Weight Loss Strategies – What Should Doctors Say to Patients?

Yesterday’s Times offered two distinct perspectives on weight loss. One, a detailed feature on gastric surgery by Anemona Hartocollis, details the plight of a young obese woman who opts for Lap-band surgery. In this procedure, surgeons wrap a constricting band of silicone around the stomach so that patients will feel full upon eating less food than they might otherwise. Allergan, the company that manufactures the device, admits to these complications on its website.

The other, a discussion of resolutions and will-power by John Tierney, considers strategies for sticking to diets, exercise regimens and other good intentions for the new year. Within this piece lies a distracting story of an obese (375 pound) hedge fund manager whose gastric band failed to keep his appetite in check. When he landed a project in Las Vegas and feared regaining weight, he aimed high – to lose 100 pounds, outfitted his hotel suite with a gym, and hired a personal trainer to stay nearby and keep him on track in terms of meals and exercise. This costly “outsourcing” of will-power is, obviously, not an option for most people.

Tierney does offer some reasonable suggestions – like setting realistic goals, weighing yourself daily, Tweeting your weight, logging into a weight-loss website, not freaking out if you blow your diet one day, etc.

Both articles are well-worth reading.

But here’s the thing – how do doctors fit into this picture? In the last few years that I was practicing hematology, I saw a few patients who had B12 deficiency after gastric bypass surgery. These patients turned out to have multiple problems after their stomachs were cut so they’d eat less food. For some it was helpful; I saw individuals who lost over 150 pounds. Still, the surgery was huge and risky. I can’t fathom having recommended it to a patient whom I cared for, unless perhaps I’d personally witnessed her struggling to lose weight for over, say, 8-10 years.

Because most people, if inspired or starved, can lose weight. This may sound cruel, but what if the doctors recommending the procedure don’t have sufficient confidence in their patients?

The Lap-band is sold as a safer alternative, but upon reading the story (an anecdote, but telling), you have to wonder what are patients’ expectations of the procedure, and how well do they understand the likely risks and benefits. Who are the doctors who tell them about the procedures, and what are their ties with industry (besides the obvious link of surgeons who do the surgery and recommend it).

Like patients with cancer, patients with obesity may feel desperate. But unlike cancer, obesity is almost always a function of choices we make, and for which I think we have to hold people responsible.

Doctors, maybe, should expect more of their patients. “Yes, you can lose 30 pounds over the next 2 years,” one might say. And they might talk about strategies, Tierney-style or otherwise, based on the patient’s preferences and personality. “Come into my office once each month for a weigh-in” might be very effective in persuading patients to shed pounds. A technician could do the monthly measurement in the office or medical home, and the doctor or nurse might follow-up with an encouraging email. Imagine that!

So why don’t more general practitioners, including pediatricians, offer this sort of weight-loss approach? Is it too simple a strategy that doctors don’t find it interesting? Or not sufficiently profitable for the office or medical center?

No answers, just thoughts upon reading, for today –

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New York City Mayor Bloomberg Promotes Healthy Lifestyle Choices

In the city where I live, it’s hard to buy a muffin at a Starbucks without stepping back from the counter and reconsidering. Swallowing 460 calories for a minimal-nutrient breakfast seems foolish.

So I eat fewer muffins than I used to. The posted nutritional tidbits, however imprecise, on the contents of pieces of quiche, slices of pizza and cups of thick soup, stick with me when I travel, and at home.

That’s me, just n=1.

Yesterday the mayor gave a speech at the U.N. He’s quoted in today’s WSJ health blog:

In a speech to the U.N. General Assembly earlier this week, Mayor Michael Bloomberg rattled off New York’s achievements: a tough anti-tobacco campaign that made cigarettes, at about $11.20 a pack, the most expensive in the nation and led to a reduction in adult smoking rates to 14%  in 2010 from 22% in 2002 (the national rate is 19.3%). A ban on artificial trans fats. Calorie labeling in restaurants. Ad campaigns linking soda consumption to obesity, and a national salt-reduction initiative.

No wonder, he noted, that life expectancy for New Yorkers has risen faster and is higher than for Americans overall, having increased 1.5 years to 79.4 years from 2001 to 2008.

