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?

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?

I end up talking a good bit with my patients about goal setting so I have been thinking about my own goals for 2010. So, in no particular order, here are some of the goals I have thought about:

• 1. Field a team of 100 racers for the Reno Rock-n-River 10K and the Kid’s Run and succeed in raising awareness of the problem of childhood obesity.

• 2. Take that awareness to the next level by making an impact in schools and communities and in the consciousness of policy makers (I know this one isn’t very specific, but I am working on it).

• 3. Run a personal best marathon time this year and run a marathon in under 3 hours, 30 minutes.

• 4. Complete the Second Edition of Out-Patient Weight Loss Surgery with thorough updates of the emerging technology, the importance of pre-operative meal replacement shake programs and many other new features and testimonials.

• 5. Give more to those around me, those less fortunate and those whom I love.

• 6. Spend more time with my children including some special time on vacations with them.

• 7. Work harder to see that the post-surgical care for our weight loss patients is comprehensive, committed, compassionate, thorough and frequent.

• 8. Improve our support groups, walking groups and ongoing support for all of our patients both surgical and non-surgical who are trying to lose weight.

Set goals for yourself today.

After some delays, we have received the shipment of my newly released book: Life Changing Weight Loss. In these times, everyone could use a guide to real, successful weight loss.

In radio interviews on stations around the country, I have been so pleased at the reception the book has received so far. One of the common threads I hear is that media people are inundated at this time of year with weight loss books and information, most of which has very little basis in the practical science of what truly works. Much of it is based on wishful thinking, marketing plans or fanciful obsessions with obscure root extracts and proprietary blends of unregulated secret, magical herbs. The truth about successful weight loss is much simpler and yet, also much more complicated.

At the end of the day, to solve a weight problem and keep the pounds off, we must find a successful strategy to consume less calories every single day, burn more calories every single day, and find satisfaction and contentment despite this. Many of us can muster the motivation on a short term basis to consume less calories and burn more calories, but we feel like we are starving ourselves or doing the impossible. That won’t work for the long term. Long term success lies in mustering that motivation, but making an internal life change, a new look at how we view ourselves, our weight, our diet and our activity. Only then does the “light switch” flip on, only then do we successfully lose the weight and keep it off for the long term.

Recent reports offered some disturbing news: a series of drugs commonly prescribed to treat mental health conditions in adolescence cause weight gain as a side effect. This is not terribly surprising news as it has long been noted that many of the antidepressants and anti-psychotic drugs have been associated with weight gain in numerous previous studies. What is disturbing is there has frequently been lack of full recognition of the deleterious effects of weight gain on the mental health conditions themselves. This is perhaps most aptly demonstrated in the relationship between obesity and depression. It is well known depression itself often leads to over-eating, inactivity and weight gain. Likewise, it has been demonstrated that weight gain and obesity lead to depressive feelings and a cycle of downward mood spiral.
These latest reports offer further disturbing news that sometimes our pharmacologic answers to serious health conditions can often have a dangerous side effect: obesity. It also speaks to the fact that when any prescribers are offering drugs to treat one condition, it would be terribly helpful to consider the negative effects of weight gain just as other side effects are factored into the decision of the prescribing the medication. In the past, weight gain has often been thought of as a relatively minor side effect, but in today’s obesogenic environment, I don’t think that should be the case any longer. Obesity is more widely recognized now as a quite serious health problem in its own right and drugs that lead to weight gain and obesity as a side effect must be scrutinized closely before they are prescribed. I would argue that patients, who are embarking upon any drugs that include weight gain as a typical side effect, should concomitantly enroll in a weight controlled program or weight reduction program to actively combat the effects of the drug.
Some of these drugs directly stimulate appetite. Others lead to inactivity, but many of them have in common the empirically noted finding that patients on the drug gain weight when compared to patients on placebo.

