Seniors need strength training, too

Many people think that beyond a certain age, you become too weak to strength train or benefit from it. But research shows the complete opposite. Without adequate muscle exercise, most adults lose 20 to 40 percent of the muscle they had as young adults. With too much muscle loss people have difficulties performing daily activities that allow them to live independently.

Experts say that even small gains in muscle – too small to see – can make significant differences in how seniors live. Strength training can affect whether an older person can get out of a chair without help. It can also influence their sense of balance, risk of falls and fractures, and the ability to climb stairs or carry groceries. Strength training can even make bones stronger and weight control easier.

One recent study of seniors showed that after six months of strength training, strength in a variety of muscle groups increased 31 percent for the duration of the two-year study. Other studies show benefits for the frail elderly living in nursing homes. People who had formerly needed walkers to get around could use a cane instead.

I extrapolate and believe that we 50somethings should do resistance training as primary prevention. And I do.

Hold That Stretch: Warm-Up Is Challenged

Now a major study is stirring renewed discussion about when stretching is and is not beneficial.

The study, a review of six decades of research by the Centers for Disease Control and Prevention, found that stretching does little to prevent injury during exercise when done outside of a warm-up. In some cases, the increased flexibility that stretching promotes may actually impede performance.

The researchers analyzed 361 scientific articles on stretching published since 1946. The findings, in the March issue of Medicine and Science in Sports and Exercise, suggest that athletes who devote pre-exercise time to stretching may be better served with a warm-up that prepares the body for activity and regular exercises that build strength and balance.

"The idea of loosening your joints up and muscle stretching makes sense, but the problem is that it really hasn't been shown to prevent injury," said Dr. Stephen B. Thacker, director of the epidemiology program office at the C.D.C. and an author of the study. "If you put on your sweats and simply start stretching, your muscles are not necessarily warmed up."

Warming up, which typically means raising the body temperature enough to send the blood flowing through the muscles, requires more intense activity than stretching.

"For your muscles to function at optimal capability, they should not be too loose nor too tight," said Dr. Lisa Bartoli, an attending physician in physical medicine and rehabilitation at the Beth Israel Medical Center in Manhattan. She likened warming up the body for exercise to taking modeling clay from a refrigerator. "You warm it up and work it a little bit," she said. "And then you can stretch it."

Like many sports physicians, Dr. Bartoli tells her patients that rather than stretching before physical activity, they should do the sporting activity at 50 percent of the target intensity.

The argument against stretching does make some sense. You need not take a joint to an angle that you will not be using. Too much laxity may make injury more likely (by preventing resistance to injury).

I like the recommendation of warming up. I notice in golf that a slow warm up leads to better golf swings on the course. I notice that prior to my weight lifting sessions, a moderate aerobic activity of 10-15 minutes helps me get ready for action.

Going on vacation. Will resume blogging either Sunday or Monday. Playing golf and giving health care thoughts a rest.

Have a great weekend!!!

Wow - sometimes research provides good news. FITNESS: Study finds no evidence stretching prevents injuries

People who stretched were no more or less likely to suffer injuries such as pulled muscles, which the increased flexibility that results from stretching is supposed to prevent, researchers found. And the injuries found in the study typically happened within the muscle's normal range of motion, so stretching them would not have made a difference, Thacker said.

Other research has found that warmups, which increase blood flow through the muscle and make it more ready to respond to exercise, can reduce the risk of injury, Thacker said. Being in good shape also helps. Strength and balance training reduced injuries as well, he said.

Sounds good - warm up, stay in shape, do not worry so much about stretching.

I might love this diet. Can a high-carb diet help you lose weight?

American Dietetic Association spokeswoman Cindy Moore agreed and said with low-carb diets hogging the spotlight, “it may be a reminder that we can lose weight in a variety of different ways.”

Foods on the successful diets included high-fiber cereal, vegetarian chili, whole-wheat spaghetti, many fruits and vegetables, and skim milk. Daily calories totaled about 2,400, similar to participants’ usual consumption.

The control group also received prepared meals with similar calories, but the foods included sausage, scrambled eggs, macaroni and cheese, French fries, whole milk and fewer fruits and vegetables.

The successful diet was not tested against Atkins and other low-carb regimens, which contain more fat and fewer carbs than the control group diet.

There is more than one way to skin a cat, and more than one way to lose weight. This way looks interesting to me. I hope we read more about this new diet.

You probably saw this on TV or read this in the newspapers. The Post-Atkins Low Carb Diet

The level of saturated fat that is permitted in the Atkins diet is still more than in other low-carbohydrate diets, and 60 percent of calories are still supposed to come from fat, although trans fats are not permitted. But setting a limit brings the diet more in line with others, like the South Beach Diet.

The diet industry is still riven by arguments over the best way to lose weight, but many mainstream researchers say that if low-carb diets have moved people away from refined carbohydrates like sugar and white flour, they have accomplished something important. And some acknowledge that a low-carb diet fills many people better than a low-fat diet, helping to keep them on the diet.

Weight loss surgery has a major "upside". Morbidly obese patients who have major weight loss have wonderful health and social benefits. Despite the danger, for many patients the risk is clearly worthwhile.

We must always remember the risk though - Mass. Panel to Probe Obesity Surgery

Massachusetts health officials announced plans Tuesday to assemble a panel of experts to examine the dangers of obesity surgery, less than a week after the state's third death in a year linked to weight loss operations.

The death rate is significant. Patients need complete disclosure of the risks. But the benefits are great enough to make the risks worthwhile for many patients.

This article explains our portion control problem very well - Want to stay slim? Get a handle on America's out-of-control food portions

Many readers have a New Year's resolution to lose weight. You can lose weight just by dieting. However, increasing activity can help greatly. Need Exercise? Count on It

"You'll lose muscle mass, your metabolism will slow down," she says. "You gain a lot more things with exercise than just maintenance of weight. You get an increase in energy, an increase in metabolism; you decrease the chance of cardiovascular diseases; you get a reduction in blood pressure, things of that nature. If you don't work out, if you only consume as many calories as you burn, you're missing out on all that."

State legislatures have taken heed. They are passing positive laws to attack the obesity epidemic. Worried about obesity, states mulling laws for restaurants, schools and public employees

Under the laws that have passed, states will:

* Test the BMI -- body-mass index, a ratio of height to weight -- of students in six Arkansas schools, and send results home. Pediatricians say regular tests like this should be performed nationwide to track children at risk of becoming obese.

* Ban junk food from vending machines in California. New York City, in an administrative decision, banned hard candy, doughnuts, soda and salty chips from its vending machines.

* Require physical education programs in Louisiana schools, and encourage it in Arkansas and Mississippi. Though once a staple, such daily classes are now only required by state law in Illinois; other states let local officials decide or require exercise less often.

For even more information on obesity - here is the Surgeon General's web page on the subject - The Surgeon General's Call To Action To Prevent and Decrease Overweight and Obesity

I harp on fitness often. Personally I work out approximately 5 days a week, some resistance training, some cardiovascular work. This article speaks to young adults, but I suspect it is rarely too late. Treadmill Tests Gauge Future Fitness

The study involved about 4,400 men and women who were given a treadmill test when they were 18 to 30. Most of them were followed for 15 years after that.

Those who did not do well on the treadmill test faced double the risk of developing high blood pressure, diabetes or a condition called metabolic syndrome, compared with highly fit participants. Metabolic syndrome is a cluster of symptoms that includes high blood sugar, poor cholesterol levels, elevated blood pressure and a fat belly.

Some of the participants underwent a second treadmill test, seven years after the first one. Those who became more fit during those intervening years reduced by 50 percent their risk of diabetes and metabolic syndrome.

The study is published in Wednesday's Journal of the American Medical Association.

The findings ``confirm what common sense has always told us -- lack of fitness in youth is not a good thing for later life,'' said Dr. Teri Manolio, director of epidemiology at the National Heart, Lung and Blood Institute, which funded the research. ``It doesn't take that long for risk factors to develop and disease to develop.''

Fitness levels were determined by how long participants could walk on a treadmill without becoming fatigued and short of breath.

We should spend public health dollars on middle school and high school fitness programs. "Phys Ed" is not a luxury for students, but rather a most important class. It should provide life long exercise habits. This is important.

Do not drink excessively when running marathons. Running the Risk of Too Much Water: Hyponatremia Can Sometimes Lead to Death for Marathoners

If you run or bike long distances, please read this article.

So how can we get Americans to exercise? Maybe incentives will work - Bribing People To Exercise?

By exercising and staying healthy, Traci and Todd Gianvito have earned enough reward points to take a trip to Florida.

And, says Destiny Healthcare member Todd Gianvito, "We'll be going to Europe next year using the airline miles and using the vacation package for part of the trip."

Destiny Healthcare offers Traci and Todd incentives every time they visit a gym or work out. They even get points for taking CPR classes and doing charity runs.

"We'll get little incentive letters saying way to go, you're earning points and here are some free movie tickets -- which I think is cool," said Traci.

And it saves cool cash for their small midwestern healthcare provider and its parent company in South Africa.

"On the financial level, it impacts dramatically on healthcare costs, people are more prudent, they are more engaged in their healthcare," said Adrian Gore, with Discovery Healthcare.

What a logical, novel, and appropriate idea!!!!

So what are the costs and benefits of bariatric surgery? We just do not know - so Louisiana will find out! La. Testing Stomach Surgery's Cost Effect

Forty obese government employees will get weight-reduction surgery in a $1 million experiment to see whether it keeps insurance payments down over the long run by preventing other health problems.

The first job will be choosing the 40 from more than 1,000 people on the state's health plan who expressed interest in the surgery. The participants will be monitored for three years.

A few states require insurance companies to cover weight-reduction operations, such as those that clip the stomach to a fraction of its original size and bypass part of the intestine. This makes people feel full much more quickly, and digest less of what they eat.

The resulting weight loss can head off long-term illness related to being overweight. The operation is generally considered only for people who are ``morbidly obese'' -- at least 100 pounds overweight.

The Louisiana Legislature refused to require coverage of the operation after insurers objected that it would cost too much. The state health plan alone would spend an estimated $25 million in its first year if it had to cover all requests immediately, Executive Director A. Kip Wall told lawmakers this summer.

``The biggest obstacle is, for lack of a better term, pent-up demand,'' he said Tuesday.

Wall said the $25 million estimate was based on a quoted price of $25,000 per operation and the more than 1,000 letters his office got after sending a notice about the proposed test a year ago to the 250,000 people covered by the plan. Nationwide, prices range up to $40,000 per operation.

A $1 million contract was approved this month for LSU Health Sciences Center -- the state's major medical school -- to pick, treat and follow up with 40 volunteers for the pilot study.

Participants in the experiment will have to pay no more than the usual co-payment or deductibles. The amount would depend on which group benefits plan they are in.

This is very important. Some obese patients really cannot lose weight without surgery. I believe that it will save money, but we will wait and "let the data speak".

New Doctor, New Diet, but Still No Cookies

Theories abound as to what has propelled the South Beach diet to the center of the weight-loss universe since the book bearing its name was published in April. Is it the image it conjures, of bikini-clad models picking at tropical fruit salad between sun-drenched photo shoots? Is it the aqua shimmer of the book jacket, as eye-catching as the surf off Ocean Drive?

Or is it that Dr. Arthur Agatston, the cardiologist behind the latest low-carbohydrate, high-protein diet, is on to something?

Dr. Agatston — whose office is not in South Beach, by the way, but the older, tamer neighborhood to its north — is not far from that giant of diet doctors, the late Dr. Robert Atkins, in his belief that refined sugar and white flour are the villains behind the nation's climbing obesity rate. Like the Atkins diet, the South Beach diet strictly limits bread, potatoes and other carbohydrates, especially during a two-week initiation period, and allows the dieter to eat red meat, eggs and cheese.

But while the Atkins diet allows just about any fatty food that is not also starchy, Dr. Agatston advocates mostly unsaturated fats, like those in olive oil, nuts and oily fish like salmon. Butter is nowhere in the South Beach diet meal plans, nor is bacon or anything fried. The South Beach diet also differs from Atkins in that it allows carbohydrates — though only those high in fiber, like multigrain bread and wild rice.

Dr. Agatston's premise is that most carbohydrate-rich foods are so processed that they immediately turn to sugar in the body. That, Dr. Agatston says, forces a quick spike in blood sugar and nearly as quick a decline. The spikes lead to more hunger, he says, and — this is the part that many experts dispute — to inevitable weight gain.

"Nobody in the history of man ever ate complex carbohydrates like we have," Dr. Agatston said last week during an interview squeezed between a photo shoot and a meeting about his new heart-imaging center, set to open in December. He was late to the interview, so his wife, Sari, a lawyer who is helping with publicity, filled the time by talking about how even she, a bread lover, has come to accept whole-wheat pita instead.

The diet revolves around the glycemic index — the amount that a carbohydrate increases sugar in the blood compared with the amount that the same quantity of white bread raises it. The concept of the index as crucial to weight gain or loss has been around since the early 1980's, when it was used to help people with diabetes choose proper diets. But skeptics — including the American Diabetes Association, which has not endorsed the index — say a food's glycemic index fluctuates depending on how much is eaten and what other foods are eaten.

Foods with a low glycemic index, like lentils, soy milk and low-fat, artificially sweetened yogurt, do not raise blood sugar as quickly and sharply as high-numbered items like gnocchi, baked potatoes and pretzels.

High-glycemic-index foods cause the body to release a lot of insulin, which quickly lowers the blood sugar again and causes hunger to recur, the theory goes. Those with low indexes break down into sugar more slowly, for longer-term energy.

This article describes a very interesting diet. It seems to have significant rationale. Of course we need good prospective studies to be sure. I would probably pick this over the Atkins' diet given the information I currently have.

Wow, this is interesting. Forget the stretch

IF the first five to 10 minutes of your workout consists of stretching exercises to reduce the risk of injury, perhaps you should save yourself some time. Not only does such stretching fail to reduce the risk of injury, but recent studies have shown it also might hinder performance.

People who stretch before exercise have about the same risk of injury as those who don't, says epidemiologist Ian Shrier. Several years ago, Shrier reviewed half a dozen studies on the effects of stretching before exercise and found that not one demonstrated that it prevented injury. He published his findings in the Clinical Journal of Sport Medicine.

"At first people thought I was crazy," recalls Shrier, a physician at Sir Mortimer B. Davis Jewish General Hospital in Montreal. But his conclusions gained credence six months later, in August 2000, when Australian researchers published a large-scale study in the American College of Sports Medicine journal that reached the same conclusion.

That study involved 1,528 military recruits who followed the same exercise, weight and conditioning program. Half the recruits stretched before exercise; half didn't.

"A typical pre-exercise stretching protocol does not produce a clinically useful reduction in injury risk," wrote the authors. "If injury prevention is the primary objective, and the range of motion necessary for the sport is not extreme, the evidence suggests that athletes should drop the stretching before exercise and increase the warm-up."

Wow! I love studies that test conventional wisdom - and find it lacking. Interestingly, my personal trainer ask me to arrive early and do 10-15 minutes of cardiovascular warm-up prior to resistance training. He seems to have it right.

Exercise Is a Habit; Here's Why to Pick It Up This article reviews some very good studies on exercise benefits for women. It does ignore us men. I can only say, exercise is very good for us also!

Strength vs. Power

Admit it. You thought the terms were synonymous. Wrong, say exercise scientists. "Strength" is a measure of how many pounds you can move in one push or pull. "Power" measures how fast you can move a weight in a given amount of time.

The different properties are functions of the two kinds of fiber in skeletal muscles: slow-twitch fibers, which are mostly responsible for strength, and fast-twitch fibers, which supply power, says Scott Trappe, director of the human performance laboratory at Ball State University in Muncie, Ind.

Novices can build strength in major muscle groups by lifting about 60 percent of the maximum they can heft one time, performing eight reps each once or twice weekly, then working up, after a month, to three or four sets weekly. That's from a meta-analysis of 140 strength training exercise studies published this year in the journal Medicine & Science in Sports & Exercise.

To gain power, recommends the American College of Sports Medicine, perform weight-lifting sets that load weight on more than one joint, such as holding dumbbells while lunging or lifting a free bar while rising from a squat.

A good weight training progam will work on both strength and power. As we age we want to maintain power. Power requires strength, therefore work on strength first.

How do we deal with the obesity epidemic (and yes it is an epidemic)? Girth control The author paints a fair picture of our obesity problem. He concludes his essay with these perceptive points.

Among other remedies, Mr. Brownell favors taxing unhealthy foods (a definition, he grants, that won't always be easy to assign), with the funds earmarked for projects such as advertising healthy foods and lifestyles.

Despite my own use of "junk," I don't like the idea of labeling specific foods "bad" because almost anything in moderation is fine. And the hint of any tax raise makes my free-market knee jerk. Yet while I once considered Mr. Brownell a radical, the fatter we grow the less radical he seems.

Still, there will never be a substitute for personal responsibility regarding obesity or anything else. For a child, there will never be a substitute for a caring, attentive parent who is willing to endure occasional whining and weeping, a tantrum ? or even the ultimate guilt-trip trick, "But all the other kids' parents let them do it." Yes, and their children may die because of it.

As my mother has always said, if all the other kids are jumping off the building should you jump? We actually can control our behavior. And we should.

I love the feeling of a good workout. A knowledge and feeling that I have exerted makes me feel energized. This physician shares that feeling. Pain Gains

The Fat Environment written by Ellen Goodman is worth reading. Just click and read. It is very simple.

An effort to get America walking seeks to stop obesity in its tracks

Results from the Colorado walking effort are being submitted to scientific journals.

Over 16 weeks, 85 percent of all participants raised their activity level by a total of 2,000-2,500 steps a day, the researchers say. But it will take a year to see if they stabilize, or even lose pounds, and it will take several years to see if the weight loss is sustained.

Like the Colorado experiment, only a fraction of America on the Move participants nationwide will be enrolled in a supervised study. Others can follow the same recommendations independently by registering on the program's Web site.

James Hill, the program's co-founder, says it's the first effort at systematically studying "how you stop obesity from getting worse."

"Our idea is dirt simple," says Hill, director of the Center for Human Nutrition at the University of Colorado Health Sciences Center. "If it doesn't work, we're in big trouble as a nation."

Statistics suggest we already are.

Obesity-related ailments cost $117 billion to treat, and contribute to 300,000 deaths annually, according to federal estimates.

Two out of three adult Americans are overweight, the government says, and they're gaining nearly 2 pounds every year. A quarter of them get virtually no exercise.

This article talks mostly about walking. They believe (as do I) that the key to weight control is movement, not diet. Diet will follow nicely. Quit suing fast food outlets; quit taxing fat content; reward walking, or any other movement.

Tax Policy That Uses Economies of Scales

First of all, obesity often persists as a result of individual choice. It may result from a disease or an inherited condition. But most individuals have the power to affect their own weight through diet, exercise and other habits.

Second, obesity is easily observable. A few measurements are all it takes to place a person somewhere along the continuum from dangerously skinny to Brobdingnagian.

