The Doctor Weighs In

by Pat Salber

I was pretty shocked when I first heard about diabulemia. This is a practice some teens and young women with Type 1 diabetes, are using in order to lose weight. They purposely underdose their insulin allowing their blood glucoses to skyrocket. The excess blood glucose is eliminated in the urine. “Traditional” bulimics purge excess calories by forcing themselves to vomit. Diabulimics purge excess calories by underdosing on insulin and peeing out unmetabolized glucose.

Girls and young women with diabulimia will tell you they feel really crummy as their glucose levels increase and they increasingly rely on metabolizing fatty acids for energy instead of glucose. The end result of underdosing insulin is a state known as diabetic ketoacidosis, that is characterized by high blood glucose and increased acidity of the blood -- a potentially fatal condition.

Here is how one young woman describes (on the internet) what it feels like to be chronically hyperglycemic and ketotic:

“…I skipped all my insulin but two units at night, sometimes only one. I would consume up to 40,000 calories a day, purge maybe half, and pee the rest out. My muscles deteriorated. My hair fell out, and many nights I couldn't breathe.

In February (2003) I had a heart attack after taking up to 80 laxatives a day for three months, so I knew I had to quit that. Even Standford [sic] didn't know what to do. They sent me home and told my Mom to expect to find me dead in my bed one day soon.

My days became consumed with EKGs, getting labs taken, and doctor visits. I was so dehydrated that if I did venture to take my insulin I would gain so much as fifteen pounds of water overnight, so I quit trying.

I became too weak to go anywhere. I would cry for no reason, low cries, because I could barely breathe from all the acid in my lungs. My heart constantly raced, I developed G.E.R.D. [reflux], my labs were always off, and I was very weak. I would sleep 20 hours a day, the other 4 hours I spent between the kitchen and the bathroom, eating , drinking, peeing and sometimes puking. My speech became slower, and it was an effort to even think.

The scariest day was when I lay awake in bed, too weak to move, and I heard my Mom whisper to my brother, "go make sure your sister is breathing".

I didn't know it at the time, but they were planning my funeral.”

Overtime, continual underdosing of insulin also contributes to the development of complications of diabetes, such as retinopathy (diabetic eye disease), nephropathy (diabetic kidney disease), and neuropathy (diabetic nerve damage). It is no laughing matter. Diabulimia is as serious as other, more “traditional” eating disorders such as anorexia and bulimia.

Here is an internet quote from “Jennie,”a women who has “practiced” diabulimia for more than 10 years:

“ I have been suffering for diabulimia for 10 years now.I became diabetic when I was 17 and quickly found out on how to keep my weight down by not taking my shots. 2 years ago I went into diabetic coma for 3 days. The doctors made my family come in and say goodbye because I was not suppose to make it. I thought that would wake me up but it hasn’t. I am 6 feet 1 inch and weighted 130 pounds for the past 10 years. I see the pain in my family eyes but for some reason I just cant get my diabetes under control. I have so much damage to my body that I feel more like a 90 year old instead of a 27 year old. I have completely ruined my chances of ever having children and I have to take a pill everytime I eat in order to digest my food. I have tried many times to get my diabetes under control but everytime I start taking my insulin regularly I gain about 20 pounds of water weight. This gets so frustrating that I just give up. If any one knows a solution to the water weight gain, PLEASE let me know. I take water pills that my doctor gave me but it does not help.”

Like anorexia and bulimia, diabulimia is a body image disorder. Girls and women with this disorder need specialized help to overcome this serious, and potentially fatal, condition. Not all doctors, diabetes educators, or behavioral therapists are adequately equipped to help individuals with diabulimia. If you are suffering from this disorder or if you have a loved one or friend with this disorder, you need to seek help from experts.

The National Eating Disorders Association (NEDA) has an information and referral hotline (800-931-2237). You can also find therapists by using the referral form on their website. Parents, family, and friends can a learn how to support their loved one with an eating disorder through the Parents, Family, and Friends Network.

I did not find any specific reference to diabulimia on the National Eating Disorder Association website, so I suggest interviewing the therapists to find out if they have expertise in this disorder prior to making an appointment. In addition, it is crucial to involve your treating endocrinologist so that he/she can help provide support for management of diabetes and any complications.

Readers, if you have other ideas please post them in the comments section.   Your suggestion could save a life.

by Pat Salber, MD

While not nearly as high profile as TV’s “The Biggest Loser,” the National Weight Control Registry has helped researchers gain a better understanding of what it takes to lose a significant amount of weight (at least 30 pounds) and keep it off (for at least a year).

The Registry was started in 1994 by Rena Wing, Ph.D. from Brown Medical School, and James O. Hill, Ph.D. from the University of Colorado. According to the NWCR website, it is the largest prospective investigation of long-term successful weight loss maintenance in the country.  Individuals who meet the criteria of “successful losers” self-report information about their dietary, exercise, and other lifestyle habits. Although not a randomized, controlled clinical study (the “gold standard” in research), there is nevertheless some valuable information to be gleaned from this weight control registry.

