OTC: Specialists in Obesity

Say it ain’t so Jared

From:  John Hernried, M.D. & Maureen Allen, MPH

   

We were dismayed to read that fast food restaurants are turning to even higher fat and higher calorie options. The latest entry is Burger King’s BK Stackers, a hamburger bun with four slices of beef and cheese. And not a vegetable in sight. At 1000 calories and 68 grams of fat (30 of those saturated) it is fast food royalty. We expect this from the King. However, particularly troubling is that Subway, the healthy alternative, has also entered the high fat arena. Their double tuna sandwich contains 1580 calories and 110 grams of fat. This represents more than an entire day’s worth of calories and fat for many of our patients.

    

In light of a growing obesity epidemic, what are these companies thinking? The bottom line, of course, not their customers expanding bottoms. Sales figures show that the worse the nutrition, the better the sales. They’re just giving us what we want.

      

Is this ethical or conscionable? Absolutely not! To make things worse, Burger King is selling collectible figurines of the Stackers Union to market the BK Stacker to children as well as their parents.

    

At some point you want to throw your hands up. If you can’t beat ‘em you might as well join them. Here are a few of our suggestions for giving the people what they want in this era of “new-trition.”

      

Chocolate coated vitamins are a must. They’re hard to swallow so let’s make it fun! Try adding Skittles instead of carrots, tomatoes and onions when making a salad. Tacos will sell themselves when finally available in vanilla or chocolate. Hold the lettuce, please. Spaghetti is amenable to all kinds of toppings like caramel or coconut cream. The Italians really had no imagination with this one. Who needs meatballs when there are marshmallows?

    

Even a 32 ounce drink (serving size 4) won’t wash that down. Let’s double the sugar so each serving has about 25 teaspoons. Now that’s a soda and a time saver to boot. By ingesting the sugar and fat with the meal you don’t need to waste precious time on dessert.

    

And finally, goodbye food pyramid - hello food donut! All food is now equal. Remember, it’s just about what you want, not what your body needs.

Follow the Leader

From: Maureen Allen, MPH

      

It’s the wake-up call no one wants to receive. You’ve hit middle age and middle age spread. If you’re lucky, you haven’t done any damage yet. If you’re not, you may get the message Arkansas Governor Mike Huckabee received three years ago. Diagnosed with Type 2 diabetes, he decided to turn his ship around. And at 300 pounds, it was a pretty big ship. Huckabee had to lose 100 pounds to become healthy again.  Younger folks get the call too, but sometimes indirectly, like Kevin Clayton of Sacramento. As a college football player he consumed and burned lots of calories. But by age 31 he had grown into a sedentary 300-pounder. Big clothes hid his body, but when his 60 year-old father died of a massive heart attack, he was roused from his denial.

   

Both men made drastic life changes, neither relying on surgery or pills. Huckabee went on a very low calorie diet, similar to the diet at the Obesity Treatment Center. Clayton reduced his calories and began to exercise.

   

The two found new lives. They are now competitive marathoners. Clayton is even training for the Ironman World Championship Triathlon in Hawaii next month.

   

Clayton’s family is extremely supportive of the new, healthier Kevin. Not so the case for the Governor in the fishbowl. Southern states are known for foods that make your heart quiver to even think about, like fried chicken and buttery grits. It’s the birthplace of Krispy Kreme for Pete’s sake! Arkansans have poked fun at Huckabee for bringing his own cooler filled with healthy foods to the many functions he attends when no suitable food is served. They were fearful when he toyed with the idea of sending kids home with their BMI number. It got shot down.

 

Patients at OTC sometimes face similar criticism. Family and friends are often anxious for the patient to be through with the diet so life can get back to normal - as if getting back to normal will keep the patient’s weight off. Like Huckabee and Clayton, patients have to dig deep when they choose the grilled chicken over the fried chicken and hear, “I thought you were done with that diet!”

Both Huckabee and Clayton stand up to the challenge.

 

I enjoy seeing and helping my patients stand up to the same challenge!

