Judging By Appearance – a Dietitian’s Journey

We form an opinion about someone’s appearance when we haven’t seen them in a while, or meet them for the first time. We do so unintentionally, but we judge by appearance. Sometimes the appearance of weight gain is not about diet but a diagnosis. 

DISCLAIMER: (August 28, 2022): This article a personal account posted under A Dietitian’s Journey. The information in this post should in no way be taken as a recommendation to self-diagnose, self-interpret diagnostic tests, or self-treat any suspected disorder. It is essential that people who suspect they may have symptoms of any condition consult with their doctor, as only a medical doctor can diagnose and treat.

The photos below are both of me. On the left is what I looked like when I began my personal weight-loss and health-recovery journey on March 5, 2017. Over the following two years, I lost 55 pounds and 12 ½ inches off my waist following a low carb, and then a ketogenic diet. The process was slow — agonizingly slow and in retrospect, I now know why. The photo on the right is what I looked like two years later, maintaining my weight loss.

LEFT: March 5, 2017 RIGHT: December 2021 – after two years weight maintenance

Almost imperceptibly, my appearance began to change.  I didn’t “see it” at the time, but I was aware that my waist circumference was different and that my clothes felt tighter. What I couldn’t understand was that I had only “gained” approximately five pounds.

The two photos below clearly show the subtle difference.

LEFT: Hiking March 5, 2021, RIGHT: Hiking March 5, 2022

The photo on the left was taken on the two-year anniversary of completion of my weight loss journey which lasted from March 5, 2017-March 5, 2019 as posted on my low carb web site. This entry in that journal which is titled From the Mountains Through the Valleys was written for my fifth anniversary, the day before the photo on the right.

The photo on the right was taken this past year in March, exactly one year after the photo on the left.  The comparison is easy because I was wearing the same clothes. While my weight was only approximately five pounds greater than on the left, it is clear to see that my face was puffier, as were my legs.  I remember getting dressed that morning and wondering why all my hiking clothes felt so tight. I also vividly remember how difficult the hike was that day — and it was a simple one with very little elevation. My legs felt heavy, and it was hard to walk up even the gentlest of inclines.

Despite having both vaccines in April 2021 and July 2021, a few days later I came down with what my doctor and I presumed was my second case of Covid-19.

I had Covid the first time in August 2020 and wrote about it in the journey entry titled, To Covid and Back).  In retrospect, I think the ‘post-viral arthritis’ I experienced afterwards may have been linked to my thyroid’s response to the virus (documented in the literature). In that post, I wrote about recovering from Covid the first time;

“By the end of August (after Covid) it was difficult for me to even walk up (or down!) a flight of stairs. This both shocked and scared me.

I began to go for walks — even though it was very hard.  At first they were literally just around the block, but I kept at it.  One of my young adult sons who lives with me kept encouraging me to walk, and would sometimes go with me.  As my legs became stronger, walks turned into short  inadvertent hikes’ and I discovered I really liked being out in the woods, even though it remained very hard to step up onto rocks, or step down from them.  I dug out the wood hiking staff that I brought with me when I moved from California and put it into service., invested in some hiking boots and other essentials’. As I said in the previous article, my hiking stick — along with my fuchsia rain gear has become somewhat of an identifier— but the truth is, without the hiking stick, I could not have possibly begun to hike.

My first breakthrough was in late November, when I did my 4th real hike which was 12 km around Buntzen Lake — which in terms of a few elevation gains was really beyond my capabilities. With frequent stops and lots of encouragement from my son, I did it.  I had to. He couldn’t exactly carry me back to the car! That day I felt as though I had beaten the post Covid muscle weakness and was on my way back to health.”

When I got Covid again this past March, the symptoms were pretty much the same as in August 2020, muscle aches and joint pain, being exhausted, feeling cold all the time and my lips were frequently blue. The only difference was this time I did not have headaches.  I was loaned an oximeter by a family member who is a nurse and I found it quite strange that my body temperature was always two degrees below normal even though I had fever-like symptoms of being cold and shivering.  The muscle aches were significant, as was the fatigue, but since these are also symptoms of Covid, I didn’t think much of it.  It was only when I began to develop symptoms that were not associated with Covid that I began to become concerned.  

Fast forward to the beginning of June which was my youngest son’s wedding. I was so very unwell, but avoided talking about it as I did not want to detract from the very special occasion.

I was experiencing joint pain and muscle aches, and chills that would come and go. I would frequently get bluish lips, and continued to have significant non-pitting edema in my legs and ankles, and was wearing compression stockings all the time — even at the wedding. Most pronounced was the debilitating fatigue.

The skin on my cheeks had become flaky and dry and despite trying multiple types of intense moisturizers, nothing helped. My mouth symptoms had progressed to the point that I found it difficult to say certain words when speaking because my tongue seemed too large for my mouth, and the salivary glands underneath my tongue were swollen.