According to results reported by lead investigator, Suzanne Phelan, PhD, at the June 2-5, 2007 Endocrine Society meetings in Toronto, 89% of 4,200 registry participants lost weight with diet and exercise. Ten percent used diet alone and 1% exercise alone. The average age of the losers was 47 years old; 77% were female, 95% Caucasian, 64% married and 82% college-educated.

Nearly half the registrants lost weight on their own, not relying on outside help such as weight loss programs or counselors. Strategies included restricting certain foods, such as deserts (87%), portion control (44%); counting calories (43%), counting fat grams (25%), and using liquid meal-replacements (20%).

The August 2007 issues of DOC News, a publication of the American Diabetes Association, reports that Phelan and her team identified a number of other key strategies:

• Low cal, low fat. Participants reported an average energy intake of about 1,300 calories per day with about 20-30% of those calories from fat. To put this in perspective, this is about the amount of calories you get when you lunch on a Big Mac with medium fries and a Coke.
• Lots of physical activity. These losers reported burning about 2,600 calories per week (walking 5 miles or engaging in 30-90 minutes of physical activity per day).
• Limited TV viewing. More than half of the participants watched fewer than 10 hours of TV per week. Only 21% watched more than 21 hours weekly. The average American watches about 28 hours/week. [Note: Not only did these folks have more time to exercise, they also may have been able to avoid the compulsive eating associated with eating while viewing.]
• Frequent self-weighing. Seventy-five percent reported weighing at least once a week. Forty-four percent weighed daily and 31% weekly.   Click here for more information on this important weight control behavior.
• Dietary consistency. Participant tended to eat the same type and amount of food on weekends and holidays as during the work week.
• Limited dietary variety. Many participants restricted their choices within food groups.
• Don’t skip breakfast. Almost 80% of participants reported eating breakfast every day.
• Limited fast food. Participants rarely ate fast food – consuming less than one such meal per week (see bullet one to see why this is important!)

National Weight Control Registry participants did not take their weight loss and maintenance for granted. They had to work at it. But they did report that the perception of the effort required decreased over time. It becomes a way of life.

If you are interested in learning more about the National Weight Control Registry visit www.nwcr.ws/ . If you are a successful loser, consider becoming a registrant - help contribute to our national knowledgebase of what it takes to take it off and keep it off.

by Brian Klepper

I routinely hear well-intentioned people say that, if Americans, and most particularly kids, would just become more responsible for their own health and start eating right, then our obesity and diabetes epidemics would turn around.

I don't think this is going to happen, at least not anytime soon. The blunt truth is that, to a large degree, we have an obesity epidemic because Congress ensures that the food industry has free rein with their marketing practices.

Late last year, Pat Salber wrote a post – she had a corresponding video commentary on Medscape – on advergaming. An important study had been released on the Kaiser Family Foundation website that detailed how food companies were using the Web to influence kids' eating behaviors, building on their TV advertising tactics. Here's a quote from the press release:

The report, “It’s Child’s Play: Advergaming and the Online Marketing of Food to Children,” found that more than eight out of ten (85%) of the top food brands that target children through TV advertising also use branded websites to market to children online. Unlike traditional TV advertising, these corporate-sponsored websites offer extensive opportunities for visitors to spend an unlimited amount of time interacting with specific food brands in more personal and detailed ways. For instance, the study documents the broad use of “advergames” (online games in which a company’s product or brand characters are featured, found on 73% of the websites) and viral marketing (encouraging children to contact their peers about a specific product or brand, found on 64% of sites). In addition, a variety of other advertising and marketing tactics are employed on these sites, including sweepstakes and promotions (65%), memberships (25%), on-demand access to TV ads (53%), and incentives for product purchase (38%).

In 2005, Consumers Union issued a report on the food industry's advertising campaigns. That press release headline read:

Certainly, the data say we're losing the war on obesity. Data from two National Health and Nutrition Examination Surveys show that the prevalence of obesity in adults (aged 20–74) more than doubled between the end of the 1970s to the early 2000s (from 15.0% in the 1976–1980 survey to 32.9% in the 2003–2004 survey).

Children and teens also grew significantly plumper. The prevalence of obesity in children 2–5 years rose 2.5 times, from 5.0% to 13.9%; for those aged 6–11 years it nearly tripled, from 6.5% to 18.8%; and for the 12–19 year olds, it more than tripled, from 5.0% to 17.4%.

It's worth noting that, while obesity has intensified throughout the country over the last several decades, certain areas, like the South, are consistently worse than elsewhere. This is traceable in part to regional dietary habits that, of course, long predate the food industry's influence, as well as to the role of poverty.

Percentage of Obese Americans - 2005

BMI > 30, or ~ 30 lbs. overweight for 5'4" person

Source: Centers for Disease Control, Behavioral Risk Factor Surveillance System, 20006 

(If you're interested in seeing the CDC's 20 year (1985-2005) annual trend data on overweight by state, go to http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm, and look for the link that says "Download the Obesity Trends Map." Play the slides in quick sequence. It's very alarming to watch as the entire country lights up, reflecting how quickly we're getting fatter.)

The reality is that most of us are susceptible to the marketing, and can't withstand the barrage of enticements. And they're everywhere. Every day, Americans are bombarded by come-ons for fast, prepared and junk foods. This diet has become part of many people's regular routine. The industry now vies to subsidize school districts in exchange for the unrestricted ability to advertise, put in vending machines and have their products available in cafeterias. They have developed books for very young children with appealing characters to create brand loyalty early on,

And except for the unhealthy part, what's not to like? These foods are cheap, readily available and, lets face it, all that salt and fat taste really good. Only the most optimistic among us can imagine that, unless something dramatic changes, we'll be able to reverse our love affair with bad food. Nor will any of the other developed and developing countries that all have the same problem.

The food industry has virtually unrestrained promotional access because Congress has willfully ignored their role in the obesity problem, preferring instead to argue that if people were just more responsible as individuals, they'd get this under control. (A quick glimpse of our Congressional representatives shows that, when they preach restraint and self-control, they're talking about us, not themselves.)

 The threats are to the national health and the national pocketbook. At the moment, for example, diabetes and related conditions alone cost Americans about $165 billion a year, about 8 percent of the national health care spend. And we're just getting going. As the population gets fatter, this is going to be a blockbuster national health care problem. Nobody will be able to afford what, in today's terms, we'll be expected to pay to keep all these people alive, semi-well, and consuming.

Congress has good reason to advocate for the food industry, in the form of millions of dollars in lobbying funds that go to buy influence. Skeptical? Go to www.opensecrets.org, the site of the Center for Responsive Politics, a non-partisan group dedicated to accountability in government, and do some checking yourself. Big dollars from the food, beverage, candy and restaurant industries to Congress, part of the larger $2,5 billion dollars that were distributed in 2006 to our 535 representatives. This is the way it is with virtually all special interests. Most effective groups lobby. Why? Because it works!

There are, of course, precedents for change. Congress decided that the tobacco and alcohol industries would be limited in where and how they could advertise, actions that have had profound impacts on America.

It's absolutely in the national interest to turn this problem around. But unless we have dramatic change from elsewhere – chemical concoctions that make junk food taste as good but have no ill effects, or some miraculous national consciousness-raising (Not impossible. Check out the teen fitness program Dance Dance Revolution or consider how the green movement is sweeping across the globe.) – we won't change our obesity and chronic disease problem. To fix that, we'll need a change in how the food industry behaves. And to get that, we'll have to change how our government works.

(The same is true, by the way, for health care reform, but that's another post.)

Brian Klepper is a health care analyst based in Atlantic Beach, Florida. You can reach him at bklepper@gmail.com.

Alli (pronounced "ally") was approved by the FDA in February and will hit the shelves tomorrow.  About half of people in clinical trial studies were able to lose approximately 5% of their body weight in six months.  The medication is supposed to be taken three times a day and will cost about $50 per month. 

Sounds good?  Yeah, but the devil is in the details -- or, in this case, in the side effects.  

This "fat-buster" may not become a blockbuster for its manufacturer, GlaxoSmithKline.  Here's why from an "oldie, but goodie" TDWI post from February 7, 2007:

If you can deal with the "icky" factor, Alli may help you lose weight

Pat Salber, MD

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Is "Accomplia" the next silver bullet in weight control?     (Note:  On February 13, 2007, a U.S. Food and Drug Administration panel Wednesday unanimously rejected Acomplia, a weight-loss drug from Sanofi-Aventis  on concerns the drug increases the number of psychiatric events like depression and suicidal thinking among users.

The results of the 2007  Food and Health Survey* are in and they show…guess what? Most people want to lose weight. Seventy-five percent of individuals surveyed said they are concerned with their weight. This is up from 66% in 2006. 70% said their reason for making dietary changes is “to lose weight,” and 56% said they are actively trying to lose weight. This is interesting as it seems to reflect reality.  According to the latest scientific evidence, 66% of Americans are overweight or obese.

Where there is a disconnect, however, is people’s knowledge of the relationship between "calories in" and "fat on."  Although 60% of Americans who are trying to lose weight say they are doing so by reducing the number of calories they consume, only 11 percent were able to correctly estimate the number of calories they should consume in order to accomplish that goal. Interestingly, most people underestimated the number of calories they thought they should consume, but that was offset by the 34% of Americans who admitted they actually consume more than they estimated they needed.

It was heartening to learn that most people (69%) say they use food and beverage packaging elements when deciding whether or not to buy and eat food products. However, the most commonly used element was the expiration date. Sixty-six percent said they used the Nutrition Facts Panel (aka the Nutrition Label) and most used the calorie information and the information about fats, particularly Trans fats. The problem is they are not paying attention to serving size – only 49% did so, down from 63% in 2006. Knowing the calories per serving does not translate into decreased caloric consumption if you do not understand serving size.  And, as I have pointed out before, serving size is not intuitive or even easy to understand (how many of us can estimate 1 oz of cashews or 30 grams of Bran Buds?).

