Tuesday, June 15, 2010

Obesity, Poker and Mike Caro's "Threshold of Misery."

Yesterday I saw one of my favorite weight loss patients. Last year he initially came to me inquiring about weight loss surgery. I work with patients who have had gastric banding (lap band) for weight loss and since it is rare that a non-surgeon can adjust and manage them I have built a nice little niche to get referrals.

As a team we decided to try diet, exercise, behavioral modification and medication management first. Although we have more work to do, he has lost close to 60lbs (300 to 240) over the last year, and feels he has a lifestyle change that he can not only live with but looks forward to. For the first time he explained how he felt when he was over 300lbs. He detailed why it was so hard for him stop gaining weight (let alone lose it).

He described Mike Caro's "Threshold of Misery," which states "you can reach a stage where the misery grows so great you stop caring because you already feel maximum pain."

This is the point where nothing seems to matter. You may have reached this point if some of the following has happened to you:

- While playing poker you have lost a relatively large amount of money either immediately or over a bad run of time and you felt utterly defeated. $300 might look like $3 when you have lost a couple of thousand.You are reckless and carefree with your money, because your are numb.

- You hit a weight on the scale that causes intense emotional pain

- You are worried about fitting in the world; especially sitting in chairs, worrying if you can fit between the arms, if it can support your weight. This happens at home, at a friends, at the doctors, in a vehicle, at the movies, when traveling, when you want to ride a horse ...everywhere. The world in essence has become unfathomably small.

- Having 100lbs or more on your body makes it hard for you to climb stairs, play with your kids, walk down the hall, have sex, do simple house-hold/work activities, and even clean yourself. Try carrying a 100lb bag of dog food around. If you don't want to run around the block I promise to not to call you lazy.

- You feel ignored, humiliated and/or discriminated by others because of your weight.

My patient felt many of these things. Even though he is not a poker player, he had crossed Caro's "Threshold of Misery." After 300lbs he didn't care about another 20. In fact by not getting on the scale he wasn't even checking his bankroll anymore. Just like gambling, food has an emotionally addicting component. Just as a losing poker player might indulge in playing poker like craps, some of us binge on foods for immediate pleasure. When your down and past this threshold, you are at risk for letting something else get the best of you...Food, Gambling, Drinking, Smoking, Drugs...Religion dare I say.

I found it interesting that my wife, who has a doctorate in psychology, and a fellowship in eating and weight disorders, has never heard of an academic equivalent to this concept of Caro's. She was aware of his remedy, and calls it the "Opposite Action" strategy. Caro was dead-on when discussing how to deal with the inevitable falls we take in poker and in life..."act like you care when you don't."


  1. Thanks for a very thoughtful post. Reminded me of my brother who died from complications of obesity (details here: http://craakker.blogspot.com/2010/02/getting-skinny-on-fat-tuesday.html). It's just very difficult to stop the spiral of disaster once it starts.

  2. I am sorry about your brother. I read through your post and had a hard time containing my anger to some of the comments left on it. People do not get the complexity of the problem. Although at the end of the day weight is simple math (calories in VS. calories out) everyone neglects the infinite biopsychosocial variables that plague both ends of the equation.

    In your brother's case I suspect he had obstructive sleep apnea that resulted in cor-pulmonale. There is alot of evidence that people with sleeping disorders have altered metabolisms and struggle with weight. In addition to carrying the burden of excess weight he was not getting sufficient sleep...good luck focusing on your weight when you are in that trap. I am sure he had a number of other obstacles as well.

    If the community was not so biased (in partiuclar the medical community) and had a better understanding of these issues people would not be so afraid to seek help. Sorry to rant about this. It is a sore spot for me. Thanks for taking an interest in my post.