BMI, healthcare rationing and casting of runes

No posts for a while, nothing much to say. Recently my weight has been fluctuating between 114kg and 115kg. Everything has pretty much plateaued, my activity levels are good but not exceptional, finding time to fit in extra exercise is challenging. Weekends over the past few months have been taken up by DIY (painting fences, painting the garage, replacing guttering etc…) and just recently with various family commitments. Now the weather has turned the idea of going for a jog in the cold, wet, dark evenings is not one that fills me with joy.

My diet has slipped into what I'd describe as a normal pattern. I'm not pushing hard to cut out calories like I did earlier in the year, but at the same time I am showing self-restraint in what I eat and drink. Sweet things are restricted to a couple of times a week and to normal sized portions. Compare that to 12 months ago and the difference is significant, back then I would eat a chocolate bar most days, and sometimes I would have more than a single serving of a sweet or chocolate on the same day.

That step change means I'm not too worried about the Christmas season, I know I can moderate myself when temptation is all around me, although I’ll need to be tough with the inevitable influx of office mince pies. The big question is whether having achieved a level of stability the time is right for another push? I have about six weeks till my next consultant appointment in early January and it would be good to hit 111kg at that. That's around half one pound a week, achievable but challenging given the season and the fact I’m starting from a lower calorific intake than at the start of the year. It would bring my total weight loss for the year months to around 14kg, over half way in my battle.

One significant positive from the whole exercise is that my BMI is now around 36 when it was tipping 40 at the start. I don’t personally hold much faith in BMI as it’s got more than a whiff of pseudoscience about it, but it’s a pseudoscience that is increasingly being used in the rationing of NHS treatment.

I recently arranged to have a vasectomy a.k.a. “the snip”. The NHS has contracted the procedure to a private hospital and I was told at the initial consultation a BMI over 40 would have seen me rejected. As I actually got the initial GP referral over a year ago, but couldn’t get suitable time off work, I would probably have been declined had I proceeded immediately. It needs to be stressed this isn’t a rule based on genuine medical science, the hospital will still carry out the procedure on people with a BMI over 40, but they have to pay privately. This seems a bit of a nonsense as the procedure is non-emergency under all circumstances, it isn’t particularly complex, and there isn’t a massive waiting list (I was able to obtain appointment slots easily). 

Surely in this day and age there must be more sensible ways of rationing treatment (if rationing must occur at all) than the arbitrary application of pseudoscience? What next, NHS treatment allocated on the basis of casting of runes?

A new approach needed

The consultant appointment came and went, the last ditch effort to lose weight failed, I stuck to the no alcohol or chocolate ban for two weeks, but it didn't really make any difference. In the end I weighed in at 115.6kg, half a kilo heavier than I did four months earlier. Ultimately it made no difference to my stats, my CKD remains stable (c. 28% kidney function according to the consultant) and my medication remains unchanged.

After that I kind of let things slip a little, having failed to make the weight loss I slackened off on the diet, not massively but just enough. It didn't help that the day after the appointment I was giving the eulogy at my Grandfather's funeral and wasn't in the mood for abstinence. So this week my weight is up again to 116.4kg.

I now need to rethink my approach, as the current one isn't working: eating a generally sensible diet with moderate consumption of alcohol and occasional sweets; combined with regular moderate exercise. There are a couple of levers, the first one is to change my diet again, I know it's too heavy on carbs, particularly refined carbs like bread and pasta. I mainly eat white bread (usually unsliced bloomers, ciabatta, baguettes etc., not that it probably makes any difference from sliced packet bread) as I've never been too keen on brown bread finding it a bit dry and cardboard like, but there are some artisan style brown breads I've tried and enjoyed, the question is figuring out whether switching will make have a material affect? It's actually quite difficult to get clear guidance on whether switching bread and pasta is materially beneficial. The other options are to switch away from bread altogether for some meals, perhaps having weetabix or muesli for breakfast instead of toast or soup at lunchtime, the only concern being whether these will fill me up sufficiently to avoid snacking or having to go with portion sizes so large they defeat the objective. It may simply be a case of try and see.

