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?

An interesting study just released looks at the long-term remission rates of type 2 diabetes mellitus after laparoscopic adjustable gastric banding.  The study reported by Dr. Samuel Sultan demonstrated that after five years of follow-up 40 percent of previously diabetic patients were now off of all diabetes medicines and had normal blood sugars and normal hemoglobin A1c levels.  In a total of 80 percent of patients the diabetes was improved (as defined by a reduction of diabetes medicine) or was totally resolved.

Not surprisingly the patients in the study who maintained the resolution of their diabetes were the same patients who maintained their weight loss over that time period and who exhibited a greater magnitude of weight loss at the five year mark.

I think what this study says about long-term resolution of diabetes after lap-band surgery is that the key is, in fact maintaining the weight loss for the long-term.  We know that the keys for maintaining that weight loss long-term are committing fully and completely to changing, adapting a new life style, participating in ongoing long-term follow-up with the bariatric surgeons office and continuing to have band fills and adjustments on a regular basis.  We also think that coaching, attendance at a support group and more active participation in activities, such as regular walking groups, contribute to the long-term success that leads to total, long-term resolution of diabetes.

Recently scientists have pointed to some concerning data from the Center of Disease Control in Atlanta, indicating that after swine flu infection, more deaths have occurred in obese individuals than would be expected statistically.  This has led some scientists to opine that overweight or obese individuals may have grater risks when it comes to a serious flu infection.

Based upon the extensive volume of data from many other disease states, it is logical to expect swine flu to carry greater risks for a person who is overweight or obese than a person who has normal weight.  Any adverse health condition must be fought off by the human body with all of its organ systems functioning and coordination to sustain health and rid the body of the disease.

So, if health deterioration has occurred in many other aspects of the body when a new disease strikes, the body is less able to sustain itself and fight off the new problem.  Think of pneumonia (a new infection in the lungs) occurring in an old or disabled person.  This person lacks the strength and robustness of all the organ systems to adequately fight off this disease state that would have been a relatively easy battle in a health twenty-year-old.

This certainly is true for obese individuals facing all kinds of serious illnesses including: cancer, heart disease, diabetes, even an automobile accident or other trauma.  The individual in a car accident who is seriously overweight faces much higher risks because of deconditioning, poor lung function, impaired mechanics of breathing, strains on the heart to pump the blood through the body, liver congestion, kidney impairment and a host of other issues.  All of these other organ problems may have resided under the radar screen until the trauma occurred, but now they serve as an ominous background upon which the disease must play out.  Compared to a normal weight individual, the risks of the body failing to fight off the disease or trauma are significantly higher.

With H1N1 flu, there could also be an immunological affect based upon the increased adipose tissue or fat tissue carried by the individual.  The hormonal changes that we see in obesity (resistance to insulin and leptin along with increased levels of inflammatory cytokines and leptin) could potentially leave the body more vulnerable to attack from the virus.  It might be that these adverse states of relative immune susceptibility only incur a very slight, increased risk of say, one percent over an overweight individual.  If a flu virus like swine flu, afflicts millions of people that one percent increased risk among obese individuals translates to a significant number of victims suffering real and serious consequences from the flu.

Lastly, the findings have increased death rates after swine flu infection among obese individuals could also stem not from a specific cause that is related to the increased fat cells in the body, but rather due to the secondary diseases that we know stem from obesity.  For example: since so many more people with obesity have diabetes and high blood pressure, it is possible that these secondary conditions of obesity are what confers the added risk of swine flu death.  More sophisticated studies that control for these variables would help us understand if indeed that is an independent risk due to obesity and excess fat, above and beyond the associated adverse health conditions of obesity.

What ever the exact cause or mechanism it comes as no surprise that as we head into the swine flu season, overweight and obese individuals face greater risks.