These are just correlative findings. But they support, circumstantially and in my mind, for one, that public policy can impact human behavior and health.

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Mars Chocolate Company Advertises With Broccoli


MARS chocolate ad

The other day, over lunch, I was reading the Sept 2011 issue of the Atlantic and came upon this image on p. 37. According to the not-so-fine print, this full-page broccoli fix is sponsored by MARS chocolate, North America, website listed:

www.marshealthyliving.com

So we can find out about nutrition from the company that manufactures M&M’s, Snickers, Twix, MilkyWay and 3Musketeers.

Part of a trend –

The New Yorker recently ran a profile of PepsiCo CEO Indra Nooyi that almost persuaded me the super-sized soda-based conglomerate does the right thing in the healthy living department.

Kinda like Shell, Exxon and BP doing good work for the environment.

Got it?

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New Fairway Delivers Fresh Produce to My Neighborhood

On the local, national and nutritional fronts:

How refreshing, in this heat, that Fairway opened a new store on East 86th Street yesterday. Coincidently, Michelle Obama’s push to eliminate “food deserts” – places where it’s hard to find affordable fresh produce and other healthy foods – was highlighted this week when several big retailers signed on to the initiative.

PHOTO CREDIT: DNAinfo/Amy Zimmer (Manhattan Local News)

There was a carnival-like atmosphere on the sidewalk outside the new store, which occupies a large, multilevel space where there used to be a Circuit City (bankrupt, closed) and a Barnes & Noble (moved). Inside, I made a rough tally of unpackaged (6 varieties), nectarines (4), plums (3), string beans (4, including a yellow variant I’ve never seen before), potatoes (11 non-sweet, +  yams and “yellow yams”), onions (7), mushrooms (5), not counting the pre-packaged kinds), peppers (11), tomatoes (9) and beets (3).

You get the picture: if you’re looking for a fresh ingredient and it’s available anywhere New York, chances are you can find it here. Downstairs, there’s fresh fish, meat, coffees, baked goods, and tons of regular and organic grocery items. I counted 22 types of pure honey, not including differently-sized items of the same brand and flavor, and then stopped. Upstairs, there’s a limited selection of prepared foods, a competitively-priced smoked fish counter, a wide cheese selection, dried fruits, nuts and more.

I spent a while meandering through, and heard only positive comments. The shoppers seemed happy; the employees registered glee. A woman next to me on a briskly-moving line summed up the consensus: “This is the best thing that’s happened to the neighborhood in years.”

We should all be so lucky –

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A Recipe for Fresh, Low-Fat Blueberry Muffins

This morning I noticed we had too many blueberries in the fridge. So while my husband went out for a run, I opened the windows wide (to cool the apartment), turned on the oven and made some fresh breakfast food.

fresh muffins, Sunday morning

It had been two decades or so since I’d baked anything like these. My recollection, mainly from my suburban childhood, was that muffins involved a fair amount of work; we used to pull out a mix-master with beaters, a flour-sifter, and all sorts of stuff that then had to be cleaned. That was far too much work for me this morning.

So I simplified and halved an old recipe I’d hand-written sometime back in my Moosewood years. And I adjusted it so there’d be less sugar, and swapped whole milk for skim.

Preparation time: 8 – 15 minutes, depending on your proficiency in the kitchen; Baking time: 30 minutes

Ingredients (for 8 small muffins):

1/4 cup softened butter (vegetable oil is OK, too; some people say that improves the texture and taste of the baked goods, but I’m not convinced and try to minimize chemicals in my cooking.)

2/3 cup sugar

1 large beaten egg

1/4 cup skim milk

1/4 teaspoon salt

1 teaspoon baking powder

1 cup flour (I used organic, which I happened to have, and didn’t bother sifting it)

optional: cinnamon, ~ 1/4 teaspoon

ripe blueberries, about 2 cups, washed

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Preparation:

1. Preheat the oven to 375 degrees (F)

2. Use a fork to smash the butter at the base of a deep, medium-sized bowl;

3. Add the beaten egg and mush everything together;

4. Add in the sugar, stir with a fork or large spoon;

5. Add the milk, swirl everything together with the spoon;

6. Add the salt and baking powder, mix thoroughly at this point to evenly distribute the salt and powder;

7. Add the flour, and mix again.

(This step completes a basic muffin batter.)

