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.

The Nevada capital is adorned in blue to draw attention to diabetes, the timing couldn’t be better. More Americans than ever suffer with diabetes. Increasingly, this disease is afflicting old and young and the vast majority of cases stem from obesity. A small percentage, less than around 5% today, of all diabetes is type 1 diabetes, a condition that typically comes on in young people and is related to a loss of function of pancreatic data, islet cells and diminished insulin production. The remainder of cases stem from the complex metabolic disorder known as type 2 diabetes. Most such cases arise with weight gain and age, but today with more and more teenagers and children becoming obese, we see a dramatic rise in type 2 diabetes among young people.
Hopefully, greater awareness will lead to more resources, thoughts and effort being applied where it will yield the greatest results: in prevention. Visit obesitypreventionfoundation.org for ways you can help.

I had a great conversation with Louie Free, the Ohio talk radio host, who himself is a vegan. He said something I thought was very important to point out and that was he knew, as a vegan, he had to eat a “healthy” vegan diet and pay attention to all of his food selections to avoid weight gain. As he mentioned, it is possible to eat snack chips and soda pop and be “vegan” and yet such a diet would be unhealthy and would lead to weight gain and obesity.
I, myself, see a great many people who are vegans with obesity.
It is not veganism that is healthy per say. A vegetarian or vegan diet is not going to prevent obesity or solve obesity or even lead to weight loss. The food choices that will lead to weight loss are a shift away from high calorie, high carbohydrate foods and toward foods with a lower glycemic index and lower overall calories. Then combine that change with increased exercise and you have a winning formula.
It’s certainly possible to eat a nutritionally sound diet that is a vegan diet. And it is certainly possible to maintain a healthy weight and be fit and well nourished as a vegan. It is also quite possible to do the same while eating meat as part of a healthy diet. The key for vegans is to not be lulled into a sense of “healthy dieting” in believing that a vegan diet that is high in simple carbohydrates and high in calories in somehow better for the body than a diet that is lower in these things or one that might even contain meat. As I have discussed elsewhere, there are many reasons individuals choose to pursue a vegetarian diet including ecological choices, environmental awareness and an appreciation of the role that animals play on this earth and how humans should interact with them. But as a physician specializing in weight loss and the treatment of type 2 diabetes , I must point out that the real enemies for human health are not animal proteins, but are high calorie, high carbohydrate foods, especially including the sweets, treats and snacks that are packed with simple sugars. Those are the worst culprits that lead to rampant obesity, diabetes, high blood pressure, sleep apnea, hypertension, blindness, renal failure, amputations and early heart attacks, even among vegans.

Many of you may have seen in USA Today and other major media articles discussing the association of obesity and cancer. The American Cancer Society and some recent scientific studies have confirmed that a high number of cancers in the United States are caused by obesity. The American Institute for Cancer Research released an analysis of cancer data and offers some striking and discouraging news about the dangers of gaining weight and becoming obese. For example, 33,000 cases per year of breast cancer are due to obesity. Another 20,000 endometrial (uterine) cancers are due to obesity. And many other types of cancer including colorectal cancer, kidney cancer, pancreatic cancer and esophageal cancer are caused by obesity in many cases.
There are likely several reasons why the cancer risk rises so strikingly with obesity. To begin with, our cellular metabolism changes and is influenced strongly by the different hormones and biochemistry associated with obesity. For example, insulin levels rise dramatically as do leptin levels with certain phases of eating, digestion and weight gain. These hormones exert powerful influences on the growth regulation of individual cells that is intimately linked with the development of cancer. Scientists have not yet unlocked precise ways to intervene and block this cancer growth and development, but research continues. In addition, increasing studies demonstrate a reduction in cancer risk with weight loss, primarily coming from weight loss surgery.

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?

