Will a Little Kid Saying "Bye Bye" Brighten Your Day?

Sure would mine.

Today's Funny Friday video involves the wide eyed, friendly innocence of youth.

Have a great weekend!

(email subscribers, you've got to visit the blog to watch).

Are Weight Ignorant Allied Health Professionals the Exception or the Norm?

Probably the norm.

And frankly, I think it's unforgivable and that their ignorance belies the fact that weight bias is alive and well in allied health professions.

How is it possible that despite one third of the population having obesity that allied health professionals remain so clueless about how to even talk about weight, let alone how to manage weight related comorbidities, how to ensure they don't add to the problem with weight gaining medications, or how to assess whether that weight is truly problematic, or rather, a healthy variant of normal?

If 1 in 3 people had asthma, do you think allied health professionals would be beyond awesome at managing, counselling and dealing with it, along with recognizing when it's a big scary deal or rather a minor periodic inconvenience?

And it's only because we're talking about obesity that allied health professionals remain perfectly comfortable with their own ignorance. The fact that they can dismiss obesity as a moral failing of their patients - nothing to see here medically - helps to exonerate them mentally from having to actually help, counsel or treat the patient in front of them, or think about the problem's actual etiology. It also helps to exonerate them from actually taking it upon themselves to learn more - something they'd no doubt do were we talking about any other medical problem or condition that they might not know much about, but which affected over one third of their patient population.

Why the diatribe?

Today, my friend Travis Saunders, co-author of the blog Obesity Panacea, recounts his recent experience going to his doctor's. Brief background. Travis? He's stupid fit. He's the guy that makes you shake your head and wonder what kind of crazy crawled into him that makes him run, bike, and ski through sun, rain and snow, day in and day out. He's also an obesity researcher. A good one.

So what happened with Travis?

The nurse practitioner at his MD's office weighed him, saw that his BMI was nearing 25, and told him he should, "watch his weight" moving forward as he was nearing the "overweight" range.

You see Travis wasn't Travis to the nurse. He was BMI 24.5.

I suspect other folks visiting that nurse weren't Marge, or Bill or Peter, they were BMI 37, BMI 32, and BMI 29.

The fact that there was no thought on the part of the nurse? No consideration of Travis' lifestyle or actual health status? That's because I'd bet to her, weight's a very simple thing to deal with. It's not the complicated amalgam of hundreds of genetic, environmental, medical and behavioural contributors. It's not something that needs to be evaluated within the context of the whole. No. She's learned that when BMI is greater than 25, that's overweight, and when BMI's greater than 30, that's obesity. Easy peasy. No need for any further evaluation. Oh, and treatment? Easy, peasy too! Just, "watch your weight".

We all know how well that advice would work.

So is she a bad nurse? An exception? She's probably not either. You see as far as teaching goes, professional schools pretty much ignore obesity. That goes for medical schools, dietetic schools, nursing schools - etc.  Instead they teach body mass indices, waist circumferences and waist to hip ratios. They teach numbers. But unlike virtually everything else that's taught, when it comes to obesity, those numbers stay in vacuums, where individuals and thorough and thoughtful exploration of the issue isn't taught or recommended, because sadly, even in medicine, obesity is still considered to be just a reflection of your patients' deadly sins, which is probably why Travis' nurse never even thought to consider him as a person rather than a number.

To read Travis' thoughts and experiences, head over to his blog and have a peek.

To my readers out there who are professors in various allied health training programs - what are your schools teaching about obesity?  Is there a new tide turning?

I sure hope so.

Is Suffering Ever a Useful Strategy?

Probably, but first some brief back story to serve as an illustration.

I turned 40 in August. And like many with big birthdays I decided to make some resolutions and included among them was weight lifting. I'd been fair to middling at aerobic activities all my life, but had never really focused much on resistance training. The thing is, as far as health and aging goes, resistance training's probably king, and so....

Anyhow, since August, aside from a brief back injury, I've been working out nearly daily. I've been alternating weights with something aerobic and Monday, Monday was weights day.

I truly didn't want to go. Now there have been days here and there where I haven't fully felt like exercising, but Monday was by far the worst. I was dreading exercising. I was tired, and the last thing I wanted to do was my weights.

