The Patient Was…

The patient was a 65-year-old male with a positive checkmark in the box of almost every serious category of illness except, luckily, cancer. He was under my care for serious cardiovascular disease, but also had diabetes, asthma and chronic obstructive lung disease, arthritis, urinary tract difficulties, plus a litany of other minor and ill-defined symptoms. Despite all of this, he was optimistic, enthusiastic, successful, and had an irrepressible zest for living that was contagious.

An additional, overriding feature of his health status, and one which contributed to several of his listed illnesses, was a significant degree of obesity. Of the so-called “seven deadly sins,” he was guilty of but one: gluttony.

His food and alcohol consumption were prodigious. Fortunately, he was very faithful in taking the medications that were prescribed for him, which probably accounted, in large part, for his tolerance of a generally unhealthy lifestyle. On those occasions when I and others in his medical fold dined together with him, we were in awe of the amounts of food and wine that were presented and ingested.

One of the diagnoses for which I was treating him was congestive heart failure, a condition in which the heart does not pump enough blood around the body to meet the nutritional needs of the various organs and tissues. In many instances, the main pumping chamber of the heart (the left ventricle) cannot empty adequately, and blood backs up into the left upper heart chamber (left atrium) and then into the lungs. This congestion of the lungs prevents a normal amount of oxygen from entering the blood stream and causes difficulty in breathing.

One of the recognized problems in this type of heart failure is excessive sodium (salt) intake by the patient. Salt, in general, causes retention of fluid in the body, and this can aggravate the congestion of the lungs and other body tissues. Swelling of the legs, known as peripheral edema, is a common sign of such fluid excess.

The patient was well aware of the issues with sodium and fluid retention, having had previous experience with lung and tissue swelling when he ingested too much salt.

 And who else but he would take such advantage of this knowledge!

On many visits to my office, we discussed the impact that obesity had on his various illnesses. Diabetes, arthritis, lung disease, and certainly his heart problems, were all adversely affected by his excessive weight. He understood it, no question, but his preferred lifestyle simply did not allow for meaningful weight reduction. On one occasion, I suggested to him that perhaps if someone close to him undertook dieting at the same time, they could support one another in the effort. It is, in fact, known that support from friends and family can enhance the weight loss process.

On his next visit to my office, the patient announced that two of his friends who were also overweight had agreed to go on a short-term weight loss program with him. He actually identified these individuals and, while I didn’t know them personally, they were sufficiently public figures for me to recognize their names and confirm that they were, indeed, significantly overweight.

The plan was to use the next two weeks in preparation for the actual weight loss period; this involved clearing calendars of social events that involved food and alcohol, and otherwise organizing their lives to support the process. After these two weeks, there would be a “weigh-in” where baseline weight would be recorded. Then, the next three weeks would be the period of intense weight loss and a final weight would be recorded.

To incentivize themselves, they agreed to a wager. Each of the three participants put up ten thousand dollars which would be awarded to the person who lost the most weight in the three-week period.

Of course, my patient had a plan: creative, yes; dangerous, even more so.

Unbeknownst to me, he spent the two-week period before the initial weigh-in, which he arranged to be in his home, eating as much salt as he could ingest and drinking copious amounts of fluid. His tissues swelled up, his breathing became labored, he could barely move around  —  and he gained about twenty-five pounds, virtually all fluid.

As soon as the weight loss trial began, he restricted his salt and fluid intake and started to take double his normal dose of the diuretic drug I had prescribed for him as part of his usual regimen of heart drugs. Diuretic drugs increase the excretion of salt and water through the kidneys, and he began to pour out large amounts of urine as his body eliminated the excess salt and water it had accumulated during the previous two weeks.

At the final weigh-in, he had lost about thirty pounds, far exceeding the modest weight losses his friends had experienced. When they realized what he had done, they protested but he maintained that no conditions or restrictions had been placed when they agreed to the wager.

They conceded, paid their debt, and, best of all, remained friends.