In a fascinating study published in the Proceedings of the National Academy of Sciences, a research team led by Tamas Horvath at the Yale School of Medicine has published findings that indicate our brains are hardwired in different ways.  Some of us are born with and continue to develop brains that do a better job at signaling satiety or fullness after taking in an adequate number of calories.  In other brains, the hardwired neurons do not.  In addition, the hardwiring of brains associated with obesity may be less effective sending signals to the body to burn excess calories instead of storing them.

The Yale School of Medicine study examined rats and assessed particular brain mechanisms associated with eventually becoming obese.  Some of the rats were likely to become obese with a high calorie obese while other rats were not likely to become obese.  There appears to be both some hardwiring that occurs at birth as well as some changes over time in the brain cells, or neurons, that affect whether an individual  gains weight and becomes obese, or simply maintains a healthy weight, even on a high calorie diet.

One of the most interesting, but troubling findings of the study is that the brains of some individuals who are more susceptible to diet induced obesity exhibit a type of brain inflammation, whereas those individuals who are resistant to diet induced obesity do not.  The concern is that this type of change in the brain or inflammatory response of the brain with weight gain, may explain why it is so hard for obese individuals to lose weight and keep it off once changes in the brain have already occurred.

More studies will lead to a better elucidation of the exact mechanisms by which certain neurons signal for the sensation of satiety or fullness and the decisions to stop eating or drinking further calories.  Additionally, we hope to learn more about how the brain signals whether calories are stored as more fat or whether they are burned.  What is clear is that some individuals are more prone to obesity than other individuals.  Yet, the primary change that has taken place in the last forty years is not one of the genetics of our brain cells, but is one of the changing environment around us and the dramatic increase in the calorie content of foods, drinks and meals, such that most of us are consuming 30-40% more calories than our predecessors were forty years ago.

So while the rat studies indicate that some of us are likely to be more protected or resistant to obesity with this new high calorie diet, most of us are not.  If public health predictions hold true, very soon the percentage of all Americans who are overweight or obese will approach 100%.

I practice in Reno, Nevada, which is not particularly close in distance to Mexico, and yet with increasing frequency, I find myself caring for people who have suffered devastating complications after undergoing bariatric surgery in Mexico.  The phenomenon poses many challenging questions for all of us and it is difficult to know exactly how to solve the problems posed by this practice.

It’s no secret that healthcare in the United States is expensive.  It’s also no secret that weight loss surgery is among the most beneficial health interventions available in the world today as measured by any outcomes measure.  And yet, while insurance plans pay for things like Viagra and futile advanced radiation and chemotherapy treatments, often they do not pay for weight loss surgery.  An increasing number of people seek the effective solution for improved health and longevity that weight loss surgery represents and they shop for the best locations, surgeons and prices.  And on price, it is difficult to compete with Mexico.

Mexican surgeons and centers are unabashed in promoting their services and their cut-rate prices.  It is impossible to do an internet search for weight loss surgery information without being bombarded with numerous advertisements and promotions of discount weight loss surgical procedures performed in Mexico.  So it’s quite understandable why a person would travel to Mexico to undergo a badly needed procedure and also save thousands of dollars.  Even the media in the United States have encouraged this phenomenon.  I previously commented on a National Public Radio story by the usually more thoughtful Jason Bovian who described the development of surgical centers and technology and availability in Mexico, and he didn’t make the slightest mention of the tremendous problems associated with this phenomenon for US citizens.

I am currently taking care of a critically ill man who may not survive his weight loss surgery that was performed in Mexico weeks ago.  After returning to his community and mine, the problems with the surgery became evident.  He became toxic with severe sepsis and has clung to life with the aid of life support, multiple corrective operations and all of the modern, sophisticated ICU care that can be provided.  It is unlikely his American, employer based insurance plan will pay for any of the bills, making this multi-million dollar hospital stay and indigent case and huge loss for our community hospital.

While the finances are a serious matter to community hospitals that are struggling to stay in the black, the problem is even more devastating for my patient and his family.  While there are no good studies on the subject, it is without a doubt that the firm impression of nearly every bariatric surgeon in the United States that the rate of serious complications is markedly higher among people who travel to Mexico.

A more insidious problem is the poor weight loss results achieved by individuals who travel to Mexico for their surgery.  If we’ve learned anything over the last decade, we have learned that weight loss surgery provides fantastic results when it is more properly a “weight loss surgery program”.  The surgery in itself is not a magic wand, but it creates the conditions for change and for success.  After that, it takes education, support, follow-up, accountability, expert advice, laboratory testing and in short, a “program” to ensure success.  No such program exists for people who travel outside the country to undergo their procedure hence weight loss results suffer greatly.

