A real energy drink should give good, solid energy for a period of many hours.

A real energy drink should not make you jittery and “hyper” and impair your concentration; it should focus it.

A real energy drink should definitely not lead to a short spike in energy followed by a big fall in your energy level – instead it should give good, long, sustained energy that is even.

The ideal energy drink would have a few other characteristics too. It would come from natural ingredients. It would not only provide some energy, some calories, but also some other important nutrients like vitamins and minerals. And for the vast majority of us who want energy, but not in the form of empty carbohydrate calories that lead to weight gain and obesity, it should help us maintain a healthy weight and healthy, long term energy. A true energy drink should not leave you craving more food, more calories, more energy drinks shortly after you have consumed one. It ought to provide some real, solid satisfaction. Also, an energy drink can have a little caffeine, that’s fine, but not hundreds and hundreds of milligrams of caffeine. Those kinds of doses are shown to cause tremors and make one feel jittery. They also often interfere with sleeping and actually make people more tired through the course of the week.
Oh yeah, and it should taste great.
So for my money the best energy drink is going to be a nice mixture of vitamins, minerals and natural whey protein to give a clean energy boost instead of all that sugary, make you fat and tired kind of energy that the big drink companies have promoted in the past.

It’s not that we want to be fat. In fact most of us find ourselves gaining weight and are struggling to find ways to stop it. But these energy drinks, sport drinks and just plain ole’ drinks taste so good and are so cleverly marketed to us that we can’t stop drinking them. At least we can’t stop drinking them unless we think about it and use our own free will a little bit.
What a lot of people don’t realize is that big jolts of simple carbohydrates make us fat. Not immediately of course, not that day or that week even, but over time. Big doses of simple carbohydrates, say those in the sucrose and high fructose corn syrup of an energy drink or other soft drinks, the simple carbohydrates are digested quickly and enter the blood stream quickly and result in a very rapid surge of circulating blood sugar or serum glucose level. This also leads to a rapid spike in the important hormone insulin and leptin followed by a rapid fall of the blood sugar level. The next step is a sense of hunger which is often even stronger than before the jolt of sugar. It is no wonder this cycle leads to obesity as it repeats itself over and over.
The make-you-fat drinks have awesome, inspired and expensive Madison Avenue advertising and marketing. They look cool, we think they’re cool and, of course, they taste great. Some of us even like that rapid spike and jittery feeling; the surge of energy, even if it is very short lived, but with a little thought we could all do a lot better.

One of the many overlooked health problems related to weight gain and obesity is the problem of incisional hernias. Incisional hernias are a common form of the broader category of ventral hernias, meaning an abnormal bulge protruding through the muscular tendinous layer of the abdominal wall. Ventral hernias may be congenital, protruding through naturally occurring weak spots of the abdominal wall such as the umbilicus and the midline areas where muscles fuse during development. Or, ventral hernias may occur in weakened areas of the abdominal wall that occur as a result of surgery.

Surgical incision sites are closed well after surgery, but they never regain the full strength of the natural musculotendinous strength-layer of the abdominal wall. Over time the strength of the closure site reaches around 95% of its original. During the healing phase and for years to come, if significant stress is placed upon the abdominal wall then the muscles and tendons in the closure area can separate creating a weak spot or hernia through which the abdominal tissues can protrude. This is known as an incisional hernia. Such protrusions are much more likely to occur with weight gain and obesity.

Dangers Of Ventral Hernias
The problem with ventral hernias of all kinds and incisional hernias in particular, is that they can produce abdominal pain, enlarge over time, produce obstruction of the intestines and, in rare occasions create strangulation of the intestines, which can be life threatening. Strangulation occurs when the intestine becomes caught within the fibrous neck of the hernia and while entrapped becomes swollen and damaged leading to ischemia – loss of blood supply of the intestines – and dangerous infection, perforation or sepsis. This does not occur often, but it is important rationale arguing for the repair of these hernias to be done when feasible.