Night Eating

From: Maureen Allen

          

Many people who struggle with their weight find evenings and nights especially difficult to keep out of the cupboard and refrigerator. Chips and dip or popcorn and soda go hand in hand with watching TV and unwinding at the end of a hard day.  Some patients actually report waking from a deep sleep for the sole purpose of eating. It’s not uncommon for people to keep their calories in check and well within healthy limits all day to find their program derailed after dinner.

   

It’s such an insidious habit that one of Oprah’s top tenets of weight management from her Boot Camp program is to stop eating anything at 7:30 or three hours before going to bed at night. It doesn’t matter if Oprah’s had dinner or not!

   

Another approach is accepting that consuming calories at night is a style of eating and therefore budgeting calories and wholesome snacks accordingly. The point is, most patients view night-time eating as a diet buster and weight management challenge and are desperate for strategies to overcome the often destructive behavior.

   

Enter Taco Bell, the fast food chain and nutrition expert. Their unique approach is to create a fourth meal – the one between dinner and breakfast. Visit their website and, after registering your age and gender, you are invited to play a series of interactive games looking for prizes that are cheesy, crunchy, melty etc. You get the idea. Madison Avenue has now legitimized late night eating while we viewed it as a problem to be solved.

      

The fourth meal ad campaign isn’t going to make someone go out and eat at night. Just the way cigarette ads on TV didn’t make it OK to smoke.

Out of the Box Thinking On Obesity

From:  John Hernried, M.D.

   

I came across this article on the newswire.  Even I was amazed at the creativity at some of the explanations.  I have written about sleep and medications as causes of weight gain. I must say that air conditioning is not something I have considered.  I can already imagine a class action lawsuit forming against Trane or York!

 

The article is thought provoking enough for me to include in its entirety.

 

Are You Fat? Doctors Have Novel Excuses

Tuesday, June 27, 2006

By MARILYNN MARCHIONE, AP Medical Writer

 

Why are so many people fat? Scientists have come up with some novel excuses, including air conditioning, lack of sleep, fewer smokers, and more sex among obese people, which can produce chubby kids.   Twinkies aren't the only things weighing   America  down, these researchers contend in a report published Tuesday in the International Journal of Obesity.

   

"I think it's very creative,"said Dr. Robert Kushner, medical director of the weight management program at Northwestern Memorial Hospital in Chicago, who had no role in the report."We are facing an epidemic with no tipping point in the near future. At this point, there are no silly ideas."

However, some critics say the authors'"Top Ten"list of alternative explanations reads more like material for a David Letterman routine than a scientific study.  "I'd put this in the category of `calorie distracters'_ `Let's just do anything to get people to stop worrying about having to eat less and move more,'"said Marion Nestle, a nutrition professor at New York University and frequent food industry critic."`And let's not say a word to food companies about misleading and manipulative marketing practices, especially those directed toward children.'"David Allison, a University of Alabama biostatistician, invited 19 other scientists in the  United States,  Canada and Italy, to work on the report.

   

They looked at more than 100 studies on potential contributors to obesity besides diet and exercise, and concluded there was at least some support for 10:

 

1. Inadequate sleep. (Average sleep amounts have fallen, and many studies tie sleep deprivation to weight gain.)

2. Endocrine disruptors, which are substances in some foods that may alter fats in the body.

3. Nice temperatures. (Air conditioning and heating limit calories burned from sweating and shivering.)

4. Fewer people smoking. (Less appetite supression.)

5. Medicines that cause weight gain.

6. Population changes. (More middle-agers and Hispanics, who have higher obesity rates.)

7. Older birth moms. (That correlates with heavier children).

8. Genetic influences during pregnancy.

9. Darwinian natural selection. (Fat people outsurvive skinny ones).

10. Assortative mating, or"like mating with like,"as Allison puts it. Translation: fat people procreating with others of the same body type, gradually skewing the population toward the heavy end.

   

Not that people necessarily should try to alter these factors, Allison said. For example,"we would never recommend that people start smoking to reduce their body weight."  The same for medications that can lead to weight gain, though doctors may want to consider alternatives if a patient piles on pounds, said Dr. Louis Aronne, a Weill-Cornell Medical School nutrition expert who is past president of the Obesity Society, the leading group of researchers in the field.