Increasingly, more people are approaching their weight loss efforts with a preventive attitude. Today in my clinic I saw two people who represented what I think is the future for forward thinking people and their doctors. Each of them was significantly overweight with a body mass index between 30 and 40, but neither of them had severe health problems from their overweight or obesity. Yet, that is.
The first patient, a thirty-three year old female whose mom has type 2 diabetes knows that she is committed to losing weight, but has just not had the right tools and knows also that if she is not able to lose the weight, her mother’s health problems will become her own. As she described it to me, there really is no reason for her to wait until she develops type 2 diabetes or hypertension or any of the other obesity related health problems before she moves forward with an aggressive weight loss program. In her case she wishes to undergo Lap-Band surgery and I believe she will be quite successful with it.
The other patient, a forty-one year old male, was told by his doctor he has a condition known as “pre-diabetes”. He wasn’t exactly sure what this meant or if it was even important, but it sounded ominous. I discussed with him the definition of pre-diabetes and we talked about his glucose tolerance test, which showed his body is unable to handle a challenge of ingested oral glucose. This means he has the high likely-hood of progressing to type 2 diabetes, which will require medications. It means that while his blood sugars are not typically out of range, if he eats and has a significant carbohydrate load then the blood sugars to rise into abnormal territory.
By some estimates, seventy-million Americans have pre-diabetes and most of them will progress to type 2 diabetes in their lifetime. Most of these people are also overweight or obese. As this gentleman stated, “Why wait for the diagnosis of full-blown diabetes”.

I saw a patient today who has battled with depression intermittently throughout her life and also struggled with obesity. She wonders if the two are related, but also about how she will manage the depression after her weight loss surgery. Is it still possible to take medications should she need them? Might her depression improve if she undergoes weight loss surgery?
Interestingly, the research on depression and obesity shows it is a two way street: depression leads to more obesity, but obesity itself exacerbates depression. It makes sense, if we think about it. Depressive feelings can lead to overeating and loss of motivation to exercise. Likewise, obesity can lead to feelings of lower self-esteem and lower one’s mood.
Research also indicates some people do experience improvement in their depression after weight loss surgery.
Similar data exists about non-surgical weight loss. Of course it is hard to separate out which comes first, better feelings of self-esteem and higher motivation that lead to successful weight loss or some improvements in weight, leading to better body image and some improvement in mood. Ultimately, this chicken and egg question may be difficult to answer, and the most important advice is to seize the day and to work very hard on both problems. By this, I mean that if you struggle with depressed mood then seek help immediately including psychological counseling and visiting with health professionals who may offer effective antidepressant medications and recommend mood elevating activities like exercise. Likewise, if you are overweight or obese, don’t let another day go by without working on this problem too. Seek professional help. Follow the strategies and tips outlined here and in my books and you will benefit with lower weight and an improved mood.
For my patient today, I also let her know that antidepressant medications can be taken and absorbed after Roux-en-Y gastric bypass surgery. We do believe it is best to change from any extending release formulations (for example Effexor XR) to the standard release formulations that usually must be taken two to three times a day rather than only once a day.
Like so many complex facets of human health, depression and obesity are closely linked. One affects the other, but more importantly one is improved by improving the other

Why to people who seem fitter, thinner and healthier also seen to be living with a higher energy level? It’s maddening, isn’t it? These same people who have all the gifts of good looks and skinny bodies also appear to be darting around and living life at a higher more enjoyable velocity than the rest of us. What gives?

There may be more to this question than meets the eye and it may be less clear what is cause and what is effect than may observers might think.

Unquestionably, even as infants, some humans are moving at a slower speed while others faster. Hormone levels like thyroid hormone play a role in dictating wide variations in things like resting heart rate, blood pressure and the speed with which simple behaviors are accomplished. So one theory has always been that those people who are blessed with a higher metabolic rate are first and foremost “high energy” people and they tend to exercise more, expend more energy, live more actively and therefore look fitter, thinner and healthier.

But, the effect may be more powerful when we consider it in the other direction. By this I mean that people who achieve a healthier weight and a trimmer waist line begin to experience a new an higher energy level in their day to day activities. They find joy in physical activity, exercise, competition and the outdoors. They feed off of the enthusiasm of other high energy people around them pursuing similar activities. And perhaps most importantly, the psychological influence on our energy level cannot be underestimated. A person who has “seen the light” and changed eating behavior and lifestyle to become fitter and healthier lives with a sense of purpose and that gusto, that enthusiasm, infects everything the person does so their friends, colleagues and neighbors admire their achievements and note how everything they do is approached with great energy.

I have patient’s who lived for years in a sadly obese state before they made a transformation. They described hours on end sitting, watching television or engaging in other passive activities with little to no physical exertion . They describe how this inertia led to more eating, more of a sense of depression and failure, more weight gain and a cycle of further reduction in energy level. That cycle can be broken. It requires new thoughts, a new commitment and new goals. Those thoughts, commitments and goals must be reaffirmed constantly and once they are, a sense of achievement takes hold and a new higher level of energy is experienced.

Want to experience a higher energy level? Don’t wait for it to come along and bite you. You have to make the change today.

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.