Repairing Incisional Hernias
In the last decade advances have been made in the repair techniques of incisional hernias. Traditionally these have been repaired with an open incision through the previous scar or over the bulge. The contents of bulging tissues are pushed back into the abdomen. The edges of the muscle or tendinous neck are sewn together if possible and then a type of synthetic mesh material is placed to further strengthen the muscle layer. In more recent years, I, and other pioneering surgeons around the country have utilized laparoscopy to repair even large and complex incisional hernias with a much less invasive technique. The laparoscopy involves placement of a camera and additional ports through small keyhole type incisions to work from the inside of the abdomen, reduce the bulging contents of the hernia back internally where they belong and create the mesh repair from the inside.

Differences in Types of Repairs of Incisional Hernias
Traditional open repairs involve the disadvantage of a larger scar that comes from open surgery. This translates into more hospital time and more recovery time in the weeks following surgery. The larger wound also creates a greater opportunity for wound infection, an especially common complication in obese individuals. Some surgeons have historically preferred the open technique because they are accustomed to this type of exposure and they try to close the muscles and tendons back together even if this occurs under tension. Open surgical repairs of ventral and incisional hernias have historically had a significant rate of recurrence of the ventral hernia over time as well as other complications stemming from the more major abdominal surgery required.
The laparoscopic or minimally invasive approach has several advantages and differences.

I had the great pleasure of talking on the air with Bill Dean on his program The Morning Brew that airs in Minnesota. Bill is a fantastic host and we got to discuss the importance of weight loss and maintaining a healthy weight as well as my recently released book, Life Changing Weight Loss. Bill also noted he himself was diagnosed with vitamin D deficiency, a surprisingly common finding for a great many of us. Usually the symptoms of vitamin D deficiency are fatigue and loss of energy so they can be very subtle. Most people don’t even realize they have it.
We also touched on a number of topics including childhood obesity.
Bill is a great host and I hope I have an opportunity to appear as a guest on his show again.

After the Kevin Smith and Southwest Airlines slap, lots of people have been scratching their heads and wondering just what is truly fair. After all, if every person pays the same amount to fly on Southwest Airlines then doesn’t that mean, because of the high cost of jet fuel, that the skinny people traveling with less luggage are in fact subsidizing the heavier people with more luggage? Of course it does to some degree, although one could argue that much of, if not most of the cost of travel stems from simply getting the aircraft from A to B including the cost of infrastructure, maintenance, purchasing of the airplane, supporting of the salaries and staff, and that only a small portion of the overall “costs” for travel really stem from the per pound calculation of jet fuel. So perhaps there is a certain baseline charge to travel that every person must bear and then any number of pounds over and above this must be paid on a per pound basis? For example, let’s say Southwest Airlines calculated the overall amount that it must pay to support aircraft, personnel, salaries, jet maintenance, runway fees, etc and established that the first 150 pounds of traveler plus luggage cost a base fare and anything above that is charged on a per pound basis to account for the additional jet fuel and additional wear on the aircraft. Something like that might take into account all of the economics of the matter and it might simply be left to decide what is the “baseline fee” per person to travel on Southwest Airlines and what is the baseline weight that fee would include. Is it 100 pounds, 200 pounds, perhaps it is 250 pounds. Interestingly, for shipping air cargo has in effect a similar mechanism where packages, regardless of weight, now cost a flat rate to ship, but larger objects, heavier objects and other types of objects that don’t fall into the standard business envelope or air cargo envelope are in fact charged on a per pound or per ounce basis.
But what of the actual size limitations posed by the seats and the inconvenience factor that many non-obese passengers experience. After Kevin Smith’s many Tweets and YouTube posts, a lot of people have commented they do not appreciated having to sit next to an obese person who in fact takes up more physical space and crowds them in their own seat, in effect making their journey less comfortable. What is the solution for this problem? Is there is a “size” limit beyond which a person must buy two seats? Should some seats be made larger and be a requirement for people over a certain size?