I am occasionally struck by the comments from medical physicians or from people in the health care community who comment that some of what I do to help people lose weight and solve their diabetes is so “radical”. Usually when they say this they are referring to Roux-N-Y-Gastric Bypass surgery, which does involve a fairly permanent rerouting of the stomach and upper intestinal system. Even though the procedure is done with a laparoscopy, or minimally invasive technique, and usually involves a one hour surgery and overnight hospital stay, I certainly agree that it is a major decision to undergo the procedure and not something to be taken lightly.

I am ,however, troubled by the real lack of understanding of the nature of the diseases of both obesity and diabetes among those making this kind of comment. I have even had, for example, people in my office who were considering weight loss surgery and brought along their skeptical spouse or significant other to talk with me. Here I would be, speaking with a person who has tried for decades to lose weight and is now seriously overweight struggling with insulin shots, umpteen medications, severe pain in the spine and weight bearing joints, high blood pressure, breathing difficulties and yet the spouse or significant other would be very discouraging, saying things like, “the surgery is too radical”. I wonder just what solution would be appropriate given the “radical” nature of the disease that is leading to such diminished quality of life for the person in such a dramatic shortening of life span with early onset of these devastating diseases. What we seek in medicine and all health interventions is proportionality wherever possible. This means that we prefer that the treatments, or intervention, be proportional to the seriousness of the disease. For example, radical brain surgery would only be considered appropriate if the disease being treated was a life threatening brain tumor. We would not recommend craniotomy surgery and its attendant risks and recovery time for a less severe brain condition, like say, headaches.

So, is weight loss surgery a proportional treatment for this disease? I would argue that it is quite acceptable in terms of this concept of being proportional, especially when compared to so many other kinds of treatments across the spectrum of so many other diseases. And especially as weight loss surgery has moved increasingly to the minimally invasive and even to the outpatient realm, it has become far less radical than the disease it treats and in many cases cures.

I saw a patient in my office recently who has a very important concern: Nearly everyone in his family has diabetes. He himself is quite overweight and has not developed diabetes but is only in his 30s. He wants to have weight loss surgery to lose weight and feel better, but also to prevent diabetes.

Should he undergo weight loss surgery? Which procedure would be the best?

I think there is little question that the roux-en-Y gastric bypass operation has proven to be the most effective procedure at eliminating diabetes once it has been diagnosed. There is also very little question that weight reduction helps prevent the onset of type 2 diabetes. But in this particular man there is probably no clear-cut, single correct answer. Certainly if my patient succeeds and really puts his mind to it, he will have a high chance of preventing the development of diabetes with either procedure. I suspect the success rate may be even higher with gastric bypass surgery, the more invasive procedure. But whether a higher rate of prevention success warrants a more invasive procedure will not be decided in the same manner by each person.

In the future, better studies will help us quantify the risk of diabetes for individuals and provide more detailed answers about the best preventive strategies. But it is noteworthy that more and more people are thinking about prevention and taking a proactive stance against diabetes and other complications of obesity.

A major problem with weight gain among kids is that it produces serious health problems and sets the stage for early development of even more serious disease. For example, kids who gain weight develop what is called “impaired glucose tolerance”, meaning that they have a type of pre-diabetes condition. This means that the overweight, or obese child does not process ingested sugars easily and the serum blood sugar level rises. There are also problems with insulin production and resistance of the tissues to insulin, both critical factors in the development of diabetes.

In addition, the circulating blood lipid levels rise in overweight kids and they develop early plaques on the inner lining of the arteries, known as atherosclerosis.

The combination of an expanding waistline together with high lipid levels and elevated blood sugars are the core findings of the metabolic syndrome, a collection of serious cardiovascular abnormalities associated with early heart attacks, strokes and death.

The kids who start out on this path at such an early age have a poor chance of living a normal, long life. Many of the metabolic results of weight gain as a child are well described in a volume by Weiss called The Metabolical Consequences of Childhood Obesity (Best Practice and Research Clinical Endocrinology and Metabolism, volume 19, issue 3, page 405).

