“You can make $20 per stool sample?” You would have thought I had won the jackpot! I just thought my colleagues and I were getting one over on the “Diarrhea Clinic” in Guadalajara, Mexico. I attended medical school there and was making a habit of “donating” regularly. What I did not realize was that I wasn’t just suffering from “Montezuma’s Revenge.” It wasn’t until I returned home that I learned I had Crohn’s Colitis, an often debilitating inflammatory condition of the GI tract characterized by abdominal pain, diarrhea, and rectal bleeding. It can often result in multiple surgeries to remove diseased colon and worse, colon cancer.
I spent the next several years on different medications including monthly infusions and weekly injections, all of which had many side effects. During my residency, I spent 10 days in the hospital due to a flare that resulted in over 20 abnormal stools per day, anemia, and almost constant pain. Despite this, I returned to my career determined to not let this disease slow me down.
I became a family doctor and practiced in the primary care setting for nine years. During that time, I discovered a passion for bariatric medicine. This evolved out of a desire to keep myself healthy which required changes in my diet. I found that eliminating processed foods and added sugars, except those naturally occurring in fruits and vegetables, helped me to keep my colitis at bay. With the help of an excellent gastroenterologist, I healed and continued to enjoy excellent health for many years. However, this hasn’t always been easy and this is where bariatrics comes back into the picture.
Taking care of myself every moment of every day requires a lot of work. It means pushing myself to exercise even when I am exhausted. It requires eating salads and protein when others are enjoying pizza or ice cream. It requires actively engaging in positive thinking and using tools like meditation, cognitive behavioral therapy and affirmations to manage stress levels. And I don’t always feel like doing these things. These are exactly the same challenges that, on a day to day basis, my bariatric patients experience.
I find that using these tools myself adds an additional layer of empathy and relatability to counseling my patients that otherwise wouldn’t be there. They often greatly appreciate this and find that I am able to help in a very unique way because I “get it.” I share my story with patients because when a doctor is able to be vulnerable, they realize they are not alone and that anything is possible.
Every day, I continue to discover new and powerful ways to care for myself, mind, body, and spirit. As my practice continues to evolve, I incorporate as many of these amazing modalities as possible. I hired a mind-body medicine physician to teach yoga, meditation and other skills who has inspired many of my patients. I have a behavioral counselor who keeps us all on track. But most of all, my patients, staff and I are all just trying to be the best version of ourselves on this human journey. I still struggle regularly — as do my patients — but we all have found better ways to be in this world. And because of that, I have found this work far more gratifying than anything I could have imagined and I believe my patients are better for it.
The idea of obesity is a difficult subject to broach on many levels. The term itself is loaded with stigma, and people who suffer from this condition can become resistant to even hearing the word, let alone talk about it. The shame and anticipation of judgement can be disabling, and yet the language we use when discussing weight is so limited. What can health practitioners do to break down the wall?
In a study published in a 2012 issue of the journal Obesity, researchers asked 390 obese adults in primary care settings in the Philadelphia area to complete a questionnaire about the terms that are most and least acceptable to describe excess body weight. Out of the 11 terms that were offered, “fatness” was rated as the most undesirable, followed by “excess fat,” “large size,” “obesity” and “heaviness.” (The most preferred terms were simply “weight,” “BMI,” “weight problem” or “excess weight.”)
These words encompass the majority of terminology currently used in health care to describe excess weight. But in an effort to change how physicians and patients engage with the topic of obesity, the American Association of Clinical Endocrinologists, or AACE, and the American College of Endocrinology, or ACE, have proposed a new diagnostic term to describe obesity: Adiposity-Based Chronic Disease, also known as ABCD.
“Right now, obesity is relegated to a simple construct of having a [body mass index] over 30,” says co-author Dr. Jeffrey Mechanick, a professor of medicine and medical director of the Kravis Center for Cardiovascular Health at the Icahn School of Medicine at Mount Sinai in New York City and past president of AACE. “But the word obesity doesn’t confer sufficient information about the disease risks.” ABCD on the other hand, focuses on a complications-centric approach to diagnosing, categorizing, and treating overweight.
