While this year’s JPM healthcare conference promises to be similar to so many in the past – frenetic, overscheduled, gratuitously wet and miserable – one significant difference for me this year is that I’ll be arriving more than eighty pounds lighter than the year before. Especially in the context of New Year’s resolutions, I thought my story and experience could be of interest to others. (L) Author, Feb 2018; (C) Weight Chart; (R) Author, Dec 2018D. SHAYWITZ While I wasn’t a particularly heavy kid, I struggled with weight gain most of my life, and engaged in what seemed like ever more extreme bouts of yo-yo weight fluctuation, where I’d gain 30 (or 40) (or 50) pounds, and then lose 20 (or 30) (or 40) pounds, generally via some kind of caloric restriction, and then the cycle would repeat. (The best account I’ve read of the challenges of weight control was this resonant New York Times essay by the brilliant Taffy Brodesser-Akner.) Maybe my struggles, like that of so many others, reflected genetics, maybe it reflected environment – I grew up in an unreservedly emotionally supportive environment, where the generous provision of food was one of the many ways affection and kindness were expressed. Good events were celebrated with a meal, anxieties were discussed over a meal, and food was always prepared in delicious excess. Neither emotional nor nutritional sustenance were ever meted out, but always offered in loving abundance. I was always able to lose weight relatively easily, generally by minimizing breakfast and lunch, and saving most of my calories for dinner. While effective in the short run, this tended to leave me hungry most of the day, and I counted the minutes until my next allotted meal. This approach was never sustainable, and the weight loss I achieved never quite matched the weight gain I experienced before and after the diet. This approach also seemed to be less effective each time. I turned fifty during August of 2017, and had casually planned to get into better shape before this milestone; failing that, I more seriously planned to get into better shape afterwards. When this quickly proved unsustainable, I began to really worry; I had always looked at my extra weight as something I could lose whenever I put my mind to it, but now, I was facing the possibility that I might be stuck at the unhealthy elevated weight, on the worst part of the yo-yo cycle. In retrospect, this may have spurred me to contemplate a more meaningful effort at change. I heard about a range of different approaches to weight loss, including the trendy low carb methods, which I had tried, informally, with little success. I switched to “low carb” or paleo bread, for example, but then apparently consumed enough of it to offset any advantage. I tried to follow the recommendations and recipes of a prominent Harvard pediatric endocrinologist, but found it too complicated to stick with; I decided that it might be easier if, as in his case, one’s spouse is an accomplished chef. Earlier in the year, during the course of researching a Forbes piece on digital health, I encountered a company called Virta Health (note: I am not an investor or associated with the company; just a paying customer), and was impressed by the results they seemed to achieve through their coaching and medical supervision program. Their focus was on patients with type two diabetes, but it appeared their general approach might also be effective for some people, like me, who had neither diabetes nor pre-diabetes. At the same time, their data were both limited and not the result of a prospective randomized controlled study, as I pointed out at the time; my piece included a critical assessment from noted diabetologist (and my former diabetes mentor) Dr. David Nathan of MGH. I was aware of assertions from low carb advocates that a diet low in carbs confers distinct metabolic advantages, but I was also aware of quality research, including work from distinguished nutrition researcher Kevin Hall, questioning these conclusions. I ultimately decided to pursue – as a self-pay patient – the Virta approach. Here’s what I was (and wasn’t) thinking. The basic idea behind the Virta version of low carb is to restrict your daily carbs to 30g a day, which is really very little. You get there by eliminating both all the obvious carbs – breads, pasta, bagels, even fruits – and many of the hidden carbs. Basically, you wind up eating a bunch of leafy vegetables (but not in limitless quantities – even they have carbs). You have a defined amount of protein a day, and then can eat fat to taste. For me, the main appeal of this approach was the contention that because of the way meals are structured, you aren’t ravenously hungry between meals – at least, that was the premise, and actually also what I experienced. After a run-in period, which involves lab tests, a telemedicine visit with a supervising physician, phone calls with your future health coach, and a slew of orientation videos, you finally get going. Besides the advice about what you should and shouldn’t eat, you also receive a device to monitor your blood ketones (obtained by daily fingerstick, similar to the fingersticks diabetics use to assess blood glucose) on a daily basis, which are intended to provide a measure of how successful you’ve been at restricting your carbohydrates. (The targeted range, which Virta calls “nutritional ketosis,” is physiologically quite distinct from, and fairly far away from, a very different type of more extreme ketosis, a medical emergency I treated as an endocrinologist called “diabetic ketoacidosis.”) Interestingly, I didn’t choose to pursue the Virta approach because I had a deep belief in the science behind it; I still don’t quite know what to make of it, to be honest. But after asking a number of endocrinology colleagues who are expert in this area (including my San Francisco-based brother Adam [no connection to Virta]), I