Among the many concerns I have for members of my community is that they are not adequately informed about these risks when they travel to Mexico for weight loss surgery.  The expose themselves to financial ruin and personal bankruptcy as has occurred among patients I have personally cared for.  They expose themselves to poorer weight loss results due to lack of an effective follow-up program with their surgeon and they expose themselves to surgical risks and complications that certainly appear to be much higher than what they would experience undergoing surgery at a US based center of excellence with all of its emphasis on continuous quality improvement and rigorous reporting of results.

A complex problem, doubtless, but one that deserves more consideration by all of us.  Greater  responsibility by employers and insurance carriers to cover weight loss surgery as a proven health benefit, greater responsibility among Mexican bariatric surgeons to provide informed consent and a mechanism for follow-up.  Greater responsibility on the part of the media to discuss these potentially devastating problems arising from traveling to Mexico for surgery.  Greater responsibility among providers, hospitals and surgery centers in the United States to cut costs and reduce profits in order to make the procedure more affordable and reduce the incentive for unwitting patients to travel to Mexico.  And greater responsibility among manufactures of bariatric surgical devices, namely the REALIZE Band manufacturers to stop providing the critical piece of equipment, the adjustable gastric band, to the centers south of the border at cut-rate prices, further adding to the incentives for Americans to travel south of the border (Allergan, the maker of the Lap-Band, does not offer the most recent  version of the Lap-Band in Mexico, but does offer older generations, which American consumers are not as interested in).  All of these are controversial areas deserving of more attention.  What do you think?

As I write this, I am taking care of a gentleman who is extremely ill, in critical condition and in the intensive care unit of one of our hospitals having undergone a sleeve gastrectomy approximately three months ago.  He experienced one of the more devastating complications of this procedure, namely a delayed perforation of the stomach.  Such perforations occur in sleeve gastrectomy more so than with other procedures.  In fact, I have seen several of these devastating delayed perforations in sleeve gastrectomies while they are nearly unheard of in the other weight loss procedures (with the exception of perforated ulcers, which can occur years later, usually as a result of Motrin, Aleve and other non-steroidal anti-inflammatory drugs attacking the stomach lining).

The phenomenon of a delayed perforation after gastric sleeve procedure is one that is increasingly discussed at meetings, but not fully understood.  There may be a phenomenon of local ischemia, meaning a local area of lack of blood supply along the gastric staple line or it may be due to other factors we may not fully comprehend.  Another theory is that some bleeding, bruising or hematoma has formed along the staple line and as this breaks down and is absorbed it creates a perforation.  What we do know is that the stomach tube or sleeve is a high pressure system after the sleeve gastrectomy procedure is performed.  With most of the stomach volume having been removed, the pressure as measured within the remaining stomach tube is higher than it would be after gastric bypass surgery or after Lap-Band.  The long staple line itself creates some vulnerability to perforation and this high pressure may play a role.  But whatever the exact cause is, it is phenomenon that we do not fully understand and we cannot fully prevent.  It is particularly devastating because it can occur weeks or months after surgery when a person appears to have been healing up nicely.

Most moms want to lose the pregnancy weight, but who can find time to start a weight loss “program”? It seems it is more difficult than ever to lose weight these days on your own. Foods are more delicious, higher in calories, and more tempting than ever before. A new mom’s life is also busier than ever, and finding time to exercise seems a nearly impossible task most days. But did you know that one of the best things you can do to successfully lose weight is get a good night’s sleep?

Research has shown that the lack of a good night of sleep leads to more weight gain. The mechanism is thought to be related to an increase in hunger and a decrease in some of our internal impulse control mechanisms. After a night of little sleep, moms are tired, hungrier, less mindful of food and snack consumption, and more apt to give in to temptation around food. To make matters worse, tired moms do not have the energy or motivation to exercise. Bad combination: eating more treats and exercising less! No wonder lack of sleep is associated with weight gain and obesity.

So what can you do about it? Here are ten important practices you can undertake today that will maximize better sleeping and therefore help you in your journey to a healthier weight.

• For starters, don’t consume caffeine or other stimulants in the afternoon or evening.
• Establish a routine in which you sleep in a safe and comfortable environment that is controlled to your liking, paying attention to the temperature and darkness.
• Avoid alcohol beyond two or three ounces of wine. Alcohol makes a mom drowsy at first but causes a rebound effect that often wakes her up in the wee hours and impairs rest.
• Avoid eating a large late night meal. This means a light dinner and no food after 8 PM.
• Negotiate some nighttime help from your partner so you may sleep more. If he is not a “50-50” parent and objects to this idea, offer win-win solutions like his favorite meal on the weekend or going to a ballgame.
• Find 30 minutes for a brisk walk or other exercise in your day or evening and you will sleep much better. Push that stroller or strap on the baby carrier.
• If you are breast-feeding and you feel comfortable doing so, pump and save milk during the day so that your partner can do some of the nocturnal feeding.
• Establish your bedtime and stick to it every night. Try to minimize emotionally charged events like, arguing with your partner about house cleaning, that occur close to bedtime.
• Set a goal of six to eight hours every night and stick to it. Once a week allow yourself to sleep longer and erase that sleep debt.
• Use babysitters, grandparents, partners and friends to allow a few extra hours of sleep for yourself. Don’t feel guilty about this; you need to be healthier for your child.