I procrastinated for near 10 minutes in my office and finally, grudgingly, headed back to my gym.

My routine our fitness director Kelly has me on right now is a pyramid. I've got 2 groupings of 5 exercises and I'm supposed to run through each of the exercises 3 times in succession.

By the end of the first set of the first two exercises in the first grouping I was already trying to rationalize either stopping altogether, or dropping it down to just 2 sets of each rather than 3.

Instead?

I sucked it up and did it all.

And I'm not going to blow smoke and tell you I was so glad when I was done, that I felt great and alive. I actually felt pretty miserable.

The reason I pushed through? Not because one day of exercise really matters in the grand scheme of things, but rather because I didn't have any good reason not to do it and I knew that if I gave myself permission for no particularly good reason to shirk my exercise, it'd be that much easier to give myself permission the next time.

Of course sometimes there are great reasons not to follow through with various best intentions, plans and resolutions, but when there's no good reason, and it's just you vs. you, I recommend not giving yourself that proverbial inch.

But wait, didn't I just post yesterday that suffering was a bad idea?

Yup, but there's a difference. If every single time I headed to the gym I loathed it, well that'd be a clear cut sign that I'd better find myself another way to exercise. That'd be excessive, non-sustainable suffering. On the other hand, if I generally enjoy it, and here and there I don't feel like it, well that's a clear cut sign I'd better stay on top of myself, as follow through and consistency are how habits are gained (or broken).

And it doesn't apply just to exercise, it's life in general. Our human nature can easily get the best of us, if we let it.

So whatever you're trying to accomplish, sometimes, for your greater good, it might be worth suffering through a rough day, as habits? Well they're the things that persist through thick and thin, but at their beginnings, sometimes you need to really muscle through the thins.

Canadian Politicians go on Public Diet and Misinform Nation

Oy vey.

Toronto Mayor Rob Ford, and his City Councilman brother Doug, have gone on a very public diet. They've challenged other politicians and the general public to "Cut the Waist", and they've received a tremendous amount of media attention.

Yesterday was their first weigh-in.

The Mayor lost 10lbs in a week, and his brother Doug, 9.

What's their strategy?

Suffering.

More specifically according to this article,

"Running a lot, lifting weights and eating like a rabbit."

It's the classic diet plan. Under-eat and over-exercise and lose in a great big hurry.

Of course if that approach to weight management were useful, the world would be a much lighter place and I'd be doing something else for a living. I mean who hasn't tried that at least once? There'd also be a great many fewer gallbladders as weight loss that rapid markedly increases the risk of gallstone formation. We'd also be a heck of a lot weaker as rapid weight loss leads to disproportionate losses of muscle, which is why, when folks do go on extreme diets and lose rapidly, when they can no longer live a life of suffering and head back simply to their old lifestyles, they have a tendency to gain back more than they lost.

In this case the sadder story is the fact that their efforts are being broadcast to a nation, and rather than actually serve a valuable role models to a thoughtful and sustainable approach to healthy living, instead they're championing the same old stupidity that has plagued traumatic dieters for centuries.

Suffering. Willpower. Crazy amounts of sweat.  And I'm guessing their fair share of salads and grilled boneless, skinless chicken breasts.

I don't wish ill on their efforts, but if someone's taking book odds on their weights two years from now, if this is how they're planning on losing it, I'd like to put my money on heavier than day one of their challenge.

Guest Post: Surgeon Chris Cobourn Defends Lap-Bands

Readers of my blog might remember a post from just last week in which I detailed the results of a case-matched sample of folks who received gastric bypasses vs. those who received gastric banding where the results were exceedingly favorable to the bypass. One of my readers and colleagues, Dr. Chris Cobourn the medical director of Toronto's Surgical Weight Loss Centre (where both lap-bands and gastric balloons are inserted) read the post and responded with a thoughtful rebuttal.

As is my practice here, I asked if it'd be alright if I posted it on the blog, and I've done so without commentary:

Good Morning Yoni:

I read your blog this morning with a little more than the usual interest and would appreciate the opportunity to give you some feedback on the Gastric Band vs. Gastric Bypass article that you reference, and some of the more relevant literature on this subject.  As a surgeon with extensive experience in Lap-Band surgery (LAGB), I think it is important to ensure your readers that Lap-Band surgery is nowhere near being “destroyed”.