decided it was, at a minimum, likely to be safe, and perhaps effective, so it seemed there was little to lose. I also made the conscious decision at the start to suspend disbelief – I would embrace the whole approach, including the details – what to eat, what not to – even while recognizing that the level of evidence behind most of the recommendations was likely limited at best. Of the many elements associated with the approach, I suspect the most useful involved the emphasis on what we called during my training “expectant management” – describing potential challenges in advance, so the patient is prepared for them if or when they occur. In particular, I thought Virta (and by Virta I mean both the informational materials and your health coach, with whom you are in touch with, generally by text, on a daily basis, titrated to your level of need) did a great job of helping anticipate challenges you’d run into, whether going out to eat, or at a family event – even rehearsing potential dialog to help put concerned relatives at ease. Besides the extremely helpful support provided by Virta’s nutrition coaches, I also benefited from the suggestions and encouragement offered by one of my brothers, Jonathan, a psychiatrist in Los Angeles who it turned out had extensive experience helping ambitious people like me who were determined to change their lives but could use some insightful support. What about exercise? While exercise isn’t formally part of the Virta program, at the time I started I initiated, on my own, a daily cardiovascular routine (generally 40 or so minutes on the elliptical machine at our local JCC, along with some free weights ever other day) – even though most everything I’ve read suggests that you exercise for cardiovascular (and perhaps mental) health, not as a means of weight loss. Through deliberate effort, I’ve managed to maintain my exercise even when I travel – motivated in part by the example set by several European colleagues, who arrived exhausted at last year’s JPM meeting and decided the best way to deal with it was to immediately exercise; The Rock seems to champion a similar ethic, and it’s one I’ve intentionally strived to embrace as well. Given the work by Christakis and others around the role of one’s social network in body weight (eg this 2007 NEJM), it’s probably relevant to note how relatively fit most of my professional colleagues seem to be – healthcare VCs like Bob Kocher (an avid cyclist) and Bruce Booth (an avid runner), and virtually everyone I seem to encounter at each year at JPM. Not including the initial loss of water which occurs with many diets, my rate of weight loss was relatively consistent, around 1.5-2 pounds a week for the first eight or nine months, with an occasional brief plateau; after that, I hit a more substantial plateau, where weight comes off far slower, and apparent gains often prove ephemeral. In addition, my average blood ketone level, while still in the target range, seems to be declining, even though my eating pattern has remained relatively constant. Take-Aways The obvious good news here is that I’m in better shape than a year ago – my BMI is in the normal range, albeit the upper part of the range, with a weight that’s still 5-10 pounds above my ultimate goal. The cost of doing this has been a profound and (I earnestly hope) permanent change in my lifestyle. Eating, particularly going out to eat, while manageable (due to the actionable suggestions Virta offers), is far less pleasant than it used to be, the menu choices far more constrained. I loved pasta, loved bagels, loved pastries, loved ice cream, and I’ve chosen to forsake all of these, forever, because I think a key success factor has been avoiding all simple carbs, so you don’t head down that slippery slope. I imagine it is similar in some ways to how recovering addicts manage – though this comparison is intended only at a superficial level, not to suggest a parallel between the experience of a “carb addict” and other, far more painful and destructive addictions. Despite having lost most of the weight I aspired to, I find myself not content, but instead, concerned, on a daily basis that, like Zeno, I’m never going to quite arrive at my destination, and that at any day I could lose my focus, and immediately gain back all that I lost – which I recognize is the fate of more than 95% of people who’ve lost a significant amount of weight. Cognitively, I recognize that stable weight can fluctuate by several pounds due to fluid movement and other factors, yet each time the scale edges up, I’m terrified that it’s the beginning of the end. Given half a chance, I’m sure my body would love the chance to scarf up a bowl of pasta – or even a few extra almonds – and it’s stressful, if necessary, to feel you need to constantly guard against this. (Interestingly, while Virta permits a glass or two of alcohol a day, their pressing concern seems to be not so much the carbs present in wine, say, but rather that your decreased inhibitions after consuming alcohol will lead you to eat carelessly.) As I write this, I wonder and worry how sustainable this effort at a healthier lifestyle will be. It’s a great experience to throw away baggy clothes, as I’ve done on many occasions, hoping it will be a commitment device like Cortez burning his ships; but it’s a miserable and, unfortunately, all-too-familiar experience to watch and feel your clothes get tighter and tighter, to rationalize you can stop it, that you can halt the weight regain at five, ten, twenty pounds, and then the next thing you know, you’re back to where you started, and then some. A dream would be to attain my goal weight and then develop the routine to maintain it, so I wouldn't need to worry about falling off the wagon every single day. I doubt this is realistic. More likely, successful long-term weight loss will require constant vigilance to maintain. One day at a time. Source