Importantly, many of us have unrecognized sleep disturbances that can only be diagnosed by a formal sleep study that is ordered by your doctor. The most common among these is called obstructive sleep apnea (OSA), a common condition that usually occurs as a result of weight gain, such as with pregnancy. OSA afflicts over ten million Americans and is on the rise. It results from airway obstruction by the soft tissues of the neck and throat. If you snore, cease breathing for ten seconds or more during sleep, sleep restlessly, wake up often in the night, experience morning headaches, or simply feel tired all the time, you may need a sleep study. And you may want to talk to your doctor about things like post-partum depression and alcohol use that impair sleeping.

Often, lack of sleep just seems like a necessity with all the other responsibilities of motherhood that take up time. If you need to lose weight, then sleeping more hours needs to become a priority. So, consider it a good day when the doctor tells you that the first item on your To-Do list toward losing weight is to sleep more hours. Enjoy those extra Z’s and you will feel better and more energetic, and you will be far better positioned to succeed in achieving your weight loss goal.

So sleep more; it’s Doctor’s Orders.

Many times I am asked what are a few straightforward and simple things I can do as a parent to help prevent obesity in my own child.  And while there are some more thorough discussions I have written in other articles on this website and on obesityprevention.org, I will describe here a few of the most important steps you can take today to prevent childhood obesity at home.

1. Set a great example.  Parents are powerful influences on children, but we lead more by example than by words so you must walk the walk quite literally speaking.  Be active and keep your own weight at a healthy level.  Avoid eating high calorie, high carb food, snacks and treats so you set the example for your child.
2. Read every label and encourage your children to read every label.  While the labels can be confusing and full of lots of useless information, they do contain some important bits of information so that you should encourage your child to always be aware of.   And here they are:  One, know the number of calories in every serving that you eat.  And two, know the number of grams of carbohydrates or sugars in everything you eat.  That’s enough, that’s all you really need to focus on and the rest will take care of itself if you stay mindful of these two figures.
3. Protein first.  This means every time you prepare a meal or snack you should be thinking             about protein first and foremost.  Protein provides greater satisfaction and does not result in immediate sense of rebound hunger like sugar does.  As a parent you are well aware of the sugar rush followed by the sugar crash, but you may not be as aware of the surges in hormones produced by sugar intake and how those result in rapid resurgence of hunger within about an hour.   Protein satisfies.  It is a good, healthy source of calories and don’t worry, your child will get plenty of carbs even without trying.  Let the protein (cheese sticks, protein bars, beans, nuts, meats and fish) satisfy them and they won’t be hungry for junk food so fast.
4. Clear out the pantry.  That’s right, you got it, this is tough love, but you need to get rid of all the high carbohydrate, high calorie snacks and treats, M&Ms, Ding Dongs, candies, chips and all those goodies that kids (and everyone else) love to eat.  It’s not doing anyone any good.  Stock your house instead with fresh fruits and vegetables and your kids will be just fine.  In fact they will be far healthier and less overweight as a result.  Sometimes parents tell me “my kid won’t eat anything but junk food.”  Trust me, if the house is full of delicious fruits and veggies and there is no junk food in the house then he or she will eat what is available and learn to love it.
5. Stay active and have fun at it.  Every kid should have 30-60 minutes of regular exercise every single day.  So make it a priority and find ways to make sure your kid is getting that activity.  Yes schools have cut physical education and we as parents no longer let our kids run loose in the neighborhoods like our parents did, but with a little effort you can certainly come up with an hour of physical activity for your kid.  Better yet do it with them.  Ride bicycles, take a hike, take the dogs out, sign up for sports, lessons, competitions, meets and tournaments.  Make sports and physical activity fun.  Find something your kid enjoys and support them.   Time will be a great investment in your child’s health.

Many people do not know that weight gain and obesity are associated with many types of cancer.  Among the most common types of cancer that are markedly increased in their incidence in overweight and obese people are breast cancer, colorectal cancer uterine cancer and ovarian cancer.  Usually the risks for each of these types of malignancy more than doubles when a person’s body mass index exceeds 40.  Numerous studies have confirmed these worrisome findings.

