In a new study released by the University of California, Davis has found a proposed mechanism by which bariatric surgery resolves type 2 diabetes in humans. In the study, a specific line of rats known as the UC Davis type 2 diabetes mellitus rat was studied. A model was created which a surgical procedure that mimics malabsorptive human bariatric surgical procedures was employed in this special group of rats. After the procedure, a dramatic reduction in the onset of type 2 diabetes was noted 120 days later. 78% of the control group rats developed the diabetes as expected while only 38% of the rats that had undergone the surgical procedure developed diabetes.

The researchers described a hypothesis in which two specific hormones are implicated in the resolution of diabetes or the prevention of type 2 diabetes. These two hormones are known as GLP1 (Glucagon- like peptide-1) and PYY (peptide YY). These two hormones have been previously identified and are involved in regulation of insulin secretion and appetite. GLP1 is believed to increase insulin secretion and increase insulin sensitivity in the tissues, which would lead to improvement or resolution- or in this case prevention- of type 2 diabetes.

The study is important in part because some of the findings about blood sugar regulation after weight loss surgery appears to contradict the hypothesis that the phenomenon is purely weight related. While long term studies of gastric banding and gastric bypass demonstrate similar rates of diabetes resolution, short term studies indicate the gastric bypass, a malabsorptive procedure with greater hormonal changes, produces faster and earlier improvements in type 2 diabetes. The explanation for this phenomenon may lie with hormonal changes such as those that occur with GLP-1.

Undoubtedly future studies on these hormones in both animals and humans will shed greater light on the subject and help us understand how and why weight loss surgery exerts is powerful effects. In addition, such studies may lead us to new drugs, pharmaceutical solutions to the problem that will involve drugs that mimic the actions of GLP-1 or block other hormones that create harmful effects and perhaps allow a way to chemically produce the effects of weight loss surgery.

Some researchers in the field of obesity postulate that within ten years we will have a whole array of new drugs that produce some of these effects, but obesity is likely to remain a complex, multi-factorial disease with many psychological, behavioral, genetic and cultural factors that play a role.

Joining the ranks of celebrities that have disclosed they have undergone Lap-Band surgery is New York Jets coach, Rex Ryan and golf star, John Daly. In addition, a change is beginning to take place in the urban centers of New York, Los Angeles and Las Vegas wherein celebrities including entertainers, athletic personalities and politicians are undergoing a Lap-Band procedure because it can be done discreetly and without much disclosure.

I personally feel we should applaud and encourage people like Rex Ryan who publically acknowledge their weight struggles and make no effort to conceal their efforts to lose weight. It is a somewhat delicate and complex new era that we are entering, but one that needs to be faced with courage and honesty.

Most Americans are now overweight or obese and in the future nearly all of us will be overweight or obese if current trends hold. So pursuing solutions for weight gain and obesity simply means taking care of one’s self and pursuing better health. So why should a celebrity be ashamed of this? Would they hide the fact that they took blood pressure medicines or underwent coronary artery bypass grafting surgery? Of course not, there is no stigma associated with these interventions even though they are aimed at exactly the same outcome: better health and longer life. Perhaps it is because we associated obesity with indulgence, lack of self control and lack of self discipline that we find people ashamed to volunteer information about their obesity treatments.

I would just note that it is certainly no secret when a celebrity becomes obese. It is generally not possible to hide this particular disease and photographs will convey far more about the obesity condition than they will about the status of somebody’s coronary artery plaques. So I would like to see a day when people openly and courageously pursue the best available weight loss solutions- and today this is undoubtedly a combined program and weight loss surgery and medically supervised long term weight loss follow-up – because it is the best thing for their health. It is also the best thing to promote and acknowledge as healthy for other people who suffer with the same conditions. For if celebrities serve any useful purpose whatsoever it is to influence the rest of us toward better and healthier behaviors.

Researchers in the United Kingdom have been studying a fibrous material in seaweed or sea kelp known as alginate. They have found this material is quite affective at preventing fat absorption. Researchers performed laboratory studies that modeled fat absorption within the human intestine and demonstrated that alginate will bind the fat and prevent its absorption into the body. The researchers believe when this material is added into commonly consumed foods such as breads and other staples that up to 75% of dietary fat would pass through the intestinal system without being absorbed into the human body.

Anyone who has taken Xenical will know that blocking absorption of fat into the body means one thing: it passes out the stool, usually in the form of diarrhea or a special greasy form of diarrhea known as steatorrhea. The appeal of fat blockers stems from the fact that fat is a very calorie dense nutrient containing 9 calories per gram of food.