The categorization takes into account a number of measures. In addition to BMI, this new system also takes into account the person’s waist circumference, waist-to-hip ratio, fat identified on advanced body imaging techniques such as ultrasound and MRI, and perhaps inflammatory markers on blood tests. The proposed model also includes three distinct stages:
Stage 0: The person is carrying excess weight but doesn’t have health complications from it.
Stage 1: The person is experiencing mild to moderate complications — such as prediabetes or slightly elevated blood pressure — due to excess body weight.
Stage 2: The person has more severe complications – such as type 2 diabetes or significantly high blood pressure – that are related to carrying excess weight.
What category a patient falls into would inform treatment, and would also increase the likelihood that a physician would focus on treating not just weight related complications, but also the excess body weight itself.
This new model will hopefully not only create a less biased way for physicians to engage with patients about their weight; it will also hopefully be a way for weight loss treatments to be more readily covered through insurance by having this new diagnostic term being incorporated into the medical coding structure — such as the ICD-10, or the International Classification of Diseases.
How we talk about obesity matters. And perhaps a better way to talk about obesity is to not talk about “obesity.” Not in the way people are used to hearing anyway. What are your thoughts?
Source: U.S. News
Blog written by Vanessa Ramalho/Robard Corporation
Good news: Medical providers are finally starting to address obesity and its impact on their patients’ overall health. Bad news: Without a standard to look to for how to discuss weight with their patients and what the best treatment options may be, providers run the risk of fat shaming their patients, leading to unintended negative effects.
A review of recent research presented at the 125th Annual Convention of the American Psychological Association looked at how unconscious bias against overweight patients can impact how physicians interact with them about their weight, leading to increased stress for the patient. This stress, combined with feelings of shame, can cause patients to delay treatment and even avoid interacting with health care providers altogether. While providers always mean well, the way in which patients are approached about their weight can make all the difference when it comes to discussing medical concerns with sensitivity.
With obesity only recently being identified as a disease — with links to more than 20 chronic conditions (and growing) that are still being researched — it’s hard to know the best way to proceed with overweight patients without a standard and clear medical protocols to refer to as guidance. You’ve taken the step in acknowledging the importance of addressing obesity with your patients, but where do you go from here?
First off, it is important to acknowledge that no one is the expert at everything. If obesity treatment is not something you have focused on in the past, there can naturally be a learning curve as far as how to discuss it with your patients, and how to move forward with treatment. Working with an experienced partner in weight loss can not only save you time, but it can also help you provide the highest quality care.
We invite you to begin learning about how to speak with your patients about their weight with our complimentary webcast, How to Speak to Patients About Obesity. Learn directly from other doctors and peers in the field about what works, so that you can continue to elevate your standard of care while saving yourself and your patients both time and money.
Good news: If you’ve committed to providing the best care to your patients by choosing to treat obesity, you’re not alone. And we’re here to help.
Source: Science Daily
Blog written by Vanessa Ramalho/Robard Corporation
Getting healthy and losing weight is not an easy endeavor — especially, if you are not following a mental diet. So much energy and focus tends to go into the physical components of weight management, but the mental aspects are just as vital. I would like to propose a “Mental Diet” to go along with the physical aspects of weight management.
The morning can be a critical compass to direct your focus for the day. Even if you are not a “morning person” that is full of energy, it is important is to start your day off with intention. This means that you will set aside time for self-care before too many responsibilities or distractions consume your morning. The morning is actually the best time for exercise or meditation, even if it is for five minutes, as you will have less excuses/distractions and more “willpower” in the morning. As the day progresses, we deplete our “willpower tank” which tends to result in an inability to tackle difficult tasks in the evening. So, the ingredients for a good mental breakfast include: At least five minutes of exercise or meditation, self-focus, gain insight and perspective on the day and start the day after taking care of yourself first.
It is important that you schedule time to break for lunch. If you are the type of person that gets busy and easily distracted, you will want to set an alarm to remind yourself to take a break. We are such as fast-paced society that we may not pay attention to how much and how fast we are eating. It’s not uncommon for people to engage in “mindless” eating while sitting at their desk, in front of the TV or driving — suddenly you realize that the food is gone and you have not paid attention to satiety. Instead of just go through the motions of putting food in your mouth, focus on eating slowly and truly paying attention to each bite and monitoring how we feel. The ingredients for a healthy mental lunch include: 15-30 minutes to recharge by refueling with a calm, mindful meal or shake.