Third, an individual's obesity can affect many people. As a result, it becomes a societal issue as well as a medical problem.

Precisely identifying these effects can be difficult. At least one seems much more important than squeezed seats on airplanes, however. Obesity increases the risk of many medical problems. When someone has a heart attack, chances are either taxpayers or members of a private insurance plan will foot most of the bill. And, thanks to modern medicine, the obese elderly survive almost as long as their thinner counterparts.

Last month, a state assemblyman from Brooklyn suggested a tax on fatty foods to discourage their consumption. An economist might take exception to this plan, because the tax would punish even people who ate such foods in moderation. Of course, that has not stopped similar justifications for taxes on alcohol and cigarettes. Even if you have just one drink or cigarette a year, you still pay heavy "sin" taxes.

Two weeks ago, Kraft Foods decided to lower the fat content of some recipes and reduce the sizes of single-serving snacks. Again, this approach is slightly clumsy. Even if you're eating rice cakes, you'll gain weight if you eat enough of them. And though some Americans may be happy with a smaller packet of cookies, others may just buy two and finish them both. (Kraft said nothing about cutting the snacks' prices in line with the portions.)

Another kind of remedy might have more success. The problem is obesity, not fatty food or anything else that contributes to being overweight. So why not take aim at obesity directly?

Basic economics recommends taxing individual behaviors that hurt society. But taxing overweight people, perhaps by identifying them and then assessing them some social cost of obesity every year, sounds draconian and impractical.

A more palatable solution might be to collect a lump-sum tax from every American and put the proceeds into a reward pool. Each year, anyone who wanted to could go to an existing government office for a simple series of measurements. People who registered normal weights throughout the year would receive cash rewards from the pool ? much like a tax refund.

This system would still tax obesity, though it would not tax the heaviest people more than the merely rotund. Nor would it tax the middle-aged and disease-prone more than the roly-poly young. Nevertheless, the incentive to lose a few pounds might be quite powerful.

He almost has the right idea. I would rather see body fat used as a factor in insurance rates. Rather than a tax, I would like to see health insurance scaled for behaviors - including obesity. Nonetheless, this type of thinking is worthwhile. It encourages us to more explicitly define the problem.

"Big Food" is changing what they sell. 'Big Food' Gets the Obesity Message

Trying to stay one step ahead of the regulators, Kraft, McDonald's and Frito-Lay have all said they will work to reduce or eliminate artery-clogging trans fats from their foods. The Food and Drug Adminstration has not yet determined how much trans fat is acceptable, but yesterday the agency said it would require food makers to start listing the amount in their products on the labels. That is the least that can be done to help consumers avoid some particularly unhealthy fats that are ubiquitous in snack foods, baked goods and many offerings at fast-food outlets and family-style restaurants.

Skeptics worry, with good reason, about the depth and sincerity of the food industry's late-inning conversion to healthy eating. An industry that has prospered by selling high-fat, high-calorie or sugary foods in ever larger quantities will probably be loath to deviate too much from a proven path to profits. But any smart chief executive will feel the increasing pressure from public health officials to combat obesity and will heed recent warnings from Wall Street that big food companies with a high percentage of unhealthy products face major legal and financial risks. If the companies are really serious about refashioning and downsizing their products, they can give a major boost to the global fight against obesity.

I remain skeptical. I do not think that food composition is the problem as much as lack of exercise. When one examines the data carefully, our biggest problem is activity (or the lack thereof). But maybe this will help.

Loyal readers know my healthy obsession with fitness. Now the American Heart Association is encouraging all physicians to adopt a healthy lifestyle. They just may be on to something important. Physicians Urged to Promote Exercise to Patients, and to Set an Example

As well as recommending regular physical exercise to their patients to prevent and treat cardiovascular disease, physicians should "personally engage in an active lifestyle," according to a new report from the American Heart Association.

Writing in the June 23 rapid access issue of Circulation, a group of experts led by Dr. Paul D. Thompson of the Hartford Hospital in Connecticut note that people who get a lot of regular exercise appear to have half the risk of atherosclerosis as sedentary people.

In addition, regular exercise appears to lower the chances of a host of other chronic conditions, such as diabetes, depression and certain types of cancer.

Consequently, Dr. Thompson and his team suggest that doctors follow recommendations issued by the U.S. Centers for Disease Control and Prevention, which support at least 30 minutes of moderate exercise, such as a brisk walk, on most or all days of the week.

As the title says - Do as I do!!!!!

Obesity costs moeny. That is the conclusion of these business leaders. Employers Plan Obesity Fight, Citing $12 Billion-a-Year Cost.

A group of large employers headed by Ford Motor, Honeywell, General Mills and PepsiCo announced a campaign yesterday to encourage overweight workers to slim down as a way to improve both their personal health and the corporate bottom line.

Dr. Vince Kerr, director of health care management at Ford, said weight-related costs were adding $12 billion a year to costs of employers nationwide, including medical bills, reduced productivity, increased absenteeism and higher health and disability insurance premiums.

"Obesity is becoming as large a factor as tobacco once was," Dr. Kerr said. Weight-related ailments are taking "amazingly large portions" of the $3 billion that Ford spent on health care benefits last year, he said.

Michigan, Ford's industrial base, is among the worst states for obesity and tobacco use, Dr. Kerr said.

He said the company's employees mirrored the general population in the growing incidence of diabetes and other diseases that often overlap with weight problems.

Ford is a founding board member of the Institute on the Costs and Health Effects of Obesity, organized by the Washington Business Group on Health, a group of 175 large employers that provide benefits for 40 million people.

The institute plans to draw on research financed by the federal Centers for Disease Control and Prevention and the Institute of Medicine of the National Academy of Sciences. The centers and the Institute of Medicine have also joined the new obesity institute board.

When business decides that obesity eats into profits (pun intended), then they act. We need to restructure our work places. We need exercise time and space. We need to walk more and ride less.

Our 'lunch rooms' and restaurants need to quick 'supersizing'. We can do much as a society and as businesses to improve this problem.

I applaud this interest from business and look forward to some positive results.

A reader questioned our inactive lifestyle as a cause of obesity. This article certainly supports that concept - Battling the bulge in the burbs

?We shape our buildings, and afterwards our buildings shape us,? Winston Churchill once said. Today, there?s new meaning to Churchill?s often cited quote: A growing number of public health researchers blame our sprawling suburban landscapes in part for Americans? bulging bellies.

NO DOUBT you?ve seen the statistics on obesity in America. Perhaps you?ve seen them on yourself.

Arlin Wasserman, an anti-sprawl advocate formerly with the Michigan Land Use Institute, says that when he moved from his native Philadelphia, where he biked everywhere, to suburban Traverse City, Mich., he put on 35 pounds.

?The move to Ann Arbor, where I logged 15,000 miles a year driving, gained me 15 pounds, even though I was still biking to work,? says Wasserman. ?But the move to Traverse City gained me another 20.?

Americans are becoming less physically active, not so much out of laziness but because of changes in the ?urban form? that are dictating more sedentary behavior, according to a new line of thinking in public health.

Advocates of anti-sprawl ?smart growth,? like Wasserman, say the theory adds ammunition to the arguments against suburban development, which has been blamed for loss of farmland and open space, as well as increasing traffic congestion.

?It?s not just a matter of our having ?super-sized? our meals or that we don?t exercise enough,? says Thomas Schmid, a public health researcher at the Centers for Disease Control. We?ve also drastically reduced the amount of regular walking, biking or getting around under our own steam as part of our daily activities, says Schmid.

I have tried to add walking to my daily routine. This is often difficult. This concept does make some sense. Can you modify your routine to include more movement?

I am a bit late getting to this important article - 'No Matter What the Data Say' . Sydney Smith (Medpundit's pseudonym) minimizes the effect of diet and blames our increasing obesity on lack of exercise.

A recent study of teenagers' habits over the past twenty years supports this observation. Nutritionist Lisa Sutherland of the University of North Carolina at Chapel Hill looked at data from the CDC's National Health and Nutrition Examination Survey and Youth Risk Behavior Surveillance System, and the Department of Agriculture's Nationwide Food Consumption Survey, all of which have been following our national weight trends, activity trends, and food consumption trends for several years. She found that over the past twenty years, teenagers have, on average, increased their caloric intake by one percent. During that same time period, the percentage of teenagers who said they engaged in some sort of physical activity for thirty minutes a day dropped from 42 percent to 29 percent. Not surprisingly, teenage obesity over the twenty year period increased by 10 percent. The logical conclusion is that it isn't junk food that's making teenagers fat - it's their lack of activity.

This isn't the first study that has suggested the importance of exercise in the obesity equation. Consider the Pima Indians. The Pima Indians of Arizona have one of the highest rates of obesity in the world, while the Pima Indians of Mexico have very low rates - even though they eat on average the same number of calories a day. The difference? The Mexican Pimas spend twice as much time engaging in physical activity as American Pimas. Or consider the study of British twins which showed less body fat in twins who exercised compared to their less active siblings. And then there are the weight loss success stories. Study after study shows that those who lose weight and keep it off are those who exercise regularly.

Medpundit makes a reasonable argument here. I have often argued that weight control requires attention to increasing caloric expenditure (more exercise) and decreasing caloric intake (careful diet). I am skeptical of dietary data. We generally rely on surveys for these data - and I am skeptical of surveys in general.

While I believe that too many teenagers and adults take in excessive calories, Medpundit makes an important point. If we get off our butts and move we can handle more calories.

Two of my favorite medical writers have addressed the Atkin's diet articles published last week. Pounds Lost on Atkins Diet May Quickly Return from the NY Times.

The studies, reported in The New England Journal of Medicine, compared the effects on weight loss and cardiovascular risk factors of the Atkins plan with the conventional low-fat, low-calorie diet recommended by most health experts. Both diets resulted in weight loss, but participants on the Atkins diet lost more weight, faster.

But it is too soon to jump on the Atkins bandwagon in hopes of achieving bathing-suit slimness by the Fourth of July. Yes, the diet does help obese people lose weight quickly, and those wanting to shed 10 pounds in the next four weeks could achieve that goal. But the research suggested that by Labor Day many, if not most, are likely to be back to their starting weight.

The first five to seven pounds lost on Atkins are not fat but water, released by the body when it gets little or no starch or sugar from food. So as soon as you are unable to resist that bun with your burger or summer's succulent sweet corn, a cooling ice cream cone, thirst-quenching watermelon or a bag of fries, those lost pounds are likely to come bounding back.

And Miracle Cure? Fat Chance from the Washington Post.

Losing weight takes commitment. About 40 percent of participants in both groups quit the studies before they ended, a fact that some scientists said could bias the results. What the findings meant to Gary Foster, clinical director of the University of Pennsylvania's Weight and Eating Disorders Program and lead author of one of the studies, is this: "No matter what diet you're on, doing it alone is tough work."

Calories count. The Atkins philosophy is that total calories consumed don't matter, provided carbohydrates are severely restricted. But in one of the studies published last week, participants in the Atkins group ate fewer calories than those in the low-fat group, although the differences were not statistically significant. "The law of thermodynamics still holds here," says Frederick Samaha, chief of cardiology at the Philadelphia Veterans Administration Hospital and lead author of the study. "Weight loss is still entirely an effect of total calories in and total calories out."

And read RangelMD for a further discussion of this tautology - The Atkins diet: A case in calorie restriction.

Pass the Butter, Please

Though the Atkins diet has been reviled by the medical establishment for decades as a bit wacky and even potentially dangerous, the two new studies and a third published last month suggest that the diet actually works better than standard low-fat diets in the short term, without any detectable signs of harm. It was a startling reminder of how little the experts know, in this obesity-plagued nation, about the best way to lose weight and keep it off.

I would argue with the last point. We do know how to lose weight and keep if off. The successful keys are portion control and exercise. What we do not know is how to succesfully get patients to follow the formula! Weight loss is achievable, but requires lifestyle changes. And lifestyle changes are not easy to induce.

So the NEJM published two articles today on low carbohydrate diets. If you read the popular press you will see various spins on the results. The AP reports - Atkins Diet Bolstered by Two New Studies

The research, in Thursday's New England Journal of Medicine, found that people on the high-protein, high-fat, low-carbohydrate Atkins diet lose twice as much weight over six months as those on the standard low-fat diet recommended by most major health organizations.

However, one of the studies found that the Atkins dieters regain much of the weight by the end of one year.

The Washington Post reports Atkins Similar to Low-Fat Diets Study: Long-Term Results Differ Little

"The findings say that no matter what diet you're on, doing it alone is tough work," said the study's lead author, Gary Foster, clinical director of the University of Pennsylvania's Weight and Eating Disorders Program.

Because the Atkins diet encourages consumption of foods high in saturated fat, including butter, cream and steak, there has been great concern that it may increase the risk of heart disease. But three months into the study, there were no differences in the two groups in either total cholesterol or low density lipoprotein (LDL), the "bad cholesterol."

"The weight loss may override the effect of the high-fat, high-cholesterol" Atkins approach, said the University of Cincinnati's Bonnie J. Brehm, who has been studying the Atkins diet in women. "These findings are similar to ours."

And this report from Medscape - Benefits of Low-Carbohydrate Diet Still Uncertain

The controversy over the benefits of low-carbohydrate diet continues, according to two reports and an editorial in the May 22 issue of the New England Journal of Medicine. A randomized trial showed no difference in weight loss at 12 months for a low-carbohydrate diet compared with a conventional weight-loss diet. Another study in severely obese patients did show a benefit, but the duration of the trial was six months. The editorialist helps to clarify the message.

"Despite the popularity of the low-carbohydrate, high-protein, high-fat (Atkins) diet, no randomized, controlled trials have evaluated its efficacy," write Gary D. Foster, PhD, from the University of Pennsylvania School of Medicine in Philadelphia, and colleagues.

...

"Severely obese subjects with a high prevalence of diabetes or the metabolic syndrome lost more weight during six months on a carbohydrate-restricted diet than on a calorie- and fat-restricted diet, with a relative improvement in insulin sensitivity and triglyceride levels, even after adjustment for the amount of weight lost. This finding should be interpreted with caution, given the small magnitude of overall and between-group differences in weight loss in these markedly obese subjects and the short duration of the study," the authors write. "Future studies evaluating long-term cardiovascular outcomes are needed before a carbohydrate-restricted diet can be endorsed."

So what does DB think? First, these studies do vindicate the concept that weight loss trumps fat intake. The most important factor in maintaining or decreasing lipid levels comes from weight. Second, one can lose weight on a low carbohydrate diet. But finally, weight loss remains difficult. Diets can start the ball rolling, but true sustained weight loss depends on lifestyle changes. No gimmicks need apply. We must all figure out how to control portion sizes indefinitely and increase our calorie expenditure (through both resistance and cardiovascular exercises).

I think we know this. Somehow exercising improves our mood - Scientists have a good feeling about exercise

Physical activity is known to exert a powerful "feel-good" effect, brightening mood and enhancing mental health ? in fact, regular exercise may be as effective as medication for some people with depression.

A growing body of evidence supports this boost to psychological well-being, but the exact mechanisms are not completely understood.

"We know exercise makes people feel better, but we're not exactly sure how," says Patricia Dubbert, associate chief of mental health at the VA Medical Center in Jackson, Miss. Dubbert is one of a growing number of mental health professionals who are prescribing exercise as a way to relieve stress and lift spirits.

This makes sense to me. I work out 2 mornings a week, and get to work in a great mood!

Regular readers of Medrants know that I strongly promote (and practice fitness). I believe that attention to fitness has many positive outcomes - including better health outcomes. Given that background, I love this idea - Tax plan to subsidize worker fitness: Health club membership would be in company health plan

Membership in a health club or an aerobic dance class could be a common part of company health plans if a tax proposal in the House becomes law.

The bill would encourage businesses to subsidize workers' workouts by letting the companies claim the contributions as income tax deductions.

The Workforce Health Improvement Program, WHIP, was drafted by a health club industry association, which sees the plan as a way to foster fitness - and, not incidentally, to get more members in the doors.

'What we are really trying to do is to extend the health benefits of exercise to as many Americans as we can,' said John McCarthy, executive director of the International Health, Racquet and Sportsclub Association.

The tax code currently lets companies deduct the costs of exercise facilities only if the facilities are at the work site, so generally only bigger businesses, with 500 workers or more, have them, McCarthy said. The proposed change would open the deduction to smaller businesses, he said.

PLAN WOULD ALLOW EMPLOYEE CHOICE

The plan would let employees choose how and where they want to work out, McCarthy said. "This bill supports all fitness suppliers - YMCAs, Jewish community centers, Jazzercise," he said.

However, WHIP specifically excludes private clubs owned and operated by their members, and facilities that "offer golf, hunting, sailing or riding."

While many could argue with the precise incentives here, the concept is a strong one. Giving tax incentives would work to encourage more use of fitness activities - clearly a desirable goal.

The Carbo War, Cont'd This article summarizes the controversy over low carb diets. It includes a common sense approach to dieting. I recommend this article strongly.

This rant does not qualify as news. The ideas are a rehash of many previous rants. Still I have not used this rant recently and I found an interesting new article related to it. A human time bomb

Worrall Thompson is the face of a new campaign to ?measure your mate?, which aims to raise awareness about the condition, known as insulin resistance syndrome (IRS). If your mate ? or any male who lets you wrap a tape measure around them ? measures more than 40in, they are at risk of IRS. The red-light figure for women is 35in.

IRS, which is also known as metabolic syndrome, glucose intolerance and Syndrome X, has been dubbed a ?medical time bomb? because it could lead to an explosion of disease in years to come. And not only among those facing midlife spread. Derriford Hospital in Plymouth last month reported that 30 per cent of 300 children between the ages of 5 and 16 were showing signs of it. Diabetes now affects about 4 per cent of the population.

The key to all this is the way that your body handles glucose. Until recently this was considered a specialised medical problem reserved for diabetics. But this comforting division is an illusion; our sedentary lifestyle, coupled with a taste for sugar and refined carbohydrates, is playing havoc with the subtle balance between glucose and insulin in our bloodstreams.

Refined carbohydrates are dangerous in the long term because they are too easily digested. The body turns all carbohydrates into glucose, which is then released into the blood. But while wholefoods, such as pulses, fruit and most vegetables, are broken down over several hours, providing a steady trickle of glucose, a sugar-laden fizzy drink, for instance, produces a glucose spike ? a sudden rise, followed by an equally dramatic fall. An occasional sugar spike is no big deal; but day after day, over many years, it can be deadly. As glucose levels rise, your body releases insulin to mop it up. After years of glucose peaks, the extra amounts of insulin have a diminishing effect. IRS then develops ? a pre-diabetic state with high levels of both insulin and glucose circulating in your blood. The result, among other things, is that hard-to-shift spare tyre around the middle and damage to blood vessels and the heart. In America the syndrome has been recognised as a medical condition, officially defined as having three or more of five conditions: abdominal obesity, high triglycerides (damaging fats) in the bloodstream, low levels of the good LDL cholesterol, high blood pressure and high glucose.

I rant about the metabolic syndrome frequently. We need to focus more energy on preventing the consequences of this syndrome. One can argue fairly persuasively that we should add waist circumference to our vital information on patients.