However, research that has focused on reduction of fat has lead to very disappointing results for the outcomes that matter: weight loss and resolution of obesity related conditions like diabetes. Research involving fat blocking drugs such as Xenical have shown very mild weight loss and to such a low extent that most professional weight loss physicians only recommend the drug (also sold as Alli over-the-counter) when a weight loss patient is suffering from constipation.

So seaweed might have an interesting role in cutting down some calories we absorb. Reducing fat calories will help the overall cause, however it is quite unlikely that reducing fat calories is going to solve obesity for most people. The epidemiological evidence points strongly toward carbohydrate over-consumption as the main culprit so unless we discover a seaweed that is a “carb blocker “then it is unlikely to make a dent in the obesity epidemic

There is really no end to the silly things that people will spend money on if the lure of weight loss can be made attractive enough. In a recent such example the Mexican “Diet Ring” is slipped around one’s finger and produces up to 38 pounds of weight loss in one week. The ring is of course developed by “oriental scientists” and retails for 399 pesos.
Believe me, I wish with all my heart that such a thing were actually true and that I could help thousands of people in my own community and in my own practice lose weight and become healthier. The truth is more complex and a bit harder. But ultimately, there is a solution to successful, long term weight loss and you can lose weight and keep it off without wasting your money on gimmicks, fad diets and “miracle” cures and solutions that are nothing more than marketing schemes, gimmicks and somebody’s get rich quick idea.
Stick with what works, what is authentic, what has been studied and what is recommended by people who sincerely want you to get healthier.

So this may seem like discouraging news to some, but a recent study from the Brigham and Women’s Hospital demonstrated that average middle age women need to exercise a full sixty minutes every day in order to avoid weight gain through the course of the year. That’s right, that is the amount of exercise simply to maintain your current weight, and that is if you are currently living at a reasonably normal weight.
For a lot of women with busy lives including chauffeuring children around to schools and lessons, maintaining a household and managing their own jobs and careers, a full hour of exercise everyday is practically unthinkable. Yet, those seem to be the facts.
But what about women who are already overweight or obese (and this is becoming most women and most men)? Well, guess what, sixty minutes was actually not enough. Yes, while maintaining their regular diet, overweight and obese women would have needed to exercise more than sixty minutes a day to avoid further weight gain.

How do we use this information? Well, I have put this question to a number of women who fit the demographic of “middle age” around my own office. Most of them feel as though these data indicate they would have to undertake a major lifestyle change in order to successfully maintain weight or lose weight. An hour or more of exercise everyday simply does not fit into their current busy life and lifestyle. What sort of lifestyle change would this involve? Well, some suggest it would involve working less, not likely, given the current financial realities and the current economy. For others it would involve simply changing and reorienting one’s life toward one that acknowledges a balance and celebrates physical activity to a much greater degree. It involves orienting one’s life much more athleticism and exercise. Alternatively, or let’s call it complimentary to this idea, would be the parallel notion of reducing caloric intake. This is really the main way to maintain weight and lose weight. Keep in mind that an entire hour of exercise may burn somewhere in the neighborhood of 700 calories if done vigorously for most people. And then think how easy it is to consume 700 calories in a few quick bites.

So my advice is to focus on both: markedly reduce calories by cutting out carbohydrates and high calorie foods, drinks and snacks. Then seek to slowly incorporate more and more exercise and activity into your daily routine and aim for the full one hour of daily exercise. If you are significantly overweight or obese then you must do even more: cut calories even further and increase exercise even more. It is difficult, it’s painful, but there are tools to help.

Mother’s Day, May 9th, 2010, kicked off National Women’s Health Week. A special week promoted by the U.S. Department of Health and Human Services and their office on Women’s Health. This year the theme of the week long campaign is called “It’s your time” and the idea is for women to take steps to improve their health and to make their health a top priority.
While there are many important things that women can do to improve their health, number one among them in this day and age is to maintain a normal body weight and avoid weight gain and obesity. If a woman has crept up to a body mass index greater than 25 than a serious effort at calorie reduction and increased exercise is in order. For a body mass index greater than 30, a more rigorous and structured program is warranted, and the evidence strongly favors taking a very proactive and serious approach including consideration of a Lap-Band operation in conjunction with such a program. For a body mass index of 35 and greater, a small percentage of women can lose the weight successfully without weight loss surgery, but for more this would be a very challenging undertaking. Even with weight loss surgery, successful return to normal body mass index will require diligence, hard work and a structured program. But these efforts are well rewarded with vastly improved health, longevity and quality of life.
Various events are planned around the country to celebrate National Women’s Health Week and these can be found at:
http://www.womenshealth.gov/whw/events/
The Surgeon General, Dr. Regina Benjamin emphasizes the importance of empowering women to make their own health a top priority.
Our recent Health Moms campaign dovetails importantly with National Women’s Health Week and the project this summer aimed at helping moms lose the pregnancy weight and promoting health families in obesity prevention among children will succeed in improving the health of not only women in our community, but the entire families that women lead.