Of the 56% of people surveyed who said they were trying to lose weight, 79% said they had increased or began to engage in physical activity; 69% had reduced portion sizes of meals and/or snacks, and 60% had reduced the number of calories. But snacking remains a national pastime with about half of those surveyed saying snacks are an important part of an overall healthful diet. Almost all Americans (93%) eat at least one snack per day with the mean number of snacks being 2.5 per day. Ten percent of those surveyed said they ate 4-5 snacks per day and 7% ate 6-7 per day. Two percent admitted to eating 8 or more snacks per day (how do they have time for anything else??).

Many people perceived foods and beverages to have health benefits, often beyond what medical evidence supports. Specifically, the following percentages of the surveyed population strongly or somewhat agree with the following statements:

• Specific foods improve heart health – 80%
• Specific foods improve physical energy or stamina – 76%
• Specific foods improve immune system function – 71%
• Specific foods improve mental performance – 66%
• Specific foods improve the risk of getting specific diseases – 65%

Can’t you just see the glint in the food manufacturers’ eyes (and the banners proclaiming health benefits plastered all over our food packages)? Food lies masquerading as food science – but, you will have to wait for that is the subject of a post yet to come.

The last item from this survey that I want to mention is that American’s perceived their health to be better in 2007 than in 2006. Thirty-nine percent of those surveyed said their health was “excellent” or “very good” compared to only 33% in 2006. And even more people (58%) said they were “extremely satisfied” or “somewhat satisfied” with their health status – this is somewhat puzzling since that means some people are satisfied with health that is less than “very good.”

So there you have it – a glimpse into how we perceive food, fat, and facts.

*The Survey, sponsored by the International Food Information Council (IFIC) Foundation and organization affiliated and supported by “the broad-based food, beverage, and agricultural industries.” The first survey was produced in 2006 based on a telephone survey of Americans performed in November 2006. The 2007 Survey is based on a telephone survey in March of 07.

Pat Salber, MD

If you liked this post, you may also enjoy reading:

We are fat and getting fatter

Big meals lead to big mistakes in calorie estimation

Yesterday’s New York Times ( May 8, 2007 ) carried a front page article by one of the paper’s premier science reporters, Gina Kolata. The article, titled “genes take charge, and diets fall by the wayside”, is an excerpt of her newly published book “Rethinking thin: the new science of weight loss- and the myths and realities of weight loss”. In the article she reviews the succession of studies started in the late 1950’s by Dr Jules Hirsch at Rockefeller University , which culminated in recent studies demonstrating conclusively that the tendency to weight gain and obesity is genetically determined. Ms. Kolata describes the heartbreak of dieting, a constant struggle of losing weight, trying to maintain, gaining, dieting again, and so on and so on. Psychological testing showed the toll this struggle can take; people are perpetually unhappy, many are chronically depressed, some are suicidal.

One of the major conclusions Kolata cites is that each body has a metabolic “comfort zone”, and dieting to go below this zone is painful, metabolically unsound, and essentially futile.

I admit I haven’t read the book yet, but if the excerpt reflects the message of the book, I strongly disagree.

Why?

For several reasons:

· Yes, a metabolic range specific to each body makes a lot of intuitive sense. But to accept it we need to see the genetic/molecular/physiological mechanisms. The evidence is still not in. Having been around the block a few times, I never cease to marvel at nature outsmarting us, and upending our ‘no brainers’ and ‘slam dunks’.

· The fact that genes control our metabolism does not mean that they are the sole players. Genes interact with the environment, and the outcome of this interaction is all important. The old debate of nature vs. nurture set up a false choice; nature and nurture operate together in biology. The best example is diabetes type 2. An individual may have the genes that predispose to this disease. But it will be expressed clinically only if that individual overeats and exceeds a certain BMI.

· The most obvious evidence that genes are not the final word in weight regulation is the recent obesity epidemic. If  "obesity genes",which undoubtedly have been with us for eons, were such an all-controlling factor, why is it that only in the last few years did this epidemic break out? The answer is well-known: we take in a lot more calories, and we exercise a lot less. Yes, the genes were there all along, but they were not expressed.

I believe that research into the genetic basis of obesity and diabetes is absolutely essential. But it should not become an excuse for the fatalistic attitude of “it’s beyond my control”. Counteracting and ovecoming the genetic dictate may be unpleasant, tough, exasperating—but it beats the alternative.

Dov Michaeli MD, Ph.D

Living with diabetes can be tough. There is so much stuff to learn and so many things to do. It can be hard to keep track of everything. And, it can seem overwhelming, particularly around the time you are first diagnosed.

That’s why I am recommending if you have diabetes or if you know someone who has diabetes, get your hands on a great little book, "Know your Numbers, Outlive your Diabetes.” It is written by Richard Jackson, MD, a doc at the world famous Joslin Diabetes Center and Amy Tenderich, a professional journalist who also happens to have diabetes (check out her website: www.DiabetesMine.com).

