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.

This past weekend was our 8^th Annual Fashion Show hosted by The Obesity Prevention Foundation and Western Bariatric Institute.  It was a great event that allowed some of our patients to share their success with friends, family and the Reno community. It also provided us with a great opportunity to spread the word about the obesity prevention foundation. Thank you to everyone who came out to the show.

I would also like to send out a very special thank you to Joe Hart who, as usual, performed impeccably as the Master of Ceremonies.  As always, Joe is a very gracious and professional host noting the tremendous life change and improvement in health of our models while also highlighting the great clothes they were wearing that were provided by many local clothiers.

I don’t have official numbers in, but it looked to me like there were around one thousand attendees of the event this year and it was near standing room only in the Rose Ballroom at the Convention Center. The Convention Center staff did a fantastic job making this year’s show appear glamorous and professional as did Kathy Parker and her excellent team in planning and coordinating the event.

This year, greater awareness was raised and mention made of the activities of Obesity Prevention Foundation, which this summer will be kicking off quite a few activities meant to raise awareness for healthy kids and healthy families.

Recently some of the U.S. High Command, some of our top generals, has reported that the number one medical reason for our military personnel being unfit to serve in the military is you guessed it, obesity. A shocking 27% of America’s fighting force in one recent survey were found to be overweight and over the regulatory limits considered the uppermost allowable weight that allowed one to be fit enough to serve in the U.S. Armed Forces.

Having served in the United States Air Force Reserved and spent several short tours in my annual active duty service at military hospitals- mainly Malcolm Grow Medical Center in Washington, D.C.- I of course also witnessed the gradual increase in the average weight of our nation’s troops. Our fighting men and women mirror the rest of society and struggle with the same temptations and the same obesogenic environment.

What is the solution? The solution is a radically different approach to health, fitness and weight maintenance in the military. All one has to do is spend a few days on any U.S. military base to see a pervasive culture and environment that promotes obesity. I believe there are many factors in action at U.S. military bases that lead them to be worse than most U.S. communities, cities, towns and schools in terms of their likelihood of promoting obesity. Why do I say this? Here are some key factors.

1. A culture that discourages work. Yes, let’s face it, as any long term military person will tell you, if they are being honest, there are an unbelievable number of people who are considered R.O.A.D. warriors. This means Retired on Active Duty. Ask some of your friends who are in the military and you will see there is a tremendously deleterious civil servant culture that incentivizes laziness and discourages productive work. More on this in other sections and chapters, but let be honest, any job that encourages people to sit, be less active and accomplish far less work in any given day than any civilian job would tolerate is not going to be conducive to maintaining a healthy weight.

2. Obesogenic food service. On the base where I would normally serve one could find several of America’s typical fast food restaurants with long lines in the drive through and a great many of the soldiers accessing the high calorie, high fat and especially the high carbohydrate fast food for their meals. Even the military food service often consisted of high carbohydrate meals, snacks, plentiful desserts, soda machines, snack machines and no real effort to discourage our fighting men and women from consuming all these calories.

3. A military that does not enforce its own fitness regulations. Nowadays, quite frequently, physicians like me will determine that a soldier is unfit for deployment only to find that they remain on active duty because of the command staff which does not want to bother with the paperwork or the termination procedure. Or, they really know that since no one really enforces these regulations anyway it doesn’t matter all that much if another soldier is vastly overweight and couldn’t run a 100-yard dash to save his life.

4. These are but a few of the dangers that America’s fighting forces face on their own home base and presumably many of these same factors continue in bases abroad.

5. An environment and culture that promotes screen time, power points, TV watching and less physical activity.

6. Very little awareness or education about the deadliness to the strength of the fighting force that is posed by high carbohydrate, high calorie diets. Very little information exists on bases. There is no real general awareness of the problem and thus no active effort underway to combat it.

Clearly the combat forces do much better with respect to weight maintenance. They are encouraged to maintain an active fitness regimen. They tend to be involved in a culture that is at the tip of the spear and does involve physical combat where personal fitness is at a premium, but it falls steeply downhill from there.

So if the number one threat to the fitness of our current fighting force is obesity, one would imagine that people concerned with national security would be interested in formulating a solution to this number one threat. I am guessing that with a thin fraction of the resources that are spent on the dozens of levels of bureaucracy in the U.S. military devoted toward preventing obesity that the results would be astonishing, a fitter, more effective, more serious fighting force protecting the United States of America.

The Brescia Marathon is coming on. Brescia is a lovely town surrounding a medieval castle in Northern Italy. I pegged the date of the Brescia Marathon on my calendar beginning back in 2009 and stuck with it despite my lack of preparation and training. I wish I could say I have been training religiously and was well prepared to run a personal best, but that is not the case. The winter months and lots of work have left me just hoping I can finish in four hours. We’ll see. It will be fun and exciting and I will have to brush up on my Italian.

The day was cool, mildly overcast, probably in the low 50’s, but calm with no winds. The sun peaked out after around 9:00, which is perfect because in Italy marathons do not start at the ungodly ours of 5 and 6 A.M. No, instead they begin at the rather humane hour of 9:30 in the morning. So after an early morning check-in we crowded to the start and began.

My first half split was respectable enough, 1:48, but I developed some foot soreness on the back half and slowed to a crawl coming across the finish line well over four hours. But, happily enough, I have my eye on some future races and hope that with the weather being nicer I will do a better job of preparing and training. I am sticking to my goal of a sub-3:30 marathon in 2010. So we’ll see!

Joanie has a great health show on the radio in San Francisco called the Joanie Greggains Show and I had the great privilege of appearing as a guest on her show this morning on March 27, 2010. We talked about Life Changing Weight Loss, the book, Joanie has some great questions about the inner motivation and the need to except internal change as a foundation for losing weight and keeping it off. We also talked quite a bit about obesity prevention among children and what it takes to fight that battle.

I think one thing many people in the public don’t comprehend is that times have changed and the environment surrounding our children is quite different now than it was thirty years ago. It definitely requires a much more active battle plan to prevent our children from becoming overweight and obese. It’s not just going to happen automatically. The environment is too rich in calories and carbohydrates and the environment also deters exercise and activity to such a great extent that most children are heading toward a path to overweight and obesity as they progress to adulthood. So as parents we must take a tougher line. We must cut against the grain of the school environments, the neighborhood environments, what is going on television and at our friend’s houses. We have to eliminate sugar beverages from the household, toss out all the snacks, candies, cookies and ice cream in the pantry and freezer and make those kinds of treats special occasion treats a couple of times a month, but not an everyday or every meal occurrence. We have to encourage ways for our children to get regular exercise and this can take some creativity given the demands and time pressures that most young students face and also the safety concerns that most parents have about letting children run loose in the neighborhoods. The battle can be won it just requires determination and a real effort.