As I have discussed previously, waist circumference provides more information than body mass index (BMI). Athletes often have increased BMI, but excellent waist circumference. Waist circumference does a better job of predicting body fat percentage - which is the real risk factor.

Now we need to understand how we get patients (and sometimes ourselves) to prevent or treat this syndrome. The solutions will involve diet and exercise. Many believe that better understanding the glycemic index will provide great benefit.

SARS, malpractice concerns and too much traveling have decreased my diet and fitness posts. Today I will provide a very nice link on modifying our diets. Pecking at the Pyramid

Not a pyramid, but an hourglass.

That's the shape of the American diet, according to a recent report from the U.S. Department of Agriculture (USDA). Written by Judy Putnam, Jane Allshouse and Linda Scott Kantor of the USDA's Economic Research Service, the report finds that consumers eat mostly from the tip and the foundation of the pyramid, gobbling lots of food high in fat and added sugars (the tip) along with refined grain products, such as pasta, crackers and white bread.

At the same time, they skimp on vegetables, fruit, low-fat dairy products, beans, lean meat, poultry and fish.

Read the entire article. Please.

I have used personal trainers for 18 months. While they do cost significant money, I doubt that I would have achieved my current conditioning without a trainer. This article describes the benefits well - Friendly persuasion that works. The article discusses many pros but adds this "con" -

So, was it worth it? Absolutely. But it is also true that two months, no matter how intense, is not enough to get into great condition. It's a start, I hope, to a more regular workout.

If there is any room for complaint, it would be that for three days a week, there was no room for flexibility in my early schedule. I also should probably have taken much more care about diet so that I could shed more pounds.

I disagree about the flexibility comment. Having a fixed time to workout is a major advantage. Since prioritizing working out, I never miss these workouts unless I am traveling. Working out is too important to allow flexibility. Flexibility makes not working out too likely. Most of us need the discipline of scheduling.

10 pounds lighter, and safely past Super Bowl

The results haven't been bad: 10 pounds lost. Down to 214.

I would have liked to lose a bit more--12, 15 pounds--and probably could have had I suffered more. But I'm deliberating trying to long haul this process. I've been on those diets where you wake up hungry in the middle of the night, gazing greedily at the clock, waiting until the second hand sweeps the 12, ushering in feed time. It's hard to keep that up.

I did skip all starches for the first week--no bread, no potatoes, no nothing. I stuck to what could be called a modified Atkins--lots of steak, breakfast, lunch and dinner. It was fun eating so much steak. I was never hungry and I lost seven pounds. But I felt weird--almost a buzzing in my ears. After the weight-loss needle stuck for three or four days in a row, I figured, rather like a struggling radio station changing format, it was time to shift from All Meat All the Time to a more pleasing mix of other foods.

That's how it's been for the last 20 days. Lots of salads. Small meals--a glass of grapefruit juice for breakfast, a power bar for lunch. Even those vile Slim-Fast drinks. Going is slow, and the hard part is not to let disappointment sap my resolve. What trips people up about dieting, I believe, is how long it takes. They gain weight over months and years, and then want to strip it off quickly because dieting is such a chore. I've struck on two helpful metaphors I want to pass along.

The first came early in the month. I had lost a good amount of weight in a short time, then realized, sadly, that I still had a long way to go. "It's like walking to New York,'' I thought. "You head off at a good clip, make 25 miles a day, and a week later you're still in Indiana.''

We should all understand life as a marathon, rather than a sprint. Lifestyle changes only occur one day at a time. As I have attacked my New Year's Goals, I understand that I will need time to succeed. We succeed when we can delay gratification of our final results and revel in our small successes.

Companies fight employee fat: Obese workers have insurance costs up to $1,500 higher. Duh! Overweight patients and especially obese patients have greater health care costs. And they needed a study.

Medical costs rose as weight did, said the report in the January-February issue of the American Journal of Health Promotion. The average cost for those of average weight was $2,225. The lowest category of overweight was slightly more, at $2,388, but costs rose more sharply after that, reaching $3,753 for the fattest people.

The finding is in line with a report by the U.S. Surgeon General, which estimated the economic cost of obesity in 2000 at $117 billion. And it comes as the Centers for Disease Control and Prevention documents a rising level of weight gain. The worst fatness - extreme or morbid obesity - nearly tripled among adults between 1988 and 2000.

So I have ranted often, why should I subsidize the overweight and obese? Why should I not receive a break on my insurance costs for living a healthy lifestyle?

Some companies are starting to consider programs to encourage exercise and weight loss. Given the impact on health insurance costs, I would bet that developing such programs should save money! Why not have more company gyms - and even schedule exercise as part of the work day? While this might sound radical, someone should try this. I would bet that one could save on health care costs, without impairing productivity.

I must link to articles on the benefits of exercise. Jogging the Mind: New Evidence Proves Exercise Keeps the Mind Sharp

The researchers used high-resolution magnetic resonance imaging to study the brains of 55 volunteers between the ages of 56 and 79. They found that those who were physically fit had lost far less of their brain's gray and white matter than those who got very little exercise.

"People who are most fit showed the largest benefit," says psychologist Arthur F. Kramer of the University of Illinois at Urbana-Champaign. "They showed the least amount of reduction in brain volume."

I find this exciting as I work my way into the studied age group. I proselytize endlessly about exercise - both cardiovascular and weight training. This gives me more ammunition.

Another study led by Kramer, which will be published in the March issue of Psychological Science, revealed some similar results. It found:

Exercise programs involving both aerobic exercise and strength training produced better results on cognitive abilities than either one alone. That suggests that the old rule of walking 30 minutes a day, three days a week, may not offer as much protection against mental decline as a more vigorous routine.

Older adults benefit more than younger people because age-related declines are more pronounced.

The magnetic imaging study will be published in the February issue of the Journal of Gerontology: Medical Sciences. The studies were funded by the National Institute on Aging and the New York-based Institute for the Study of Aging.

Getting Physical. Now that is more like it!

Ten years ago kids like Kale Granda warmed the bench instead of working up a sweat. Physical-education classes were showcases for budding athletes, a yawn for the able-bodied and a hardship to be endured by the rest. But now baby fat has morphed into a national health crisis. Nearly 15 percent of kids between 12 and 19 are overweight?up from 5 percent in the late 1970s. They?re also more sedentary than ever. Less than 25 percent of school-age children get even 20 minutes of vigorous daily physical activity, well below the minimum doctors prescribe. Public-health officials predict that many members of the Joystick Generation will begin to experience costly, debilitating illnesses like high blood pressure, heart disease and diabetes even in their 20s and 30s. These warnings have prompted some physical-education teachers to rethink their old Darwinian view of gym class. Instead of helping the natural athletes refine the perfect jump shot, proponents of the New PE say their goal is to get "mouse potatoes" moving again.

All school systems should adopt this philosophy. Educating students about physical activity represents an investment in future health. I hope this trend spreads rapidly throughout the country.

Exercise critical to melt internal fat Study: Activity helps older women reduce chronic disease risk. This study provides even more evidence of the benefits of aerobic exercise. The original study is in today's JAMA.

Get Up and Get Moving. How could I pass on this article? It just could not happen. Newsweek has several articles on diet and exercise, which are available on MSNBC.com. I will review the diet article either later today or tomorrow. But first the exercise article. I love the title. Have you planned your exercise activities for this week? That is the key for me. I know when I will exercise each day this week. It is part of my weekly plan!

We all know we should exercise. But we?re too busy and too tired. And we?re also increasingly confused: How much is necessary? Is it 60 minutes (gasp!) most days of the week, as the Institute of Medicine suggested last fall? Or 30 minutes? Three days a week or five? Running or mall walking? Researchers are attacking those questions and they?re delving even further into how physical activity affects our bodies at the molecular level. No matter how far the science goes, though, there?s one finding that will remain indisputable: any amount of exercise is better than none. ?Being active and fit is good for you whether you?re young or old, man or woman, tall or short, skinny or fat,? says Steven Blair, president of the Cooper Institute in Dallas, a health-research group.

Research suggests that both greater duration and more rigorous give better results. One should not start with long runs and heavy weight. Rather one should strive to increase duration and intensity slowly over time.

So where does the 60-minute recommendation fit in? When it was issued in September, the Institute of Medicine report seemed to fly in the face of the surgeon general?s guidelines, but the two may not be quite as incompatible as they seem. The 30 minutes is aimed at reducing the risk of chronic disease in the future. The 60 minutes, on the other hand, is paired with dietary recommendations and focuses on weight control in the present. Researchers found that among healthy people with a body mass index (a ratio of weight to height) of less than 25 (with 18.5 to 25 being desirable), 60 minutes of physical activity was necessary to maintain body weight and avoid excess gain. But the finding should not negate what the CDC recommends, says Dr. Ben Caballero, who was a member of the Institute of Medicine panel and is director of the Center for Human Nutrition at Johns Hopkins school of public health. The two ?guidelines, he says, ?are complementary.?

...

Any exercise program should also include resistance training for 20 minutes three times a week, using weights or exercise bands, or doing push-ups or squats. Weight training increases muscles and improves bone density?critical for baby boomers who?d rather bungee-jump than use a walker. ?There?s no other way you retain muscle mass and strength,? says William Haskell, an exercise specialist at the Stanford School of Medicine. Better strength also means fewer falls, which are the leading cause of death from injury in people older than 65. And new research suggests resistance training can even be good for the ticker, too: the Harvard runners study found that men who trained with weights for 30 minutes or more per week cut their risk of heart disease by 23 percent.

So when will you exercise this week. Make a plan and stick to it. You owe it to your body.

Weight loss is big business. Ad Campaigns Expand for Weight Loss Programs. Maybe I should chuck this blog and write a weight loss book! Naw, go to any bookstore, we have too many such books already.

Dr. Robert Atkins, the king of the high-protein and low-carbohydrate diet, and Dr. Dean Ornish, a staunch proponent of the low-fat lifestyle, have become the Norman Mailer and Gore Vidal of the diet industry, duking out their opposing views on television and in newspapers and magazines.

Now the battle between the doctors and their companies and products is spilling over into the advertising world.

The article also includes Weight Watchers and Jenny Craig. Weight loss is big business. Unfortunately, the clients are often unsuccessful (taking the long term rather than the short term view). The business has no shortage of clients. So our society responds to excess food and decreased exercise with artificial fixes - the diet industry. These programs work, but few will continue to follow them for long periods. It is boring but true, successful weight loss with maintenance requires lifestyle changes. And how many Americans willingly and knowingly make lifestyle changes.

So I could write a book. But it would be very short. You need to make time for exercise - both aerobic and resistance - every week. You should modify your portions to first allow weight loss, and then maintenance. I believe in weighing daily and using short term aggressive dieting when I slip as little as 2 pounds.

Think I could turn that into a book? Anyone have a catchy title? Anyone know an agent?

Research Links Food Stamps and Obesity. If you have blinked twice on this story, join me. I really do not even believe the title!

Besharov said that how much people eat is directly connected to how much they?re given.

"When we give poor families food stamps instead of cash, we know that they will consume 20 percent more food," Besharov said. "That might be great at a time of hunger and malnutrition, but at a time of obesity, that?s a mistake."

The overeating epidemic is growing fastest among poor kids: 16 percent of low-income children are either overweight or obese, twice the rate of other children. That puts federally-funded school breakfast and lunch programs ? which are mandated to provide 60 percent of students? total daily caloric intake ? under the microscope.

Besharov thinks the government should continue to fund food programs but needs to change the emphasis from quantity and caloric intake to nutrition counseling and healthy eating habits.

I do not make up this stories - honest. People say and do these things.

The Annals of Internal Medicine has an important analysis of the Framingham data in the current issue - Obesity in Adulthood and Its Consequences for Life Expectancy: A Life-Table Analysis (subscription required). Several news articles summarize this article. Being Fatter at 40 Can Shorten Life by 3 Years

Nonsmokers who were classified as overweight, but not obese, lost an average of three years off their lives. Obese people died even sooner. Obese female nonsmokers lost an average of 7.1 years, while obese male nonsmokers lost 5.8 years.

Scientists have long known that overweight people have shorter life expectancies, but few large-scale studies have been able to pinpoint how many years they lose.

"This study is saying that if you are overweight by your mid-30's to mid-40's, even if you lose some weight later on, you still carry a higher risk of dying," said Dr. Serge Jabbour, director of the weight-loss clinic at Thomas Jefferson University Hospital in Philadelphia. "The message is that you have to work early on your weight. If you wait a long time, the damage may have been done."

For smokers, the results were worse. Obese female smokers died 7.2 years sooner than normal-weight smokers and 13.3 years sooner than trim nonsmoking women. Obese male smokers lived 6.7 years less than trim smokers, and 13.7 years less than trim nonsmokers.

Sobering data, maybe this will stimulate some readers to start exercising and watching their diet.

The LA Times has an interesting group of articles today (free registration required) - Five views on nutrition.

...we asked five of Southern California's leading dietary professionals what they recommend for weight loss. We also wanted to know if they practice what they preach, what dietary tricks they use and how they feel about the current nutrition debates (carbohydrates versus protein, for one).

Their advice -- and their core messages -- vary. One focuses on getting children off to a good start, another believes people's preferences must be factored into their diet, a third recommends radical wholesale changes -- and two others tout gradual modifications.

However, they did agree on three key points: We need to eat more vegetables. Regular exercise is essential. And healthy eating isn't just what you do before your next high school reunion -- it's forever.

The article has links to the five opinions. I will summarize my take on these articles.

• Fruits and vegatables should form the base of any food pyramid - not carbohydrates.
• Minimize refined carbohydrates and rather eat complex carbohydrates.
• Portion control is the key to life long healthy eating
• Everyone should get some form of regular exercise

These are the points that I have been making (perhaps incessantly). They also recognize the different people need different diets. The diet must fit your likes, your personality, and you work/home situation.

Each morning, often as I am working on this blog, I consider my plans for the day. What do I want to accomplish? This habit started several years ago, thanks to Steven Covey's 7 Habits of Highly Effective People . While I highly recommend the book (or the audio tapes), this link does a nice job of summarizing the principles in the book - Seven Habits Condensed Summaries. While I have found all seven habits worth considering, today I want to concentrate on the seventh habit - the principle of balanced self-renewal. Quoting the summary:

Suppose you came upon someone in the woods working to saw down a tree. They are exhausted from working for hours. You suggest they take a break to sharpen the saw. They might reply, " I didn't have time to sharpen the saw, I'm busy sawing!"

Habit 7 is taking the time to sharpen the saw. By renewing the four dimensions of your nature - physical, spiritual, mental and social/emotional, you can work more quickly and effortlessly. To do this, we must be proactive. This is a Quadrant II (important, not urgent) activity that must be acted on. It's at the center of our Circle of Influence, so we must do it for ourselves.

The Physical Dimension.

The physical dimension involves caring for your physical body - eating the right foods, getting enough rest and relaxation, and exercising on a regular basis.

If we don't have a regular exercise program, eventually we will develop health problems. A good program builds your body's endurance, flexibility and strength. A new program should be started gradually, in harmony with the latest research findings.

The greatest benefit of taking care of yourself is development of your Habit 1 "muscles" of proactivity.

I will assume that you are one of the many readers who either has committed to exercise or would like to. The LA Times has a well considered piece on keeping your New Year's Resolution on exercise - Resolve all you want, but fitness needs a real plan. This article does not have quick fix ideas, rather it goes through the steps one should take to achieve fitness success.

"People spend an inordinate amount of time planning a trip or a wedding, but when it comes to getting in shape, people are unwilling to plan," says Charles Stuart Platkin, author of "Breaking the Pattern: The 5 Principles You Need to Remodel Your Life" (Red Mill Press, 2001).

That resurrects old patterns and habits that didn't work then and won't work now: "If every year you join a gym but you hate going to the gym, then maybe you need to come up with something else that provides you with cardiovascular and strength training."
Platkin, founder of the Nutricise weight-loss program, suggests rediscovering some long-forgotten but favorite sport, such as racquetball or swimming. If socializing is important, get a workout buddy (preferably one with equal zeal), join a team or make friends at the gym.

If just the thought of setting up an exercise routine seems daunting, break it into manageable steps, says Jerald Jellison, a professor of psychology at UCLA. "If you're going to join a gym, bring a checklist of things you want to know, such as the quality of the instructors, the kinds of classes they offer, and when they're open."

So each morning, as I am considering my day, I think about exercise. Is this an exercise day? If so, where and what are my plans. For example, today I plan to run on my treadmill in the afternoon after work. Yesterday I went to the gym and used an elliptical machine plus I did some leg strengthening work. Tomorrow I will workout with my trainer. This exercise variety - variety in activities and sites - works very well for me. But I must emphasize that I have developed this plan over time, understanding myself, my motivations and my habits.

Each person should find a system that works for them. I know people who do the same routine almost every day. While that system works for them, I would not work for me. Do you need variety or consistency?

Why are you exercising? What are you trying to achieve?

Setting unachievable goals is one way to almost ensure dropping out of a fitness program. Expecting to run a marathon by spring or dropping 30 pounds in a month is unrealistic for most people. Instead, focus on training for a 5- or 10-kilometer run before tackling anything more. Also, replace amorphous objectives with specific ones. Says Maidenberg, "What is the goal and how will you know when you succeed?"

Goals are very helpful. I set modest goals each 2 months. I also have some long range goals that I am working towards. For example, I have used body fat percentage as a goal. One of my two month goals have been to decrease my body fat by at least 1%. I am now nearing my overall goal, and will be resetting my goal towards maintenace.

I also have strength goals. I decided that I wanted to be able to bench press my weight. So I worked with my trainer to develop an exercise plan to achieve that goal (which I achieved 2 months ago). I am working on a long term goal to be able to do pull-ups. We have a plan and work towards that each week.

Often goals remain unattained because people focus only on their ultimate objective, which doesn't come fast enough. Resolutions are broken during the critical first few weeks of a new exercise program, when the pounds haven't come off, abs haven't gone flat, and getting up early and schlepping to the gym is still an excruciating chore. Small victories are frequently ignored, but they shouldn't be.

"Do you feel like you have more energy or can handle daily hassles better?" says Marcus, coauthor of "Motivating People to Be Physically Active" (Human Kinetics, 2003). "Do your clothes feel a little less tight? Do you just feel less bad? Short-term benefits could be having time for yourself to take a class, dance like you don't really get to, socialize and laugh. The fitness part is almost secondary."

Marcus and others advise keeping a diary of not just weight loss or time spent exercising, but also notes about positive changes in mood, sleep habits and overall health. "Write down if you did something active for 10 minutes. Then try to get in two 10-minute sessions. Feeling like you're making progress motivates all of us."

Jellison recommends looking to friends or family for positive feedback, "one or two people who are sincerely interested in the details of your progress," to act as designated cheerleaders.
There's also nothing wrong with a tangible incentive every now and then -- as long as it's not a piece of cheesecake. "When you lose 5 pounds, buy yourself a CD or call a friend," Jellison says.

If you are planning to make a resolution involving weight loss and exercise, really plan. Think through what you are trying to achieve. Break it down into achievable steps and celebrate each attainment. You can achieve amazing things once you understand how to plan each day and work towards each intermediate goal. Good luck and Happy New Year!!!

Frequent readers know of my fitness obsession. I hesistate to provide this link as it trivializes the fitness boom, nonetheless here goes - Body worship by Suzanne Fields.

The new shrines of worship have no steeples, spires or domes, but (stationary) bicycles and treadmills. These are the gyms where the penitents wear workout suits instead of hair shirts. In these worldly temples the craving is physical rather than spiritual, and the sacred icons are barbells, leg curls and chest presses. The flock is made up of men and women who want to change the shape of their lives by changing the shape of their bodies. You might say they're trying to sweat their way to salvation.

  Personal trainers and yoga masters are the leaders in this counter-reformation. An abstract mantra replaces personal contrition and faith in prayer as push-ups and pull-downs give new life to rituals of self-flagellation. Purification through fitness focuses on acts of humiliation commensurate with stress and flab.

   "Like Christian salvation, the holy grails for gym-goers may be distant and unattainable, and the paths towards them painful, but the rules and routines that their pursuit involves seem to provide comfort to a new and growing breed of secular puritans," declares the Economist, the British newsweekly, analyzing the expanding market of gym franchises and health clubs both here and in Britain, whose sponsors promise deliverance through body-building and body worship. Forget the pulls of virtue and sin, yin and yang, karma and nirvana, the polarization after the physical fall from grace is between the fat and the fit.

...

So beware of the New Age snake oil in the Gymnasiums of Eden. Satan can find Eve on a Stairmaster or in a rowing machine and Adam will drink the forbidden fruit juice wherever it's offered. Fitness may be just another fig leaf to hide from our inner selves. It might be better to eat, drink and be merry than to be miserable on the exercise machine. Happy holidays.

This rather cynical commentary misses the point. Hopefully she just rails against those gyms which have become 'meat markets'. The gyms that I frequent are filled with all ages and all shapes. I see people working hard to improve their fitness. And many previous posts have discussed the benefits of improved fitness.

I always include good fitness articles. As readers know, I have become a zealot on both cardiovascular fitness and resistance training. Some physicians have wondered about the risk and benefits of running. Could the jogging cause osteoarthritis? Does it have other adverse effects? (I suspect those physicians fit more into the couch potato mold). Jogging is back in the running

JOGGING HAS BEEN THE SUBJECT of many medical scare stories in recent years. It has been blamed for everything from sagging breasts to premature wrinkles and damaged joints, and has even been cited as a fast route to a heart attack.

So it is astonishing to learn that some experts are now suggesting that if you make one concession to the post-festive fitness frenzy, it should be to take up running.

Not only is jogging considered good for us because it whittles away fat cells, but it is thought to be helpful in protecting — yes, protecting — our joints. Scientists at Stanford University in California have recently carried out research which suggests that regular running can delay the onset of arthritis by 12 years.

Professor Jim Fries, an expert in healthy ageing, and his colleagues at Stanford’s school of medicine followed 538 runners and 423 couch potatoes for 17 years. They found that only 5 per cent of the joggers experienced osteoarthritic pain during that time, compared with 20 per cent of the sedentary group.

...

Injuries are more often caused by the shoes a jogger wears than by the action of running. “Most of the injuries I treat are caused by people wearing worn-out or unsuitable running shoes,” says Trevor Prior, a leading podiatric surgeon who treats many top athletes and football players, and works for UK Sport (formerly the Sports Council).

“Trainers have a shelf life of 300 to 500 miles,” Prior says, “after which they lose their support and cushioning and need to be thrown away. You should make sure that you visit a specialist shop when you buy a new pair, as requirements differ. It is natural for most people’s feet to roll inwards (or pronate) when they run, but some shoes don’t compensate for this. If you wear trainers that cause you to over-pronate, you may be at risk of backache, hip pain and knee problems.”

Let me emphasize this point. I started a serious cardiovascular fitness program 3 years ago (when I lost around 30 pounds). For around 6 months I was doing fine, then I developed knee and foot pains. At the time, I was very unsophisticated about shoes, but a friend recommended that I go the a running shoe store. Lo and behold, buying the right shoes greatly helped.

I still had knee pain though. Many runners and most trainers know that runners often develop relative atrophy of the vastus medialis . When this occurs one can develop the patello-femoral syndrome . Shoes helped greatly, but until I started strengthening my quadriceps I still had pain after running.

So what is the moral of my ranting? First, do cardiovascular exercise regularly. Second, invest in a good pair of shoes which fit your foot pattern. Third, if you choose running, do some resistance training, especially focusing on you legs. Your heart, bones and joints will all benefit.

I write a lot about fitness. These cardiologists 'just do it'. Dungeons and doctors: These physicians take a no-frills approach to exercise: It's cold, spartan and dank. But the garage-now-gym is the early-morning place to be for four weight-lifting cardiologists.

Three days a week, before work, Dr. Mishkel and three colleagues from St. John's Hospital come to lift weights at the Dungeon Training Center, a garage-turned-gym in Springfield, Ill. With its concrete floor, exposed wiring and insulation and duct-taped window, it seems an unlikely place for doctors to exercise.

But they love the camaraderie here, the workout routines and the physical and mental boost that pumping iron provides. Proudly, they are slaves to the dungeon.

"It's freezing in the winter and it's boiling in the summer. There are times when it's cold and I wish at 5:30 in the morning we had some heat," said Dr. Mishkel, 45. "It's not a gym that one would normally associate a bunch of physicians to be at."

From about 5 a.m. to 6:30 a.m. Monday, Wednesday and Friday, the Dungeon is where you will find Dr. Mishkel, Stephen Jennison, MD, Richard Ammar Jr., MD, and Kriegh Moulton, MD. All four work for Prairie Heart Institute at St. John's in Springfield. They range in age from 37 to 50.

The workouts offer them a way to practice what they preach. Advice about staying fit means more coming from a healthy doctor than one who's noticeably out of shape.

"It's very hard to preach to patients if you're overweight. In many ways, you can motivate patients if they see you're in reasonable shape," said Dr. Mishkel, who stands 5 feet 9 inches and weighs 170 pounds.

Dr. Ammar agrees. "Coming from a slightly pudgy cardiologist, patients are like, 'Yeah, right buddy. What about you?' "

My personal experience supports this last comment. Patients do take you more seriously when you have a desirable body habitus (at least in terms of fitness and weight loss advice). I would love to see a study comparing pudgy and fit doctors advice (and even the likelihood that they would emphasize fitness and weight loss).

Recently I endorsed working with a personal trainer if one is naive about resistance training. I assumed in that recommendation that one could find a QUALIFIED personal trainer easily. This article discusses the problems of finding the right trainer. Who Trained the Trainer? : As Fitness Credentials Differ, So Do Knowledge And Safety. The facility that I use has a very structured training program. I know the owners (who are very experienced trainers themselves) and have seen them training new trainers. This model is an unusual one though. If you are looking for a trainer, read this article carefully.

A reader writes "past 60, I understand that weight lifting helps strength, balance, and bones. However, there is a proper way to do this, or one can damage muscle etc. Where do we find the instructions??". There are several ways one can proceed. Being past 50, I find this an excellent question. The questioners assumptions of the benefits are correct.

The best (although more expensive) way is to work with a qualified personal trainer. Personal trainers can help you pick strength training exercises and emphasize proper technique. I use a personal trainer and am very pleased with my results - improved strength, decreased body fat and greater sense of well being. However working with a personal trainer is not an option for everyone.

In researching this topic, I found this highly recommended book - Strength Training Past 50

Muscles lose size and strength with age, resulting in physical weakness and a variety of degenerative problems. But muscle loss may be largely avoided with regular strength training, and a large amount of muscle tissue already lost can be replaced, regardless of your age. Strength Training Past 50 presents research-based guidelines to help anyone over 50 develop and perform a sound, safe strength training program.

Wayne Westcott, PhD, and Tom Baechle, EdD, two of the world's most recognized strength and conditioning experts, have developed this comprehensive, practical guide for the over-50 fitness market, one of the fastest-growing segments of the industry.

Wayne Westcott is one of the fitness industry's most visible and respected experts, whose articles have appeared in Shape, Fitness, Prevention, Men's Health, and other popular publications and whose research has contributed much of the mounting evidence showing the great benefits of strength training for people past 50. Tom Baechle is the author of Weight Training: Steps to Success, which has sold more than 100,000 copies, as well as several other books. He is also editor of Essentials of Strength Training and Conditioning, the definitive text in its field.

Strength Training Past 50 uses data collected and analyzed in a five-year study that examined the effects of regular strength training on previously sedentary adults. Results showed that regardless of gender, age, or physical condition, the 1,132 men and women who participated in the strength exercise program made significant improvements in terms of added muscle, lost fat, and reduced resting blood pressure. In fact, in this group, in which the age range was 21 to 80, participants over 60 responded just as well to strength exercise as everyone else.

Research clearly shows that you're never too old to get great benefits from strength training. Strength Training Past 50 explains and shows the most effective way for mature adults to work their muscles by presenting

* specific strength tests,
* 9 safety essentials,
* 39 age-appropriate exercises,
* a 10-week workout plan, and
* personalized programs for increasing muscle size, strength, or endurance.

America's Epidemic of Youth Obesity

That Americans are getting heavier is especially hard to deny the day after Thanksgiving. But America's weight problem has less to do with holiday binges than with everyday choices and circumstances. That's especially true for children, who are gaining weight in epidemic numbers, particularly in minority communities. Mexican-American and African-American children are twice as likely as non-Hispanic white children to have a body mass index of more than 25, the definition of overweight. In the last three decades, the number of overweight young Americans has tripled, with no sign the trend is abating.

Far from being just the stuff of cruel schoolyard taunts, the issue has serious long-term implications. For the first time, children are being diagnosed with weight-related chronic ailments that usually strike much later in life, including hypertension and Type 2 diabetes, popularly known as adult-onset diabetes — a name that now needs rethinking. These diseased children are at risk, as similarly stricken adults are, for heart and kidney troubles, blindness and limb amputation, but at an earlier age. Further, as odd as it seems, a number of these children suffer from malnutrition from the unhealthy diets that made them fat. As they age, they can be expected to strain the health care system.

Genetics, while important, is just one piece of a larger physiological and psychological puzzle. At the National Institutes of Health, no fewer than 16 studies are being financed to study how to change environments to encourage a healthier lifestyle for young people — from day care and after-school activities to educating children about food. "There is a panoply of forces that are all conspiring to get us to eat more and exercise less," says Dr. Susan Yanovski, director of an institute obesity and eating disorders program.

...

In many low-income minority neighborhoods, fried carryout is a cinch to find, but affordable fresh produce and nutritious food are not. Those same neighborhoods often lack many safe public places to play and exercise — an essential part of any weight-management equation. Dr. Michael Myers, who works daily with obese patients in Los Alamitos, Calif., says that even when an ideal weight cannot be achieved, regular exercise and activity can delay or prevent the onset of health complications for an overweight child. While more study of the problem is needed, helping to make the victims of this epidemic more active cannot hurt either.

While it seems politically correct to focus on obesity in underprivileged areas, we see obesity in the rich suburbs also. Hopefully, the NIH funded studies will reveal the multifactorial nature of obesity. When in doubt, start moving that body, walk, lift some weights and turn off the TV. Get rid of the video games, using them as a reward after an hour of exerise.

Should we subsidize healthy food options? A reader suggested a special program to help startup companies interested in offering 'healthy fast food chains'. Interesting concept.

As I have discussed previously, body fat is a much better measure than BMI. Ideally we should strive towards a goal body fat rather than a weight. As you and your patients make plans for the inevitable New Year's resolution (more exercise, better diet), you might want to consider this as a measuring stick - No Calipers or Cringing: A Discreet Gauge of Body Fat

As an alternative, Mrs. Lawton, 38, purchased a body fat analysis scale that she could use at home.

"I wanted to keep on top of my measurements since I had a certain goal of losing a specific amount of body fat, but I didn't want the hassle of having to go to the gym," she said.

Mrs. Lawton had plenty of options. Fat-analysis scales were introduced six years ago, and as early as 2000 most manufacturers offered at least one model. Today fat-analysis scales are so mainstream they can be found in most home, hardware and department stores alongside traditional mechanical and digital scales. Companies like Measurement Specialties, Tanita and Taylor Precision Products make the scales, which cost from $50 to $200.

Fat-analysis scales look like traditional bathroom scales, and, in one respect, act like them too: they weigh the body when they are stepped on. But placing your feet on a fat-analysis scale also puts them in contact with electrodes that send a small (and undetectable) electrical current through the body. The scale compares the current entering the body with the current leaving it and calculates body fat composition using bioelectric impedance analysis, or B.I.A., which is based on the difference in the ways that an electrical current is affected by muscle and fat.

I just might buy myself one to compare with my caliper measurements.

Reborn to Run: How a Non-Jock Learned to Love Running, or at Least Act as if She Does. Before any quotes, click on the article and read it. This is fun writing. She is honest, explains her motivations and gives some great tips.

For me, running has always been a source of dread, recalling memories of despotic gym teachers and certain humiliation. The sensory memories themselves are painful: feeling winded and slightly nauseated, saliva coursing down my chin as I pant around a hard asphalt track.

So how can I explain that, at age 47, I now happily run 20 to 25 miles a week?

Quite simply, I lie, cheat and steal. I throw out the rules and make my own. Instead of a macho, suck-it-up approach, I use goofy tricks, mind games and some nifty headphones to diminish the pain of my exertions, or at least distract myself from them. I know these strategies are infantile. Just try to take them away from me.

In the past 18 months I've dropped nearly 30 pounds and, more or less, kept them off. My heart rate has fallen to that of a hibernating animal and I have more energy than I've had for years. My approach will never appeal to serious athletes, but they have never needed much help. You, I figure, might be another story.

Please read the article. It is great!

I agree with much that she says. I do have a suggestion though. Buy a flash memory mp3 player. I recently bought RCA's Lyra (128 mB) which will hold up to 4 hours of songs. I use funk tunes to either run or use the elliptical machine. The author has discovered a truth that many know. Music does enhance the workout. Another trick is to have a TV in your workout room and find a TV show to run/walk/jog. I will often pick a show and use the show to set the time of my workout.

I hope this article will help some of you and your patients. You (they) may never love it, but you (they) will like how it makes one feel and look. I love the complements I get from friends. Vanity is a reasonable motivation.

Atkins diet beats low-fat fare

At least three formal studies of the Atkins diet have been presented at medical conferences over the past year, and all have reached similar results. The latest, conducted by Dr. Eric Westman of Duke University, was presented Monday at the annual scientific meeting of the American Heart Association, long a stronghold of support for the traditional low-fat approach.

Westman, an internist at Duke’s diet and fitness center, said he decided to study the Atkins approach because of concern over so many patients and friends taking it up on their own. He approached the Robert C. Atkins foundation in New York City to finance the research.

Westman studied 120 overweight volunteers, who were randomly assigned to the Atkins diet or the heart association’s Step 1 diet, a widely used low-fat approach. On the Atkins diet, people limited their carbs to less than 20 grams a day, and 60 percent of their calories came from fat.

“It was high fat, off the scale,” he said.

After six months, the people on the Atkins diet had lost 31 pounds, compared with 20 pounds on the AHA diet, and more people stuck with the Atkins regimen.

Total cholesterol fell slightly in both groups. However, those on the Atkins diet had an 11 percent increase in HDL, the good cholesterol, and a 49 percent drop in triglycerides. On the AHA diet, HDL was unchanged, and triglycerides dropped 22 percent. High triglycerides may raise the risk of heart disease.

While the volunteers’ total amounts of LDL, the bad cholesterol, did not change much on either diet, there was evidence that it had shifted to a form that may be less likely to clog the arteries.

Wow!! These studies are causing a paradigm shift. While the medical research establishment sometimes embraces the wrong theories, it consistently respects data. These studies will probably 'open the flood gates' of research into the Atkins diet. In the meantime, I have changed my position on advising patients and friends. If they want to use the Atkins diet I support them psychologically. I do not yet understand why this happens, but this is certainly a fascinating development.

Fat chance: How physicians can help patients lighten their load: The directions are clear: Eat your fruits and vegetables. Drink water. Exercise regularly. Still the numbers on the scale go up. How can doctors get patients to comply? Read this long article. It clearly defines the problem Doctor, heal thy self!

But with time and scheduling tight, some doctors shy away from this investment, instead feeling relief when a patient actually doesn't gain weight. Others, however, maintain that there is something to be said for taking on the issue and being a role model.

"Some doctors don't address [weight and exercise] with patients because they don't address it for themselves," said Melina Jampolis, MD, a San Francisco internist who specializes in bariatric medicine. "You can't expect to have a meaningful conversation with a patient when you are winded from walking down the hall and into an exam room."

When physicians talk about their own diet and exercise behavior, they generally agree that they are not all that different from their patients.

"It is a huge challenge to get out and exercise," said Michael Schneider, MD, an anesthesiologist in Orange County, Calif., mostly because of the hours. But when it is a priority, it happens. A colleague doesn't schedule surgery before 8:30 a.m. so she can go running first.

Some studies, Dr. Cheskin said, show that doctors are somewhat more adherent, but there is a lot of variability.

What Dr. Schneider sees when he looks around a hospital "runs the gamut." There are plenty of physicians who are overweight, and there are anesthesiologists who smoke. It's hard to say whether doctors overall are healthier than the general population. "As a physician, you are exposed [to the message] more frequently. If you don't internalize it, that's a different problem."

The fact that doctors and patients are in this together plays a prominent role in the physician-patient dynamic. And physicians who admit to not always doing the right thing say it makes them more empathetic.

This is important. We are role models. We must figure out how to balance our lives and succeed in healthy behaviors. Then we can help our patients. This is important.

Having trouble developing your own exercise program - read this - In Your Corner: Motivation

Here's the truth about exercise: If you dread it, you won't do it. How is it that we say we've got no time to exercise, yet we've seen every episode of West Wing since it began? The truth is, we choose not to spend some of our free time exercising. The psychology is simple: We make time for what we enjoy, and we put off - or avoid entirely - what we don't.

The key is finding ways to make exercise less of a chore and more of a choice, says James Annesi, Ph.D., exercise psychologist and director of wellness for the Metro Atlanta YMCA. Try these simple strategies, he says, and you may find yourself skipping - OK, taping - West Wing episodes to avoid missing workouts.

Leaner times in fast food

In a Harris Interactive survey of 1,900 adults last November, one-third of the respondents reported eating less often at fast-food restaurants than they had a year earlier. Asked why, almost two-thirds said they were shunning burger joints in order to eat more nutritiously.

Quick, turn up the grill. Jazz up the flavors. Toss a salad, bring on the poultry, and modify the fries. That's one path - along with lower prices - that the fast-food industry is taking to attract new customers and hang onto old ones.

Chicken - grilled, roasted or broiled, in sandwiches and salads - is a key element in strategies to coax diners back to McDonald's, Wendy's and other quick spots.

I saw yesterday that McDonald's had a poor financial quarter. Maybe, just maybe, capitalism works. When we (the consumer) start expecting a different diet, by gosh the restaurants will provide it.

Study: Exercise Hits Cholesterol Risk

Cholesterol is an essential fat, or lipid. It circulates through the body by attaching to protein particles. Cholesterol appears more likely to clog the arteries when it is carried by small, dense protein particles than when it is moved by relatively large, fluffy ones.

The latest study finds that people who exercise develop these bigger particles, even if their total amount of cholesterol stays the same.

``Using this analysis shows clearly that exercise has beneficial effects that are not revealed by standard tests,'' said Dr. Ronald M. Krauss of the Lawrence Berkeley National Laboratory, who studies the protein particles.

The study, conducted at Duke and East Carolina University, involved 111 sedentary, overweight men and women. They were randomly assigned to three exercise groups: the equivalent of walking 12 miles a week, jogging 12 miles a week or jogging 20 miles a week. All were instructed to eat enough to keep their weight constant.

They found that the cholesterol effects of walking and jogging 12 miles were the same, while jogging 20 miles resulted in more pronounced changes.

Measuring protein particle size is sometimes done in large medical centers, but it is not part of standard physicals. Kraus said he expects the tests, which cost two or three times more than standard cholesterol tests, to become more widely used.

Dr. Joann Manson, head of preventive medicine at Harvard's Brigham and Women's Hospital, noted that exercise has already been found to have many other benefits for the heart, including improvements in blood pressure, blood sugar, clotting and inflammation.

Studies show that briskly walking 30 minutes a day can lower the risk of heart disease by 30 percent to 40 percent.

This study provides another explanation of the benefits of exercise. Do you get it 20 miles each week?

If one can remove the barriers to exercise, then what? With Enough Help, Even High Barriers to Exercise Fall .

In the best circumstances, sticking with an exercise routine is difficult. Under the worst circumstances -- living in extreme poverty with gang members on the doorstep, say, or coping with obesity and diabetes, or maybe an utter lack of social support and a long-entrenched habit of sedentary living -- it can seem nearly impossible.

But it's not. A study funded by the federal Centers for Disease Control and Prevention (CDC) and the National Institute on Aging recently found that members of high-risk, low-activity groups who cited some or all of the above conditions can be helped to start and maintain an exercise program. A group of 31 people living in Chicago's urban core, most of them African American women with an average age of 54, showed up for 87 percent of their three-times-a-week workouts over three months. For their efforts, participants reaped measurable improvements in strength, endurance and fitness with no major adverse medical events.

The tactics that made it work? The program was free and provided both transportation to the gym and telephone check-ins by program coordinators after missed sessions. "Removing obstacles to working out results in a high turnout rate," says the study's lead author, James H. Rimmer, an exercise physiologist and professor at the University of Illinois at Chicago. "Providing transportation and love and care will help people get results for good health." The study was published in the American Journal of Preventive Medicine.

The one-hour fitness sessions, which took place under a trainer's supervision, included 20 minutes of strength training; 30 minutes of cardiovascular activity on treadmills, exercise bikes or elliptical trainers; and 10 minutes of stretching for flexibility. Lower body strength improved by 40 percent, cardiovascular fitness by 14 percent and flexibility by 10 percent. "Movement is critical to feeling good," says Rimmer. "So many of our participants were sitting or lying down almost 24 hours a day. They'd come into the sessions moping around and end up laughing and joking around."

I wonder if our society would benefit from programs like this one. If exercise programs can decrease health care costs, they just might pay for themselves. We evolved as an active people first, only in the last century have we become such couch potatoes. This could be (and probably should be) a major concern of public health.

You know that I love this one. The power of lifting weights

Yet the metabolic rate -- a measure of how many calories your body needs to function -- is rarely responsible for weight-loss woes. "The metabolic rate is remarkably similar in most individuals," Evans says, once you control for these two critical factors:

Lean body mass, the percentage of body weight that comes from muscle, bone and organ.

Restrictive dieting, consuming significantly fewer calories than you expend.

Arguably the single most important determinant of metabolic rate is lean body mass. "The more lean tissue you have," Evans says, "the higher your metabolic rate."

Muscle mass boosts metabolism because muscle is active tissue that helps convert food into water, heat and energy. Fat is more passive, acting primarily as a stored form of body energy. So when your body is deciding what to do with the food you've eaten, the more muscle you have, the more calories it can send to muscle cells to be burned. This leaves fewer calories to go to fat cells to be stored.

Their higher proportion of muscle explains why, in general, men have higher metabolic rates than women and younger people have higher metabolic rates than older people. Starting around age 30, muscle mass in sedentary individuals declines by about 2% to 5% per decade, says Evans, adding that caloric requirements -- and metabolic rate -- decline accordingly. This is why an active, muscular 20-year-old can eat much more than a sedentary, pot-bellied 55-year-old without gaining weight.

Dieting also can ratchet down metabolism. "When you go on a restrictive diet, your body senses starvation and slows your metabolic rate to conserve energy," Evans said.

...

"What's remarkable is the change you can make in your metabolic rate with strength training," he adds. "Several excellent new studies suggest that formerly sedentary adults who do a program of strength training for three months gain about 3 pounds of muscle -- that's a pound of muscle a month."

Researchers found that this 3-pound increase in muscle mass boosted the participants' resting metabolic rate by about 7%, Westcott says. "So with just three months of strength training you can reverse decades of the aging process."

I am a firm believer. Weight training is part of my personal program. The benefits include the higher metabolic rate. Proper leg training cured my knee tendonitis (caused by a weak vastus medialis from running without strength work). Several other pains are cured. I feel better and apparently look better. It does take a committment and some hard work. I love the sense of physical achievement as I can do more in the gym each month. If you want easier weight control, you should consider adding weight training to your program.

Long time readers know that I love this one. Exercise: Quality versus quantity

Researchers have debated whether pace makes a significant difference in protecting the heart, but the new study found that men who exercised at high intensity were 17 percent less likely to develop heart disease than those who did low-intensity exercise.

High-intensity exercise includes running or jogging at 6 mph, while low-intensity activities include walking at a pace of about 2 mph.

Researchers also have debated whether weight-training has a big impact on the heart, since it does not give the heart and lungs the kind of workout they get from aerobic activities such as brisk walking or running for at least 20 minutes.

But in the Harvard School of Public Health study, men who engaged in weight training for 30 minutes or more weekly had a 23 percent lower risk of heart disease than men who did not pump iron. The researchers said the benefits may result in part from reductions in blood pressure and body fat achieved through weight training.

Given the independent results from weight training, the researchers theorized that adding weight training to a high-intensity exercise program would reap even greater benefits.

Improve your odds and increase that exercise level. This requires dedication and slow steady increases. Serious exercise can help both quality and quantity of life.

Give me Strength!

Researchers are learning that a moderate strength-training (weight-lifting) program can do wonders for our bodies. After we turn 30, we lose about 10 percent of our muscle per decade, or a half-pound of muscle every year. That may not sound like much - but by age 70 it means we've been sapped of at least 40 percent of our strength. Lugging a 20-pound bag of groceries at age 30 may be a chore; by age 70 it could be a pipe dream unless we do something to maintain muscle.

Whether you are 20 or 90, strength training stops muscle loss and builds new muscle tissue. That muscle will burn calories, give your body shape, influence your flexibility and sense of balance, and protect you against several diseases.

To a certain extent, strength training even reverses some of the changes normally associated with old age, such as decreased stamina, energy and balance.

I am a zealot. Read the entire piece and consider. We should encourage weight training for many patients. This is an important part of a healthy lifestyle!

Earlier this week I referred to this week's articles on obesity. Jane Galt commented on those articles also - Apparently, many Americans are clinically obese, but don't know it.. Over on Jane's site, many comments centered on the definitions of overweight and obesity. I believe that we should use a combination of BMI (with its flaws) and waste circumference. Let's review some data.

An article in the current issue of the American Journal of Clinical Nutrition ( Waist circumference and obesity-associated risk factors among whites in the third National Health and Nutrition Examination Survey(NHANES): clinical action thresholds) addresses this issue in a careful and systemic manner. The investigators used the NHANES data to ask whether measures of obesity predicted cardiac risk factor presence (one of low HDL, high LDL, high blood pressure or high glucose). This study only examines white participants.

Using complex statistics, they determined thresholds for BMI and waist circumference as predictors of cardiac risk factors. They derived a variety of results, but I will focus on the point of standard risk (i.e., above that measure you have increased risk, below that measure you have decreased risk). For BMI in men that point equals 26, for women it equals 25. For waist circumference in men that point equals 96 cm (37.8 inches), for women it equals 85 cm (33.5 inches). They also showed that waist circumference predicts these cardiac risks better than BMI.

An accompanying editorial (no link available) discusses this issue in depth. They make several important points. First, waist circumference is the best anthropomorphic measure of total body fat. Second, the editorial and article debate the appropriate cutpoints or action thresholds.

The article proposes the following action thresholds: overweight = waist circumference greater than 90 cm (35.5 inches) for men or 83 cm (32.7 inches) for women; obesity = waist circumference greater than 100 cm (39.3 inches) for men or 93 cm (36.6 inches) for women. I propose a two pronged approach, only because waist circumference takes more time and effort to follow. We should measure patients at their first visits (accurate height and weight as well as waist circumference). If the waist circumference is less than the overweight threshold, one need not address weight as a risk factor. If the waist circumference shows either overweight or obesity, then one might calculate the BMI for correlation. If the BMI and waist circumference show similar values, one can then simply follow the weight, measuring the waist circumference again after weight loss. This strategy will help classify the tall (for whom BMI works less well) and the very fit (who often have an elevated BMI from muscle weight). When the waist circumference looks good, yet the BMI looks elevated, one should believe the waist circumference.

How should we measure waist circumference? "How to measure waist circumference: With a tape measure, comfortably measure the distance around the smallest area below the rib cage and above the umbilicus (belly button)." Waist circumference I like waist circumference because we can each follow our own waist circumference easily.

Now for those with elevated waist circumference, how do you lose weight? I have written extensively on this issue. The principle is simple - you must eat less and burn more. There is no magic. Weight loss requires life style change. So does maintaining weight loss.

Maintaining Weight Loss

How do people successfully lose weight and keep it off?

Healthy low-calorie and low-fat diets as well as high levels of physical activity are the foundation for success, according to the researchers who maintain the National Weight Control Registry (NWCR), a database of people who have self-reported successful weight loss and maintenance of weight loss.

Although the criteria for entry into the NWCR is the achievement and maintenance of weight loss of 30 pounds or more for at least one year, the average NWCR participant has lost about 60 pounds and kept it off for about five years.

When participants were asked questions about how they maintained their weight loss, the NWCR researchers found that:

* 92 percent limited their intake of certain foods (one example: eating at fast food restaurants less than once a week).
* They consumed an average of 1400 calories per day, of which 24 percent of calories was from fat, 19 percent protein, and 56 percent carbohydrates.
* They ate five times a day, on average.
* They burned an average of 2,800 calories a week through exercise (an equivalent of about 400 calories day).
* 75 percent weighed themselves regularly - at least once a week.
* About one-third described weight maintenance as hard, one-third as moderately easy, and one-third as easy.
* 42 percent reported that maintaining their weight loss was less difficult than initially losing the weight.

Approximately 80 percent of NWCR respondents are women, 97 percent are white, and 54 percent have an undergraduate or graduate degree.

To read more about sustained weight loss - The National Weight Control Registry

One of the most popular myths about weight loss is that everyone who loses weight will eventually gain it back. The National Weight Control Registry is a research study which has exploded this myth and shown that successful weight loss is indeed possible. Developed by Rena Wing, PhD, at Lifespan, Brown University and the University of Pittsburgh, and James Hill, PhD, at the University of Colorado, the National Weight Control Registry has identified nearly 3,000 individuals who have lost significant amounts of weight and kept it off for long periods of time.

So I have given you a long answer to our initial question. We should not ignore overweight and obesity. They do greatly increase your chances for disease. Patients can address this problem. We physicians must continue to motivate the patients. Many will fail, but if a few succeed than we have done a good job.

Look around and what do you see - huge bellies, and big butts. We are getting fatter and this study proves it. Study Finds That in U.S., 1 in 3 Are Obese

While waistlines are expanding across the board, the study shows that some groups are getting fatter faster than others. For example, more than half of black women 40 and older are obese, and more than 80 percent are overweight.

The findings suggest that "we are totally losing the battle to prevent and treat obesity," said George L. Blackburn, chairman of nutrition medicine at Harvard Medical School.

Also troubling is the rise in extreme obesity, according to the study, which is one of three papers on obesity published today in the Journal of the American Medical Association. Obesity is defined as having a BMI of 30 or greater, while extreme obesity is defined as having a BMI of 40 or greater. The number of adults with extreme obesity -- equal to a 5-foot-10-inch person weighing 280 pounds or more -- rose from 3 percent to nearly 5 percent from 1999 to 2000, according to the CDC. That trend worries public health officials, because this group is at greatest risk for severe health problems, including diabetes, high blood pressure, heart disease and kidney failure.

"The greatest concern is about African American women," said William H. Dietz, director of the CDC's Division of Nutrition and Physical Activity and co-author of the JAMA paper on extreme obesity. "More than half are obese, and 15 percent have a BMI greater than 40."

One can easily define the problem. Unfortunately, we do not know how to address the problem.

The Lean Plate Club: Healthier, Yes; Health Food, No. Sally Squires of the Lean Plate Club has written a very nice article about fast food and snacks.

Here's how to help make snacking part of a balanced, healthy Lean Plate Club approach to eating:

Read the fine print. Just because a snack food contains broccoli (or other vegetables) doesn't necessarily make it a health food. Take Terra Chips (made with sliced sweet potato, yuca, taro root, balata and parsnip). A one-ounce serving contains seven grams of fat -- one gram more than Tostito's White Corn taco chips. The Terra chips have three grams of fiber -- that's two grams more than the taco chips -- but they have half the calcium. You'll get identical amounts of iron from both types of chips, and each contains one gram of saturated fat. As for calories: Terra Chips clock in at 140 per serving while the Tostitos contain 130.

Check portion sizes. You've heard it before, but it can't be underscored enough: Portion size really does count. And just because a package of snack food looks like a single serving doesn't mean that it is. Take pretzels. Some vending machine packages contain 2.5 servings per bag. Ditto for microwave popcorn, which pops about 12 cups per bag, enough for three servings -- or about 420 calories, including 12 grams of fat, 2.5 of them saturated.

Boost nutrition with snacks. Registered dietitian Mercer, of Ann Arbor, Mich., eats snacks to embellish her diet with healthy food. She has a banana for a mid-morning snack, low-fat string cheese with whole-wheat crackers as a late-afternoon snack and a small, pre-measured portion of nuts (with healthy fat) while she's preparing dinner. And when she yearns for chocolate, she eats a Crave bar, a snack item from Kellogg's.

Does Variety In Exercise Matter? Not really.

Sugared Soft Drinks Make You Softer in Middle. We should file this one under 'duh', however the data may help in patient counseling.

So say Danish scientists who conducted a study of 41 overweight, middle-aged people for 10 weeks, asking them to add sweet drinks to their regular diet. Half the participants were given sucrose-sweetened drinks and half were given drinks sweetened with artificial sweetener. Participants were not told which type of beverage they were drinking.

Those whose drinks were sugar-sweetened gained an average of three pounds, while those who drank diet drinks lost a little more than two pounds on average.

"We were astounded that these soft drinks could change weight that much. We didn't expect soft drinks to have this fattening effect," says Dr. Arne Astrup, a nutrition professor in Copenhagen and an author of the study, which appears in the October issue of the American Journal of Clinical Nutrition.

Men and women have this in common, many of us are unhappy with our bodies. Men suffer body image disorders

Writing in the journal, the researchers said: "If more men are taking to the gym in order to increase their musculature, some may be at risk of developing muscle dysmorphia."

They add: "In a changing culture where men's bodies are becoming more visible alongside an increased acceptance of physical exercise as a desirable activity, MD in men may be one negative consequence of physical exercise behaviour, particularly weight training, being motivated primarily by physical appearance.

"How to prevent this and, if it occurs, what to do about it are important questions for both researchers and practitioners."

This is not a joke. Expect to learn more about this as knowledge increases.

Today the Washington Post has a series devoted to walking for one's health. I am linking the main article - you can find the supplementary articles. This one may be worth saving for patient eduction! Take a Walk: Despite the Proven Benefits of Walking, the Nation Remains Unmoved. It's Time to Step Up

Insurance companies do not fund programs for weight loss. Wrestling With Weight Issues: Insurance: Health plans can be stingy in their coverage of obesity and diet treatments.

Given obesity's role in triggering heart disease, high blood pressure, diabetes and other ailments, it's no surprise that people would expect their health insurance to pick up the tab for treatment. But getting your health insurance to pay for weight-loss treatments is a big "if," depending on which type of insurance coverage you have and where you live. Coverage is spotty, and many insurers still seem to take the attitude that being overweight is a personal failure of will.

Attitudes are changing--but slowly. In California, one of the most common disputes between consumers and health insurers involves an operation known as gastric bypass surgery, used to treat morbid obesity. The California Department of Managed Health Care, which regulates health plans, reports 86 cases in which patients appealed a health insurer's decision involving treatment for morbid obesity, a condition defined as someone who weighs at least 100 pounds more than his or her ideal weight. When those 86 cases were sent to an external review board, a panel of independent doctors hired by the state, the patients won 49 of the appeals, an unusually high success rate.

Despite the rulings, insurers are skeptical about the value of some obesity treatments. Aetna-US Healthcare, one of the nation's largest insurers, largely excludes coverage for obesity surgery, said Jill Griffiths, a company spokeswoman. Employers who provide health insurance for their workers have the option of including obesity surgery as a benefit, she noted.

"There is a fair amount of disagreement in the medical community about when [gastric bypass surgery] is appropriate and when it is not," said Jim Anderson, a spokesman for Kaiser Permanente. Anderson said that the surgery can be risky and that Kaiser wants to make sure patients have tried all other alternatives. Even so, Kaiser approves hundreds of gastric bypass procedures a year, he said. In at least one case, however, state medical reviewers overturned Kaiser's denial of a patient's request for obesity surgery, ruling that the operation was appropriate.

Insurers are more likely to approve obesity treatments today than five years ago, said Dr. Gary Anthone, director of the bariatric surgery program at USC's Keck School of Medicine. Attitudes have begun to change as the medical community has begun to consider that obesity is a disease itself, not just a contributing risk factor to other diseases.

Anthone says gastric bypass surgery is appropriate for people who have tried diet and exercise unsuccessfully and who are threatened by the other ailments that can come from obesity, including diabetes, heart disease and sleep apnea. But only as a last resort. The operation has a 1% death rate within 30 days of the surgery. And it means a permanent lifestyle change for patients who will be taking special vitamins and nutrients for the rest of their lives and eating tiny meals.

We need support for treating the obese. This disease is endemic and causes great morbidity.

10 Weight Loss Promises That Spell F-R-A-U-D

The Lean Plate Club: Diet Ads That Are Hard to Swallow .

The FTC said that these types of diet ads are proliferating and generated $35 billion in sales in 2000. The deceptive ads bombard consumers on television, on the radio, the Internet, in magazines and, yes, even in this very newspaper. Last week, the FTC also announced that on Sept. 3 it had charged a Canadian corporation operating in the United States under the name Bio Lab with deceiving consumers through ads and sales of Quick Slim and Cellu-Fight. Quick Slim is a dietary supplement sold as a "fat blocker" that appeared in free-standing inserts that were distributed through the Phildelphia Inquirer, the Dallas Morning News, the San Francisco Examiner, the Los Angeles Times and The Washington Post.

So why do so many otherwise savvy consumers continue to reach for the quick fix when it comes to weight loss? "We are told we can buy our weight out with the right product," explained Lynn McAfee, medical advocacy project director with the Council on Size and Weight Discrimination, who described her lifelong struggle with obesity at the FTC press conference last week.

McAfee said she "lived in a hopeless world when I constantly felt out of control of my body and my life," until she discovered the ads for various weight loss products in her mother's women's magazines. "Suddenly," McAfee said, "it was not that my body or my will was in error, but that I could buy a secret. . . . Is there anyone in this room who would not choose to do something the easy way?"

Waist Girth Predicts Cardiovascular Risk Better Than BMI (article from Medscape - registration required).

Waist circumference is a better indicator of cardiovascular (CV) risk than is body mass index (BMI), according to results from the National Health and Nutrition Examination Survey (NHANES) III published in the September issue of the American Journal of Clinical Nutrition.

"Body fat distribution is a more powerful predictor than is BMI for risk factors, diseases, and mortality," write ShanKuan Zhu, from Columbia University in New York, N.Y., and colleagues. "Measurements that are more sensitive to individual differences in abdominal fat might be more useful than BMI for identifying obesity-associated risk factors."

...

Waist circumference correlated more directly than did BMI with overall CV risk. Using receiver operating characteristic curves, the authors identified "cutoffs" of 90 cm (35 inches) for men and 83 cm (33 inches) for women. To minimize CV risk, they recommend advising patients with waist circumference at least as large as the cutoff value to lose weight.

"Waist circumference is more closely linked to CV disease risk factors than is BMI [so] it is inappropriate to base waist circumference thresholds on their association with BMI thresholds," the authors write. "Rather, thresholds for each should be based on their relation to risk factors."

In an accompanying editorial, Michael J. Lean and Thang S. Han discuss practical problems involved in clinical measurement of waist circumference. They recommend that future studies develop similar correlations for subjects of other races and for those who have other chronic diseases.

I hope we see more such studies. Waist circumference is easier for everyone to understand - it makes an excellent goal for patients.

Jonah Lomu is fat ... according to the official method of measuring obesity, the body mass index. There must be a better way, says Michael Hann So who is Jonah Lomu.

There are not many sportsmen in the world who have made an impact on their sport as great as Jonah Lomu has.

He burst onto the scene during the 1995 World Cup in South Africa aged 19, scoring eight tries, helping New Zealand to reach the final.

Since then, Jonah has become the most famous rugby player in the world.

He has become a role model for young rugby players in New Zealand and across the world.

Ah, there, Jonah Lomu is apparently the Michael Jordan of rugby. In this country one would substitute Michael Jordan in the headline and get the same effect. Many world class athletes have high BMI (body mass index). The body mass index does work for most patients. This article makes some interesting points about when we should not use BMI and discusses a better indicator of disease risk - body fat.

Well, that shudder may have been a little premature, because in individual cases the formula is not as helpful as you might believe. The BMI, a method used worldwide to determine how healthy a person's weight is, is based on the relationship between an individual's height and weight. At a reading of 25 or above, you are overweight. But so, according to the calculations, is Mel Gibson. And at 30, you become obese; but so are Arnold Schwarzenegger, Jonah Lomu and Sylvester Stallone.

The simplicity of the BMI makes it a godsend for looking at trends. But it is also something of a broad-brush tool. It takes no account of age, sex or race; it makes no allowance for your fitness. Most importantly, it does not measure how much fat you are carrying or how that fat is distributed.

Professor Ian Macdonald, co-editor of the International Journal of Obesity, explains that the fat you need to worry about is abdominal fat. Fat above the hips puts a strain on your heart, putting you at risk. Below the hips, it is not such a problem.

The system also fails to take into account the amount of fat you are carrying - hence the reason for the "obesity" of Jonah, Arnie and Sly. Dense, muscled physiques can weigh more than flabby, unfit ones, with the result that the superfit can end up being categorised as obese.

...

He says that too many health professionals in this country do not understand that a healthy weight is about more than a BMI reading. "I've been on a personal crusade about it," he says. "But it's what doctors in this country have always been taught."

Campbell, Macdonald and others say there is an easy and simple alternative: look at your waist size. For men, a waist size of more than 91cm (36in) should give you cause for concern. More than 101cm (40in) and you need to lose weight urgently. The equivalent figures for women are 80cm (32.5in) and 88cm (34.5in). By this criterion, Lomu, with his 27in waist, kicks the obesity tag into touch.

Macdonald, though, offers a word of caution to those who think this gives them an excuse to avoid that trip to the gym: "You can't get away with saying, 'I've got a big frame, so this doesn't apply to me.' It does."

Jack La Lanne’s fitness formula: Father of modern fitness gives tips on living longer — and stronger. He is a bit "over the top" but the message has some validity.

Feeling Under Par? Ask Your Doctor for Golf

Doctors will be able to refer unfit patients to the town's municipal golf course for an eight-week session.

"The golf professional will go round with them and give them a few tips on how to improve, to make sure they don't get frustrated if they can't hit the ball," Chapman said.

Patients will pay 36 pounds ($56) for the treatment, with local government picking up the rest of the 200-pound bill.

"Our golf course is quite short so it won't be a long old hike," Chapman told Reuters. "It's not overstrenuous and it's not hilly. It's quite a sedate course."

I love this story!

Obesity will 'become the norm'. Obesity may become as big a crisis in GB as in the US.

Three-quarters of the UK population could be overweight within the next 10-15 years, top experts have warned.

They say obesity will overtake smoking as Britain's top preventable killer.

And they have accused the government of being too scared of the food and transport industries to tackle the problem properly.

I guess the blame culture lives across the pond. We should blame industries because people eat too much and exercise too little. Poppycock!

Restrictions will not work. We need to provide options. We need more fast food with low calories and reasonable portions. Subway does great business, and the do have reasonable food on the menu.

We need to make exercise easier and more desirable. Use positive reinforcements and change behaviors. But please do not blame and regulate.

McDonald's Fat Debate Goes On

Lost in all the hoopla is that even with fewer trans fatty acids and saturated fats, anyone ordering a Big Mac, super-size fries and a super-size Coke will consume more than 1,600 calories. For children, the meal takes care of all daily calorie needs, with some left over for the day after.

"This is nothing more than dressing up nutritionally poor and calorie-dense food, at a time when obesity has reached epidemic proportions" and 10 to 15 percent of children younger than 10 are obese, said Dr. Henry Anhalt, director of pediatric endocrinology at Maimonides Medical Center in Brooklyn. "McDonald's will sell more French fries, and the public is being duped."

I was sitting in clinic yesterday with 5 residents. We were discussing diet philosophy. One resident has lost 30 pounds over the past 6 months (since delivering her son). Having read the literature, and understanding physiology, we quickly focused on portion size and especially 'unnecessary calories'. I specifically mentioned french fries. One has a perfectly filling meal with a Big Mac and a diet drink. The fries are not necessary, but are tasty and very easy to eat.

The McDonald's announcement diverts attention from the real issue: calories. No one wants to talk about calories because cutting them means dealing with the concept of eating less food, an unwelcome thought for many people. It smacks of privation. Except for the most disciplined (who probably don't eat a lot of fast food anyway), when people are confronted with more food than they need, they will eat it.

Dr. David Levitsky, a professor of nutrition and psychology at Cornell University, has produced a fascinating study to prove the point. "The more food you put in front of college students, the more they will eat," he said. At the beginning of the experiment, the results of which were presented this year, 13 students took as much as they wanted from a buffet on Monday, Wednesday and Friday. That food was weighed. The following Monday a third of the students were given the same amount they had eaten the Monday before, a third were given 25 percent more, the final third 50 percent more. Each group had an opportunity to eat the three different amounts. "The more we gave them, the more they ate," Dr. Levitsky said, adding that when they ate at the 150 percent level, they ate about 200 additional calories. "I think this shows that if we are served larger portions, we will eat them," he concluded.

Dr. Levitsky also said that people tend to eat larger portions when they eat out and that the fat content of fast-food meals is far higher than what people consume at home.

And that is my point exactly. We must work on calories and the most important key is portion control. While this seems simple, how often have you heard others, or even yourself, complain about a restaurant serving small portions.

When I was losing my weight 2 years ago, I became fanatic about portion control. I still fail sometimes and will eat too much. In our society this requires planning and will power. But one can control portions. And we must.

Train Your Brain

The finding was so serious that it could be comparable in its health effects to a vitamin deficiency, medical experts said. It was so shocking that U.S. News & World Report published a special 11-page section warning the nation.

"There is deep concern in high places over the fitness of American youth," the magazine's report began. "Parents are being warned that their children — taken to school in buses, chauffeured to activities, freed from muscle-building chores and entertained in front of TV sets — are getting soft and flabby."

The date of that report was Aug. 2, 1957.

Decades of Admonitions Fail to Get Americans Moving. You can probably tell that I am not adverse to beating a dead horse. I cannot resist providing more and more evidence of the benefits of exercise and the problems of inactivity. This article does a great job of summarizing data that I have written about previously.

"We can't just throw up our hands and say, `We tried,' " Dr. Haskell said. He is convinced that one reason people are getting fatter is because they are so sedentary and because they don't know it, with many thinking they are moving more than they really are.

Dr. Haskell and others are undeterred, determined to keep trying to find a way to change Americans' exercise habits.

"Physical activity is as close as we've come to a magic bullet for good health," Dr. Manson said. "It's more difficult than popping a pill, but it's worth it."

Amen! Posted by at 05:46 AM | Comments (0) | TrackBack (0)

High-Fat Diet: Count Calories and Think Twice. Jane Brody in today's NY Times writes intelligently about the Atkins diet and the low fat philosophy. The entire article makes good reading. I will excerpt some high points.

Does it help people lose weight? Of course it does. If you cannot eat bread, bagels, cake, cookies, ice cream, candy, crackers, muffins, sugary soft drinks, pasta, rice, most fruits and many vegetables, you will almost certainly consume fewer calories. Any diet will result in weight loss if it eliminates calories that previously were overconsumed.

This diet seems easy because it places no limits on the amounts of meats, fats, eggs, cheese and the like you can eat. These foods digest slowly, making you feel satisfied longer. Also, a diet without carbohydrates causes the body to make substances called ketones that may create a mild nausea, suppressing hunger.

We all really knew that much. Atkins is not magic. You omit so many foods that you almost have to decrease caloric intake.

What is surprising is that after three decades of simmering and soaring popularity, the Atkins diet has yet to be tested for long-term safety and effectiveness.

In an interview, Dr. Atkins said: "A long-term study would cost millions and millions of dollars. We can afford to do a six-month study." Those shorter studies, he said, have shown "major improvements in lab tests and well-being." He said his foundation has contributed to a study under way at Harvard comparing the short-term effectiveness and health effects of diets low in carbohydrates versus diets low in fat.

Dr. Abby Block, nutritionist at the foundation, said studies of the Atkins diet lasting six months to a year and extensive clinical experience, have shown consistent improvements in blood lipids and glucose levels, suggesting that the diet can improve health despite its high levels of saturated fats and cholesterol, long associated with heart disease risks.

Why hasn't the government tested it? One possible reason is that it is unlikely to be approved by any review committee, given what is known about the effects of animal fats and cholesterol on the risk of heart disease, strokes and some cancers, as well as accumulating evidence that diets rich in fruits and vegetables and moderate in protein and fat can prevent diseases like high blood pressure, prostate cancer, heart disease and diabetes.

The Atkins diet is shy on several vital nutrients, including the B vitamins and vitamins A, C and D, antioxidants that slow the effects of aging, and calcium. And, a diet rich in animal protein can draw calcium from the bones, increasing the risk of osteoporosis and hip fractures.

Brody may be correct, but as I have stated on multiple occasions, one should not use theories to stop research. There are preliminary data on the Atkins diet which seem counterintuitive. Maybe our theories are wrong. Given appropriate consent (which would include disclosing the countervailing theory) one could easily get volunteers. I understand the argument; I just do not buy it!

When nutrition experts began urging Americans to cut back on fats, many filled in by eating more carbohydrates — a lot more than anyone recommended. Food producers jumped on the bandwagon to produce low-fat snacks and desserts, and Americans went hog wild, eating as much of them as they wanted.

Many fat-free foods have as many calories, or nearly as many, as their original high-fat versions, since sugars and other carbohydrates replace the fat and reduce the loss of flavor.

Third, Americans are not eating a low-fat diet. Despite a decline in the percentage of fats in the American diet, most people still eat the same amount. As caloric intake rose, the percentage of fat calories dropped but the total amount did not. Americans are eating more of everything, especially refined carbohydrates, which are made from white flour and sugars, doing neither their health nor their waistlines any good.

Too many refined carbohydrates can raise blood levels of heart-damaging triglycerides and may increase the risk of diabetes as well as obesity. Neither is it wise to cut out all fats. The body needs fat to aid in the absorption of essential nutrients, fat enhances flavor and satiety, and some fats actually promote health.

Brody points out the key problem with the low fat movement. By emphasizing low fat, we did not focus on carbohydrates. Most diet gurus agree that too much carbohydrates (especially refined carbohydrates) will cause weight gain. The question and challenge we all have is how to cut back on carbohydrates. To which Dr. Alice H. Lichtenstein, professor of nutrition at Tufts University in Boston, added: "Reducing fat alone is no guarantee of weight loss. You must cut calories or increase physical activity."

Dr. Denke concurred: "No matter what anyone tells you, it's calories that count. Carefully controlled metabolic studies show that it doesn't matter where extra calories come from. Eat more calories than you expend and you'll gain weight."

There you go. It really is simple. Expend more calories than you ingest (the fancy doctor's way of saying burn more than you eat). There is no magic.

Medpundit weighs in on the IOM report - An Hour a Day?!!!!. She finds the second day 'spin' debriefing from the Philadelphia paper. The spin:

Walk and take stairs whenever possible, advises Penny Kris-Etherton, a nutrition professor at Pennsylvania State University and a member of the committee that drafted the guide.

...

"It seems like a lot of time for very busy people, but remember, you have 16 hours every day to work with," said Kris-Etherton, who gets in her hour by walking for 15 minutes on a treadmill in the morning and again in the evening, and by walking and taking stairs during the day.

"We're not calling for an hour of formal exercise in the gym," she emphasized. "We're trying to encourage people to incorporate more physical activity in their daily lives so an hour doesn't seem so daunting."

I was taught early in life to say what I mean. Common parlance suggests that when recommends exercise, one means exercise above and beyond that achieved in daily activities. I believe that the report meant to sensationalize. However, if your recommendations seem unreasonable to even health conscious physicians, then you have missed your target. 'The road to hell is paved with good intentions.' I do not know if that fits here, but I did think it. The should more precisely say what they mean, and not sensationalize their reommendations.

I agree with more daily walking. I climb stairs all day and walk from place to place. This makes sense for me, but will it work for those who have less freedom in their work place. What rankles me is that the most people will only remember the headline and shrug off the report as unrealistic! They missed an opportunity. As Abba Eban once said about the Palestinians - 'they never miss an opportunity to miss an opportunity'. This frustrates me.

Panel Urges Hour of Exercise a Day.

Americans need to exercise more — at least an hour a day, twice as much as previously recommended — to maintain their health and a normal body weight, according to new guidelines issued yesterday by the Institute of Medicine, the medical division of the National Academies.

In a thousand-page report, a team of 21 experts suggested for the first time a range of recommended amounts for what are called macronutrients — proteins, fats and carbohydrates — and also included advice on how much dietary fiber and exercise people should strive for to maintain good health. Previous reports over the last 60 years have dealt only with recommended levels of vitamins and minerals.

The panel's recommendations give wide leeway in choosing an acceptable diet. The report said that to meet daily needs for energy and nutrients while minimizing the risk of developing chronic ills like heart disease and diabetes, adults should get 45 percent to 65 percent of their daily calories from carbohydrates. It recommended a maximum of 25 percent of calories from added sugars, 20 percent to 35 percent of calories from fats, and 10 percent to 35 percent of calories from protein. In addition, the panel recommended that adult men 50 and under consume 38 grams of fiber a day and adult women 21 grams a day.

The new guidelines, called the Dietary Reference Intakes, are intended for use by professional nutritionists in private practice, hospitals and schools, as well as by individuals.

Do these recommendations sound difficult on exercise and loose on sugars? They do to me, and apparently they do to this expert.

Dr. Marion Nestle, chairwoman of the department of nutrition and food studies at New York University, called the exercise recommendation "amazing but impractical," given that 60 percent of the population is now totally sedentary.

"I hardly know anyone — and I know a lot of health-conscious people — who exercises an hour a day," Dr. Nestle said. "This creates a lot of tension between what's ideal and what's possible. We know half an hour a day confers substantial benefits. Wouldn't it have been better to say some exercise is better than none, and more is better than some?"

Dr. Nestle said she was also concerned about the panel's recommendation that as much as 25 percent of calories could come from added sugars, the caloric sweeteners added to manufactured foods and beverages like soda, candy, fruit drinks, cakes, cookies, ice cream and other sweets. The 25 percent limit would allow a person who consumes 2,000 calories a day to drink three and a third 12-ounce sodas each day, if soda was that person's only source of added sugars.

"This is a huge amount of added sugars in a country where soft drinks, a major source of sugars in the American diet, are increasingly a factor in the rise in overweight," Dr. Nestle said, adding that most earlier recommendations called for no more than 10 percent of calories from added sugars."

For those interested, the press release can be found here - Report Offers New Eating and Exercise Targets To Reduce Chronic Disease Risk and the entire report is available online - Dietary Reference Intakes for Energy, Carbohydrates, Fiber, Fat, Protein and Amino Acids (Macronutrients) (2002).

With a resounding 'Duh ' comes this report based on a NEJM article - Girls stop exercising in teen years.

The study did not ask the girls why they were not exercising.

“Is it they think it’s less cool? They’re more interested in shopping? Does it seem like more of a tomboy-is activity? These are all interesting questions worth pursuing,” said Eva Obarzanek, a research nutritionist at the National Heart, Lung and Blood Institute, which funded the study.

The girls’ decline in physical activity was affected by lower levels of parental education, heavier weight, smoking and pregnancy. Girls with better-educated parents may be better informed and more encouraged to exercise, the researchers suggested.