    

Allison said no food or beverage makers funded any part of the report, though he and some collaborators consult for such companies.  The point is, there is more to obesity than diet and exercise, he said.  "These are 10 reasonable hypotheses, and as scientists, we should be open-minded,"Allison said.

ARE YOU OBESE? READ THIS BLOG IF YOU SAY “NO”

From:  John Hernried, M.D.

    

Most patients who come to the Obesity Treatment Center have a medical diagnosis of obesity and know they need help.  However, I know we are treating the tip of the iceberg when it comes to obesity. I was always amazed in my internal medicine practice, when an obese patient would say; “I may need to lose a few pounds sometime.” Even if I pointed out that their weight was dangerously high and would lead to serious medical problems, they would say:  “At least I’m not obese.”

      

It turns out this type of thinking is not uncommon in the overweight. An  interesting new study presented in April at The American Society of Nutrition Conference by Dr. Kimberly Truesdale of the University of  North Carolina at Chapel Hill asked patients of various weights to assess their own weight status (underweight, normal weight, overweight, or obese).  Those who were of normal weight or overweight estimated correctly about 90% of the time.  However, only 15% of patients who were obese correctly assessed their own status as being obese. 

      

“These findings have important public health implications,” says Dr. Truesdale. “If obese adults do not consider themselves to be obese, they are not likely to pay full attention to public health messages about the consequences of being obese. More research is needed into why obese adults do not consider themselves to be obese, with two possibilities being perception and denial.”

      

I’m concerned because I’m only reaching 15% of the population at risk and wonder how to get the message out to the rest.  I believe that not recognizing your body size is an image disorder just the opposite of anorexia but just as pernicious.  There is likely a neurobiological component that allows the body to be in denial and “save” the excess storage for time of famine.  Learning how to address this denial will play a key role in dealing with the obesity epidemic.  I am greatly encouraged that BMI is being noted at nearly every physician visit at many medical institutions in my community because it is an objective measure that cannot be denied.

      

I recently read a business book that discussed how several good companies faced the “Brutal Reality” in order to make the necessary adjustments to be successful.  If you are reading this blog entry, take a deep breath, and link to our BMI calculator and see where you are.  If you have a BMI over 30, take another deep breath and consider asking for assistance.  Congratulations, you are now in the 15% that realize you have a medical condition that requires attention.  This is a big first step!!

Magical Weight Loss Cures

       

I review all applications for patients joining OTC. I am constantly amazed at the number of patients who mention using over-the-counter weight loss supplements.  I have yet to see a patient with long-term success with any of these.

      

Then why do my patients, who are very insightful and intelligent, spend good money for their products?  Are they convinced they are effective?  Are they desperate to try anything?  Are they aware of the risks?  Are they getting spammed on the internet or are they watching infomercials at 3 am?

      

I am amazed when I see a huge newspaper ad claiming miraculous benefits or a B list celebrity touting “medical proof” of a health claim.  The marketing must const hundreds of thousands or millions to peddle a $50 bottle of pills.  Clearly it works.  The sales of weight loss products is 23 billion dollars a year.

    

The truth is…THERE IS NO OVER-THE-COUNTER WEIGHT LOSS MEDICATION THAT IS EFFECTIVE FOR LONG-TERM WEIGHT LOSS.  Even more, some of them are dangerous to your health.  Unfortunately, there is little the medical profession can do to stop the sale of “miracle” cures.

      

How did we get to a place where ineffective products can be sold?  Congress intended to pass a law to control substances that claimed to offer health benefits.  Instead, the 1994 dietary supplements Health & Education Act gave free reign for substances to be sold without scrutiny.  This is compared to prescription medications which must undergo years of testing before it is approved by the FDA.

      

So what are the substances and can it cause you harm?  Man of these were products where tested by Consumerlab, an independent lab that evaluates products for their content.  According to Consumerlab, many products did not contain what was on the label.

