Dear Dr. Benjamin

I had the privilege to hear and meet our Surgeon General, Dr. Regina Benjamin, at UAB yesterday as we kicked off National Nutrition Month with a great event sponsored by the Department of Nutrition Sciences. In one of the introductions describing the wonderful person that she is, Dr. Benjamin was described as the health care Santa Claus for the nation. She has been preaching a message of joyous health and working hard to bestow the gift of healthiness for all. As the nation's doctor, she has worked to deliver a message that our health care system should be focusing on health promotion and prevention of disease just as much as we focus on developing the best medical technology in the world for treating disease. Since we were there to focus on nutrition, a lot of her remarks dealt with obesity. I figured that I might follow up with a Christmas list of things I'd hope to see as we all try to fight the obesity issues we face.
My list for healthcare Santa Claus:

1. Prescriptions for healthy eating- as a primary care trained internist, I know and appreciate the benefits of modern medicine. Prescriptions for medications to control acute and chronic diseases are wonderful to have available; the insurance coverage for these medications is even better (when available). I would like to see us use prescriptions for healthy foods in a similar way. Let those of us with the appropriate training (physician nutrition specialists, dietitians, nurses, etc) prescribe healthy food options for those at risk for or those who have preventable diseases. The prescriptions would provide a voucher or some discount on the prescribed foods (primarily low energy dense fruits and vegetables, lean protein, nuts, beans, and healthy fats). By paying for these foods, we may save money on medications that don't prevent the conditions or expensive procedures that are needed because the conditions are out of control. We have an exercise is medicine movement that has been active for some time now…I see food as medicine as the next step.
2. Provide insurance coverage for obesity treatment by obesity specialists- I know that Medicare has announced that reimbursement for obesity counseling will be provided to primary care practitioners in the near future. Most of us still doubt that this will lead to effective treatment because the primary care practitioner has little training and fewer resources to deliver the type of therapy that has been shown to be most effective. With all of the great resources I have at my disposal and the primary focus of my career being obesity treatment and weight management, I still find it challenging to do the things we do. I would like to be able to prescribe the most effective treatment for my patients, regardless of considerations about the patient's ability to pay, but I can't because all of the effective medical therapies we have available are not covered by insurance. So, those who often need it most are forced into an alternative that may be less than ideal, even when they have good insurance. I'm not suggesting that primary care practitioners shouldn't be involved…I believe they play a critical role in raising awareness, helping patients make the connection between body weight and health issues, and providing referrals to credible treatment options. However, we need to develop medical and behavioral specialists (physicians, psychologists, dietitians, exercise therapists, nurse practitioners, PAs, etc) who can treat complicated obesity just in the same way as the surgical field has the bariatric surgical specialist.
3. Get rid of the junk- My last wish is for Santa Claus to get rid of the snake oils and phony treatments being peddled as "cures" for obesity. If we could limit the amount of time and effort being put into these supposed treatments that have no scientific evidence as being effective, our patients would save a lot of time and money. This time could otherwise be focused on developing the skills and knowledge necessary for people to take better care of themselves and develop healthy lifestyle habits. We've finally gotten the FDA to declare HCG treatments for obesity as fraudulent. Hopefully, this trend will continue, and we can elevate the practice of obesity treatment to a higher standard. I think my wish list item #2 is critical to seeing the evolution of treatment and disappearance of the snake oils.

Is that ALL I lost this week?!!!

If you have tried to lose weight before, you probably uttered the dreaded "P" word-- PLATEAU. A plateau, otherwise known as the lack of weight loss after doing a plan for a period of time, is not inevitable, if you're working with someone who knows how to guide you.

But this post really isn't about how to beat the plateau. It's more about how to not freak out if you think your weight loss is slowing down. Many of my patients anxiously compare week to week weight loss numbers, calculating every ounce of lost weight since the last encounter with the scale. I encourage everyone to weigh themselves regularly, especially if you are attempting to lose weight. Once weekly is good enough in my opinion. However, I don't want my patients to get overly concerned about the week to week difference.

Why not? The patient's job is to focus on implementing the weekly plan; my job is to focus on making sure we have the right plan that gets results. Try as you might, you can't control the number on the scale. Even if you do the same thing every day from one week to the next, the weekly weight loss will be different. This is due to a number of factors that are out of your control like how much water you retained that day, various hormonal levels, and metabolic changes occurring as a result of your ongoing weight loss. Unfortunately, losing weight is not a linear process.

As long as the average weight loss remains good, you know you're doing the right things. And those are the things you should continue to focus on-- daily food journal, consistently meeting your exercise goals, and achieving a good eating structure.

Don’t Let that Gym Membership Keep You from Being Active

Is your gym membership holding you back? Have you ever considered this question…it could be keeping you from being active on a regular basis.

