By Mercy Hylton, MD

“When are you expecting?” Eighteen months after my third child was born, I was tired of hearing this question. In addition to the embarrassment I felt, I became increasingly worried that something was wrong with me as my body stubbornly held its postpartum shape.

Within a year of delivering each of my first two children, I was able to lose most of the weight I had gained and maintain a normal BMI in between pregnancies. Despite not gaining excess weight during any of my pregnancies, I developed gestational diabetes during all three and had to inject insulin as early as the beginning of the second trimester to control my hyperglycemia. Thanks to my OB, endocrinologist, and insulin, I was able to maintain good glycemic control despite my only slightly healthier-than-standard American diet, the absence of a regular circadian rhythm, and the stress of practicing emergency medicine. Each of my three babies was born healthy, of normal weight, and with no hypoglycemia. My hyperglycemia resolved after each delivery. But something was nagging at me that my third postpartum recovery was different.

I delivered my third child when I was over forty years old. The ego-bruising label of “geriatric pregnancy” (pregnancy over age 35 years) is one of the common realities of being a female physician due to delaying childbearing after the rigors of medical training with or without the added burden of slowed fertility. Perhaps my advanced maternal age was to blame for my difficulty in losing the extra inches around my waist. After my first and second children were weaned, I followed the perpetual medical adage to “eat less and move more,” and it worked. I was doing the same calorie reduction and exercise after weaning my third baby, and, if anything, my waistline was getting bigger.

True to my years in emergency medicine, my mind wandered to worst-case-possible scenarios. I worried that it was ovarian cancer or some other abdominal mass causing my swollen belly. I asked my OB for an ultrasound. The ultrasound and lab tests were negative for anything suspicious.

As my third child approached eighteen months of age, I had enough of the intrusive pregnancy queries. I made an appointment with a well-regarded plastic surgeon, let me call him Dr. V., to discuss possible abdominal contouring options. I was hopeful that abdominoplasty or liposuction might be the answer I was looking for.

Consultation day arrived. The opulent furnishings and soft classical music playing in the plastic surgeon’s office were a stark contrast to the bare-bone look and loud chaos of the emergency department. I found myself in an uncomfortable state of undress as the surgeon’s assistants photographed, measured, and marked every part of me. The discomfort of strangers seeing my body in that way was only acceptable because it meant that I was one step closer to a solution.

After Dr. V came in and introductions were made, we talked about my reasons, hopes, and goals for being there. We had a good rapport with each other. He methodically examined my areas of concern. Without rushing nor hesitation, he delivered his kind but firm analysis. “You are not a surgical candidate. If you had those procedures, you would not have your desired outcome. Your issue is not subcutaneous fat nor a diastasis; it is visceral fat which we can’t touch with surgery.”

I was stunned and deflated. This was not a turn of events I had anticipated. I had expected a discussion of the risks and benefits of surgery, but that didn’t happen. He had flatly turned me down.

He went to his office and brought me a book titled Wheat Belly, as well as several handouts about diet and exercise. He shared that he and his family had gone wheat-free for a few years, resulting in many health gains, including decreases in abdominal girth.

I left feeling humiliated, hopeless, and a little angry. “Eat less and move more” wasn’t working this time. This lauded surgeon was encouraging a fad diet over surgery! No wheat? I rarely ate bread and never drank beer. How could that work for me? The book became part of the dusty pile of well-intended but ignored reading material on my bedside table.

A few months after my consultation with Dr. V, I had my annual visit with my endocrinologist. My hemoglobin A1c, which had been steadily creeping up over the past decade, was now 6.4. I knew I was staring a type 2 diabetes diagnosis in the face. As an emergency physician, I was used to seeing the life-changing complications of this cruel disease. I was in my early forties with three little kids, and I feared for my future.

Ultimately, my HgbA1c and the realization that there was no “easy” surgical fix catalyzed a lifestyle shift for me. In 2016, I read The Obesity Code by Jason Fung, MD, a Toronto nephrologist who was tired of watching his patients with diabetes-related ESRD hopelessly and quickly decline. I learned for the first time about the impact of our modern Western diet, highly processed food products, chronic high stress, and culture of consumerism on our health and our waistlines. I sought out other books and podcasts on similar topics.

I started restricting my refined carbohydrate intake without counting overall calories. With some trepidation, I tried time-restricted eating (a type of intermittent fasting) and found it to be beneficial and easy to fit into my chaotic ED shift schedule. Six months later, my HgbA1c was 5.2. At the end of that first year, I had lost about 25 pounds and a staggering 14 inches from my waist circumference without any substantial change to my exercise routine. Now, instead of being asked if I was pregnant, colleagues were asking me what I was doing to lose weight.

Over the next five years, my lifestyle changes solidified into habits. The more I learned, the more I fine-tuned my healthy choices and successfully maintained my goals. I informally coached several friends and colleagues in making similar successful lifestyle changes and found great satisfaction in helping them. I took every opportunity to educate patients with lifestyle diseases and their families about the benefits of making lifestyle changes. As I progressed in my career from a young EM doc who enjoyed the endorphin rush of emergency procedures and resuscitations, I evolved into a physician who preferred the quiet satisfaction of teaching patients about their own health. I considered one of my biggest wins when a patient came back to tell me that they had quit smoking because I had spent the time to talk to them in the ED. Of course, emergency department staffing was never built for time-consuming patient education, and as the years moved on, the ED staffing became even tighter and in further conflict with my evolving priorities and professional satisfaction. I knew that my once-loved ED had irrevocably changed, and so had I. By the end of 2021, I had left EM and sought a new path.

I found lifestyle medicine. The American Board of Lifestyle Medicine (ABLM) became a member of the American Board of Medical Specialties (ABMS) in 2017. I believe that “lifestyle diseases” need lifestyle treatments. Lifestyle medicine emphasizes evidence-based lifestyle interventions as the primary modality to prevent, treat, and reverse chronic diseases like type 2 diabetes, obesity, and others over the more traditional “prescribe and manage” approach. In 2023, I achieved board certification in lifestyle medicine.

The six pillars of lifestyle medicine illustrate a holistic approach to patients’ lives: nutrition, physical activity, restorative sleep, stress management, avoidance of risky substances and positive social connections. In my opinion, adequately exploring and addressing the interconnection of these aspects of a patient’s life is what determines the sustainability of lifestyle changes in any domain.

The current paradigm of reimbursement in traditional health care settings does not support the time-consuming yet effective personalized patient education, therapy, and intensive health coaching needed to support lifestyle changes that will eventually become lifelong habits. The traditional health care system’s own inadequacies in addressing lifestyle factors have given lifestyle interventions an unfair reputation of predictable failure in the minds of many physicians. I was one of those cynical physicians, until I became the patient.

No one wants to feel the rejection and disappointment of being told “no,” but in retrospect, I came to be grateful for the “no” that Dr. V gave me. He did not enable me to seek the “easy” surgical option. Being declined by an experienced surgeon was the catalyst I needed to seek more effective lifestyle changes. Patients often judge physicians based on the success of active interventions and provide feedback accordingly. Positive reviews for services not offered or provided are rare. Yet, we are called to ethically follow our professional judgment. Primum non nocere. So, I thank Dr. V and all physicians reading this, who practice good medicine: for choosing good ethics over good reviews and patients over profits. Thank you, Dr. V, for having the conviction and courage to say “no” when I needed to hear it: You saved my life.

Mercy Hylton is a pediatric emergency physician.