8. Now, add the fruit.* For blueberries: With extra-clean hands, grab a fistful of washed blueberries and squeeze them into the batter for flavoring. Then add in the remaining whole berries and mix those around, gently.

9. Insert paper cupcake holders into the holes of an oven-proof muffin tray. Drop about 1/3 cup of batter into each cup, not overfilling.

10. Bake for 30 minutes at 375 degrees in the center of the oven.

11. Remove from the oven. (If you’re compulsive, as I am: insert and withdraw a toothpick with a quick in-out stroke; if the muffins are cooked, raw batter won’t stick. If batter does stick to the toothpick, put the muffins back in the oven for 5 minutes or longer, until they’re done.)

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If you follow these instructions, you can make fresh muffins with minimal equipment and little to clean up. You can freeze and store the muffins, no problem, once they’ve cooled.

*There are countless fruit variations and other add-ins you might use. This morning I prepared half of the batter using a ripe, diced banana and a fistful of cut-up walnuts.

Considerations:

Not everything I cook is nutritious. And while I don’t advise eating muffins regularly, as these are essentially confections, I figure if you’re going to serve these to your family, it’s better that they be prepared with fresh ingredients and a minimum of chemicals, sugar, salt and fats. These have some relative advantages over similar breakfast treats:

These lack preservatives;

They’re roughly half the size of typical store-bought muffins (countering the super-sized effect);

They’re made with skim milk instead of whole milk;

They have approximately 2/3 the usual amount of sugar.

Besides, they came out great!

Of course, dear readers, I’d like to know what are the true nutritional benefits in blueberries, and what happens to their putative anti-oxidant properties once they’ve been baked for 1/2 an hour. But I don’t think anyone knows, for sure.

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Cooking With Leeks

A note on cooking with leeks, inspired by a NYT Well post with a list of related Recipes for Health:

I use leeks all the time, as my neighbors are probably too aware. I use leeks sautéed in olive oil as filler, mixed with an egg and flour for a tart, or to season simple pasta, or to flavor and decorate roasted potatoes.

How I prepare leeks is this:

First I cut off the base and ragged tips of 3-4 stems, slice the mainly dark-green stems lengthwise, and then cut the stalks into 1 – 3 inch sections, depending on what they’ll be used for. Because there’s often dirt from the ground deep in the lower, paler sections of the leeks, I manually expose and separate each rounded layer, and then wash everything  under briskly-running water, thoroughly rinsing at least three times.

You don’t have to dry the cut, washed leeks. What I do is heat a heavy, wide pan on the stove, add a thin layer of olive oil, and then throw on the damp (or dry) leek pieces. With the flame set low, I toss on about a half teaspoon of salt for a volume of 3-4 large stalks. Sometimes I add fresh ginger, cut into tiny pieces, into the mix.

And then I work on other things in the kitchen – often while listening to NPR or talking to my mom on the phone – while the leeks wilt. If I’m running late, I’ll put a lid on the pan, which makes the leeks soften faster, but that’s not ideal. Every few minutes I stir them around a bit with a wooden spoon or spatula, until they’re soft and, typically, shiny with varied shades of green.

You can store cooked leeks in the refrigerator for a few days, if they’re in a sealed container. So you might, as I have, use a small amount with pasta on a Monday, and then use the remainder for a goat cheese and leek tart later in the week. There are many variations, and I’ve only started using this vegetable in the past four years or so.

This summer I intend to try making a potato-leek soup.

According to Martha Rose Shulman, writing for the Times, leeks are milder than onions but contain sulfur compounds present in onions and green garlic that some people find hard to digest. Leeks are a good source of nutrients like lutein and zeaxanthin, carotenoids – thought to be important in vision, calcium, iron, magnesium, phosphorus, potassium and vitamin K. Leeks are fiber-rich, I might add.

I should learn more about each of these elements; how they’re best cooked and absorbed. Unfortunately I’m still searching for the nutrition textbook they never assigned in med school.

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A Nutritional Tidbit, on Quinoa

I first heard about quinoa a few years ago, when food-sellers started marketing the stuff as a cereal-like, cholesterol-lowering nutritious substance.