You need to have a moment to digest the day. It is important to recognize that “emotional eating” and cravings may increase toward the end of the day. Unfortunately, you may have used most of the energy from your “willpower tank” and begin to want sweets or snacks after dinner. After a long day, “rewarding” yourself with unhealthy foods may sound like the perfect way to unwind. However, indulging in unhealthy foods will only leave you craving more and potentially feeling guilt and remorse. Instead of trying to “eat” your emotions, talk it out or journal your thoughts and feelings. As you prepare for sleep, limit your time with “screens” such as TV, phones and computers and start to focus on relaxation. So the healthy mental dinner includes: Reduce the mental weight of the day by writing down three things that went well for the day and if there is anything that you might need to do for the following day.
Behavioral change and extensive patient education materials are interwoven into all of Robard’s weight loss programs. If you’re a medical provider and would like more information, click here.
Blog written by Devin Vicknair, Ph.D., LPC, Behavioral Health Coordinator at Gwinnett Medical Center: Center for Weight Management.
Why should a busy healthcare provider take time out of their day to treat obesity when their patients are dealing with so many other health issues? This seems to be the prevailing question among many providers, despite obesity’s 2013 designation as a disease. There are so many other diseases and ailments that need to be treated, so why obesity?
The answer: Because we can’t afford not to! And that applies to time, money and the health of your patients.
It’s true that chronic diseases suck up the majority of healthcare resources; 75 percent of all health care costs are linked to chronic conditions. People with chronic conditions are the most frequent users of health care in the U.S., and they account for 81 percent of hospital admissions; 91 percent of all prescriptions filled; and 76 percent of all physician visits. Chronic disease is widespread, and it’s only getting worse. By 2025, chronic diseases will affect an estimated 164 million Americans — nearly half (49 percent) of the population
In response to the growing concern over chronic disease, many healthcare providers and hospitals are investing thousands of dollars in resources and time to implement multi-level treatment plans targeting chronic conditions. But the question many advocates are forgetting to ask is: What is one of the most common links between many chronic conditions?
The answer: OBESITY.
Obesity is associated with significantly increased risk of more than 20 chronic diseases and health conditions that cause devastating consequences and increased mortality. Consider the following statistics:
• In the often-cited Framingham Offspring Study, obesity was responsible for 78 percent of cases of hypertension in men and 64 percent in women
• The well-known Nurses’ Health Study of more than 44,000 women found high waist circumference resulted in a two-fold increase in coronary heart disease
• More than 85 percent of people who have type 2 diabetes are overweight, and more than 50 percent are obese
• Overweight and obesity are associated with increased mortality from diabetes and kidney disease, resulting in over 60,000 excess deaths per year
And this is just the tip of the iceberg. Obesity, in many cases, is the direct cause of many of the chronic conditions that we are spending so much time and money treating. Many of these conditions can be prevented, delayed, or alleviated by simply treating the cause, not just the symptoms. Research shows that modest weight loss (five to 10 percent of body weight) can reduce the risk of developing chronic conditions dramatically, and this amount of weight loss is achievable through various evidence-based medical obesity treatment models.
Not only can obesity treatment save physicians time and money by decreasing healthcare costs associated with comorbid chronic conditions, it has also been shown to be a proven revenue generating model, with real financial benefits. In a climate when we’re unsure about where we will stand with insurance and Medicare, it is imperative for healthcare providers to proactively look for new and innovative models to save time and money, and ultimately, to save lives.
Are you still asking yourself, “Why treat obesity?”
Sources: Partnership to Fight Chronic Disease, Hospitals & Health Networks, Stop Obesity Alliance
Blog written by Vanessa Ramalho/Robard Corporation
Have you ever thought there must be more to losing weight than just dieting and exercise? Well, it turns it you are right! Gaining and losing weight can be due to many things, for example: Sleep deprivation, nutritional imbalances, genetics, environmental toxins, gut flora imbalances, food addictions, allergies, and inflammation.1
Frequently ignored is the impact of hormones on weight and metabolism. Hormones determine what your body does with food; therefore, balanced hormones are crucial to controlling weight
In men and women, hormone production declines with age which can trigger a sluggish metabolism and weight gain. Body shape changes (almost always an indicator of hormonal imbalance) with fat appearing around your middle, belly, breast, and arms.2 Hormones affecting weight in both men and women are cortisol, insulin, thyroid, estrogen, progesterone, and testosterone. When any of these are imbalanced, hormonal disorders ensue causing weight gain and or difficulty losing weight.