Less well proven is that weight loss can reduce the risk of cancer, but there are many studies that give us some encouraging evidence that this phenomenon does indeed occur.  Among the studies are those by Flynn and many others that have demonstrated a reduction in cancer risks after successful weight loss surgery.  In a large population based study, these researchers have demonstrated a reduced risk of these same cancers in the years following weight loss surgery.

We know that weight gain and obesity markedly increase the cancer risk for human beings.  We know that in weight loss surgery studies this cancer risk subsequently declines.  We hope that research will also demonstrate that successful weight loss with medically based programs, such as the iMetabolic program, also result in a drop in cancer risk, but those long term studies are not yet available.  What is know is that cancer is yet another very compelling consideration and a powerful, motivating tool we should all take advantage of to help encourage long term weight reduction and maintenance of a healthy weight.

Well it was very gratifying that Doctor’s Orders: 101 Medically Proven Tips for Losing Weight won the bronze medal for Book of the Year in the health category.  This book, a practical guide with research proven tips to help a person lose weight, was up against some very stiff competition.

Doctor’s Orders has been the most in demand of all of the books I have written and it’s nice to see a little bit of critical praise as well.  Thank you very much to the Book of the Year judges and officials of the contest and to the readers.   Hopefully that will help expand the readership a bit and bring some vital health information to so many people who need to lose those unwanted pounds.

After a year’s long process, I was very gratified to receive the designation as a Fellow of the American Society of Colon and Rectal Surgeons.  The society has quite rigorous criteria and requires extensive training including fellowship residency training beyond general surgery training plus a passage of a series of board exams and an application process including review of colon and rectal surgical cases.

It is an honor to become a fellow in the society that sets such high standards for colon and rectal surgery.  My areas of expertise are particularly focused of laparoscopic and minimally invasive intestinal abdominal surgical procedures.  I was fortunate to receive extensive training in minimally invasive surgery for intestinal disorders and colorectal disease as well as other gastrointestinal and abdominal disorders.  And in the years since that training have been fortunate to be in a position to further refine the techniques for successful outcomes with less invasive surgical intervention.

Minimally invasive intestinal and colorectal procedures allow for people to return to work sooner and recover more quickly after surgical intervention.  I perform a high number of laparoscopic and minimally invasive intestinal surgical procedures for many abdominal and colorectal disorders including colorectal cancer, inflammatory bowel disease, Crohn’s disease, ulcerative colitis and a host of other abdominal conditions including gallbladder disease and hiatal hernias as well as, of course, bariatric surgery.

So my thanks to the society for designating me a fellow and I look forward to participation in the society in the future.

According to a recent study in the New England Journal of Medicine,  China has surpassed India as the world’s leader in diabetes.

Over 92 million adults in China are afflicted with type 2 diabetes, a disease primarily related to obesity, high calorie diets and sedentary lifestyle. Yang Wenyng, chairman of endocrinology at the China Japan Friendship Hospital in Beijing, lead a team of researchers studying more than a dozen Chinese hospitals across 2007 and 2008 to determine the prevalence of type 2 diabetes. In addition to their findings that over 92 million Chinese individuals currently suffer with type 2 diabetes, they further report that an estimated 148 million Chinese have pre-diabetes (this is a condition that leads to full blown diabetes and time and is measured by higher than normal circulating blood glucose levels and abnormal glucose tolerance tests).

This study and other reports related to diabetes in China, indicate a massive economic and social toll from the disease. A high toll of early cardiovascular death is expected from the rapid rise in type 2 diabetes across China and poses a major public health problem.

In the United States there are estimated to be around 26 million diabetes sufferers or around 12% of the population. There are many more than this number who are pre-diabetic and will develop diabetes as the years progress. As the epidemic of obesity widens, these numbers will markedly increase over time. Obesity and diabetes are sometimes together refered to as “diabesity” post a major, worldwide, public health challenge.

We’ve seen the long haired, young Jesus, the bearded serious Jesus, the bare chested Jesus, the suffering on the cross Jesus, but I don’t think I have seen the morbidly obese Jesus.

Why do you suppose it is that artistic depictions of the Last Supper depict increasingly larger and larger portions? According to a recent finding described in the International Journal of Obesity and shared through scientificamerican.com, over the last thousand years the portion sizes depicted in the paintings of the last meal shared by the Apostles and Jesus has grown markedly. Brian Wansink, a clever obesity and eating behavior researcher, together with his brother Craig, a religion professor, examined fifty-two Last Supper paintings. They found the serving size of the bread depicted was 23% larger in modern paintings and the serving sizes of the other entrées had grown by 70%! They used the size of the Apostles craniums as a control measure so as to help avoid exaggerations that were simply due to a different scale of the painting.

I think Da Vinci would be astonished to learn just what supersizing has done to actual portion sizes in modern times.