The decision to have bariatric surgery is a serious one, and it is important that individuals be presented with a balanced approach and current information.  The senior author is Dr. Michel Suter from Switzerland.  Dr. Suter has published previous  articles (1)  in this field and has a reputation as being very critical of the Lap-Band.   Due to his early experience with the gastric band, Dr. Suter is no longer performing the procedure, so the current study is another reiteration of his original and now outdated experience.  I debated Dr. Suter on a panel at the IFSO meeting in Capri a few years ago, when he presented his series of 300 Lap-Bands performed over a 10 year period.  It is unfortunate that the results of such a limited experience, a number of years ago are published as representative of today’s technique and experience in high volume centres.

My specific concerns about this paper are:

·         This study is described as a Case-Matched study.  Although better than a random comparison, it does not have the strength or validity of a prospective randomized trial.  There have been very few randomized controlled trials comparing RYGB and LAGB.  I have included two of them as attachments for you to review.  Although these studies show better weight loss with RYGB compared to the Lap-Band, the authors raise important questions as to whether the difference in weight loss is clinically relevant.  Both procedures induce weight loss substantial enough to resolve comorbidities and improve health which is the obvious goal. 

·         All of the patients in this report had Lap-Band prior to June 2005 and thus all had the procedure prior to the introduction of the latest model of Lap-Band.  As well, an undisclosed number had their Lap-Band procedure with a technique that is no longer used.  The peri-gastric technique that was used was shown to have a higher risk of complications and has not been used for at least 8 years.

·         Recent research into the mechanism of action of the Lap-Band has changed the way we manage post operative counseling and band adjustments for our patients.  Again this has been shown to have a significant effect on reducing post operative complications.  The patients in this paper did not have the opportunity to benefit from this new knowledge and this has likely contributed to some of the problems that were discussed.

·         The authors spend very little time discussing the short term complications of the either procedure.  This is a significant omission when comparing LAGB and RYGB.  The short term complications of RYGB have been consistently demonstrated to be more common, and more severe when compared to LAGB.  As well, there is a definite mortality risk associated with RYGB that is not discussed or identified in the study.  The failure to define and document “major morbidity” is a conspicuous deficiency in this study.  The relevance of this study is diminished without this discussion.

In regards to the discussion of long term LAGB complications, I have a number  of comments:

o   The authors report a 10% incidence of esophageal dilatation.  This is extremely high when compared to the current literature.  It likely relates to the principles used in band adjustment and the type of older model of band that was used in this series.

o   The authors report a 7.7% incidence of band erosion. This again is extremely high.  At the Surgical Weight Loss Centre (SWLC), in our first 3500 bands our erosion rate is 7/3500 = 0.2%

o   Port catheter leak rate of 6.8%.  Once again this is very high.  Our rate in 3500 bands is 1.5%

o   The authors report a 6.8% incidence of band removal for various reasons.  Band intolerance at SWLC leading to explantation is < 1%.  The authors have a high rate of conversion  from band to other procedures such as RYGB and BPD.   In our practice, where quick and easy access to RYGB is not available, we continue to work with patients to resolve their problems rather than remove the band or convert.  This is a major contributing factor as to why our band removal rate is so low.

o   No comment is made about long term nutritional issues after RYGB, which are well described.  Failure to acknowledge and discuss this potentially serious complication is a weakness of the study if their intent was to truly compare the procedures.

o   The methodology used to compare long term complications is not well described.  Some of the LAGB complications may be duplicated.  As well, the severity of the complications is not accounted for.  It is not appropriate to assume that all complications are “equal” when some can lead to major surgery and major morbidity and others require only minimal intervention.

One of the areas not discussed in the Suter paper is the well recognized rate of weight regain, starting at about 3 years after RYGB surgery.  You get a hint of it by looking at Figure 1 in the paper but it was not discussed by the authors.  This is an important issue for bypass patients that is unfortunately rarely mentioned.  There is a good paper by O’Brien and colleagues comparing both band and bypass in the long term (2) that shows no statistical difference in excess weight loss after the first few years.