Stress — real or imagined — throws the body into panic mode and cortisol is released into the bloodstream. Cortisol raises blood sugar and breaks down fat for energy. This response is lifesaving when faced with life threatening situations. When the immediate stress ends, cortisol rises, leading to craving for fatty, salty, sugary foods to replenish the source of energy that was just depleted. Then cortisol falls to normal levels. Prolonged stress leads to continuously high levels of cortisol which causes continual excess calorie intake. Since these calories aren’t needed immediately, they get deposited as abdominal fat.3 Chronically elevated cortisol keeps blood sugar elevated which can lead to insulin resistance.
Sugar (glucose) stimulates the release of insulin which carries glucose into cells to be used as fuel. When cells have received enough glucose, excess gets stored as fat, especially in the belly and buttocks. Insulin resistance is when the body produces insulin but cells are less sensitive to it. As a result, the pancreas will pump out increasingly more insulin, but the insulin is unable to push glucose into cells. This excess circulating insulin causes sugar cravings, increased appetite, and weight gain.
This hormone regulates the metabolism of every cell in the body. When the thyroid gland is not making enough of this hormone, it’s called hypothyroidism. Hypothyroidism causes a slowing of most bodily functions. Sometimes, people have symptoms of low thyroid including fatigue, hair loss, sluggishness, weight gain and or difficulty losing weight. However, their lab tests are normal. 4 This is a source of great stress for individuals who know something is wrong but the cause is not obvious. Thyroid hormone needs to be suspected and tested properly.
Testosterone, Estrogen, and Progesterone
As men and women age, testosterone levels decrease, leading to a loss of muscle and bone, accumulation of belly fat, and decreased metabolism. The effect is more severe in men because their testosterone levels are much greater to begin with. Ovaries produce less estrogen and progesterone in women starting as early as age 35. When estrogen is not in correct balance with other hormones (primarily progesterone), weight gain can occur. Signs of estrogen excess are weight gain around the abdomen, hips, and thigh, water retention and abdominal bloating. Estrone, the main estrogen in menopause, shifts fat from hips to abdomen. Progesterone helps the body utilize and eliminate fat and increases metabolism. Excess progesterone production relative to estrogen leads to an increased appetite and fat storage. 5,6
To prevent weight gain from hormonal imbalance:
1. Limit carbohydrate intake
2. Reduce stress
3. Have hormones levels checked and balanced
4. Take a probiotic
5. Exercise 45 min., 5 days/week
To learn more about medical weight loss and how it might be able to help your patients control the effect of hormones on weight and metabolism, click here.
1. Smith, P., “Why you can't lose weight: why it's so hard to shed pounds and what you can do about it.” Garden City Park, NY: Square One Publishers, 2011
2. Smith, P., “What You Must Know about Women’s Hormones,” Garden City Park, NY: Square One Publishers, 2010
3. Epel, E, et al., “Can stress reshape your body? Consistently grater stress-induced cortisol secretion among women with abdominal fat” Psychosomatic Med 2000; (62):623-632
4. Brownstein, D., “Overcoming Thyroid Disorders.” West Bloomfield, MI: Medical Alternatives Press, 2002
5. Kalkoff, R, et al., “Metabolic Effects of Progesterone “Journal Obstetrics Gynecology, 1982: 142-146
6. Vliet, E., “Women, Weight and Hormones.” New York: M. Evans & Company, 2001
The journey doesn’t really end once you’ve hit your weight loss goal. Once you achieve your desired weight, another goal is automatically set: Keeping the weight off. Some may find this more difficult than losing the weight to begin with, and according to some research there could be some medical reasons behind that.