    

“Ephedra Free” products usuall contain a similar compound called synephrine (listed on the bottle as Bitter Orange) plus a load of caffeine.  Combined, these can cause significant cardiovascular side effects.  For example, Ripped Fuel Ephedra Free contains as much caffeine as 14 colas plus synephrine and Zantrex-3 has as much caffeine as 30 colas a day (or 12 cups of coffee).

    

Chromium picolinate is a substance that has been around for a long time.  I have been concerned about the side effects, including kidney, liver and blood disorders.  Part of the complications may rise from a contaminant found in chromium picolinate products called hexavalent chromium.  This is the same cancer causing compound that was made famous in the movie “Erin Brockovich.”

    

There are several other products sold that have shown no effectiveness in weight loss.  These include:  pyruvate, conjugated linoleic acid and chitosan.  In addition, testing of the products has shown either lower or higher amounts in the pills than what is listed on the bottle.  Higher doses can lead to toxicity and increased and dangerous side effects.

    

The hottest product out here is Hoodia.  There is NOTHING known about the product, yet is widely used.  I will write on this product in an upcoming blog.

    

The sad thing is that all these products distract from some of the proven treatments that exist.  Searching for the elusive “magic pill” enhances the sense of failure and futility.  This is just another way these pills cause harm.

From:  John Hernried, M.D.

Fighting the Middle “Spread”

From:  John Hernried, M.D.

         

One of the more common complaints I hear in my internal medicine practice is from 55 year-old women complaining about their increasing abdominal size.  Many of these women had few weight problems prior to menopause, and now are frustrated with their changing shape.  The usual cause of this is a buildup of visceral fat, which is known to be a risk factor for diabetes, hypertension and coronary artery disease.

The Strong Health and Empowered (SHE) study, sponsored by the NIH showed the importance of strength training in fighting increased fat.  Women in the study used free weights and machines and worked out for an hour twice a week.  A control group was just given information about exercise.  The results showed that women in the study group had a markedly reduced rate of abdominal fat and their overall body fat percentage declined by 3.7%.  The patients were told not to change their diet and their total body weight did not decrease.

This well-designed study reinforces the benefit of fitness.  Through their two hours a week, they have markedly reduced their risk for heart disease and diabetes for years to come.

How can you prevent your own “spread?” For those who wonder how to get started, this is a great opportunity to contact a certified personal trainer at a gym or in the community. The resistance training that was done in the study would be difficult to reproduce at home.  However, this is a good use of a local gym or a small training studio.  Most gyms offer one or two free consultations with a personal trainer to orient clients to the weight machines.  Make sure it is a certified trainer with one of the following certifications:  ACSM, NSCA, or ACE.  Once you get going, make an appointment with the trainer monthly so that you can progress forward.   

Dancing Away Obesity

From: John Hernried, M.D.

After my IHOP confession, I want to report an activity I enjoy with my family. A while back I found Dance Dance Revolution (DDR) at an arcade and was pleasantly surprised that I could compete. For those who aren’t familiar, DDR is an interactive video game that involves coordinating steps on a floor pad with a video image on a screen in front of you. It is accompanied by a wide variety of music. I will admit I am a terrible dancer, but I found copying the dance steps on a screen was easy and very exciting. At Christmas, we actually purchased two DDR pads for our home. It has turned out to be an excellent source of exercise for the whole family. Not surprisingly, my ten year old has far surpassed me. I am amazed how fast he moves his feet! After a song, and dance, my heart rate is elevated and I am sweating. The best part is it’s fun and seems effortless because I’m too busy concentrating on the correct steps to notice my exertion.

Fooling people into exercise is an excellent behavioral trick. Since I’ve started, I’ve learned that several
of my patients also use DDR to stay in shape. DDR offers a reduced perceived exertion—meaning you are actually getting more physical activity with less “pain.” It is a great way that technology can help.

DDR isn’t fooling only adults into moving. It is being used in schools as a form of physical activity for children. According to a story on the CBS Early Show, West Virginia is even incorporating it into their physical education program.. Curious? Put on your dancing shoes and check out their website for a demonstration of DDR.

The game can be purchased in conjunction with an Xbox or Playstation, or it can hooked directly to a TV. There are many different types. I found a lot of information by searching for “Dance Pads” on Amazon. DDR Game is another site that sells many different kinds of dance games.