The second lever is more exercise. This is not as easy to affect. I have my morning walk from the station (instead of taking the tube), and I have my lunchtime constitutional, but after that it becomes more difficult. I try to slot in walks/jogs in the evenings, but these are not easy. With two young kids and their various activities (after school clubs, homework, feeding, bathing and getting to bed) as well as the day to day chores that need to be slotted in finding a suitable half an hour and time for a subsequent shower is not as easy as it sounds. Too soon after a meal and it's uncomfortable, push the meal back and it's going to bed with a full stomach and inevitable indigestion. Jogging/running has never been my thing, even back before the kids, when I played rugby league and went to the gym several times a week. I now find heels and ankles can hurt afterwards. There is also no gym or swimming pool close enough that I could take advantage of it. sufficiently to justify a membership.

It's given me something to think about, but I can’t mull it over for too long as I need to get some momentum back up.

Special Measures

Well, my plan to get down to 111kg by my next visit to the consultant on 13th September is completely in tatters. This morning, with two weeks to go, I weighed in at 116.1kg, basically 1.5kg heavier than I was 4 months ago. It's not that I have been especially bad with my diet or exercise, I just haven't been disciplined enough overall.

The lack of progress is a combination of daily 'extras' like ice cream and/or a couple of beers, particularly whilst I was on holiday in August, and a few 'bad' days like my cousin's wedding or Saturday's challenge cup final where I ate more or drank more than I would normally. It's not like I've been on any mad benders or have binged on food, it's just that there haven't been enough days where I've burned off more calories than I've consumed. I can get away with those occasional bad days if I keep the days with 'extras' to a couple of days a week, unfortunately I haven't done that.

So my new target is 113kg. That is basically 3kg in two weeks, very challenging but not impossible. I'm working on this basis that I can shock my system back on track by cutting out chocolate and alcohol for two weeks, and adding a regular evening walk/jog to my routine. I still do my daily morning and lunchtime walks, and I follow my late breakfast and no morning snack routine at work, but I suspect that my body has simply normalised to this so I need to increase the work rate to get benefit. I think it will be an important milestone to break below 114kg.

The Flatline... again!

Staring to get a little nervous about my diet again, I've stabilised at 114.6kg, but I'm now half way between my four monthly visits to the consultant and need to get some downward movement. I've set myself a target of 111kg by the next appointment on 13th September, that works out at one pound per week. It's a challenging but realistic target. 

I need to be more ruthless tackling unhelpful patterns which have crept in, such as sticking to my diet on most days but then having days when I'm not so good. The diet works best when I'm in a regular meal routine and I don't get too hungry because the gaps between meals are too long, which only tempts me to snack. Bad days mostly involve a handful of peanuts whist waiting for dinner or 'extras' like an ice cream after dinner or a couple of beers midweek. 

The early part of July had several days when I was too indiscipline, on Saturday 2nd we went out for tapas and as we tend to order too much food I end up feeling compelled not to waste it. The next day we went to a garden party at the in-laws, for some reason I thought it was going to be a barbecue, but instead it was a mid-afternoon light buffet which turned out to be the worst possible combination. Firstly, it was too close to lunch which meant I wasn't really hungry, secondly (and rather unusually) there wasn't really enough food so when I was hungry there was nothing left. Thirdly, as it was a warm afternoon I ended up drinking the equivalent of five pints which is atypical. So instead of a regular meal I ended up with a slice of pizza, cookies and beer! Then came my birthday, I didn't particularly go overboard, but there were sweets and cake. Fortunately things have settled down in the last couple of weeks.

I got the Fitbit for my birthday, so now I'm keeping better track my exercise. The good news is that I am averaging over 10k steps a day, but it does confirm I'm not getting enough intense exercise and also not enough sleep/good quality sleep (a mixture of recent hot weather and kids waking in the middle of the haven't helped). I've been taking Allopurinol for over two weeks now without any severe gout reaction, although I did take two magic tablets a day for the first fourteen days. At the moment I'm trying to make sure I squeeze in a walk every lunchtime and plan to restart the jogging regime I abandoned in June due to gout. I'm also hoping that the two weeks holiday I have booked in early August will increase my activity levels as I get out from behind a desk.

Slippage

Well it had to happen given the temptations laid in my path, my weight loss inevitably started to go backwards last week. When I got on the scales on Wednesday I was 115kg up 1kg. Fortunately, the gout attack has significantly receded, although there is still a small amount of pain in my left foot (ball of the big toe and heel) it hasn’t got significantly worse for about a week. The course of steroids didn't finish it off and I still needed another cycle of magic tablets early last week, but at least things are now settling down now. I’m planning a final cycle of Colchicine this weekend in the hope I will be able to start Allopurinol early next week.