The recent Lincoln University story that I wrote about has sparked some additional interest and conversation. It is my thought that the administrators of Lincoln University have really stepped forward beyond so many leaders in society and in education in recognizing the seriousness of the health risk that obesity poses to the Lincoln University student body. However, there are clearly some flaws in the application of those ideas and insights, as is inevitable with any efforts to make policy changes.
While I found some fault with applying fitness classes only to people with a high BMI, in general I do laud the wisdom and the intentions of the Lincoln administrators. It has caused many of us to think about other obesity prevention reforms and how they might ideally be applied and instituted. My first suggestion was the classes could be offered for every student and not just for those with a high BMI.
In addition, a real forward thinking policy would involve whole communities and school districts approaching this from a very early age and bringing in much greater emphasis on nutrition, weight and fitness at an early age. This is not a health problem we can sweep under the rug or avoid talking about because it is uncomfortable. We have to develop a vocabulary to talk about it to help kids get on a healthier track toward a healthy weight and not to a young adulthood that is comprised of doctor’s visits and insulin shots. Yet, we all recognize that any such interventions involving children are necessarily going to raise everyone’s awareness and consciousness of individual kids and their body shapes and sizes, something that will also have some negative consequences. But, we have to be able to find a solution and confront the issue of childhood obesity and obesity prevention without shying away from these difficult challenges because the health consequences are so grave and so sweeping.

Recent news coverage of Lincoln University in Pennsylvania and its policy requiring students with a BMI over 30 to take a three credit fitness course raised some challenging questions.
Under the headline “Colleges too Fat to Graduate Rule Under Fire”, Elizabeth Landau, CNN reporter, describes the way in which the policy has affected some students including a freshman who is quoted as saying she thought “it was a great idea” and that many of her classmates don’t find it offensive. However, another student wrote an editorial in the student newspaper and indignantly wrote “I didn’t come to Lincoln to be told my weight is not in acceptable range.”
The educators and school policy makers point out that the historically black college must do more to combat the serious health problem of obesity and diabetes, which disproportionately affects African-Americans. Currently approximately 80% of African-American women are overweight or obese and this contributes greatly to the high rates of diabetes and early mortality.
On the one hand, we find a historically black university generating a policy aimed at addressing the most threatening social and health problem that its students face. On the other hand, the policy involves an obligatory class to be taught in fitness for only those students whose body mass index is over 30. Some of the students object to what they see as discriminatory treatment and they don’t like being singled out in such a stark fashion for their weight problem.
A number of specific questions are raised by this story. One of them is a question of what roll universities and, for that matter, high schools, middle schools, grammar schools and nursery schools, should play in combating this deadly epidemic of obesity striking our young people. Clearly this is a classic public health problem that is going to be much more easily addressed through prevention efforts than through sweeping treatment efforts aimed at correcting the obesity that is well established in the adult population. Efforts by public entities and educational institutions should be lauded if only because they indicate a level of understanding of a global and sweeping health problem that will adversely affect the students more so than virtually any other educational, health, social or other public problem. Yet policies that may be instituted to combat the problem will potentially run afoul of our sensibilities about what is a personal or private concern and what is a discriminatory policy based on a person’s physical characteristics.
Another question raised by this story is whether a fitness class, which meets three hours a week, will have any success in reducing the chance of obesity among its students? I would argue that such classes are indeed part of the necessary effort, but they must begin at far earlier ages, probably in the kindergarten level and continue through university ages. As a physician treating obesity, I would also say that offering treatments, in this case a fitness class, to a group of people makes some practical sense, but why offer it only to those students who already have a body mass index over 30 when, statistically, 80% of the students risk becoming obese later in their lifetimes. One could argue that the more important target group is the group with a body mass index of 22-29 or, realistically, just everyone.
What are publicly funded universities to do about this pandemic of diabetes, obesity and the many attendant health problems such as sleep apnea, hypertension, early heart disease, blindness, renal failure, amputations and decreased life expectancy? In the absence of some sweeping local state and federal policy, the usual patchwork of solutions emerges from many different institutions in many different corners of the country. Only through discussion of all of these different ideas and the conflicts they raise, will solutions to the greatest health problem of our time emerge.

