to, not playing any tennis now and swinging a golf club very little, plus since the rotator cuff repair I've stopped doing even the workout with light weights that I had been doing.   So it is not hard for me to envision that there is less mass in my arms than their used to be, relative to overall body mass.  (For those who are thinking about less mass in the head, stifle the urge.) 

* * * * *

There is a long way yet to go to reach my overall goal, which is to weigh the same as I did when I got married and then to sustain that weight thereafter.  It's probably not yet an even money bet that I'll get there, but I'm far enough along where that now seems possible.

In the meantime, one other thought keeps coming back to me about immediately after I lost all that weight at age 21.  Losing the weight proved to be the easy part.  The hard part, especially since everyone I met in grad school had no knowledge of me as an undergrad, is that nobody seemed to understand that while I was an ordinary looking guy all my prior college experience was based on being seen as an overweight guy.  The folks I met during graduate school couldn't see that past, but I was still living my past emotionally.  It took years and years after the weight came off to make the right sort of emotional adjustments.  At the time, I wished I could have done it much faster. 

Now it makes me aware that if I am successful reaching my weight goal, I likely will need to make other substantive adjustments, those of the emotional kind.  They tell you not to get ahead of yourself.  So I won't do that here.  Success may have spoiled Rock Hunter, but it will not spoil me.  Not this time. 

No comments: