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Prediabetes Lifestyle Interventions Shown Cost Effective

Sunday, July 3rd, 2011

Few medical interventions both improve health and save money. Treating prediabetes with metformin is one of them, according to 10-year follow-up data from the Diabetes Prevention Program.

Intensive lifestyle intervention,  did an even better job at improving health and quality of life, and at a favorable cost when compared with some common medical interventions for other diagnoses, Dr. William H. Herman and his associates reported at the annual scientific sessions of the American Diabetes Association.

In this study, the cost per quality-adjusted life-year gained with the intensive lifestyle intervention compared with the placebo group was $12,000. That $12,000 is on the low end of a $10,000-$50,000 range that’s widely accepted for medical interventions, including the use of beta-blockers after MI, the use of antihypertensive therapy for patients with very high diastolic blood pressure (greater than 105 mm Hg), or the use of statins for secondary prevention of cardiovascular disease in patients who’ve had an MI. Dialysis for end-stage renal disease costs $50,000-$100,000 per quality-adjusted life-year gained.

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Monday, February 7th, 2011

Five Tips To Lose Weight …

…That Are Not True!

Myth #1: A Calorie is a Calorie is a Calorie….Is it true?

It is not unusual for people battling weight gain to hear from a dietitian or a physician “a calorie is a calorie is calorie.” This old saying implies that to lose weight it doesn’t matter what we eat as long as we cut back on the total calories consumed. The less the total calories taken in, the more the weight loss…. But is it true?

Indeed, outside of our bodies a calorie from orange juice is the same as a calorie from chicken or chocolate. But inside our bodies that old dogma doesn’t hold up because foods are not just consumed, they have to be digested as well. The process of digestion or integration of nutrients into the body is not equally efficient for different food types. For example, fat is 95% efficient. Meaning of 100 calories of fat consumed, 95 calories are stored in the body (mostly in fat cells.)

Carbohydrates are about 85% efficient meaning 15% of calories are lost during digestion. Finally, protein is only 70% efficient. Our body cannot store fish, beef or chicken protein. It has to break down all amino acids (the building blocks of proteins) and re-assemble them into human proteins. This process wastes about 30% of the calories consumed from protein. That is one reason that all calories are not the same.

Another reason all calories are not the same has to do with our metabolism – how our bodies decide to process food at any given time. For example, studies have showed that eating the same amount of calories (in a study of college students it was 2000 calories) in one meal in the morning versus in the evening have different effects on body weight. Eating more at night causes more weight gain.

Myth # 2: Shut your mouth and you will lose weight!

How many times have you heard overweight people say but “I do not eat much at all?” How many times have you noticed that your overweight friends or relatives eat very little at the dinner table? People who skip meals or even starve themselves are under the impression that the only way they will lose weight is to drastically cut their caloric intake. Indeed, even doctors tell their patients “shut your mouth and you will lose weight…” We now know that this “myth” is not true.

The discovery of a gut-brain axis regulating appetite and satiety has shed a new and fascinating light on the physiology of cravings, feeding, as well as energy storage. Signals released from our stomach such as the hormone ghrelin, or leptin which is released from fat cells, among others, all “talk” to neurons in our brain.

Ghrelin levels rise when we fast, peak immediately before meals, and are typically higher during weight loss and in anorexia – as if the stomach is telling the brain to eat more. Before a meal, blood ghrelin levels can double depending on the timing and amount of calories eaten at the previous meal. Skipping lunch would therefore trigger more appetite for a bigger dinner. In addition to controlling appetite, ghrelin also shifts the body’s metabolism to an energy-sparing mode by slowing fat breakdown and by lowering body temperature.

So, people who starve themselves should know that by doing that, they are shutting down their metabolism and increasing their appetite. When they finally eat, whatever the portion size, the food “sticks to them” that is it goes directly to fat cells for storage.  By eating the right food choices, it is possible to lose weight while eating more. Raising your metabolism is similar to feeding a furnace high-octane logs around the clock. It burns faster and hotter!

Myth # 3: Tell me your secret..

There is a diet out there called the “Da Vinci Code diet.” When people ask me what it is, I tell them I do not know because it is a secret! At any given time, roughly half of all American women are dieting – often in secrecy. None of us like to admit that we are unhappy with our weight and are trying to lose weight with the latest diet. The latest diet because the previous ones are no longer trendy or failed to work. Even when people succeed, they do not want to tell friends, family members and co-workers that they had to diet to lose weight.

The truth is that there is no secret diet or weight loss solution out there. Even if there were secret solutions, they would not apply to everyone. Your secret diet, supplement, surgery, medication, or exercise routine may not work for your friends even if you divulge it to them. It is not about a secret formula or a secret diet. When people ask “oh, what is your secret” they are really saying “ congratulations!”

Here is how I see it: As you lose weight the healthy way, people acknowledge your success and are appreciative of your newly regained sense of control. There is indeed a lot of pleasure in weight loss. The waistline is shrinking, the cheekbones are once again prominent, and energy and libido are back up to where they were decades ago. People are noticing, sometimes they even try to ask you out. Others come to you and quietly ask you how you did it, where did you go, what are your secrets, etc. You are glowing in success. You have truly achieved something that millions of people want but are unable to get. You have lost fat, gained strength in body and in your spirit and look fantastic. If your life and body transformation do not bring you the sweetest pleasures there is something wrong! You are delighted that your efforts have paid off. You are body proud and you know it: that is your secret!

Myth # 4: Doc just tell me what me what to do.

Unfortunately, I hear this from my patients more often than I would like to. “Doc jest tell me what to do” translates as “Doc spare me the details of the process just give me a diet…” The problem is without grasping the knots and bolts of the process of change, all diets (or any lifestyle change) are bound to fail. Dietary and exercise guidelines are important. But cognitive skills such as time management, setting priorities and boundaries, organizational and stress reduction techniques are more important. Further, these skills have to be customized and personalized. For example, for people who travel a lot, lifestyle change tools have to take into account and adjust to time spent in airports, meals at restaurants or the road, nights spent in hotels and sometimes lack of access to healthy food choices or exercise equipment.

The flip side of this myth is in the fact that doctors cannot tell people what to do when it comes to lifestyle change. Docs do not learn much nutrition, even less about exercise in their medical training and have even less understanding of weight gain or loss! Finally, they do not have time to interview their patient in debt to give them personalized and relevant lifestyle change advice.

So what are you supposed to do? First, understand that there is no quick fix even it is recommended by your doctor. Second, understand that the “money” so to speak is in the coaching process. Third, understand that there are many ways to lose weight – some are more successful or easier than other – and that there is one approach out there that will work for you. Finally, understand that for lifestyle change to take roots, it has to be constantly re-evaluated and changed. The exercise you begin with will have to be modified for you to reach your goals. The food choices and the portion sizes have to be re-examined as well. So, “doc just tell me what to do” should be replaced “doc I need a health coach, can you help me?”

Myth #5: No Pain No Gain. Exercise to get bigger?

I often hear: “Doc I exercise everyday and I am getting bigger.” Or, “I had to fire my trainer because he would kill me but I was getting bigger and bigger.” Is it possible that exercise would cause more weight gain? Absolutely, most exercise regimens are anabolic meaning they help you get bigger and stronger. Sometimes, it is important to gain muscle to lose fat. But usually, people who are overweight or obese have plenty of muscle. Therefore, they just have to use them to burn calories. Sub-maximal and frequent fat-burning exercise such as a brisk walk or low-impact aerobics, and whole body callisthenic workouts is the way to go. Here are other reasons why some people don’t lose weight with just exercise:

Exercising, dieting and still gaining weight?

Which group do you belong to?

Hefty Athletes (crew, football and hockey players in particular) who eat everything in site after a long aerobic training session.

College Partiers who exercise hard for three straight days but party and hang out starting Thursday nights till Sunday (pizza, pasta, beer, cake…)

Good Wives who watch what they eat all day and even exercise an hour a day but overeat to keep company of their husbands at nights or weekends – husbands usually choosing the menu!

Weekend Bingers. They work hard all week, exercise regularly and then drop the ball completely on the weekends. A weekend getaway: extra bonus!

Socialites. Try to be committed to weight loss, fundraisers and board meetings all at once! The “society calories” win over the private sweat and chagrin.

Boat People. Once off shore, the rules of thermodynamics no longer apply. Calories do not count when consumed on the boat!

Serious Bingers, Night Eaters and Closet Eaters: Calories do not lie no matter how much you exercise.

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More on Rewards

Monday, December 27th, 2010

Previously, I have written about effective use of a personal reward system to stay motivated. In addition to daily rewards, I encourage my practice members to choose weekly and monthly rewards.

Weekly rewards are a bit more significant. Here the strength is not in numbers. These rewards have to be delicious and joyful enough to attract you like a night lamp attracts moths. A session of physical pleasure and/or relaxation is a good choice: massage, pedicure or manicure, a nice long bath, yoga or a dance class would qualify. Spending time with children, with your partner or going out with a friend may be fun. But keep in mind that rewards have to be about you, reminding you that you are on a mission entirely about You – not your children or your family. During my interviews, I ask every one of my patients to name a few of their most favorite activities. By simply asking that question I remind them that they have not been putting themselves “first” and that now it is time to reset priorities.

Monthly rewards have one common characteristic: they are permanent. Daily rewards get their strength in numbers, weekly rewards are about pampering, and monthly rewards are here to stay. Effective monthly rewards include inspirational pictures, objects or projects. Framing that picture of you when you were fit and placing it somewhere special; buying a special decorative object such as a lamp for your bedroom; a pottery piece for your office; or painting a room a nice color or working on a piece of antique furniture are examples. Of course, clothes (if your closet is not full of clothes that you are dying to be able to wear again) are big monthly rewards. After a few months, these monthly rewards may become more ambitious, such as a trip for two to a favorite getaway destination. (Trips are not permanently displayed so do not forget to take lots of pictures or bring back souvenirs.) Finally, even bigger rewards are reserved for the time when you reach your goals. These may include buying a new car, remodeling your house or landscaping your garden, etc.

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Some Exercise Tips

Friday, November 26th, 2010

The “eating season” has begun! Coming next is the guilt of self-indulgence constantly reminded to us by extra inches around our waistline… Every year around this time people get motivated to lose weight with exercise. So here is an interesting take on exercise.

In his erudite book, Ancient Medicine, Edelstein summarizes a typical exercise regimen as recommended by ancient Greek physicians:

…youths and men go to the gymnasium for training; older men go to the bathhouse, or likewise go to the gymnasium, to anoint themselves. When this is done, a carefully selected meal is eaten at home, toward noon, after which a nap in cool shade is beneficial…Next a walk is taken, then a rest, and one returns to the gymnasium. Immediately after the exercises, which take the entire afternoon, one takes a bath or anoints the body, and goes home to an evening meal shortly before sunset. At this meal, too, only dishes selected in accordance with definite rules are served. Following the evening meal, one either goes to bed immediately or takes another walk…

(Ancient Medicine, Ludwig Edelstein, The Johns Hopkins University Press, 1987, p307.)

One wonders if Greek men who followed this kind of regimen ever worked! Nonetheless, the exercise regimen described here (which would be varied from day to day) was meant to be an integral part of a lifestyle. It was incorporated in a program that also included diet, and rest as well as self-care. For an exercise regimen to be sustainable and successful, it has to be safe, carefully planned, and gently paced. Wellbeing was the main goal of the Greek’s ancient exercise training and should remain our goal in the 21st Century.

East River Sunny Side

Some Tips For a Personal Exercise Program:

– Understand that a program that worked for you when you were in your twenties may not be advisable for you in midlife. Also, a regimen, which worked for a friend of yours or even a family member may not give the same results for you.

– Do not lose focus of your goals. You may have long-term goals such as fat loss or a certain dress size. You may also have short-term goals such as increasing your cardio respiratory capacity. And you may even have weekly and daily goals. Do not lose sight of your goals and if you get discouraged or lose motivation, remind yourself of your goals. An individual without a fitness goal becomes a “gym rat,” that is a person who just hangs out at the gym wasting time!

– Be kind to your body. Do not use exercise as a means to stress your body or to “punish” yourself for acts or feelings that frustrate you, such as overeating. Use exercise as a positive tool to de-stress and to feel good about yourself. Do not push yourself beyond reason and do not get into a competition with yourself.