Chenopodium Quinoa (Wiki Commons)

It’s from the Andes, I knew, and comes in some varieties. If you purchase the raw stuff or receive a gift, say, from a Peruvian person who knows her quinoa, you’ll find quickly that you have to rinse it a few times with water before cooking it with whatever seasoning you choose, such as cilantro or just a pinch of salt, or with some olive oil and ground pepper, cinnamon or curry, because the starch has to be rinsed of its saponin (soapy) coating.

What I learned yesterday, beginning with an informative feature in the Times, is that quinoa is not a grain but a seed. According to that article and Wikispecies (a fabulous web-find, in itself), quinoa belongs to the chenopod family or subfamily of plants which includes the likes of beets and spinach. The word chenopod stems from the Greek roots: <chen> (goose) and pod (foot), as in goosefoot. These are said to be flowering plants that lack petals.

The U.S. MyFoodPedia site is devoid of information on quinoa, as is the USDA’s Nutrient Database, as of this morning. Sellers say it’s rich in fiber, protein and minerals. A research study published by agricultural scientists based in Santiago, Chile, found an ideal balance of amino acids and minerals mixed in the starch, along with omega-6 oils and vitamin E.

In my fourth year of medical school, I spent most of two months in Bolivia studying infectious and other diseases in Cochabamba. But I don’t think I ever tried quinoa. And it’s definitely not something I learned about in class.

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A Vitamin Chart From the National Women’s Health Information Center

Lately I’ve been worrying about Kevin’s refusal to eat broccoli, and wondering what exactly is so good about those green bunches of roughage. In browsing the Web for more detailed information on the matter, I found a helpful vitamin chart.

This table comes from the HHS-sponsored National Women’s Health Information Center – a good spot to know of if you’re a woman looking on-line for reliable sources. It’s a bit simple for my taste. In the intro, we’re told there are 13 essential vitamins our bodies need. After some basics on Vitamin A – good for the eyes and skin, as you probably knew already – the chart picks up with a quick review of the essential B vitamins 1,2,3,5,6, 9 and 12 (my favorite), followed by a rundown on Vitamins C, D, E, H (that would be biotin) and K:

Vitamins, Some of their Actions, and Good Food Sources
Vitamin Actions Sources
A
  • Needed for vision
  • Helps your body fight infections
  • Helps keep your skin healthy
Kale, broccoli, spinach, carrots, squash, sweet potatoes, liver, eggs, whole milk, cream, and cheese.
B1
  • Helps your body use carbohydrates for energy
  • Good for your nervous system
Yeasts, ham and other types of pork, liver, peanuts, whole-grain and fortified cereals and breads, and milk.
B2
  • Helps your body use proteins, carbohydrates, and fats
  • Helps keep your skin healthy
Liver, eggs, cheese, milk, leafy green vegetables, peas, navy beans, lima beans, and whole-grain breads.
B3
  • Helps your body use proteins, carbohydrates, and fats
  • Good for your nervous system and skin
Liver, yeast, bran, peanuts, lean red meats, fish, and poultry.
B5
  • Helps your body use carbohydrates and fats
  • Helps your body make red blood cells
Beef, chicken, lobster, milk, eggs, peanuts, peas, beans, lentils, broccoli, yeast, and whole grains.
B6
  • Helps your body use proteins and fats
  • Good for your nervous system
  • Helps your blood carry oxygen
Liver, whole grains, egg yolk, peanuts, bananas, carrots, and yeast.
B9 (folic acid or folate)
  • Helps your body make and maintain new cells
  • Prevents some birth defects
Green leafy vegetables, liver, yeast, beans, peas, oranges, and fortified cereals and grain products.
B12
  • Helps your body make red blood cells
  • Good for your nervous system
Milk, eggs, liver, poultry, clams, sardines, flounder, herring, eggs, blue cheese, cereals, nutritional yeast, and foods fortified with vitamin B12, including cereals, soy-based beverages, and veggie burgers.
C
  • Needed for healthy bones, blood vessels, and skin
Broccoli, green and red peppers, spinach, brussels sprouts, oranges, grapefruits, tomatoes, potatoes, papayas, strawberries, and cabbage.
D
  • Needed for healthy bones
Fish liver oil, milk and cereals fortified with vitamin D. Your body may make enough vitamin D if you are exposed to sunlight for about 5 to 30 minutes at least twice a week.
E
  • Helps prevent cell damage
  • Helps blood flow
  • Helps repair body tissues
Wheat germ oil, fortified cereals, egg yolk, beef liver, fish, milk, vegetable oils, nuts, fruits, peas, beans, broccoli, and spinach.
H (biotin)
  • Helps your body use carbohydrates and fats
  • Needed for growth of many cells
Liver, egg yolk, soy flour, cereals, yeast, peas, beans, nuts, tomatoes, nuts, green leafy vegetables, and milk.
K
  • Helps in blood clotting
  • Helps form bones
Alfalfa, spinach, cabbage, cheese, spinach, broccoli, brussels sprouts, kale, cabbage, tomatoes, plant oils. Your body usually makes all the vitamin K you need.