Don’t get me wrong; having a gym membership is a perfectly reasonable way to gain access to a place that will allow you to exercise. But having the membership does not automatically imply that you will use it. The gap between ownership and usage is pretty large. There's a large group of people who are nodding their heads in agreement with me on this. These are the people who started 2012 with great intentions of getting into better shape and losing weight. Their first move was to jump on that local gym membership special. It seemed like such a good idea at the time, and it worked out well for the first month.

Then there was the change in the schedule for the daughter's dance lessons; or there was the unexpected job assignment that required some later hours; or (you fill in the blank).

Now it’s been 3 weeks, and you pass by the gym on the way home but haven’t graced them with your presence. In the meantime, you opt to do nothing until you can get back on track. After all, you are paying for this membership and you plan to use it…sometime. One of my patients once explained it to me like this—why go out and walk around the neighborhood or do something at home when he had this perfectly good gym membership that he should be using. He would feel guilty for cheating on the gym by exercising elsewhere.

Physical activity and exercise need to be SIMPLE, structured to MEET YOUR LIFESTYLE DEMANDS, and ENJOYABLE enough for you to look forward to the time. Trying to do the latest fitness craze won’t be successful for you if it’s too complicated for you or you loathe the idea of turning on that DVD. Feeling that you have to meet a pre-conceived idea about what physical activity or exercise is can hold you back from doing anything at all. If the gym membership isn’t working for you, don’t be afraid to drop it and find something you can do. Invest that money in a good pair of shoes and start a walking program or a Couch to 5K program.

This week, devise the simplest plan you can think of to get some higher levels of physical activity. It could be a 10 minute walk at work or a quick loop around the block before you head in the house upon your return home. Let's work on this for the week. Continue your daily journal and keep track of your activity levels. We'll come back with more on exercise this week.   

Smoke and Mirrors

Ok, the third week of our program is here. Now it's time to talk about food.

You've completed a food journal on a daily basis for the past 2 weeks and are starting to recognize some patterns by now. You understand that for every ACTION you take, your body responds with a REACTION that should be fairly predictable, now that you have some data. If you skip breakfast, you're starving by 1 pm. If you wait too long to eat, you make poorer choices. If you're really tired, you graze to keep yourself awake.

So what should you be eating? I'm going to suggest that for now, we ignore the number of calories that you should eat. Again, I'm not crazy, just evil. Here's the rationale for ignoring calories for now. I want you to focus on how to fix the structure of your eating, and this is NOT dependent on calories. As you may have noticed, the days that you consumed fewer calories and didn't starve yourself, you were more regular in the timing and spacing of your meals. Your portions were probably more consistent, and you likely avoided extremes of hunger and fullness.

We've become so calorie focused in our efforts to lose weight that we lose focus on what's important. We begin to implement smoke and mirror tricks to say we can eat whatever we want as long as we don't go over the calorie limit for the day. We trick ourselves into saying that we're "saving up" calories like we're about to make a down payment on a new car. As a numbers game, it may work for a while. Then the weight loss stops and no amount of manipulating those calories from the candy and ice cream will work to get it going again.

Rather than give you a calorie target to manipulate, I want you to use a simple method to get started with your plan of what to eat. Start by adding fruits and vegetables to your day based on the table below. 

Current number of fruits and vegetables per day	Number to add per day
< 2	2
2-4	3
5+	4

Add the fruits and vegetables in place of the highest calorie items you consume (for most of us, it's fried potatoes, juices and other sugar beverages, and desserts). Ideally you should have 5 eating episodes per day. If you have spaces in your day where you were not eating, add the fruits and vegetables there as well.

If you start here, this will naturally lower your caloric intake and keep you more satisfied throughout the day. You are simply swapping higher energy dense foods for lower energy dense foods, reducing calories without trying to cut the amount of food you are eating. Simple how it works...almost like magic!


Keep journaling to see the results...

Never Enough to Lose Weight

Routinely, I ask my patients what they need to be successful with losing weight. Invariably the responses include two things you will never have enough of—motivation and willpower. If you're banking on this to help you make a lifestyle change, you're setting yourself up to fail.
Why do I feel this way? Motivation can be misplaced and fleeting. Willpower by its very nature is inconsistent at best. When these two factors are the things you call upon to help you make better decisions and make changes in your lifestyle consistently, you will find that consistency is hard to achieve.

Let's deal with willpower first. The battle of willpower is something you will always lose. It's like gambling…you may get on a good roll, but if you do it long enough you lose. A misperception I hear all the time is that some people must have incredible willpower to stay thin or not eat certain foods. More likely is that these individuals manage their environment and avoid tempting themselves repeatedly with the things they are trying to limit. If I like to eat chocolate cake (and I do), and I only want to allow myself the option to eat it once a week, it makes no sense for me to bake a cake and leave it sitting on my counter top all week. Every time I walk past the cake, I'm going to think about it and have to expend mental energy to not have some. I may be able to do this when I'm at my best, but the next time I'm upset or really hungry or tired from working all day, I'll probably give in and make an exception. However, as soon as I finish that last bite, I'll resolve to NEVER DO THAT AGAIN.