The muscle weakness had progressed to the point where it was difficult for me to get up from a chair, or to get out of my car without pushing myself up with my hands. My eldest son was helping me get to and from the beach for the photos, and out of the car.  He thought it was me aging, and when I recently asked my other two sons, they assumed the same thing.  I was wondering if I had some form of “long-Covid,” but what got me starting to think that my symptoms had something to do with my thyroid was the very noticeable swelling in my face.

At my son’s wedding I looked like I did when I was 55 pounds heavier!

LEFT: March 5, 2017, RIGHT: June 3, 2022 at my youngest son’s wedding.

The photo on the left, above is what I looked like when I began my weight-lost journey on March 5, 2017. The photo on the right is what I looked like June 3, 2022, at my youngest son’s wedding. I look more or less the same in both pictures, but with a fifty pound difference in weight. 

I found out a few weeks later, I had hypothyroidism and was displaying many of the symptoms of myxedema. [I have written an article from a clinical perspective about the symptoms of hypothyroidism, which is posted here.]

While we do it unintentionally, we all judge by appearance, and “weight gain” is no different. If we see someone at one point in time, we form an opinion based on what we see.  If anyone would have bumped into me three months ago, it would have been reasonable for them to assume that I had gained back all the weight I had lost, and then some. But that wasn’t the case. 

But what causes the appearance of “weight gain,” without gaining significant amounts of weight? 

As I explain in this recent clinical post about hypothyroidism, the “puffiness” is due to the accumulation of mucin under the skin. Mucin is a glycoprotein (a protein with a side chain of carbohydrate known as hyaluronic acid) that is naturally produced in the skin. Under normal circumstances, hyaluronic acid binds water to collagen and traps the water under the skin, keeping it looking moist and plump, In fact, hyaluronic acid is injected into the skin by dermatologists to make aging skin appear younger. The problem in hypothyroidism is that an excess of mucin accumulates under the skin, giving it a “tight, waxy” swollen texture. (I would describe it as feeling like an over-inflated balloon). 

Below is a photo showing the change in appearance in my left leg from November 3, 2021 (left), to July 16, 2022 (middle), to August 26, 2022 (right).

The photo on the left was taken by me last November while I was doing some stretches. It was still on my phone in mid-July when I took a picture of the swelling in my lower legs and ankles caused by mucin accumulating in the skin. The photo on the right was taken this morning, and while much of the swelling has been reduced, I am still unable to pinch any skin on my legs due to the remaining mucin. I have read that it can take 6 – 8 months for this to resolve.

I want people to understand that the appearance of “weight gain” and “weight loss” in hypothyroidism is different than weight gain and weight loss due to dietary changes. The difference, however can be very subtle.

In my case, the appearance of “weight gain” occurred very slowly.

My appearance between March 5, 2021 and exactly a year later are almost indistinguishable. It is only in retrospect, that I can see the puffiness in my face and legs. At the time, I was puzzled why my clothes fit tighter when there was only a 5 pound difference in my weight, but beyond that I didn’t give it any thought.

Below is a composite photo to help illustrate how slowly my appearance changed at first, and how quickly it progressed as my thyroid disorder progressed. Look how rapidly my appearance changed in only three months, between March 5, 2022, and my son’s wedding on June 3, 2022! 

[NOTE: As I’ve mentioned in all of my previous articles and posts about hypothyroidism, each person will present with different symptoms, and even those with the same symptoms may have very different appearance because of differences in their thyroid dysfunction.  Keep in mind, these photos describe only my own experience.]

Below is a composite photo to illustrate how quickly the appearance on my my face has resolved after only two months of thyroid treatment.

An Expanded Perspective

My clinical practice changed 5 years ago when I came to understand what hyperinsulinemia was, and how early clinical signs of developing type 2 diabetes are evident as long as 20 years before diagnosis. In a similar way, my clinical practice is changing again now as the result of what I am learning about hypothyroidism.

Understanding the wide range of clinical and subclinical symptoms that people may have leads me to ask additional questions, to look at lab test results differently, and to ask for additional ones if it seems clinical warranted. While it is beyond the scope of practice of a Dietitian to diagnose any disease or to treat hypothyroidism, I am more aware of what to look and this helps me to refer people back to their doctor if I feel there may be a clinical concern.

Final Thoughts…

We form an opinion about someone’s appearance when we haven’t seen them in a while or when we meet them for the first time. While we do so unintentionally, in developing that opinion, we judge by appearance but sometimes the appearance of “weight gain” is not about diet, but about a diagnosis.

If anyone had seen me three months ago after not seeing me in a while, they might have assumed that I had gained back all the weight I had lost.

When we encounter someone who is overweight, we ought to bear in mind that don’t know where they are on their journey. We don’t know if they have metabolic issues related to glucose and insulin metabolism, are struggling with food addiction, or have an endocrine dysfunction, like hypothyroidism, or something else.

People seeing me now have no idea that less than three months ago I looked as I did on the left, and was very ill.

As much as it is natural for all of us to form an opinion, let’s try not to let that opinion become a judgement.  Listening is a great way to find out more.

To your good health!


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