Five Numbers to Know

This book points out that there are five essential tests everyone with diabetes should have:

• Hemoglobin A1c (often just called A1c). This is a measure of the average blood glucose levels over the previous two to three months
• Blood pressure
• A full lipid profile – not just a total cholesterol, but a full panel that determines LDL, HDL (often called good cholesterol), and triglycerides (blood fats that go up after we eat)
• Microalbumin: a test of whether diabetes has cause kidney damage
• A Retinal Eye Exam to asses whether there is any evidence of eye damage

The authors explain what these tests mean and how often you should get them. What I particularly like is that they stress that you need to be the owner of these numbers:

“These numbers belong to you, and knowing them is your right, as well as critical to your health – just like the numbers in your bank account.”

They even give you advice on how to get your hands on these numbers:

“It is your right to request them, so don’t feel intimidated about speaking up….A call to the office should suffice…” but they recommend, “make the call at a time when you have some other paperwork to do, and use a speakerphone so that you don’t get too frustrated trying to get through or waiting on the line.”  It seems like they may have had some first hand experience calling doctors' offices.

Don’t feel like you have to do everything at once

There is a chart in the book that the authors titled “Your Diabetes Health Account.” Using it, you can compare your numbers to the certain targets in order to determine how well you are doing. For example, if all of your numbers are at optimal targets, you can see that you have five “bags of money” in your diabetes account. These are your health assets. If your tests are past due or way out of whack, then you have health debts which should be paid off as soon as you can. By taking a close look at your diabetes health account, you can pinpoint your focus of what you need to do to get your health account back in balance.

They counsel, “Rather than depressing you, knowing your priorities should boost your confidence; you have learned exactly which health factors are most important for you right now and which may not need attention on an everyday basis."

Take Action

Once you learned your numbers and assessed your diabetes health account, it is time to take action. The book provides strategies for how to improve every one of the five essential factors. The tips provided are practical, but detailed enough to help even a novice diabetes-self-manager get started.

The first part of the book lays out the strategies for improvement and the second part dives deeper into the diabetes toolkit they are helping your prepare. Advice on diet and exercise are clear and easy to follow. For example, one strategy for portion control, an important element of a weight loss diet, is to share a meal. Pretty simple, huh? Or you can divide your food before you start to eat and have it put into a “doggie bag” before it automatically goes into your mouth to end up around your middle. Avoid buffets. We all know we eat too much at buffets…it is simply too easy to pile it on the plate.

Other good information

There are chapters on diabetes drugs and diabetes devices as well as information about low and high blood sugar. The chapters are well laid out with important information placed in boxes.

Sprinkled through the book are stories of real people living with diabetes, like Loretta, a kindly grandmother with type 2 diabetes who lost weight and brought her hemoglobin A1c into control or Marci, a “high-powered New York City account executive" who enlisted her husband to help her deal with “diabetes frustration.”

Empowerment

Yeah, I know, some of you hate the “empowerment” word. But that is what this book sets out to do. It arms you with information. It helps you understand your particular needs and challenges. And it provides guidance on how to go, one step at a time, from where you are now to where you want to be in terms of diabetes health.

So, there you go. If you have diabetes, if someone you care about has diabetes, or if you are a health professional working with people with diabetes, then buy (and read) this book. You will be glad you did.

Pat Salber, MD

It isn’t often that you get a good chuckle while reading a medical journal. But today I did. I am on a plane again (not United Airlines, thank heavens) .  I am flipping through some recent issues of the Journal of the American Medical Association (JAMA). One article catches my eye. It describes the case of a woman with polycystic ovary syndrome (PCOS).   I decided to read it in detail to see if there was anything new in the cause, diagnosis, or treatment of women PCOS since I last wrote about it – there wasn’t.

PCOS is one of the most common causes of anovulatory infertility. Women with the condition have irregular periods, and cycles where they don’t ovulate. They also have physical findings related to hyperandrogenism (excess hair growth, acne), and they are frequently overweight or obese. Many are insulin resistant and some will go on to develop Type 2 diabetes. PCOS is risk factor for that condition.

As I read through this case study, I found that I didn’t really agree with the physician expert’s take on the case. The patient, “Ms R,” was worried because she had gained weight despite a pretty rigorous exercise regimen (she bikes 20 miles a day and swims regularly). She was described as 59 inches and 122 pounds with a BMI of 25. Did I do the math right? That means she is quite short to be packing around 122 pounds. She says she eats the same as she always has, but at the ripe old age of 27, she finds that she has gained weight.

The doctor discussing this case kept saying it was good that Ms R was “normal” weight, but we never learn whether she is slender or. in fact, is “abdominally” obese. And, he doesn’t mention whether he actually assessed how much she eats in a typical day or if he just believed her uncritical self-assessment. Before I started logging my food intake, I probably would have told you that I ate the same amount of calories as I did when I was thirty and thin. But once I started weighing and measuring and counting and recording my intake, surprise, surprise, I was actually quite an oink-oink. The weight started dropping when I decreased my intake to a caloric amount more appropriate for my height.