The Endocrine Society recently released a new statement recommending more research to understand what causes difficulty with long-term weight loss. The statement suggest that it could be more of a biological issue as opposed to a dieter’s unwillingness to continue to do what earned them the weight loss to begin with.
Authors of the statement believe that once the dieter has lost the weight, the combination of decreased energy expended while hunger increased is the perfect recipe for weight regain. “Our therapeutic focus has traditionally been on achieving weight reduction. Most patients can do this; what they have the most trouble with is keeping the weight off,” says Michael W. Schwartz, MD, of the University of Washington in Seattle, and the chair of the task force that authored the statement.
Obesity is an awfully expensive issue in America. According to the Centers for Disease Control Prevention, it costs an estimated $147 million a year to treat obesity. That amount includes treatment for those that lost the weight and regained it. So the question is, what can be done to keep the weight off?
Your best chance at maintaining the weight loss is to going into it with a plan. The beginning part of the process will likely be the most difficult, just like it was when the journey originally started, but with the right focus and the right people behind you it can’t be done.
Although the statement issued by The Endocrine Society emphasized learning the factors for regained weight, that isn’t the only thing they felt deserved further research. Other issues that they felt merit more research were: brain imaging to better understand appetite and feeding behavior, effect of socioeconomic status on obesity risk, the role that diet composition plays in the development of obesity, and more.
Source: The Endocrine Society
Blog written by Marcus Miller/Robard Corporation
A major reason for the failure of current
medical treatment for “overweight” is that “weight” problems often are
actually eating problems. Higher weight may be due to genetic loading,
metabolic or hormonal conditions, neurotransmitter imbalances, chronic
dieting and weight cycling, or other causes, but it often occurs because
people are eating in ways that are out of sync with appetite cues for
hunger, pleasure and satiation. To resolve this problem, eating
disorders’ therapists have been successfully using psychology of eating
approaches for more than three decades and it’s time for other health
care professionals to follow their lead.
comes in several varieties, including emotional eating, mindless eating,
and binge-eating. Usually patients have more than one form of eating
dysfunction and often engage in all three types. Underlying them all is
anticipated or actual distress (generally felt as anxiety or bodily
tension) lessened by the act of eating, which prevents or reduces it.
Discomfort might come from obsessing all evening about the leftover
lasagna in the refrigerator and keeping busy to refrain from eating it,
then finally scarfing it down in one fell swoop before falling exhausted
into bed. Or, distress might arise in a flash, driving someone to
mindlessly polish off three cookies in a four-pack, in spite of having
reached satiation after having consumed only one. In broader clinical
terms, this dysregulated dynamic could be called obsession (intrusive
thoughts about eating or distress about refraining from eating) followed
by compulsion (the act of eating), which reduces the anxiety caused by
the intense food craving. Thus, is habit formed, for who wants to
experience ongoing internal angst when it could be made to disappear in a
delicious twinkling. This dysfunctional dynamic overrides “normal”
eating appetite cues: to eat when hungry, choose foods that are
enjoyable, eat with awareness and an eye toward pleasure, and stop
eating when full (quantity) or satisfied (quality).
Here is how dysregulated eating plays out in emotional, mindless or binge-eating:
Emotional eating is done to avoid, prevent or reduce emotional distress
which may be caused by internal or external stress, memories, or simply
experiencing mildly unpleasant or uncomfortable feelings. Emotional
eating is meant to cheer you up or calm you down. Eating a pint of Ben
and Jerry’s ice cream might act as a pick-me-up and be the highlight of a
boring Saturday night alone or, alternately, help soothe rattled nerves
after your boss chews you out in front of your entire department or you
finally mail in your taxes minutes before the federal tax deadline.
Such eating has a distinct, specific purpose: to re-regulate emotional
dysregulation by tuning it up or toning it down. It also can serve as a
prophylactic to unwanted feelings such loneliness, anger or
disappointment. Why feel bad when you can, instead, eat something that
2. Mindless eating is just that—snacking or
grazing through what’s in your food cabinets or refrigerator on
auto-pilot. Or it could play out as overeating because you’re not paying
attention to fullness or satisfaction cues. Mindless eating is done as
if you’re in a trance and is usually not driven by any one specific
discomfiting emotion, unless it’s boredom or the desire to avoid tasks.