The investigators also indicate to the reporter that obesity doubled during the teen years. What I find most disturbing is the inverse association of parental education with exericise. We have a de facto social class system (as does every country with which I am aware). How can we provide equal opportunity when a fundamental factor (parental education) puts children at such a life disadvantage? Should we do more in the schools? Would it help?

The Active Life

I have a confession to make: For too long, I believed you had to be a hardcore jock to be fit. But I've learned my lesson - solid research shows that moderate physical activity can reduce the risk of heart disease and early death.

This article has a great message. If you are a total couch potato, get off that couch. Start walking and moving. The activity will help you even if you do not lose weight !

I have written recently on CRP (C-reactive protein). CRP increases suggest widespread inflammation. These increases correlate with cardiac risk. Patients with elevated CRP are more likely to have coronary events. A new study supports exercise - showing that exercise lowers CRP levels - Heart-Stopping News on Exercise: It Reduces Inflammation, Too

What Really Makes You Fat? Should you count calories or carbs? The latest research may surprise you - Well written and balanced article. And in the same issue, a debate between Atkins and Ornish - Low Fat vs. Low Carb The doctors present their dueling diet theories:. Atkins says,

For over 30 years, I've been a lone voice in the wilderness. I am grateful that the National Institutes of Health is now examining controlled-carbohydrate and low-fat nutrition. These studies may end up showing that excessive carbohydrates are the true culprits, not fat. At what point am I allowed to say, "I told you so"?

I have written about that frequently over the past months. Ornish responds,

Here's how you lose weight: burn more calories. Eat fewer calories. That's it.

You can burn more calories by exercising. You can eat fewer calories by consuming less food. You can lose weight on any diet, but it is hard to keep the pounds off because you feel hungry and deprived. An easier way to consume fewer calories is to eat less fat, because there are nine calories in each gram of fat, whereas protein and carbohydrates have only four. So eating less fat allows you to consume fewer calories without eating less food.

I agree with the high-protein advocates that it is wise to eat fewer simple carbohydrates, like sugar, white flour and white rice. They are also low in fiber, so you get a lot of calories that don't fill you up. On top of that, simple carbohydrates get absorbed quickly, causing your blood sugar to zoom up. Your body responds by making more insulin, but too much insulin accelerates conversion of calories into body fat.

The goal, however, is not to go from simple carbohydrates to bacon and brie. Instead you should opt for whole foods with complex carbohydrates such as unrefined whole-wheat bread, brown rice, fruits, vegetables and beans. These are packed with thousands of protective substances. In addition, they are rich in fiber, which slows their absorption, thus preventing a spike in your blood sugar and an excessive insulin response.

They really are not that far apart. This is a good reference.

Spot Reduction? Forget It! Wisdom from a runner.

As long time readers know, I worship at the altar of data. I want to know truth not theory. We have preached for years that stretching prevents muscle injuries. Stretching 'fails to stop muscle injury'

These showed that stretching reduces soreness by such a small amount that most athletes would not consider the effect worthwhile. Neither does it significantly help to prevent injuries.

Data from two studies on army recruits in training, whose risk of injury is high, show that muscle stretching prevented on average one injury every 23 years.

...

Researcher Dr Rob Herbert, from the University of Sydney, told BBC News Online the belief that stretching reduced injury first came to prominence in the 1960s.

The theory was that muscles were more likely to spasm, and cause pain, if they were suddenly called into vigorous action.

Dr Herbert said: "It sounded like a good idea, and the timing was perfect - around the time we were learning that physical activity reduced risk of heart disease, so recreational exercise was becoming very popular.

"But like many good ideas, the muscle spasm theory of muscle soreness was wrong and has since been discredited, but the practice of stretching before exercise persists."

Dr Herbert said it was possible that a gentle warm up before strenuous exercise may reduce the risk of injury - but even this was far from certain.

"There is no proven way of preventing muscle soreness associated with unaccustomed exercise apart from repeated performance of that specific type of exercise.

"With unaccustomed exercise, people get sore, but with repeated performance of the exercise they become resistant, for a time, to the muscle damage that causes soreness.

"It appears that the only way to prevent soreness is to get muscle soreness."

For those who like reading the original article - Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review

Seven Weight Loss Resolutions That Really Work. I actually see myself in each of these resolutions. Could you transform yourself into using them?

Exercise tips have interesting twists. This well written review makes two outstanding points. First, the book's author compares (appropriately) the effects of aging to the effects of weighlessness.

The first twist, as intriguing as it is relatively new, is that aging appears to have much in common with space travel. Evans, an adviser to NASA and former head of a special nutrition and physical fitness team for the National Space Biomedical Institution in Houston, is now running a study to figure out what exercises can best protect astronauts' bones and muscles during a Mars mission, likely to occur in 2013 or 2018.

Indeed, writes Evans, prolonged space flight in near-zero gravity results in remarkable physical changes within the body that are astonishingly similar to our journey into old age. In fact, he says, within weeks of blasting off, the astronauts' muscle cells will atrophy, calcium will be leached from their bones, and normal bone growth will be upset to the point where the risk of fracture soars. Recent research, he says, has determined that one month of space flight yields bone loss equivalent to five years of aging. By Evans's calculations, this means that with their muscles and bones weakened by gravity deprivation, even young, healthy astronauts may become as weak as most 80-year-olds.

Second, he focuses on our technique in weight lifting. He champions the eccesntric rather than the concentric (most readers are now wondering what language I'm typing). Let the article explain,

Evans's exercise prescription (for all of us, not just astronauts and research volunteers) focuses on eccentric (which means away from the body, not weird) muscle movements, as opposed to concentric (or toward-the-body) moves. The idea, which is contrary to the way most muscle builders work out, is that it's the away-from-the-body motion that strengthens muscles most quickly.

Take a biceps curl. When you start with a dumbbell at thigh level and raise it to your shoulder, the raising, or upward-bound, part of the motion is considered concentric; the lowering of the weight back down is eccentric, or as Evans prefers, E-centric. Muscles grow in bulk by undergoing microscopic tears during training; it is during the repair of these tears that muscles increase in size.

And it's E-centric motions that produce the most microscopic tears, hence the most muscle growth. The secret, Evans says, is to raise a weight (or move the business end of an exercise machine) quickly, to a count of two, on the concentric motion and lower it slowly, away from the body, to a count of six, in other words, taking three times as long on the eccentric maneuver.

The book is called AstroFit. I just might buy it.

Land of the free, home of the fat and unhappy

It sneaked up on the nation the way it often creeps up on individuals. Its arrival was a surprise, even though it had been a long time coming. We were used to looking in the mirror and seeing a tough, lean country of do-it- yourselfers. Then, seemingly overnight, our image changed. We looked in the mirror and saw that we had become fat. And we've been upset about it ever since.

Of course, people in other countries have been calling us fat for years. In 1990, France's Le Monde published articles about "les Americains obeses" and referred to our kids as "les enfants du Coca-hamburger." The Coke-hamburger kids.

It's easy to ignore a message from the other side of the Atlantic, but when Southwest Airlines told us this summer it would charge those of us whose derrieres don't fit on one 18.75-inch wide seat for two 18.75-inch seats, we finally woke up.

I assume the royal we means the media. Physicians have known this for years. Generally, we do not know how to manage and treat weight problems. This frustrates us, and our patients.

But we haven't gotten where we are today through eating habits alone. We also don't exercise. In fact, we hardly move at all. Less than 20 percent of American adults exercise the federal government's recommended minimum amount -- just 30 minutes a day, five days a week.

Our kids aren't moving any more than we are. Physical Education has been cut so severely in public schools that many youths get no P.E. at all, or it's offered only as an elective. Playtime after school is spent watching television or exercising one digit -- the thumb -- on the GameBoy or PlayStation.

I type the same message constantly. Weight control requires 2 things, eat less and exercise more. The rare patient makes that committment. Our society gives us too many excuses to eat more and exercise less. Few of us resist the easy path.

The American Obesity Association reports that 89 percent of Americans believe that overweight individuals -- not their environment or genetic makeup -- are to blame for their size. Heavy people feel this condemnation at work, in public and in the doctor's office. A study conducted by Rice University's Department of Psychology found that Texas physicians spent less time with heavier patients than with average-weight patients, and "a significant number indicated that it was a greater waste of time to see patients who were heavier. "

For HMOs and health insurers, it's not a question of a waste of time, but of money. Individuals who fall into the obese category have discovered they cannot get independent health insurance, even if they have no other health problems.

When asked if Blue Cross Blue Shield of Florida denied a 26-year-old woman insurance solely because of her weight, spokesperson Rick Curran said yes, that might have happened. "Obesity," he explained, "is considered a health risk factor that can lead to debilitating and chronic diseases." If a person's weight "significantly exceeds recommended guidelines," he said, "that person might receive a rejection letter that states that their weight would need to become more stable and more closely aligned to what is considered healthy."

It's a cruel policy that won't help anyone but the stockholders of Blue Cross Blue Shield, but Curran is right. Obese people often develop such serious health problems as heart disease and Type 2 diabetes. The research institution Rand reported that "obese individuals spend 77 percent more on medications" than non-obese people. Armed with such statistics, health insurers have decided that doing business with fat people is not cost- effective.

Physicians do spend less time with obese patients. I would guess that we respond to our learned futility by giving up on these patiens. We want to help patients, but we rarely fix problems, we just give patients the tools to help themselves! After you try to help obese patients for several years, you rarely if ever have any successes. This learned behavior affects how we treat the obese.

I suspect that obesity will provide this blogger ammunition for a long time. Oh but that were not so! Would that I could influence patients to change their lifestyle. I know that it can be done, I live the proof. But I do work it every day, choosing my diet, even my cheat meals! I exercise 6 days a week on average, and plan that exercise on a weekly basis. Can we get most Americans to do that? And if you read the British press, they have the same problem!

Stepping up the weight loss. This article, which sets up a series of reports from the ninth International Conference on Obesity in Sao Paulo, Brazil, talk about how one loses weight, and how one maintains that weight loss.

Many experts believe that most people today who want to maintain a healthy weight have to be vigilant constantly in countries such as the USA, where high-calorie foods are ubiquitous and exercise has been programmed out of many people's lives.

"It takes a lot of conscious, cognitive effort," says James Hill, director of the Center for Human Nutrition at the University of Colorado Health Sciences Center in Denver. "People who are not devoting substantial effort to managing body weight are probably gaining weight."

Samuel Klein, president of the North American Association for the Study of Obesity, agrees: "It means making weight management a priority in your life."

Statistics reveal how difficult that is to do. Worldwide, more than 1 billion people are overweight, and of those, 300 million are obese, according to the International Obesity Task Force. A startling 61%, or more than 120 million people, in this country are either overweight or obese, according to government statistics. Obesity is roughly 30 pounds or more over a healthy weight.

While not the only theme of this blog, weight control and exercise articles do consistently attract my attention.

"The bottom line for weight loss is you have to eat fewer calories than your body needs," Rolls says.

Brownell says that if people watch portion sizes, eat fruits and vegetables and less junk, "they'd be 90% of the way toward a healthy diet." And "if anything has become clear over the past 10 years, it's the importance of exercise in weight loss and maintaining."

There you go, eat intelligently and exercise. In our society this represents work. One should ask oneself whether that work is worthwhile. I would argue that question has a simple answer. Make rounds with me and you will probably agree.

Mindscapes, Heartstrings & Soul-searching writes today about 'Health, Weight and Happiness'. Her tale is well told and highlights the downsides of weight obsession. We run a fine balance between appropriate diet and exercise and obsession. Read her tale.

Myth Vs. Fact: Weight Loss Resolutions. The author addresses several myths. The short story:

• Myth: A resolution to lose weight is an empty gesture; hardly anyone succeeds.
• Myth: Only 5% of all dieters keep the weight off - the rest gain it back.
• Myth: Dieters who habitually lose weight and gain it back should just give up making resolutions to lose weight.
• Myth: Forget crash dieting as a way to keep a weight loss resolution; it will only make you fatter.
• Myth: The problem with following through on a weight loss resolution is that it's so painful.

I am currently in my third year of success. I never reached obesity (BMI <30), nonetheless, I have lost 30 pounds and kept it off. As I read this article I recognized several important issues. I have developed my own dietary modifications. My diet is not strict, but I do eat less high calorie stuff. I do exercise very regularly. I do think about when I am going to "cheat", accept the fun of that cheat, but resume my healthier eating immediately thereafter. Read this article, it may help you.

All fast food is not bad. Sometimes that is your only good option. This article gives you some good choices - Nutrition watchdog praises fast food giants

Making Time to Walk

It's too easy for some of us to create and accept reasons not to exercise. If you find yourself giving in to common excuses for not keeping active, look at this list and counter each hurdle with ideas to stay motivated, weave movement naturally into your day, and stay on the road to a healthier you.

Tailoring a diet to fit is the way to keep fit .

Mary Schreiner's take on dieting is direct and to the point: "Diets are dull and boring, and you can't have your favorite foods. You have to come up with an eating plan that works for you and incorporates the foods you love."

...

"People are making this hard, and it's not that hard," she says. "They are eating the same things over and over and not exercising and wondering why they don't lose weight."

She believes that about 80% of what most people are doing is fine, but they need to fine-tune 20% of their habits. For some people, the problem is they eat at fast-food restaurants a lot and that needs to be cut back, she says. And for many people, the problem is they don't do enough physical activity.

Every morning Schreiner walks and jogs for four miles on the treadmill at her house, and then later in the day, she walks for another 30 minutes. "I know I eat at least 2,500 calories a day — that's why I exercise.

"You have to make the diet program or weight-loss program fit you," Schreiner says. 'Don't take somebody else's idea."

The only trick is developing the discipline.

Good advice from the "Lean Plate Club" - The Lean Plate Club: Foraging for Fiber

Many readers remember that I am an addicted golfer. I tell my residents, friends and fellow golfers that I play golf for fun, but I do not delude myself. I work out for fitness. Now golf gets a health warning: Many top players are flabby and have wobbly ankles. But Tiger is leading the gym revolution . Since beginning my more strenous workout program a year ago, I have noticed continued golf improvement. While I do not workout just to improve my golf game, it is certainly a nice benefit.

Advice to all women frustrated by slow weight loss...

Research from East Carolina University shows that African-American women burn less fat during low-intensity exercise (such as walking) than their Caucasian counterparts. Published in the Journal of Applied Physiology, the trial goes some way to explaining the slow weight loss often seen in African-American women.

According to some estimates, 5 out of 10 African-American women are obese. They're also more likely to suffer from high blood pressure or type II diabetes than obese Caucasian women. Although their slow weight loss has been attributed to differences in their diet or lifestyle, researchers also suspect that genetic factors may be to blame.

We must study this phenenomen more carefully. We should understand why people burn fat differently given the same exercise. This research may help us understand obesity in some patients.

Now is a great time to start your exercise program. Excuses are just excuses. Read these common sense motivational tools - In Your Corner: Motivation

'Munchies' Study Sparks Diet Drug. There is a lot of money in diet drugs. Thus a lot of research.

Drink 8 glasses of water each day! Everyone knows that now - it is conventional wisdom. Apparently for most of us it really is not that necessary. Is Drinking Lots Of Water All Wet? The comments come from a very well respected researcher.

The journal asked him to review all the scientific studies he could find and he concluded that someone misinformed has been telling people to drink large amounts of water when most do not need to.

“I am referring to healthy adults in a temperate climate leading a largely sedentary existence,” Valtin said. “Persons with certain diseases must have large volumes of water — kidney stones are probably the most common example.”

The rest can just drink enough to slake thirst — and this includes coffee, tea, and even beer — despite their diuretic effects, Valtin said.

He hopes people will be relieved of the guilt of not getting enough water, and of the expense of buying bottled water to drink throughout the day.

“There is also the possibility that if you drink a lot of water that happens to be polluted then of course you get more pollutants,” Valtin said.

“Then there is the inconvenience of constant urination, the embarrassment of having to go to the bathroom all the time,” he added.

Patients sometimes ask us about supplements. Creatine has become very popular with the weight lifting set - studies show that it does help increase the amount of work one can do in the gym (by about 10-15%). No one has yet found a major documentable side effect. Here is a good summary for your archives - The Power of Creatine: It's Real but Subtle.

Thanks to SciTech Daily Review, I found this interesting essay from last year - Brain and Mouth Disease.

The person describing the health benefits of the Mediterranean Diet was Dimitrios Trichopoulos, Professor of epidemiology and public health at Harvard University. When we completed our respective talks we shared a cab to Washington’s National Airport en route back to our home bases. On the way I asked Dr Trichopoulos "If I faithfully follow the Mediterranean Diet, how much longer will I live?" He seemed taken aback by the remark and said something like "That’s a very interesting question. Perhaps we should put a graduate student on the problem."

I don’t know if he ever did. But a lengthy article by Gary Taubes in the March 30 issue of SCIENCE, the premier American scientific publication, suggests that the answer to my question "How much longer will I live?" is — not much. And if the analysis is correct, it will have an explosive impact on the vast industry in this country and in fact the world which is based on the notion that fat is bad and that consuming it will kill you. But as Taubes points out, 50 years of mainstream nutritional research and hundreds of millions of research dollars have not proved that if you eat a low-fat diet you will live longer. Certainly your cholesterol levels will be lower. But the link between diet and longevity it has been argued remains undemonstrated.

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Since the beginning of the 70's Americans have dropped their consumption of fat to about 34% of their calories from fat, down from over 40% beforehand. The incidence of heart disease does not seem to have declined, as a 10-year study reported in the New England Journal of Medicine in 1998. Nonetheless, the treatment of heart disease has improved enormously - with more than 5.4 million heart-related procedures compared with 1.2 million in l979. This may provide the questionable impression that it is dietary change which is responsible for improved coronary experience.

Furthermore, the replacement of fat-containing foods by carbohydrates may have contributed to an epidemic of obesity and then diabetes among Americans. The term "fat-free" on a product appears to provide permission to consume large portions of it, producing an intake well beyond what appears to be necessary to balance energy consumed and energy used. ...

...

Nevertheless, humans evolved as omnivores and we seem well-equipped to eat well-balanced and moderate diets of the foods which were in our environment as we evolved - animals, fish, legumes fruits, vegetables, nuts, berries, and honey when we could get it. Ample fruits, vegetables, and nuts may deliver protective impacts and are obviously one sign of the current good gastronomic fortune of North Americans - our temperate climate provides us with a good cross-section of an ideal grocery store. And it would be irresponsible to avoid stressing exercise as a factor in healthy nutrition - we were born to run, for our dinner.

It appears that people who are committed to low-fat diets almost invariably turn to high-carbohydrate regimes, many components of which provide physiological stimuli to increased hunger. Perhaps a dab of fat will do you, to provide a satisfying experience with food and transform it from battle rations into a calmly sensible aspect of the pursuit of pleasure.

© New York Press, April 18, 2001

This well written essay balances a quest for data with common sense. I like that!

Do we need lawyers or government to protect us? R. Emmett Tyrell says no - and points to President Bush - Fat food foibles.