The connection between being overweight as a child or adolescent and then later having adult obesity and cardiovascular disease is made clear in a study by Srinivasan in the journal Metabolism (volume 45, issue 2, page 235, February 1996). In this study, 783 subjects surveyed first as adolescents and then again as young adults age 27 to 31. They found that the excess weight present in the adolescents persisted into young adulthood and had a strong and negative impact on health as measured by multiple cardiovascular risk factors (high blood pressure, elevated cholesterol, adverse lipid profile and diabetes).

So, unfortunately, while we would like to think of some of the youngsters as still retaining some of that “baby fat” and hoping that it will melt away as they age into adulthood, the facts speak otherwise. Childhood weight gain and obesity lead to adult obesity and disease.

We cannot afford to neglect childhood weight gain and adolescent obesity as serious problems and as an important opportunity to intervene for improved long-term health.

Did you know that a 20-ounce soda, like a Pepsi, has 69 grams of carbohydrates and 250 calories! This astounding fact, these astronomical amounts of carbohydrates and calories in just one soda, is both very good news and very bad news.
The very bad news is that millions of people are drinking soft drinks and consuming unprecedented amounts of calories in the form of carbohydrates, sugars, and high fructose corn syrup. These drinks have zero nutritional value. Some of the doctors I work with in the field of weight loss and obesity refer to them as “diabetes delivery vehicles”. How many people do you know who drink two or three or four or even five or six Cokes or other soft drinks a day? The harm that consuming that much carbohydrate brings is quite substantial. Massive carbohydrate calorie intake quickly leads to the metabolic syndrome, obesity, elevated blood pressure and the onset of diabetes. Those conditions bring about early and very serious health problems including heart attacks, strokes and other deaths.

Wow! So what’s the good news?

Well, the good news is that if you currently are in the habit of drinking soft drinks, fruit drinks, even fruit juices on a regular basis every day, then you have an amazing opportunity to very quickly and very successfully lose weight and become healthier by making one single change in your routine: Eliminating high carbohydrate drinks.

But wait, some people say, “I’m totally addicted”, and, “I can’t stop drinking my favorite soda pop”, and “I love it, it helps me get through the day.”

Let’s face it, no change is easy. All of the behavioral, activity based, and overall lifestyle changes that I write and speak about to my patients are more difficult than this one single change of eliminating high calorie soft drinks from your diet. In other words, there is no single change that is easier and that has a greater impact on your health and weight than this.

Our rule at iMetabolic is all drinks must be zero calorie. (The only exception for this is children who may choose milk or water as their beverage).

But how do I Eliminate High Carb, High Calorie Drinks?

If you really feel like you can’t live without your high calorie, full sugared, high fructose corn syrup laden beverage, first consider the harm it is doing to your body. If you are trying to lose weight and become healthier, adding in 200, 300 or 400 calories per drink several times a day is immediately leading you absolutely no room to consume any good quality calories. The soft drinks are typically high in sodium which can lead to elevated blood pressure, but the killer is really the carbohydrate calories. This is a highly effective way of tacking on pounds and pounds of fat and developing diabetes, high blood pressure, metabolic syndrome and obesity.

Now is the time to switch from high sugared, high carbohydrate drinks to equally delicious zero-calorie beverages. That’s right, equally delicious. It just takes a little time and there is a little pain involved in the transition, but you will be completely and equally satisfied with one of the many zero-calorie drink options available today. These include all kinds of energy drinks, non-carbonated beverages and “diet” sodas and soft drinks.

I recently had the pleasure of speaking at a medical conference devoted to diabetes. Mine was the talk focused on the association between weight gain and diabetes. While there are a great many interesting discoveries occurring all the time in the field of diabetes, it remains the case that the disease itself marches on, increasingly affecting more and more people around the country and around the world.

What strikes me as the most stunning statistic is the one which describes the close relationship between obesity and type 2 diabetes mellitus. The relationship is truly stunning. Even modest weight gain leads to dramatic increases in the development of type 2 diabetes.