It’s done because there is food somewhere to be had. You think of it or
see it and you eat it. It’s that simple, no thinking required.
Unconscious eating is also born of habit: before you flop down on the
sofa to watch TV, you automatically gran a bag of chips or you keep
eating simply because the food is in front of you. Overeating is another
form of mindless eating. When it’s all gone, you’re done, and not
3. Binge-eating is classified as a Feeding and Eating
Disorder in the Diagnostic and Statistical Manual of Mental Disorders.
It involves eating an excessively large amount of food in a short period
of time—often rapidly, with little awareness, to well beyond full—“on
average, at least once a week for 3 months” without the ability to
control intake, followed by feelings of guilt, shame, or disgust (1).
Bingeing is a self-driven activity that takes on a life of its own, an
act accompanied by feelings of frenzy, madness and desperation. In its
aftermath, the stomach feels distended and aches and you are wracked
with guilt, shame and remorse.
To understand patients’ specific
eating problems, health care professionals need to ask questions about
their state of mind before, during and after eating. Moreover, patients
need to hear that they are not bad, permanently defective or societal
outcasts because of their dysfunctional eating patterns, and that they
can resolve them by obtaining emotional and psychological support via
therapy and intuitive-eating or health coaching, as well as through
groups, workshops, books, blogs, podcasts and videos tailored to healing
(1) American Psychiatric Association, ed. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (Washington, DC: American Psychiatric Association, 2013), 350.
Please note that this article is intended for informational and
educational purposes only. It is not intended as a substitute for the
medical or psychological assessment, advice and individualized care from
your personal health care provider or mental health professional.
Please consult with your personal health care professional regarding
your individual situation and concerns. For health care providers, the
information contained herein may not be applicable or appropriate for
every patient. Paige O’Mahoney, M.D. and Deliberate Life Wellness LLC
specifically disclaim any and all liability arising directly or
indirectly from the use of any information or products contained in
these materials. Mention of products, techniques, methods, resources,
approaches, or other entities in our materials is for informational
purposes only and does not indicate endorsement.
According to a recent article by CNN, 2 billion adults and children worldwide – the equivalent of one-third of the world’s population -- is overweight, and the U.S. is among the countries most severely affected.
The article reflected the results of a study published in the New England Journal of Medicine that included 195 countries and territories. The study also notes that an increasing number of people globally are dying from comorbid conditions related to obesity, such as cardiovascular disease.
“People who shrug off weight gain do so at their own risk -- risk of cardiovascular disease, diabetes, cancer, and other life-threatening conditions,” said Dr. Christopher Murray, director of the Institute for Health Metrics and Evaluation at the University of Washington, who worked on the study. “Those half-serious New Year’s resolutions to lose weight should become year-round commitments to lose weight and prevent future weight gain,” he said in a statement.
The conclusions of the study do important work in highlighting obesity as a growing concern in global public health as a chronic condition in and of itself; however, researchers also hope to educate the public at large about the link between obesity and other diseases in the hopes that preventative measures and treatment can help people avert early mortality. Almost 70 percent of deaths related to an elevated BMI in the analysis were due to cardiovascular disease, killing 2.7 million people in 2015, with diabetes being the second leading cause of death.
The study notes that obesity rates rose in all countries studied, irrespective of the country’s income level. “Changes in the food environment and food systems are probably major drivers,” they write. “Increased availability, accessibility, and affordability of energy dense foods, along with intense marketing of such foods, could explain excess energy intake and weight gain among different populations.”
While obesity rates continue to rise in the U.S., with approximately one-third of our own adult population being overweight or obese, we are luckier than other countries to have access to medical resources that can help curb this epidemic. Now more than ever, the need to begin treating obesity is becoming a public health imperative and medical providers are being called on to lead the charge. (Interested in learning how obesity treatment affects population health? Register for this free webcast!)
Treating obesity is easier than you may think, especially when you work with an experienced partner. Robard takes all the guess work out of treating obesity, and provides all the tools and resources to get you started within 60 days. Join in the conversation that’s happening, not just around the country, but around the world, and learn more about medical weight management today.
Blog written by Vanessa Ramalho/Robard Corporation