In an interesting article by Tara Parker-Pope, food labels get a new look. A consumer advocacy group called the Center for Science in the Public Interest proposes giving the standard food labels a makeover. Miss Parker-Pope does a nice job illustrating what the new food labels would look like and itemizes how each of these changes would occur.
The Nutrition Labeling and Education Act passed almost twenty years ago and is the law governing the descriptions that we now read on the foods we buy. Many of us have noted the problems with food labeling and my pet peeve has always been that food producers can still play fast and loose by choosing ridiculously small serving sizes and thus offering a misleading low amount of calories and carbohydrates. The new food labels would put calorie and serving size information in larger type at the top of the label. It would make changes in the ingredient list by separating them with bullets instead of allowing all the ingredients to run together. Similar ingredients would be grouped together and their percentage shown by weight. Miss Parker-Pope notes this would be especially important for sugars including things like sugar, corn syrup, high fructose corn syrup and grape juice from concentrate, all of which are forms of sugar that would be listed under a catch-all heading of sugars. In addition, the new labeling proposal would add the word “high” if a particular food had more than 20% of the daily recommended allowance for fat, sugar, sodium or cholesterol. It would also display the percentage of whole grains contained in the product. The proposed food label would also list the milligrams of caffeine contained in the product.
All in all, the new label makes some improvements. It will highlight the serving size more prominently and make is somewhat less easy to mislead consumers with unrealistically small serving sizes chosen. It is unlikely, however, to end this practice. The recommendations though do make a good deal of sense and highlighting which products are “high” in fat, sugar, sodium and cholesterol may help consumers make better decisions.
These recommendations do make a big assumption that fat, cholesterol, sugar and sodium are all similarly important to highlight and presumably for consumers to reduce or control consumption for these nutrients. It’s not entirely clear that is in fact the case. The best evidence would certainly suggest that calories alone would be the most important thing to highlight and control followed closely by sugars. For some people, especially those with hypertension, controlling sodium also makes sense. Controls on consumed fat and consumed cholesterol may be a bit harder to justify from a scientific basis, but the concept may have some validity. It does confuse body fat and serum cholesterol with consumed fat and consumed cholesterol and the link is not nearly as clear in science as such labeling would suggest.
Nonetheless, I support the proposed labeling makeover for the most part. In my position as head of organizations aimed at combating obesity and preventing childhood obesity, I would like to see greater emphasis placed on highlighting the serving size and preventing food manufacturers from choosing misleading and unrealistically low serving sizes. I would also like to see more emphasis on calories and sugar and less emphasis on consumed fat, cholesterol and caffeine, none of which have anywhere near the kind of impact on obesity and diabetes as calories and sugars.
What are your thoughts?

As we move into unprecedented levels of obesity, diabetes and disease, it is worth asking how the buckling healthcare budgets will manage to suffice in the future. As other aspects of healthcare are examined it must be considered how the social policies could potentially influence or at least finance what will be a huge healthcare burden in the future due to obesity related disease. So with more and more states in the United States lurching towards populations that one-third of which are obese (BMI over 30) how will these societies prepare to pay for unprecedented demand for healthcare for the burgeoning type II diabetes population, increased needs for cardiovascular treatments, CPAP machines, insulin injections, ER visits for stroke and kidney failure and cancer treatments all obesity related.

One proposal that has emerged and as was discussed recently on national public radio on the Diane Rehm Show, is taxation on calories or carbohydrates or some specific nutrients. The logic goes something like this: unprecedented costs arise from obesity. Obesity arises from excess consumption of calories, specifically carbohydrate calories. Therefore taxation on the consumption of these calories may both curb behavior in a healthier direction and lays funds to support the demand for medical services.

Is this just? Is it fair? Does it make sense?

Weight Loss Tip# 6 Fight Back When the Day Gets Crazy

From Doctors Orders: 101 Medically Proven Tips for Losing Weight

Some days just don’t fall into line, no matter how well you plan. The day turns crazy. The kids need something. A crisis happens at work. Unexpected events cancel your well-planned lunch and dinner regime.

What can you do to avoid the binge that can happen if you go too long without feeding the beast?

Keep some low-carb snacks available. Some of the protein bars don’t hold up well in the car in the summer heat, but others do. Experiment and try stashing a box of the kind that are not covered in chocolate somewhere in your car.

Then think of some other snacks that work for you: beef jerky, cheese sticks and other low-carb snacks, keep them available for when the day falls apart, you’re out running errands and there is no way to have an organized meal.

For more information on Doctors Order: 101 Medically Proven Tips for Weight Loss Click Here, and don’t miss out on our Twitter and Facebook Contest happening through November 31’st.