This article also does not mention Ms R’s ethnic background. Asians and South Asians can have abdominal obesity (and associated insulin resistance) at BMIs that are considered “normal.” It isn’t the BMI that is the problem, it is the abdominal, and in particular, intraabdominal or visceral fat – that is the problem. (I am willing to bet Ms R has plenty of fat around her middle.

Although her most recent fasting glucose level is normal, this woman is at risk for Type 2 diabetes because her father had it. And, as the doctor discussant pointed out he didn’t test her to see if she was glucose intolerant. You have to do a glucose tolerance test (drink a sugary substance and have blood drawn at regular intervals after that) to detect this type of insulin-resistance-related abnormality in glucose metabolism.

So I am already a little annoyed by the way this case is being discussed, but then, on the last page, this doctor says that he would counsel the patient that she appears to have a mild case of PCOS (not sure if this is the equivalent of doctors who tell their patients that they have a “touch of sugar.”) He recommends she keep on taking birth control pills that help her have regular periods and counteract the hair growth and acne cause by the increased androgen levels characteristic of PCOS (I agree). He enthuses that Ms R has “done an admirable job at weight control.” Yeah? But he did say he would refer her to a dietitian for further counseling on diet.

And then, comes the comic bombshell: He says, “I would counsel her against excessive “Googling” of PCOS on the web. I kid you not…I can hear it now, “No excessive googling, dear, you might learn something I don’t agree with?”

I have already written about Google’s ability to diagnose. This doctor has taken “Googling” to a new level by including this admonition in his case discussion in a respected medical journal. What a hoot.

Pat Salber, MD, MBA

Cheerios for breakfast?  The box says only 110 calories per serving.  But, that is without milk or sugar or fruit. 
An official Cheerios "portion"

So when I say, "I only had a bowl of Cheerios for breakfast.".  You may think.  She had a serving.  That's only 110 calories.  Very good! 

If you remember to add in the skim milk calories, it is still a reasonable 150 calories.  But one cup of Cheerios is a pretty small portion and it is pretty boring with out the fruit.

So, here's is what I really eat.  I fill the bowl up.  It is a small bowl after all.  Then I put in some fruit (4 medium sized strawberries in this case).  Finally, a sprinkle or two (or three) of brown sugar.  Then I pour on enough milk to moisten it all (a full cup) and what do I have? 

What I really eatHmmmm.  Let's add it up:

      2 cups of Cheerios               = 220 cal

      1 cup of skim milk              =   80 cal

      4 medium strawberries   =   25 cal

      2 loosely packed teaspoons of brown sugar (yum)  =  34 calories

      for a GRAND TOTAL OF 359 calories, triple the amount of a "serving." 

Portion wise?  or portion lies?

A reader takes issue with my positive presentation of VBLOC. Read on:

"Pat - I am surprised you would be advocating for VBLOC that is in the same category as bariatric surgery and does not "require any change in diet or exercise"! I personally believe that most chronic illnesses and conditions such as obesity are emotion-based - including my own, Crohn's - and that drug/technology interventions -are ineffective or short-lived solutions....of course I am not mainstream in this thinking...”

I think many of you who follow my TDWI posts know I am a strong advocate of diet and exercise. Sometimes, I feel like the diet and exercise nag. But I am also a pragmatist who recognizes that some people can't/won't/will never be successful in achieving a healthy weight with diet and exercise as their only options.”

There are alot of reasons why people fail good old fashioned lifestyle change. Some people have a physiologically stronger appetite drive than others and yes, some people with the thrifty genotype may be better at storing excess energy as fat. Some people preferentially store bad fat (aka visceral fat) and end up with the complications of cardiometabolic syndrome. And some folks have socioeconomic factors that make it harder to lose weight via life style changes alone - they live in unsafe neighborhoods, work long hours, and don't have easy access to healthy foods like fruits and veggies.

I think we make a mistake when we send a message that there is only one right way to lose weight; that is, eat less and exercise more. Yes, we should all do that if we can. But, medical and surgical approaches, including bariatric surgery are viable and valuable options for some people.

"Memoirs of a Fat Broad" by Wendy Hanawalt is a powerful story that opens your eyes to how hard it is to live with fat and its metabolic consequences. Wendy describes in detail what it is like to be really, really fat and she tells us how a doctor who suggested gastric by-pass saved her life. She was suffering so many complications of her obesity that she had contemplated suicide. That is not to say she didn't have problems after her surgery, she describes her life after her gastric by-pass surgery in a follow-up article to her Memoirs....nothing in life is completely free after all but compared to her life before, she says, post-by-pass and post-weight loss, the changes in her life are "miraculous."

So, diet, yes. Exercise, absolutely. But, if you can't get where you need to be without adding something more aggressive, I say keep your options open. Scientifically-proven medical adjuncts to weight loss may help you get to goal.

