The Washington Post recently reported it is becoming increasingly common for paramedics and ambulances to be called upon to transport patients weighing 350 pounds or more. In fact, this has become a daily occurrence. According to the article, every few months patients weighing as much as 600 pounds require emergency transportation.

The super-sized patients require super-sized equipment as well as additional training to avoid injuries among the emergency medical personnel and paramedics. Expensive equipment upgrades have lead paramedic communities to increase their fees for transporting patients who are obese.

I know from my own experiences talking with hospital and emergency medical personnel that back injuries are a serious concern for these workers when transporting obese patients.

It is an increasing problem not only in the paramedic/ambulance situation, but within the hospital itself. A great number of these workers who themselves are often becoming overweight, suffer increased strains and lumbar and cervical spine difficulties as a result of having to lift and transfer heavier and heavier patients. Purchasing expensive equipment upgrades provides only a partial solution, but it does not really solve the day-to-day needs of transferring a patient say from a gurney to a bed. This normally requires human hands and human bodies. With the shortage of personnel, healthcare dollar cutbacks and lower staffing models, there are fewer people available to help with these tasks. More often than not, a two person team will be forced to perform the transfer even if the patient is obese.

A vaccine is most effective when given in the intramuscular position, meaning the vaccine substance and molecules enter the muscle tissue where the immune fighting antibodies can be activated. If the vaccine is simply injected into the subcutaneous fat then it is probably less effective at generating immunity. We have long known that vaccines were less effective in obese individuals, probably as a result of this fact. Now recent studies indicate that vaccines are more effective when a longer needle is used, presumably because the vaccine can enter directly into the muscle tissue and not be wasted in the subcutaneous fat.
It is striking to me that virtually every facet of health and disease is adversely affected by obesity, even preventive efforts such as vaccinations. In this most recent study analyzing the effect of Hepatitis B vaccines, the Baylor College of Medicine researches compared the antibody levels with short needles compared to long needles. The antibody numbers when short needles were used were about half of that when a longer needle is used. The authors note that there already exists a CDC recommendation to use longer needles (usually 1.5-inch long) in obese individuals.

A recent study out of Singapore, which examined over 60,000 people over the course of fourteen years, found that those subjects who drank two or more sugared soft drinks per week had doubled the risk of developing pancreatic cancer than those who did not.

It is not known why increased soft drink consumption could lead to an increased risk of pancreatic cancer or whether this effect is going to be born out in other studies. Some facts we do know about cancer: many cancers are markedly increased in obesity. Colorectal, breast cancer, endometrial cancer and others double or more than double among obese individuals when compared to normal weight individuals. We know there is an association between soft drink and sugar consumption in obesity, so it stands to reason that some link may exist between the soft drinks and cancer development. Pancreas cancer in particular may be one that has some special sensitivity to the elevations and hormonal surges of insulin, leptin and other hormones associated with carbohydrate consumption and obesity.

Whether some subtle toxin could be present in soda cans or whether there is something specific about the soft drinks as opposed to other sugar drinks like fruit juices remains to be seen.

What is known is that drinking lots of sugared soft drinks is bad for your health. It leads to weight gain and obesity, which increases cancer risks markedly. This latest study is one more, small piece of data that should discourage drinking high carbohydrate soft drinks.

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?

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.