A friend of mine who has been an inspiration to me recently suffered and Achilles tendon rupture that seemingly struck out of the blue. She is one of those people who seems to do it all, a super-mom who manages to run and continue an impressive career, maintain fitness, recover well from childbirth and just about everything else. But recently a recreational game of racquetball, lead to a snap and a diagnosis of a ruptured Achilles tendon that is going to require months of lifestyle change, rehab, crutches and more. It has been yet another reminder of how fragile we are and how tenuous our hold onto health and fitness truly is even when we are seemingly doing everything right. So what lessons do we take from it? Well, one thing is to certainly appreciate everyday that we have in this wonderful world and especially appreciate every day we have with good health. Never take such days for granted and cherish the precious minutes of nice weather and the ability to exercise and experience vitality and nature. It also reminds us to be careful and try to balance the risks of our activities against the enjoyment and the benefit of them. For example, many of us are a lot less reckless on the ski hills nowadays than we once were in our youth. I see far too many serious orthopedic injuries and brain injuries among skiers, both of which would be pretty problematic for my kids so I take a little more caution and go a bit slower (but still have just as much fun!).

Research indicates that running and vigorous long term exercise is not associated with increased orthopedic injuries. This runs contrary to popular opinion on the subject, but nonetheless it does appear true from a large Stanford study and other trials that comparing, for example, runners to non-runners over the course of many years, runners experience no greater incidents of knee injuries or other orthopedic ailments. On the other hand, skeptics argue that these runners are “self selected” because they have more durable knees and joints, but it is difficult to prove. It is certainly better for our cardiovascular health and our mental health to exercise regularly throughout our lives and hopefully into advanced age. Whether capricious injuries derail that hope is something none of us can predict. But one hopes my friend will recover uneventfully and will go on to have a long and health career exercising and the rest of us can avoid injury by being careful, staying active and eluding the risks we take. And above all, acknowledging and cherishing every day of good health we get.

As I look over the summer calendar I am tempted to sign up for loads of running races. Fortunately, my work calendar and kid duties preclude such a silly idea, but I am selecting three or four races through the summer and fall in which I hope to participate. But, how many is too many? Or better stated, what is the right amount?

I know that races or special events do help me maintain some focus and motivation with training and regular exercise. And I know from talking to many of my peers who participate in bicycling, running, swimming, dancing and other activities, that events, races, competitions and performances help us all maintain focus and motivation. But there is probably a number that is an appropriate number of competitions every year. And there is probably a number that is too many. So how do we figure that out?

I don’t know the answer yet, but I do know that at least several per year is probably appropriate for most people, if for no other reason that is gives one focus for a period of time of weeks to a few months. If our only competition is six months or a year away we tend to put it out of our mind and not prepare for it, just like taking a final exam at the end of the year is not generally sufficient motivation for a student staring out in the fall. We need some shorter term goals to focus our energies.

So, practical realities of life prevent me from doing more than a handful of races a year so we will see how well that strategy works.

The subject of children and adolescents potentially undergoing weight loss surgery has evolved greatly in a short number of years. When it was initially proposed the only operations were invasive procedures such as the open Roux-en-Y gastric bypass. With the advancements of minimally invasive surgery and laparoscopic instrumentation, there are now several minimally invasive choices, most notably the laparoscopic adjustable gastric band (LAGB, Lap-Band or REALIZE Band). The LAGB procedure does not involve any cutting, rerouting, reconnecting or other irreversible changes to the gastrointestinal system of a young person and so has emerged as a potential procedure, perhaps more worthy of consideration on a wider scale in young people.

The rationale for weight loss surgery being performed among young people is that serious comorbid conditions are developing in young people and extremely important formative events are occurring in social, intellectual, academic and career realms for the young person, all of which are profoundly negatively impacted by obesity. Weight loss surgery performed at a young age offers the potential benefit of impacting not only the young person’s health and quality of life, but also substantially enhancing long term prospects for improved career, earnings, relationship formation and social development. For this reason many advocates of childhood health and adolescent well being have endorsed the concept of offering weight loss surgery to obese adolescents and young people.

When should a young person be considered for weight loss surgery?

1. When the body mass index is over 35 it is reasonable to begin consideration.

2. When the body mass index is over 40 weight loss surgery should be included in any discussion with the patient and family of the weight loss options.

