My 27-year-old patient with a body mass index of 64 kg/m2 presented to my clinic with back and leg pain. Unfortunately, I was not the least bit surprised.

When bending over, he developed acute onset of back pain, with radiating pain down the lateral side of his right leg to his foot. Exam and history were consistent with lumbar radiculopathy.

Over the next several months, the patient had intractable pain in the presence of escalating opioids. The neurosurgeons said that his weight created too high a risk for intraoperative and postoperative complications, with which I agreed.

And so began the work of titrating his pain-modulating agents, along with the significantly less glamorous and substantially more challenging task of helping him lose weight.

He was staunchly opposed to bariatric surgery and could not afford weight loss medications, presenting a bit of an impasse. To me, the fact that his insurance company would have covered his spinal surgery but not his FDA-approved weight loss medications embodies one of the great medical mysteries of modern times.

His mother accompanied him on one of his several visits and chimed in, “He needs to eat bread, doesn’t he?”

One of my common weight loss counseling mantras is “no whites for breakfast, lunch, or dinner.” These whites would include rice, bread, pasta, and potatoes. The airwaves have been crackling for a while with calls to decrease carbohydrate consumption to combat the obesity epidemic and to eat bread only if you’re a duck. As a result, bread consumption has declined worldwide.

So how bad is bread? Are all breads the same?

Luis Serra-Majem and Inmaculada Bautista-Castano of the University of Las Palmas de Gran Canaria, Spain, conducted a systematic review of the impact of bread consumption on obesity and abdominal adiposity ( Br. J. Nutr. 2015;113:S29-S35 ). The authors concluded that white (refined grain) bread, but not whole-grain bread, may be associated with excess abdominal fat.

Proposed hypotheses for how breads impact adiposity differently are:

1. Whole-grain bread increases satiety more than white bread;

2. Whole-grain bread results in lower plasma glucose and insulin responses than white bread;

3. Higher fiber content of whole-grain bread limits glucose absorption more than white bread; and

4. Whole-grain bread may positively influence gut microbiota through a probiotic effect.

My advice to the patient was to restrict calories, avoid carbohydrates, and if bread must be consumed, then it must be whole grain. Baby steps.

But he found religion in this (and in walking) and lost 200 pounds over the next 5 years. Miracles are still possible.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

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