(from womenshealth.gov, table accessed 2/19/2011)

Overall I’d say the chart is useful, a good place to start if you want to know, say, what’s a good, non-citrus source of Vitamin C. It could be improved by provision of more details, like the precise amount of Vitamin B2 per cupful of Swiss chard, and how preparing foods in distinct ways – like roasting, sautéing, boiling, or serving them raw – affects the nutritional value.

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Contemplating Diet and Nutrition: A First Look at the USDA’s New Guidelines

On Sunday afternoons I tend to think about food for my family. Sometimes that’s because we’re having a few more than usual at the dinner table. Also, it’s a time when I order the bulk of fish, meat, produce and other ingredients for the week ahead.

Since I had cancer, I’ve paid much more attention to the food I serve in our home than before. While a balanced diet is no fail-safe for avoiding disease, I do think it’s prudent to be aware of the variety and quantity of food we eat. In medical school we learned surprisingly little about nutrition. Most of what I know I’ve learned from reading books – like Michael Pollen’s In Defense of Food – and reading through detailed reports like the USDA’s new Dietary Guidelines for Americans (7th Edition) issued a few days ago.

From the press USDA and HHS joint press release:

Because more than one-third of children and more than two-thirds of adults in the United States are overweight or obese, the 7th edition of Dietary Guidelines for Americans places stronger emphasis on reducing calorie consumption and increasing physical activity.

The Times summed up the new guidelines nicely in its headline: Government’s Dietary Advice: Eat Less.

But it’s not a trivial report. Rather, it’s a hefty-if-printed (I didn’t) 112-page pdf with some fluff (even blank pages for notes) and some excellent, hard-to-find-elsewhere details on nutrients. Some highlights include Figure 5-1, which demonstrates with abundant clarity that we don’t eat sufficient fruits, vegetables, whole grains or most other recommended foods:

I’m still digesting (sorry, I can’t help myself) detailed chapters and tables in the full report. There’s a lot of useful information to take in. For example, Appendix 11, on p. 85, charts the “Estimated EPA and DHA and Mercury Content in 4 Ounces of Selected Seafood Varieties” – handy if you serve fish for dinner at least twice per week, and like me, figure it’s best to hedge on potential toxic effects by serving a variety of fish.

More from the press release, on tips that will be provided to help consumers translate the Dietary Guidelines into their everyday lives:

• Enjoy your food, but eat less.

• Avoid oversized portions.

• Make half your plate fruits and vegetables.

• Switch to fat-free or low-fat (1%) milk.

• Compare sodium in foods like soup, bread, and frozen meals – and choose the foods with lower numbers.

• Drink water instead of sugary drinks.

All of these seem wise, but obvious. Still, it’s clear that most of us aren’t following the guidelines, or even common sense.

Setting guidelines should help, so teachers in schools and cafeteria-caterers can know what to tell and feed kids, so they develop good eating habits. But really I think that most of the information, if you can call it that – what constitute our dietary habits begun in childhood – has to be cultivated in our homes, the popular culture and community at large. So my plan is to delve further into the USDA report, and elsewhere, and once each week (maybe) post a nutritional ML. I hope it won’t be too simple or boring.

Like a diet, we’ll see how this goes –

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