For those who’ve been at it for a while, you can also dance against someone via the internet. I’m not quite there yet. But any day now I may be looking for a challenge to Hey Momma from the Black Eyed Peas.

IHOP—SIN OR THIN?

From:  John Hernried, M.D.

         

I will confess that I ate dinner at IHOP yesterday.  I picked up my kids at 6:30  after their tortuous day of school and activities and we were all starved.  The thought of preparing dinner was daunting.  My seven year old wanted to choose and insisted on IHOP.

I have mixed feelings about International House of Pancakes.  I have fond memories as a child stuffing myself beyond full with pancakes topped with strawberries, whipped cream and syrup.  Some things don’t change in that the menu is about the same and most of the food “feels” greasy and unhealthy to me. Yet, when a hungry seven year old looks you in the eye and says “please”—resistance is futile.

We were promptly seated and handed a new menu.  The redesigned menu had new, greasy choices but it also had nutritional recommendations and substitute suggestions. In addition, there was a reference to a healthier menu, which was not offered to me when we sat down.  I asked for the new “IHOP for Me” menu and was pleasantly surprised to find some good choices with calories listed.  I enjoyed a vegetable scramble which was loaded with fresh vegetables.  It came with a two fair sized pancakes and was not topped with butter. I enjoyed a nice dinner for about 600 calories.  Other options on this menu include fish, chicken and various low carb options.  Interestingly, there were no salads on this menu and the focus was still on meat, eggs and pancakes.

The children’s menu was also redesigned and they had several healthier options on the right side of the placemat menu.  But let’s be realistic.  When children are given the choice of a large pancake with a whipped cream smiling face versus “junior cod”—do you really think I can get them to make a good choice?  It was a great opportunity for a teaching moment for my boys—but afterwards they chose the smiling pancake.

Why is IHOP making these changes?  Perhaps public tastes are changing.  However, it is more likely due to political action and media attention.  They only had four of the special menus for the entire restaurant and skewed the children’s menu towards high fat, sugar and calorie choices.  This shows that the restaurant industry still has not bought into the public health concerns about our food intake.  Still, it is a start and I hope other restaurants will offer better choices with nutritional labels on the menu.

NEAT

From: John Hernried, M.D.

      

NOTE: PLEASE READ THIS ENTRY WHILE STANDING UP

While my professional focus is on the treatment of adult obesity, I am interested in efforts to prevent obesity in childhood.  There has been considerable discussion how to make children more active.  I know firsthand what a challenge this is..  In my family, we really have to “work at” keeping my boys physically active. Organized sports may not be the only solution.

Researchers at the Mayo Clinic are looking into changing the classroom to allow children to have purposeful activity while they are learning.   It is a fascinating story of collaboration and use of technology to create a classroom that has children standing and moving most of the day.  The details include:

• Video-streamed "pod-casting" as a teaching aid

• "Learn 'n Move" bays -- a step beyond traditional learning stations

• Wireless technology

• Personalized laptop computers

• An earpiece that measures physical activity of the student

• Vertical magnetic work spaces that double as projection screens

• Innovative telemetry that collects data for scientific comparison

• Personalized white boards (instead of one large blackboard for a room)

• "Standing" desks -- where the children will stand and work, rather than sit

For details and more photos, please see this Mayo Clinic link.

The concept behind this “Classroom of the Future” is a concept called N.E.A.T.  This stands for Non-Exercise Activity Thermogenesis. It is the number of calories burned during our daily activity at home and work.  By standing up and reading this blog, you are increasing your NEAT. With modern technology (remote controls, automated vacuums, working at a computer rather than a factory line) we burn about 100-200 fewer NEAT calories than we used to.  This may account for some of the obesity epidemic. 

We always think we have to run marathons to keep our weight down.  But there is some evidence NEAT actually decreases as we exercise more.  The result is that for some people, they may still gain weight while they exercise. Not to be discouraged. At OTC, we are looking at ways to measure NEAT and planned physical activity to best help our patients.

I can only hope there is a “classroom of the future” for my sons in the near future.