We think of a normal body mass index as being 18-25, but really when one goes from a healthy body mass index to a body mass index of 25, the risk of type 2 diabetes more than doubles. Then when the body mass index climbs even higher, hold onto your hats because the risk of diabetes climbs through the roof. What does this mean? How are we to treat this runaway epidemic?

While there are new drugs that come out every year and better insulin management regimens hold promise for steadier regulation of the blood sugar, these treatments do nothing to reverse the growth of the disease around the country among men and women, young and old and people of all races. What is needed is really a prevention solution or a solution aimed at the root cause.

The only real solution at this point in time that reverses and eliminates the disease is weight loss. Weight loss takes a person back down curve and below the threshold at which their body can no longer handle the blood sugar. So while the treatment must involve controlling the blood sugar, and must involve medications, attacking the root cause by losing weight, must become the top priority for most people with type 2 diabetes.

Medically supervised weight loss holds the best promise for producing sustained weight loss in moderately overweight people. Weight loss surgery provides the best results for people with type 2 diabetes with body mass index over 30. There may even be a role for gastric bypass surgery as a type of “metabolic surgery” as the treatment for type 2 diabetes in normal weight individuals.

In our practice, we developed a sense that all problems resolve after weight loss surgery. I bet if you polled the nurses, the nurse practitioners, office staff, physician assistants and the doctors at Western Bariatric Institute, you would find that through the experience of thousands of patient having undergone weight loss surgery, our clinical staff has come to believe that most health problems fade away and disappear.

This is not hubris; it is just the impression one gets from seeing people in follow up who gradually reduce the number of medications they are on and show up years later looking like an entirely new, and healthier, person. It is very common for people to have been on eight or twelve medications plus CPAP machines for their obstructive sleep apnea, only to return a year or two or three later not only looking like an entirely different person, but also having stopped all their medications and their CPAP.

This impression may be accurate for many people. However, there is some concern among the sleep specialists that obstructive sleep apnea may be a bit more complex disease than we have imagined. In the world of medically supervised weight loss and in bariatric surgery, we tend to view all diseases as being purely weight-related or obesity-related. But that of course is not entirely true.

Around 25% of people with obstructive sleep apnea are not obese. Their risk factors may be more of an anatomic one, having to do with the shape of their mouth and jaw and pharynx. So if a normal weight person has obstructive sleep apnea and then goes on to gain weight, you can imagine that the sleep apnea becomes more severe. Once the weight is lost through bariatric surgery or medically supervised weight loss, the structure of the face and throat has not really changed, so it stands to reason that some degree of obstructive sleep apnea would continue.

As weight loss doctors, we have not taken a highly sophisticated approach to the long-term follow up of obstructive sleep apnea. We probably thought that if the patient reported they were sleeping better and feeling better, and they had lost weight, then what would be the reason for more studies of their sleep?

Well, although there is not much long-term data out there on this question, it may be the case that people with obstructive sleep apnea do need long-term follow up and many of them do need ongoing CPAP. Most of the people who lost weight and kept it off do not need the same level of CPAP. For example, they do not need the pressure settings to be as high as 15 or 18 cm, but rather they can use CPAP more comfortably at 7 or 8 cm. But the big reason to continue with CPAP and to continue visiting the sleep doctors is that independent data shows that untreated sleep apnea carries its own risks of mortality and contributes to other health problems including hypertension and daytime sleepiness.

We see such dramatic resolution of patient’s health conditions like high blood pressure, diabetes and high cholesterol that we naturally lump in obstructive sleep apnea in the same categories and expect its complete and total resolution after weight loss surgery. The truth is probably a bit more complicated. Patients with obstructive sleep apnea undergo weight loss surgery, lose weight and markedly improve or resolve their sleep apnea, but many patients will benefit from ongoing CPAP at lower pressures to avoid the long-term risks and adverse effects of untreated obstructive sleep apnea.

One future study we may undertake at Western Bariatric Institute will be a long-term observation of obstructive sleep apnea over the course of ten years and beyond after their weight loss surgery. This would provide really meaningful data on the need for ongoing sleep studies and titration of CPAP.