The vigorous president has taken personal responsibility for his diet and his lifestyle. He did not need the Prohibitionists' remonstrances. He once drank too much. Without benefit of the Prohibitionists, he cut out the booze and picked up the personal training regimen. The consequence is that he is fit, beyond the dreams of any Prohibitionist or trial lawyer ever heard of.

...

Allow me to recommend to Mr. Barber the splendid figure of Our President. He is precisely Mr. Barber's age, 56. He took stock of his health a decade or so back and did not need lawyers or Prohibitionists to tell him what was necessary. He demonstrated personal responsibility and he is now in the pink. He did not need more government regulation and higher excise taxes to direct him toward a better diet and toward exercise. Yet more government regulation and taxation are what the Prohibitionists demand. Ironically, the result will not be a leaner but a more corrupt America, if the tobacco scenario taught us anything.

Regulated industries are always subject to the corrupt practices of pressure groups. Substances burdened with high excise taxes are always subject to bootleggers. Given the disparity of onerous taxes on tobacco among the states and municipalities, organized crime is now extending its grip on tobacco sales. Just as the Prohibitionists of the 1920s were the Mafia's best friend, history is repeating itself today as the Prohibitionists' taxes on tobacco widen the opportunities for Mafia bootleggers to take over tobacco distribution. When the states start imposing more regulation and taxes on junk food the opportunities for corruption will multiply.

Yet, as the robust George W. Bush demonstrates, if we take personal responsibility for our diet we will not need the Prohibitionists, the trial lawyers, and now — as I hope I have demonstrated — another of their allies, the Mafia.

While I try to blog on a wide variety of medical issues, I am consistently attracted to fitness and diet articles. Hopefully, I will help at least one person's motivation. If so - this article is for you - Fitting fitness back in your life

But you have plenty of company. You've joined the 4-in-10 adult Americans of all ages who admit they are not physically active at all, according to the President's Council on Physical Fitness and Sports.

Exercise experts like Richard Cotton and Cedric Bryant have heard it all before — busy boomers complaining that, between carpools and van pools and making ends meet, they barely have time for a movie, much less a regular exercise routine.

Cotton is an exercise physiologist and also a spokesman for the American Council on Exercise in San Diego, Calif., an organization that certifies instructors and oversees exercise research. Bryant is the chief exercise physiologist for the council.

They both specialize in motivating inactive people to become involved in exercise programs. They inspire woefully out-of-shape, middle age lapsed exercisers or never-exercisers to consider the benefits of incorporating workouts into their however-hectic-or-sedentary routine, convincing them that the stress-reduction and disease-risk reduction benefits are worth the effort.

Check out their tips - very commonsense yet perhaps uncommon advice.

Into our stomachs, out of our minds: Are we gluttons for diet nonsense?. I recommend reading this link. Sally Squires has summarized the issues very well.

While most overweight people could resolve their problems through more intelligent diet and exercise, some cannot. Why do so many of us eat too much most days? Researchers are addressing the basic science of appetite and the underlying hormones. Hormone That Causes Full Feeling Is Found. Interesting story about PYY

The hormone, Peptide YY3-36 or PYY, is made by cells in the small intestine in response to food and then circulates to the brain, where it switches off the urge to eat.

"It stops you feeling hungry," said Dr. Stephen R. Bloom, a professor of endocrinology at Hammersmith Hospital at Imperial College School of Medicine in London, who led a study of the hormone that was being published today in the journal Nature. "It controls you and me after every meal we eat."

...

Like many other scientists, Dr. Bloom attributed the rise in obesity to the increased availability of fattening foods. Humans had evolved to survive famine, not feast, he said, and people today are the descendants of ancestors who had withstood starvation because they had genes that enabled them to store fat as a reserve.

"We didn't evolve for this environment of supermarkets at every street corner," Dr. Bloom said. "So what we do is, we find out how appetite is regulated and we work to readjust that regulation to make us more fitted to the environment we're in. We interfere with nature to alter the bad effects of this environment for which we haven't evolved."

Currently, PYY remains experimental and will only work parenterally. It is unlikely to be "ready for prime time" for many years.

MSNBC also has a good story on this research, putting several recent discoveries about appetite hormones into perspective - Hunger hormone may fight obesity: Natural chemical shown to make people feel full in buffet experiment

This is an interesting story. We are probably years away from understanding which patients will benefit from this knowledge. Hormone breakthrough in obesity

The treatment is based on injections of leptin, a hormone that appears to play a central role in suppressing appetite by informing the brain when the stomach is full.

Doctors believe its use could form the basis of a new and highly effective way to treat severe obesity.

...

Dr Ian Campbell, chairman of the UK National Obesity Forum, told BBC News Online that the treatment sounded promising.

But he warned that only a small proportion of severely obese people were deficient in leptin.

"This shows that replacing leptin can have a profound effect in achieving weight loss, but what remains to be seen is the effect leptin would have on people who are not deficient in the hormone in the first place."

We still have a lot to learn about obesity. This does not obviate the benefits of diet and exercise for the great majority of patients. Nonetheless, I find such research very interesting.

The Atkins diet sure get a lot of attention - Researchers chew the fat on merits of the Atkins diet

Some of the nation's leading obesity researchers and nutritionists are outraged by the diet, arguing that it runs contrary to the advice of most major health organizations, which advocate a diet relatively low in saturated (animal) fat and high in complex carbohydrates (grains, vegetables). Those recommendations are based on scientific evidence that a diet rich in fruits and veggies and low in saturated fat reduces the risk of heart disease, some types of cancer and other health problems.

Still, many dieters swear by the Atkins diet. And until recently, there haven't been many studies investigating its safety and effectiveness.

As a skeptical physician, I am always happy to question the "advice of most major health organization'. I worship at the altar of data. We need to see the data - 'show me the money'.

In one new study, conducted at Duke University Medical Center and funded by a grant from the Robert C. Atkins Foundation, participants ate a very low carbohydrate diet of 25 grams a day for six months. They could eat an unlimited amount of meat and eggs, two cups of salad and one cup of low-carbohydrate vegetables such as broccoli and cauliflower a day. Of the 50 patients enrolled, 80% adhered to the diet for the entire study, losing an average of 10% of their original body weight. The average weight lost was approximately 20 pounds, says Eric Westman, associate professor of medicine at Duke University Medical Center.

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In another pilot study, obesity researchers at three universities recruited 63 people who were 30 or more pounds overweight and assigned them to one of two programs. One group was given a copy of Dr. Atkins' New Diet Revolution. The other group was put on a conventional diet with about 30% of calories from fat, 55% from carbohydrates and 15% from protein.

At the end of six months, those following the Atkins diet lost about 10% of their starting weight and those on the conventional diet lost about 5%. Atkins dieters also were more likely to stick with the plan than conventional dieters.

...

Foster and fellow researchers are going to continue to investigate the Atkins diet with a longer-term study sponsored by the National Institutes of Health. They will look at several different aspects, including whether the diet may be more useful for some people than others and how much people are able to exercise while eating a low-carb diet. They also want to investigate why some dieters seem more likely to stick with the Atkins program than a more conventional diet.

The data speak. At least in the short run Atkins works for dramatic weight loss. I am glad the the NIH is studying the diet in a longer-term study. That seems a good use of federal funds.

Read this wonderful essay - Fads and Big Fat: Diet plans, lawsuits. What happened to the human will? .

There are no rigorous medical studies to prove that any of these diets really work, but that has not stopped them from becoming bread-and-butter issues. In California, "Fat Liberation Activists" want to classify obesity as a disease and give weight-loss treatments and diet plans special tax benefits. If they have their way, Dr. Atkins's book, and food deliveries from the Zone, will be tax deductible.

By codifying obesity this way, the fat activists have taken the individual out of the equation, making weight gain another one of the "it's not my fault" maladies and Krispy Kreme a kind of disease transmitter. That litigious New York man is taking aim at fast food, but it is conceivable that one day someone will file suit against a diet plan that fails to deliver on its promises. After all, a weak human will is not to be blamed.

There are of course nongimmicky diets, such as Weight Watchers, that preach sensible eating and exercise, and these seem to work. But the bottom line remains self-discipline--e.g., eating less. For those who follow the fads and fail, a faith in easy fixes remains, as the rising number of weight-loss surgeries attest. This year alone, nearly 60,000 Americans will undergo stomach stapling, at a cost of $5,000 per operation. That's 50% more surgeries than in 2000.

The author, an internist, writes well about this complex topic. We will continue to read and write about overweight and obesity. It is a big deal.

CBS has this story on 4 decades of weight watchers - The Four-Decade-Old Diet

Instead of linking to the news story, just read with Rangel says Does AM Exercise suppress the immune system!? He has a nice summary and opinion. The data present a theory rather than an observation. He analyzed the problem well.

Recently, Medical Rants has focussed much attention on diet. This article summarizes a study about the value of whole grains in ones diet. Whole Grains Can Help Cut Insulin, Cholesterol

In their study of close to 3,000 middle-aged adults, these foods were associated with lower levels of total cholesterol and LDL (the so-called "bad" cholesterol) and improved insulin sensitivity. Insulin, the body's key blood-sugar-regulating hormone, tends to be elevated in those at risk of type 2 diabetes.

People who consumed the most whole-grain foods also had a lower body mass index (BMI), a measure of weight in relation to height that is considered a more reliable gauge of overweight than weight alone. Indeed, adults who were overweight or obese had the highest insulin levels and consumed the least amount of whole-grain foods, researchers report in the August issue of the American Journal of Clinical Nutrition.

This study adds to a growing perception that refined carbohydrates are the bad actors. My wife has only provided whole grain foods for year. She has a point.

I really like this series from the Washington Post - A Year of Lean Living -- Together: Lean Plate Club Members Encourage One Another in Their Adventures in Good Nutrition

The Lean Plate Club, once a mere nugget of an idea, marks its first anniversary today as a solid corps of enthusiastic members who help each other to eat and live more healthfully by sharing their triumphs, their tips, their recipes and, yes, their stumbles.

The club -- formed around the Health section's weekly nutrition column and accompanying Web chat -- is not about dieting, but rather about eating smart and setting realistic goals. It's about rediscovering the joy in eating good-tasting, healthful foods and finding the fun in being physically active -- whether you do it by walking, stretching, tap dancing, riding a bike or simply taking the stairs instead of the elevator.

I continue to have a goal of getting my BMI to less than 25. I started at around 28. I'm stuck at around 25.2. Over the past 6 months my body fat decreased from 23% to 18% (measured by fat calipers). Weight lifting and a great personal trainer have made this possible. I am not overweight by body fat criteria; most people think I'm in very good shape, but technically I'm still 2 pounds overweight. This self revelation highlights the point of this article - Who you calling fat?

These questions ring with new resonance following the release last week of a report from the state Department of Public Health showing that 52 percent of adults in the state are officially fat. In fact, researchers discovered that the number of people who are overweight or obese ballooned by 29 percent during the 1990s.

Those findings relied on the body-mass index, the same standard employed by the US Centers for Disease Control and Prevention when it declared an epidemic of obesity last year.

''It definitely has some drawbacks - it's not perfect,'' said Megan McCrory, a Tufts University nutrition research scientist. ''If somebody is relatively muscular, because muscle is more dense than fat, they'll have a BMI that's relatively high. It might look like they're overweight, but, actually, if you measured their percentage of body fat, they would be really lean.

''But,'' and McCrory paused, ''let's be honest. Most people in the United States who have a high BMI are not going to have a high BMI because they have too much muscle.''

I consider BMIs between 25 and 29 and opportunity to discuss diet and exercise with patients. I should probably add fat calipers to my obesity screening. Knowing one's percentage of body fat is often chilling. Few with a BMI over 29 are just too muscular, and I do not need calipers to recognize them. Nonetheless, we may hear more abou this controversy.

Budgets cuts have decreased the former emphasis on physical education in schools. Some have argued that physical education was not important for students. I would argue that we have a chance to create life long habits of exercise. I stole this idea from those who are trying to do that. Regimens: When P.E. Class Includes Exercise

When they looked at physical education classes for 1,140 older children, ages 11 to 14, the researchers found that some classes required students to take part in as little as 6 to 10 minutes of aerobic exercise.

They then set out to modify the classes by tripling the amount of time some of the students were active.

After eight weeks, the students in the group that exercised more were found to have slightly lower blood pressure readings, and when "skin-fold" tests were used, those students also had lower levels of body fat.

A British study will try to prove what we believe. Obese patients to diet for science Actually, they have an interesting hypothesis to test.

Researchers are hoping to recruit 400 overweight and obese people for a study to see whether excess weight and a lack of exercise causes the joints of the knee to fail.

...

They will be split into two groups, one undergoing a tough weight loss programme, the others will simply get advice leaflets.

Half of both groups will also be put through an exercise programme to strengthen the quadricep muscles in their knees.

This will allow scientists to study whether it is the lack of exercise or the excess weight which has caused the problems.

This is an interesting study design. I will be interested in the results, and especially at their success rate. Can we do a better job motivating patients and helping them lose weight and become more active? We probably should do many such studies.

We have our new diet philosophy emerging. Decrease grains, maybe even whole grains. Rethinking Our Daily Bread: As obesity and diabetes soar, some U.S. nutritionists and researchers back off from pushing pasta and rice. The emphasis is on vegetables and fruits. This article present a well balanced discussion of this current nutritional controversy. Few would argue with the mantra of increasing fruits and vegatables.

Frequent readers expect me to link articles like this one - Give me Strength!

Researchers are learning that a moderate strength-training (weight-lifting) program can do wonders for our bodies. After we turn 30, we lose about 10 percent of our muscle per decade, or a half-pound of muscle every year. That may not sound like much - but by age 70 it means we've been sapped of at least 40 percent of our strength. Lugging a 20-pound bag of groceries at age 30 may be a chore; by age 70 it could be a pipe dream unless we do something to maintain muscle.

Whether you are 20 or 90, strength training stops muscle loss and builds new muscle tissue. That muscle will burn calories, give your body shape, influence your flexibility and sense of balance, and protect you against several diseases.

To a certain extent, strength training even reverses some of the changes normally associated with old age, such as decreased stamina, energy and balance.

Are you taking care of your body?

Some interesting thought here, although I believe more in changing dietary patterns and exercising. Nonetheless, this might help someone. The best ways to banish your hunger cravings...

I have to link this article, as one of my faculty is a co-author. The findings are interesting - too bad I don't enjoy tennis. I hope that any ongoing exercise works. Score One for Tennis: It's Good for the Heart

The low carbohydrate hypothesis has figured prominently on my soapbox recently. As I read more primary literature, I become more convinced that healthy eating decreases simple carbohydrates. This study adds to our database on the subject - Low-Carb Diet Reduced Weight by 10% in 6-Month Study (requires free registration). I look forward to reading the article which will appear in the July issue of the American Journal of Medicine (I'll look for it this week). The summary provides interesting data which support Atkins and the NY Times Magazine article from 2 weeks ago. I am personally trying to be more careful in my choice of carbohydrates, sticking with more complex carbohydrates, and more protein. I love scientific controversy for out of controversy we often arrive at truth!

I cannot resist little articles like this. In February I made a personal committment to climb the stairs at work. I work on the 6th floor, and come in on the 2nd floor. When I walk to the VA, our patients are on the 5th floor. I climb a lot of steps at work. I think it makes a difference. Fitness Timesaving Tips

Diet May Prevent Alzheimer's Disease New Research Indicates Heart-Healthy Lifestyle Could Prevent Alzheimer's Disease. I like this news. As I continue to strive towards a heart healthy lifestyle, I seem to receive multiple benefits.

Researchers at Case Western University School of Medicine and University Hospitals of Cleveland, Ohio, found that a diet of more fruit and vegetables, and less red meat, offers more protection against the development of Alzheimer's.

Collecting data regarding what foods people ate during adulthood, Grace Petot and her colleagues discovered that low-fat diets containing vitamins such as A, C and E in fruit and vegetables are associated with a reduction in risk for Alzheimer's.

Three other studies to be presented at the conference in Stockholm, the largest gathering ever of Alzheimer's researchers, bolster evidence that taking cholesterol-lowering drugs could reduce the chances of developing Alzheimer's.

A study by Dr. Robert Green at Boston University School of Medicine found that people taking cholesterol drugs called statins reduced their risk of developing Alzheimer's by 79 percent. With 2,378 patients, it is the largest study to investigate the connection and the first to include large numbers of black people, who are disproportionately likely to develop Alzheimer's.

The study also found that types of cholesterol-lowering drugs other than statins were not linked with a reduced risk of Alzheimer's.

Tricks do not work, nor do the many advertised "supplements". This article has no surprises, but much data. Fat Busters

Finding the "Best" Exercise.

Instead of looking for the "best exercise," think about the best reasons to exercise.

Take weight control. The fundamental principle of weight loss or control is simple: Burn more calories than you consume. Use up 100 excess calories, and it doesn't matter if you do it by running, washing your car, digging in your garden or even cross-country skiing - you will lose weight.

Likewise, your heart and muscles aren't picky about the activity you choose; they'll be happy whether you choose to jog or play tennis. What matters is the regular physiological stress placed on the various body systems, which results in improved fitness.

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So, when I am asked, "What is the best exercise?" I have a very simple answer: "The one that you like to do."

Are you exercising this week? Do you recommend exercise to your patients? If you don't exercise, how can you get your patients motivated. Doctor, heal thyself. (Sometimes I just love having this soapbox!!)

As usual, the lean plate club provides common sense on eating. The Lean Plate Club: Gut Check: Are You Really Hungry?

Getting back in touch with hunger -- and with its opposite, satiety -- is a smart strategy to help hold the line in the waistline wars. "It's a really good thing to ask yourself, 'Why am I eating now?' " says Mark Friedman, associate director of the Monell Chemical Senses Center in Philadelphia.

You might want to learn how to eat at restaurants, or at least how to eat intelligently - How to Eat Out Without Tipping the Scales

Here are two interesting pieces to consider. The first discusses the Paleolithic diet. The philosophy here states that evolution occurred with an available diet. We should eat like those ancestors - Against the Grain: The case for eating like a caveman.

There is, and one burgeoning argument about what it is is the agricultural revolution. Step back for a moment. We evolved as hunters and gatherers. A graduate student in my Rutgers department, Matt Sponheimer, published an article in Nature in 1999 showing from the microanalysis of wear on fossil teeth that our ancestors were eating meat over 2.5 million years ago. We mainly ate meat, fish, fruits, vegetables and nuts. We have to assume our physiology evolved in association with this diet. The balanced diet for our species was what we could acquire then, not what the government and doctors tell us to eat now.

If you've ever tried to lose weight with a low-fat diet, chances are you felt hungry most of the time. That's because certain types of low-fat foods can trigger hormonal changes that stimulate your appetite. This promotes excessive food intake in people who are overweight.

Dietary fat has been demonized over the past two decades. However, this study shows that a low-calorie diet deriving 35% of its total calories from fat will help you lose weight and keep it off for longer.

While I believe we are still searching (and hopefully researching) for the answer, I'm leaning towards decreasing refined carbohydrates and not totally restricting fats. I'll continue to follow this issue closely.