Despite the attention that this paper will attract, it is not a definitive statement on the subject.    I am not sure that there will ever be such a paper.  RYGB and Lap-Band are different procedure both designed to produce sustained and significant weight loss.  Both have been shown to be effective at doing so in high volume centres of excellence that provide the operations using the latest techniques and that provide comprehensive follow up care.

We are in the process of publishing our results showing weight loss results comparable with other major centres, and with a very low rate of both long and short term complications.  We have already published our low rate of short term complications with Lap Band surgery (3).

Lap-Band surgery is a reversible procedure which is a significant benefit, the benefit of which is underestimated.  If research leads to an effective non-invasive or pharmaceutical treatment for obesity, patients could have their La-Bands removed with a simple procedure and then embrace the new treatment option.  This option is not available to any other bariatric surgical procedures.

The risks of bypass and band are very different and well understood.  Although the weight loss may be more rapid, and potentially a little better with bypass, I do not believe there is consensus that the difference is clinically relevant.  Although band patients may have a higher chance of revision surgery, the revision procedures are rarely performed for serious or life threatening complications.  Lap Band surgery is reversible which may be a benefit, but may also  lead to a higher rate of conversion to other procedures if the  results are less than anticipated.  Realistic expectations should be established, and a full and frank discussion of the short and long term risks are critical and mandatory for both procedures.

I appreciate your time and would be happy to discuss this paper and all the issues around it at your convenience.

Best Wishes

Dr. Chris Cobourn | Medical Director and Surgeon

Surgical Weight Loss Centre

www.swlc.ca

References

1.      A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates    Obes Surg. 2006 Jul;16(7):829-35.

2.     Systematic review of medium-term weight loss after bariatric operations.  O'Brien PE, McPhail T, Chaston TB, Dixon JB. Obes Surg. 2006 Aug;16(8):1032-40.

3.    Laparoscopic gastric banding is safe in outpatient surgical centers.  Cobourn C, Mumford D, Chapman MA, Wells L. Obes Surg. 2010 Apr;20(4):415-22.

Saturday Stories: Ivory towers, farmwashing and antibiotics

The Atlantic and the broken economics of ivory tower research publications.

Andy Bellatti covers Kellogg's Farmwashing

Marion Nestle covers the topic of antibiotic overuse and the FDA's undersight.

Star Wars Doggy Nerdgasm

I think I need to buy a VW.

Don't know if you remember last Superbowl's VW Star Wars themed ad....but today Funny Friday is apparently a teaser for this year's.

[BTW, true story - I marched down the aisle to the Star Wars theme. I had wanted to walk down to the Death March, but I made the newbie mistake of telling my now wonderful wife the name of the tune]

(Email subscribers, you have to head to the blog to watch)

Have a great weekend!

Paula Deen has Diabetes and takes Victoza. So What?

I've been kicking this story around in my head since it came out.

Celebrity TV chef with obesity who makes repulsively, insanely, calorificly obscene foods (like the bacon, fried egg, doughnut burger of hers pictured up above) develops type II diabetes, doesn't tell anyone for 3 years, and then not only has a big reveal, but signs a deal to endorse an injectable hypoglycemic medication.

So what?

Certainly the blogosphere's abuzz with outrage over the irony, the hypocrisy and the message being sent, and while I agree it's ironic, nutritionally hypocritical and a rather sad message, try as I might, the furthest I get is plain disappointed - I just can't work up any consternation.

Sure, the food she promotes (and presumably eats) is ridiculously decadent calorically and not what any would describe as healthful.  Sure eating that sort of food on a regular basis would likely lead you to weight gain which in turn will put you at a much higher risk of diabetes. Sure the message of, "don't worry about your diabetes, there's a drug for that, so keep eating whatever you want" isn't exactly a healthy one. But I'm still confused as to why people are so up in arms.

What I mean is, Paula's not an allied health professional, she's a TV chef with diabetes who cooks far from healthy fare, who apparently now takes Victoza, who frankly was never even remotely seen as a healthy living role model even before her diabetes diagnosis.  Did people really look to her or her meals and think she or they were such a picture of health that on that basis they increased the frequency with which they actually prepared her recipes?