Motivation is necessary, but only as a means to get you to reorder your priority list. Your motivation becomes sustained when you can recognize how the benefits of your lifestyle change outweigh the benefits of doing your default. When this happens, you make time for meal planning or exercise. You find ways to pack your exercise clothes for the business trip. You spend your time and effort doing the things that you care about most. If doing the things that are needed to make a lifestyle change and lose weight isn't important enough, you won't do it. The key phrase here is that you need to care about DOING THE THINGS. You have to care about the PROCESS just as much as you do the OUTCOME.
Losing weight is a challenging proposition for many, but very doable. Set yourself up for success by valuing the benefits of the small lifestyle changes you make (walking, eating better choices, journaling, good sleep) and by managing your environment.

 

My $0.02- Leveling off of obesity in US

Last week there was a lot of news around the fact that obesity rates seem to be leveling off in the US (http://www.npr.org/templates/story/story.php?storyId=122536128). Generally speaking, this is good news. No one really knows why this is the case, especially since we continue to find creative ways to eat butter at every turn (Exhibit 1: see Paula Deen's Fried Butter Balls).

If you take your own weight as an analogy for what's happening to the country, we might be able to understand some of the dynamics at play here. If you're newly married or just got a nice job, you will likely have more access to food, eat out a bit more, and have less time to exercise like you did before you had a partner or were expected to show up somewhere on time. The adjustment to this new lifestyle can take some time. In the meanwhile, you put on a few pounds until your new level of activity balances with the new pattern of eating you've established. This might be where we are as a country. Our new lifestyles, filled with computer screens, mobile phones, 3D televisions, and food anytime and anywhere, have caused us to put on some weight while we're reaching that new balance. Perhaps, that leveling off time has occurred.

However, the natural course of weight gain suggests that we shouldn't become content. We know that kids who are overweight grow up with a higher chance of being overweight as adults. We also know that we continue to gain weight with age; this is already evident in the fact that median body mass index is shifting higher already. And, we know that the environment will continue to produce more devices that promote sitting and highly palatable foods.

Two things buried in this story that most concern me: a lot of the health consequences are yet to be realized and not everyone has leveled off at the same spot. The pending diabetes epidemic that is soon to follow because of obesity will blow the lid off of health care costs in this country, and unfortunately, a lot of that burden will be in low-income and/or minority communities where obesity rates are as high as 56%, nearly 20% higher than the general population.

We've still got work to do.

Every Super Villain Has a Story

After having my name bantered about the blogosphere by several people, I figured it was time for me to take control of my story and tell my side of things.

You see, a couple of years ago I got labeled as the Evil Dr. Ard by a young man who shall remain nameless (to protect the identity of minors). However, his grandfather (Dean Harold Jones) is primarily responsible for initiating my turn to the "Dark Side." As I recall the story, he and his grandson were playing with action figures and Dean Jones, who had recently started the EatRight program at UAB, prompted him to come up with some nicknames for me. I'm sure his grandson said things like "Really Great Doctor" or "Super Man", but not being satisfied with those depictions of me, Dean Jones pushed for something a bit more sinister. Hence, you have the creation of the Evil Dr. Ard. (If you're interested in the whole story see Dean Jones is Losing It )

Well, being the popular guy that he is, Dean Jones got this nickname spreading around pretty fast. He told all the staff at EatRight and many of the other patients. He even paid Shonnie Wilson, one of our many outstanding OPTIFAST patients and author of another great blog- Diary of an Angry Fat Woman, to adopt the name. No matter how I try to shake the name, it seems to be sticking.

So, when you can't beat'em, you join'em. I'll be using my Evil Dr. Ard blog to share strategies to help you lose weight and keep it off. We work with individuals in the Birmingham, AL region on a daily basis in our award winning EatRight by UAB program, so I know that the fight to lose weight is a challenge. However, it's one that can be overcome with the right help. Our philosophy is that there is no magic bullet or one-size fits all approach. Everyone is different and may require some unique approaches based on those differences. We focus on the best medical evidence and technology to stay above the fray of fly-by-night weight loss plans that have no chance of working. What I plan to do with this blog is give you access to my expertise and opinion about how to tailor a plan for yourself.

The staff at EatRight will be assisting me with topics from time to time. We have a great team of professionally trained dietitians, exercise specialists, behaviorists, nurses, and physicians who provide a comprehensive perspective on what you need to build a successful weight loss plan. Please follow along and send your specific questions. I may be evil, but I'm always happy to help!