Pat Salber, MD, MBA

Lose weight without diet or exercise! You’ve seen ads for devices and drugs that purport to melt away the fat without much help from you. They’ve been around for years and they make some companies a ton of money. You really like the idea (right?), but deep down inside, you know they don’t really work.

Typical Hoodia ad - take a pill and look like me!Hoodia, an extract of a cactus from the Kalahari desert is all the rage. It is supposed to block your drive to eat and slash calorie intake in half. The problem is there are no good medical studies that I can find to show that it works. Further, some Hoodia products have been studied and found not to have any Hoodia in them – remember that unlike the pharmaceutical industry, the nutritional supplement market is like the Wild West -- anything goes.

So a small article out of Australia caught my eye, mainly because of the involvement of Surgeon James Toouli, a Flinders’ Professor of Digestive Surgery who has written a ton of medical papers and even a couple of surgical text books. Apparently, his medical center in Adelaide is involved in testing a new obesity treatment called VBLOC. VBLOC stands for Vagal Blocking for Obesity Control. It involves the use of a pacemaker-like device that sends low power electrical signals that block the vagal nerve.

The vagus nerve has a number of different functions in the control and function of the gastrointestinal system. It is the nerve that allows communication between the brain and our digestive system. It not only plays a role in stomach function and control of digestive juices, but it also plays a role in the sensation or hunger and fullness.

In the old days, before the availability of effective drugs for peptic ulcer disease, people with intractable symptoms used to undergo an operation called a vagotomy. Many of these people lost their appetite, had reduced absorption of nutrients from the gut, and lost weight after the operation although they eventually gained both back for reasons that aren’t entirely clear.

The medical device behind VBLOC is made by EnteroMedics, a Minneapolis company whose tag line is “Orchestrating Obesity Solutions,” (pretty nice). According to information on the company’s website, it is important to only block the vagus nerve intermittently so that the body does not develop ways to accommodate for the loss of information from the nerves that occurs when it is completely cut, such as in a vagotomy operation.

The company has farmed out its clinical trials to a variety of institutions. Prof. Toouli’s lab is one of the research centers that is testing whether or not the device works. The Mayo Clinic in Rochester, Minnesota is another center studying the device. If you want to participate in a clinical trial of the device, you can sign up online. Your information will be forwarded to one of the testing centers to determine if you are eligible to participate (Note: this is information only on my part and should not be considered a recommendation to participate. If you want to learn more about why your should participate in clinical trials, check out this link.)

According to the online news report that caught my eye, early results from Prof. Toouli’s lab are quite promising.
Graphic of VBLOC implantation The first person (of ten people) implanted with the device lost 20 kilograms (that’s 44 pounds) “without changing her dietary habits or exercise regime.” Prof. Toouli is quoted as saying: “These nerves [the vagus], control the movement of the stomach and they control some of the secretions used for digestion, and by blocking these intermittently, what it does is it slows down the aching of the stomach so consequently people don’t feel as hungry.”

Sounds too good to be true. Well, it may be. But then again it may actually end up working. We have to await the results of studies, such as the ones described above to be subjected to peer-review and published in reputable medical journals. Meanwhile, there are some peer-reviewed animal studies that support the contention that vagal nerve stimulation may cause weight loss in pigs (pigs!)

As exciting as it is to read that a handful of people lost weight with the device, it does not necessarily mean the results will hold up when larger numbers of people are tested in randomized controlled trials (the gold standard in medical research). The history of device and biotech companies is full of stories of companies who had promising early results only to fail when subjected to rigorous testing.

I think the best news of all about this story is that obesity research is now attracting the best and the brightest, innovators who understand the complex regulation of appetite and body weight. This fuels hope that one day we will have an effective treatment that doesn’t require starvation and sweat. Until then, I'll see you at the gym.

Pat Salber, MD, MBA

On February 7, the Food and Drug Administration (FDA) approved the first drug for weight loss that is scientifically proven to be effective to be sold over the counter (AKA OTC). That means you can buy it when and where you want. It also means experts deemed the drug safe enough that mere consumers can decide for themselves whether or not they want to use it.

The drug’s generic name is orlistat. It will be marketed under the brand name of Alli. (Alli?) The brand name of orlistat available by prescription is Xenical. It turns out it Xenical has not been a blockbuster for its company, Roche, despite being relatively safe and modestly effective – the average weight loss is 5-10% of body weight).

Here’s why. orlistat works by blocking the breakdown and absorption of fat from the intestine. If you eat a lot of fat while taking the drug, it does not get broken down and absorbed from your gut. That means it stays inside of the intestines and is eventually passed (if you know what I mean) as a greasy stool that floats in the toilet bowl, generally making a mess. The unmetabolized fat that you ingest can also be passed when you fart (sorry, have flatulence). That means smelly, oily, fecal stains on your underpants. I am sorry to be so graphic, but that is just the way it is. Oh, by the way, if you take orlistat, you also have to take a multivitamin because orlistat-induced fat malabsorption can impair absorption of fat-soluble vitamins, vitamin A, E, D and K.