A few weeks back Michelle Obama launched her national campaign against Childhood Obesity. I am very pleased to see that the first lady has chosen this incredibly important issue to help the future of America. I will be posting my thoughts from time to time regarding the progress and effectiveness of the “Let’s Move” Campaign headed up by Mrs. Obama. I have already sent her a letter thanking her for her efforts on this important cause. Let’s hope that together we can make progress to win the fight against childhood obesity.

Here is a copy of the letter:

February 17, 2010

The White House
1600 Pennsylvania Avenue NW
Washington, DC 20500

Dear Mrs. Obama,
I am writing to thank you for your “Let’s Move” initiative and your efforts to raise awareness of childhood obesity and combat this serious health problem.
As a physician battling on the front lines of the obesity epidemic, I am grateful for your leadership and courage on this issue. I hope that our own Reno-based Obesity Prevention Foundation may be kept apprised of your further efforts and endeavors in this regard so that our community, schools and kids may be of benefit.
The complex problem of obesity requires a solution at many levels, at the personal and family level, at the school and community level, and at the state and national policy level. Your own work greatly helps our own local community effort with the Obesity Prevention Foundation as we work to educate parents and children, raise awareness of the disease and provide tools to combat and prevent it.
Best wishes to you and your family.
Sincerely,

Kent C. Sasse, M.D. , MPH, FACS
Founder of the Obesity Prevention Foundation
Medical Director, iMetabolic.com
www.obesitypreventionfoundation.org

Are there legitimate discriminatory practices against obesity? I have argued for quite some time obesity is a disease and deserves to be treated as one. This means, we must, as a healthcare community, marshal all of our resources to find cures, solutions and preventions, vaccines if you will. We must treat obesity just like we treat cancer and heart disease because it is just as deadly. And worse, it starts young and affects are children, derails them from life’s possibilities. So this disease deserves our very best efforts. In fact, our society and our future depend upon it. People with this disease deserve fair treatment and consideration without discrimination just like people with any disease deserve such consideration. But where are the boundaries of such consideration? What about diseases that involve behavioral components such as smoking; might they be treated somewhat differently in some ways? To what extent is obesity a self inflicted disease and to what extent does personal responsibility play a role when it comes to how society and businesses treat people with obesity?
All challenging questions raised by one obese person who could not fit in an airline seat. Should that person buy two tickets? If the cost of fuel is calculated per pound of cargo, should airlines charge passengers by the pound? Should we each stand on the scale with all of our luggage and pay a price per pound to travel by air? That is essentially how we ship Christmas presents. At the end of the day, with respect to obesity and people with obesity, what is ethical treatment?

A big thank you to Rob Kingsbury for serving as such an interesting and enthusiastic host. I was fortunate enough to appear as a guest on his radio program and Rob, perhaps more than any other radio host, put me through the paces on everything from personal weight loss strategies to personal responsibility failures to national policy. Childhood obesity, vitamin deficiencies and personal motivation were topics that Rob explored in depth. He is not one to shy away from controversy and I really enjoyed the opportunity to be on his program.

There has been quite a bit of press coverage about Kevin Smith’s experience while flying on southwest airlines. For those of you that are unaware of what happened:

Kevin Smith was asked to exit the aircraft after flight crew had deemed him to be too large to safely fly in one seat. This is in accordance to a “customer of size policy” implemented 25 years ago which requires said passengers to purchase a second seat when traveling to accommodate their larger size. The interesting nuance here is that Mr. Smith was aware of this policy and had purchased a second seat.

He was flying stand-by to get on an earlier flight which had only one seat available. When asked to exit the plane. Kevin Smith was obviously embarrassed and insulted. He immediately began expressing his feeling on his Twitter account. With over 1.5 million followers it wasn’t long before everyone was watching this situation unfold pretty much as it was happening.