I have been trying harder with the diet this week, albeit temptations are everywhere. One of the downsides of my current workplace is the culture of bringing in cakes and sweets to share on a near daily basis. This piece on the BBC about "office cake culture" is a rather timely example of the problems I face. Most of the time I resist, but yesterday I did indulge in one of the donuts a team mate procured to celebrate his birthday. It didn't help that the boxes were stacked right next to my desk ensuring a steady waft of sugary smells in my direction.

Talking of birthdays, it's my own next week. My wife is treating me to a fitbit, which is something I've been looking at for a while. I'm keen to start recording just how many steps I'm taking daily, and use it as motivation to increase, particularly by fitting in more lunchtime walks. Now I just have to decide whether I take in cakes next week, or whether I just let the day pass quietly (my preferred approach to my birthday).

Father's Day Temptation

It was Father's Day Sunday just gone, and with it came temptations to spoil my diet. On the Saturday we went out for an Italian, a starter portion of carbonara followed by calzone weren't exactly the healthy options, but then there's no point in paying to eat out somewhere special and then ordering stuff you're not fussed about, may as well just stay at home. I did pass over the option of a dessert, but that wasn't much of a hardship, desserts in Italian restaurants (and Spanish for that matter) are usually pretty mediocre. I don't drink coffee so the ever predictable tiramisu is of no interest and unless they have a good selection of proper gelatto then ice cream is a waste of valuable calories.  

On Sunday morning the kids gave me a large bar of Reece's peanut butter chocolate, which I've so far avoided opening. I love the stuff, but once it's open the chances are I will struggle to avoid eating it in one or at best two sittings. It was a nice day, so we took a picnic to Priory Park, the only problem being that I always end up eating more at a picnic lunch than I would normally. My typical lunch is a roll or sandwich and occasionally some crisps at the weekend, but I ended up adding not just crisps but some snack sausage rolls and a chocolate biscuit, then a little later in the afternoon we had ice cream from the cafe.

In the evening the in-laws came up for dinner, which of itself wasn't a problem, but I wasn't very happy with the volume of dessert my wife had bought. For four adults and two children we had a large cheesecake and a large chocolate fudge cake, each of which would give six generous adult servings. Add in berries and fresh cream and it was more than double the amount of dessert we really needed. I resisted, but made the point that going so far overboard with dessert was wasteful and doesn't make things easy for someone trying to diet.

Side Effects of CKD

One of the funny things about CKD is that until you get down to the final stages it has little in the way of external symptoms, this is one of the reason why early warning signs weren't pieced together in the development of my own CKD.

Around fourteen years ago I had an ultrasound scan to investigate a stomach problem and the technician noted my right kidney was very small, which wasn't actually as big a surprise as it might have been given my Mum had one kidney removed as a child and my brother was born with only one kidney (albeit his one kidney is apparently larger than typical). But that comment was tangential to what the scan was actually for.

Then around ten years ago a routine check at my GP's surgery had picked up that I was suffering from mild hypertension (higher than normal blood pressure), but it wasn't considered significant enough to treat because there was no link to my kidneys. Then a little while later I failed a medical due to protein being detected in a urine test, my GP investigated further but the conclusion was that there was nothing to worry about. These disparate pieces of information did not link together and therefore no steps were taken early that might have prevented some of the deterioration that followed.

It was only after I had a procedure to treat two bulging discs in my back and the hospital flagged concerns about my blood pressure that the problem was uncovered, unfortunately by that time I'd also experienced significant weight gain due to the back problems (there is a whole other story for another time about that).

The only direct physical symptoms of my CKD is the sporadic gout, which has been getting worse as my kidneys get worse. But whilst gout is linked to CKD plenty of people with gout don't have CKD, especially overweight men such as myself. The only other physical sign of my CKD is actually a reaction to the Ramipril medication which has left me prone to sudden bursts of cramp in my calf muscles, something a previous consultant confirmed was a not uncommon side effect. I have trained my body through force of habit to avoid stretching too quickly in a morning, instead I gently work my way into stretches, I'm careful not to bend over too quickly in certain ways or to spend too long sitting in certain positions. Of course sometimes it cannot be avoided, sometimes I'll turn a certain way in my sleep and wake up screaming as the pain shoots through my legs and I have to get up and stretch my calves or I'll end up in pain the next day. It's not something my wife impresses my wife who gets woken up a stupid o'clock in the morning.

But I consider myself lucky so far, there may come a time when I'll look back in fondness to the days when gout and cramp were the only side effects.