3. Attempts at non-surgical weight loss: young people by virtue of their higher resting metabolic rate than older persons, often have a greater ability to lose weight through non-surgical means. Additionally, young people may have a greater power to make behavior and lifestyle change than older people. So, determined efforts should be made to engage in non-surgical weight loss programs with a structured medically supervised approach involving dietary change, counseling, exercise, psychotherapy, use of protein based meal replacements and support groups. If these efforts fail then weight loss surgery should be considered.

4. Health status: For adolescents who have already shown health problems stemming from obesity such as type 2 diabetes, high blood pressure and obstructive sleep apnea, weight loss surgery should be a consideration.

5. Age: At what age should weight loss surgery be considered? This remains a debated topic. Our own center chose a lower range cutoff of age 15 below which we offer non-surgical, medically supervised weight loss. At 15 and above we will offer laparoscopic adjustable gastric banding weight loss surgery. At age 18 and above patients and families generally have the option of LAGB or laparoscopic Roux-en-Y gastric bypass surgery. Other centers around the country have chosen a lower age cutoff of, for example age 12 and above for consideration of weight loss surgery.

Tips for success with adolescents and weight loss surgery:

1. This must be a whole family effort. Everyone must be educated and motivated to help the young person succeed.

2. Support groups for the young person and the parents and siblings. This is not a “go-it-alone” journey. Quite the opposite is true. Support, encouragement and coaching from parents, siblings and peers enhances successful weight loss.

3. 0-calorie beverages. This principle must be enforced within the household to avoid “drinking all your calories” and maintaining resuming obesity.

4. Protein first. This principle means that everything eaten, drunk, prepared, bought, opened, sniffed or dreamed about must be protein first. This guarantees a greater sense of satiety and an emphasis on lower intake of simple carbohydrates, which are appetite stimulating.

5. Exercise for life. The habit must be engrained not only for the young person, but for the whole family that daily exercise is part of life even if it is simple walking. Exercise is a powerful predictor of long term weight loss success

Here are a few thoughts about how we could make our fighting force more effective, more lethal and better able to protect the United States of America:

1. Set a new standard for fitness and actually enforce it. There is no reason why nearly every person in the United States Military could not maintain a body mass index of 25 or less. Going to 26 quadruples one’s risk of type 2 diabetes so this is not an arbitrary number chosen.

2. Actually create the environment on military bases to foster fitness instead of inculcating obesity as we do now. Yes, this means actually promoting the notion that our fighting forces need to be physically and mentally fit and prepared to defend the nation. This means creating a culture of regular exercise, a culture of modest calorie intake and a culture that eschews diets consisting of massive carbohydrate and calorie intake. This does not require a big brother technique on the base. It simply requires setting standards eliminating all the obvious places of abuse of the dietary requirements (starting with the deluge of high fructose corn syrup on the bases, the high carbohydrate, high calorie meals being served and replace these with some fantastic tasting, but very good for you protein based snacks and meals).

3. Change the culture by rewarding people for productivity instead of rewarding people for laziness. Yes I realize this will make me unpopular with all sorts of mid level bureaucrats in every sort of job in the country that implicates a culture of less and less activity, but think about it. Ask anyone in the military how to get ahead and they will begin explaining the politics to you. Getting ahead does not involve being more productive, working harder or doing better. It involves kissing the right asses, keeping your head down and creating the appearance of work at the proper moments. How do you change corporate culture? Well, there are dozens of great books on this, but let’s start by using the obvious levers such as rewards like pay, vacation time, and rank, all the obvious things that go the people who are the best schmoozers. Toss out this system of brown-nosing and replace it with one that attempts to recognize measurable productivity.

Imagine a fighting force in which the valuable administrators, the corporals, sergeants, lieutenants, captains and majors who make the whole system run were actually rewarded for getting their work done early and doing it well. They do not have to resort to tricks like leaving their lunch bag and hat on the desk with the light on so the colonel would think they are in the building when actually they are surfing the web at their apartment.

The United States taxpayers currently pay for something like half a million U.S. active duty service people deployed outside the United States at bases around the world. Those people could be representing America as the fittest, strongest, most vital people on the planet. But, it would take a culture change in the United States Military for this to take place. It would require recognition of the science of diabetes, health and nutrition- one that recognizes that cutting simple carbohydrates and overall calorie intake is critical to maintain fitness- emphasizes regular exercise and acknowledges the connection between mental and physical fitness and the ability to perform one’s job to the best level. This culture currently does not exist in our U.S. Military and in precious few places around the country. But I believe the U.S. Armed Forces represents an important area where a great difference could be made where great improvements in the health of the men and women who proudly serve could occur and where the national security could be improved. All it takes is leadership.