We all accept differing degrees of risk into our lives. Jaywalking, biking without a helmet, driving short distances without a seatbelt, smoking, drinking, drugs, processed meats, trans-fats, improper weight lifting techniques, avoiding the doctor, not taking our medications, etc. The fact that Paula wants to continue to risk her health by presumably continuing to eat her bacon fried mac and cheese? That's her business, and were she explicitly telling people her extravagances were healthy, it would certainly be horribly hypocritical, but that's not how she sold them or herself.  Consequently I don't think she or her show are any more or less reprehensible now than before her diagnosis.

I guess really what I'm getting at is that I don't for one millisecond believe that the reason people so regularly eat terrible diets is because Paula Deen cooks appalling food on her show.  That'd be giving Paula way too much credit.

So could good come from Paula's diagnosis and drug deal?

Maybe.

What if her diagnosis inspired people who were already eating horrible Paula Deen'esque diets to go to their doctors to get checked for diabetes, or if they already have diabetes, go and ask about whether or not Victoza would be suitable for them?

Great I say. If her being a spokesperson for Victoza leads to improved secondary prevention of type 2 diabetic complications then bully for her, and who knows, some people with newly Paula Deen inspired diagnoses may even elect, unlike apparently Paula, to make marked lifestyle changes.

Yes, it'd be lovely if we all ate exceedingly healthful diets, yes it'd be great if we all exercised regularly, and yes it'd be great if we rarely if ever cooked any of Paula Deen's ludicrous concoctions.  But that's not everyone's world, and for those already living in Paula's, becoming more aware of type 2 diabetes and its treatments is probably a good thing.

Could Paula have taken this opportunity to become a healthy role model for America?  Yes.  Did she?  Clearly not, and while I would have hoped that as a human being she would have seen value in that, her obvious refusal to step up to that plate leaves her playing the same role she always has - a B list celebrity chef whose claim to fame is cooking nutritionally repugnant food.

Too bad she didn't trade up and become someone laudable.

Gastric Bypasses Destroy Lap-bands in Head to Head Study!

While this wasn't a randomized or blinded trial, the results were striking.

442 case-matched patients were followed for 6 post-operative years. Half received a gastric bypass, and half a gastric band.

While early minor complications were higher in the gastric bypass group (triple the rate seen in banding), major complications were similar. Aside from that, it's all bypass with the bypassed patients enjoying quicker losses, larger maximal losses and significantly better maintenance of losses.

How much better?

After 6 years, for every failed gastric bypass, there were 4 failed lap bands (with failure determined by BMI greater than 35 or reversal of the procedure). For every 1 long-term bypass complication there were 2 lap band complications, and for every 1 re-operation of a bypassed patient, there were 2 of lap banded ones.

Given how damning these results were, the journal invited noted band surgeon Jacques Himpens from Brussels to try to provide some balance in an after article commentary.

Dr. Himpens critiques?

• The study could have used surgeons known to be leading experts in banding and bypass.
• The mechanistic failing of banding to impact on weight related gut peptides might turn out to be an advantage in the very long term.
• The band is more readily reversible.

Of course Dr. Himpens also clearly stated that he himself agrees gastric bypass is a "better" procedure than gastric banding.

Seems like the decision of which surgery to have just became a great deal clearer for those who are considering one.

Romy, S., Donadini, A., Giusti, V., & Suter, M. (2012). Roux-en-Y Gastric Bypass vs Gastric Banding for Morbid Obesity: A Case-Matched Study of 442 Patients Archives of Surgery DOI: 10.1001/archsurg.2011.1708

McDonald's Invited to Teach Nutrition to 5th Graders in Connecticut?!

A ways back I blogged about how in Japan McDonald's was rolling out lesson plans for elementary students and in so doing, blatantly healthwashing their food.

In my head I somehow figured that this was a practice unique to Japan, and that a program like it could never exist in North America.

Boy was I wrong.

In what sounds like a carbon copy, the Connecticut Post reports on workshops conducted by McDonald's for Eli Whitney Elementary School's 5th and 6th graders.

What are the kids being taught?

Well according to 11 year old Shannon Mullings who's quoted in the piece,

"I learned that McDonald's can be very healthy for you if you make the right choices."

11 year old Jack Kyzer (that's him in the photo up above) was quoted as stating,

"It was the best thing that ever happened to me."

The mind boggles.

Not in so much as McDonald's is running this sort of a program, but rather that at least one school board and one set of school administrators think it's a good idea.

What do you think?