For some people who are motivated to lose weight, these nasty side effects are enough to make them avoid fatty foods. That is good since fat is the biggest calorie bomb of all of the nutrients we ingest. However, lots of folks continue to eat fat and choose instead to give up the orlistat instead.

The FDA, in its wisdom, has approved over-the-counter orlistat to be sold in 60 mg doses, half of the usual prescription dose of 120 mg – like consumers can't figure out that taking two OTC pills is the same as taking one of prescription dose pills. Duh?

Roche has licensed orlistat OTC, Alli, to GlaxoSmithKline (GSK), a pharmaceutical company with lots of experience marketing directly to consumers. Be prepared, there will be, for sure, a barrage of TV and magazine ads with smiling, singing, dancing slim (and beautiful people) telling us how they got slim and beautiful by taking Alli.

According to the NY Times, GSK will package Alli capsules with seven pocket reference guides that “provide advice on meal-planning, what to order when eating out, a fat and calories counter, and a journal for recording daily food intake. GSK will also make available a website, myalli.com, where “customers taking Alli will be able to log in, track their progress and obtain personalized advice.” Alli will sell for $2-3 per day (that is $60-90/month). So, these additional health educational materials are no big deal when it come to profit for GSK.  I am willing to bet that these additional weight loss “aids” will cost the company just a few pennies on the dollar.

And, let’s be honest, folks who turn to Alli probably already know what they should and shouldn’t eat. This is not about a of lack of knowledge.  It is, rather, a matter of will power. Frankly, some of us may be motivated enough to lose weight so that we are willing to take a pill that causes fat malabsorption.  To avoid that, we may forgo dietary fat in order to avoid an oily “discharge” – to the degree that happens, orlistat will be “part of the solution” even though it clearly creates some other problems -- at least for the person who has to do the laundry.

Cynicism aside, overall, I think it is a good thing that orlistat will be available over-the counter. But, heck, I also think statins (lipid-lowering agents) should also be over the counter. We need more low-cost, convenient options to help folks get healthy.

And, by the way, the consuming public can buy lots of things more dangerous than orlistat and statins. As a former emergency physician, I can tell you that aspirin and Tylenol overdoses were far more common causes for ER visits than complications related to statins or concern about fecally stained undies. But no one is advocating changing  these common pain-killers from OTC to  prescription drugs. Why not?  It should come as no surprise that our approach to pharmaceuticals is not grounded solely in patient safety – rather the real driver is$$$$.

While I do think, in the long run, we need a more sustainable solution to the country’s “obesity crisis,” orlistat OTC is one small step that may help some motivated folks lose weight. If you can deal with the “icky” factor, maybe, just maybe, Alli is a drug for you.

An article in the NY Times declares that one in eight adults in NY City has diabetes. That is 12.5% of the population or 700,000 people. Lest you feel relieved that you don’t live there, let me remind you that the rest of the country is not all that far behind. Overall, about 10.3% of Americans have diabetes and about a quarter of them don’t know it (yet). 

An additional 24% of adults in NY (and in the rest of the country) have abnormally high blood sugars that have not yet reached diabetic levels.  This condition is known as pre-diabetes.

Not too many years ago, the diabetes rate was 6%--half of the current NY rate. But our self-indulgent ways have caught up with us. Too little exercise, too many calories plus too much stress adds up to an epidemic of obesity, particularly abdominal obesity.  Abdominal obesity, especially visceral obesity, is linked to the development of Type 2 diabetes in genetically predisposed individuals.

It’s just a “touch of sugar.” Why all the concern? Because diabetes and it precursor, pre-diabetes, are the most familiar manifestations of a constellation of metabolic changes, known as cardiometabolic syndrome. Other manifestations of this syndrome are high blood pressure, dyslipidemia ((high triglycerides and low HDL (“good”) cholesterol)), clotting abnormalities, and problems with inflammation. People with cardiometabolic syndrome, even if they haven’t yet developed full-blown diabetes, have an increased risk of heart attacks and strokes.

Cardiovascular disease, strokes, and peripheral vascular disease are all very expensive conditions to treat in our technologically sophisticated health care system. These conditions already occupy some of the top slots when it comes to where our health care dollar are spent. So imagine what is going to happen now that the rates of diabetes have doubled (with no end in sight).

So, this epidemic of diabetes and pre-diabetes is not just a health care issue that burdens individuals and their families living with the disease. It is a looming societal problem that threatens to bankrupt our already fragile health care system. It could cause health care insurance premiums to escalate even further, impacting not only employers who provide coverage, but also public payors, like Medicaid and Medicare.

It is time to get deadly serious about doing something about prevention. We need to rapidly move to institutionalize regular exercise programs in school and at work. And we need affordable, easily accessible healthy eating options. That means we must be willing to regulate, legislate, and maybe even implement taxes (oh, oh, the tax word!) that can get us to where we need to be. Failure to do something now will almost certainly result in huge adverse financial consequences that will ripple through society in the not too distant future.