Now there are several aspects to this story that probably warrant their own blog posts and perhaps I will spin back to touch on those at a later date. But I wanted touch on something in this post regarding the treatment of obese individuals during travel. There are two sides to this story and both have very valid arguments.

The “customers of size” are people with feelings who have paid to fly or ride on whatever means of transportation. They are not intentionally infringing on the space of fellow travelers nor do they choose to be a safety concern. Often they are willing to pay more for additional seating space to accommodate their size and adhere to the policy of the company they are traveling with. Do they not deserve to be treated better? If and when a situation arises that is caused by a violation or concern related to their weight or physical size should that situation not be handled with greater discretion?

On the other hand, put yourself in the seat next to the “customer of size”. Did that traveler not pay for the entire seat? Should that traveler be forced to be more uncomfortable then today’s air travel can already be?

What could be a better solution to this problem?

What if we simply charged people as if they were freight. I think most of us would agree that air travel today often feels like you are being treated as human cargo anyway. Why not use the same model for pricing. Instead of weighing your bags to determine if they qualify for penalty fees or charging for extra baggage, just have the traveler and their bags get on the scale and charge per pound. This would be a fairly easy equation to figure out. Airlines can simply set the per pound price they would need to charge to make their targeted profit on a given flight. The traveler would simply stand on the scale with their baggage. Total weight x price per pound = Ticket price. In this case if a “customer of size” takes up more space on the plane then a smaller traveler, well, they paid extra money to do so, and there would be no reason to treat that person with insensitivity after they had boarded. Of course, a thoughtful method of weighing us all with our baggage might have to be conjured up, to avoid casting unwanted attention on anyone at the ticket line. Lots of issues here: is our weight our own private matter, or does it become relevant when jet fuel costs more per pound and we plan to fly? Can a better way to accommodate larger people be found than simply yanking them off airplanes?

Logistically, speaking there are obvious issues that may occur from this suggestion, but what can we as travelers think of to make this situation better for all involved?

In a recent study by Genco and Colleagues (Surgical Endoscopy, Volume 23, pg. 1849-1853, 2009) a bariatric center compared the effectiveness of laparoscopic sleeve gastrectomy against the Bioenterics Intragastric Balloon (BIB) with twelve months of follow-up.

The mean surgical time for the sleeve gastrectomy was 120 minutes. The mean endoscopy or balloon positioning time was around 15 minutes for the BIB. Prior to surgery, the body mass index was 54.1 for the BIB group and 54.8 for the sleeve gastrectomy group. At six months follow-up time, the BMI had fallen to 46 for the BIB group and 45 for the sleeve gastrectomy group. At twelve months, the BMI for the BIB has risen to 48 kg/m² and the BMI for the sleeve gastrectomy had fallen to 43 kg/m². Eighty patients underwent the BIB procedure and 40 patients underwent the sleeve gastrectomy procedure. Failure of weight loss (defined as weight loss of less than 10%) was similar in both groups (2 out of 40 for the sleeve gastrectomy and 4 out of 80 for the BIB procedure.

These authors conclude that the BIB procedure is considered a preferred option for a “first step procedure” for patients with high surgical risk or for patients with high body mass index (super obese BMI greater than 50) or for patients who plan to undergo a more complex bariatric procedure.

The Bioenterics Intragastric Balloon has emerged as a valid option in treatment of morbid obesity in certain circumstances. For example, author Bufetto demonstrated that placement of the BIB as a first step reduced the subsequent risk of conversion to open surgery during the eventual bariatric surgical procedure. It also reduced the risk of intra-operative complications in “super obese” patients, those who had a body mass index over 50. (Bufetto, L., Pre-operative Weight Loss by Intragastric Balloon in Super Obese Patients Treated with Laparoscopic Gastric Banding: A Case Controlled Study, Obesity Surgery, Volume 14, pg. 671-676, 2004)