– If you have medical conditions, talk to your doctor about exercise. Your doctor may not be an expert in exercise physiology, but he or she may alert you to certain risks and conditions, which you may have so you can discuss them with your trainer. For example you may have forgotten that you have suffered from abdominal hernias in the past or you may overlook nerve damage in your feet.

– Finally, our bodies change and so do our goals. It is important to reassess your program periodically. If fat loss is your primary goal, you need to reconsider the frequency and intensity of your routines, rest intervals, the specifics of your regimen, every few months. Once you have reached your weight loss goals, you have to reassess your regimen for maintenance or toning purposes.

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Stress and Weight Gain

Tuesday, November 9th, 2010

Stress is a big player when it comes to weight gain. Stress causes weight gain – usually as belly fat – directly by changing our metabolism. Stress also causes weight gain indirectly by changing our eating habits, food choices and other behavioral responses. But first, one has to be able to identify the source of stress or “stressor” to then be able to work on undoing it. One way to look at stressors is to divide them into three categories. I describe them shortly here.

Stressors are either external or “on the outside of the body” such as work, home situation, money, etc. Stressors can also be “inside the body” like chronic pain, asthma, sleep apnea or other disease conditions that stress the body on an ongoing basis. Finally, stressors are often mental in nature that is they are “inside our head.” These psychological stressors can be conscious such as worries, fears, obsessions, addictions, etc. Or they can unconscious such as PTSD, personality disorders or psychiatric disorders affecting our moods such as anxiety or bipolar disorders.

In all cases chronic stress can cause weight gain. Sometimes stress causes fat build up without any change in eating habits or caloric intake. Physicians know that when they prescribe prednisone for their patients, they should advise them about changing their diet or they will gain weight. Prednisone is the synthetic equivalent of the natural stress hormone cortisol. In fact, when the body produces too much cortisol, whether due to chronic stress or a hormonal imbalance, it gains belly fat even if the caloric intake is the same. Abdominal fat resulting form excess cortisol is considered to be one of the main causes of metabolic syndrome leading to diabetes and heart disease.

Next, I will share with you my experience with “stress eating.” Meanwhile you can contemplate on how you feel stress. Are you a stress eater?

East River Reflection

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Accidental Meditation

Tuesday, November 9th, 2010

I first learned to meditate as a teenager, exchanging 2 hours of meditation practice sessions per day in exchange for 3 hours of labor at a camp. At first, it was difficult if not painful sitting in the lotus position and trying not to chase any thoughts, instead focusing on breathing. Later, things got a little easier taking advantage of yoga to get the restless body ready for “nothing.”

I call “accidental meditation” or a pause moment, the kind of meditation, which does not require much preparation and even happens unintentionally but is powerful enough to leave you with a moment of transformation. I have had it happen to me walking, turning my car switch on, talking to people, during exercise and in many other situations.

What is it then? I cannot really explain it well but I can give a few examples. These moments are mostly visualizations, which cause a moment of pause, a quick reflection or insight. Sometimes they trigger a moment of joy and bliss.

East River at Sunset

Birds have recognizable flight patterns. Take a blue jay’s flight pattern when in a routine flight from tree to tree. Enjoying the ride, swinging up and down a few feet flapping wings just enough to stay in the air. Now imagine the same blue jay holding tightly to the latest “catch of the day” in its beaks. Now, the flight pattern is a different visual, little swinging up and down, no noise and no time to waste. This is not a flight pattern of joy and happiness; this is a blue jay on a mission, which needs to fly. Get to the destination quickly…don’t attract others….don’t drop the food!  The pattern (and thus our perception of it) changed from a moment to a goal. From and end-in-itself to a means to an end… And indeed they look different.

Okay, so where is the meditation? Next time you see a blue jay in flight, watch it carefully. Observe the visual flight pattern in the sky. It does not stick around long like jet fuel in the sky. But the flight pattern is captured long enough to be registered and to be recognizable again: is it a joy ride or a mission flight? Do you see the catch of the day to confirm your observation? These ephemeral traces can be retraced in our minds in different occasions and for various uses. Next time you see a blue jay in flight you will know what I mean. And you will get the accidental meditation.

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Rewards

Tuesday, November 9th, 2010

In my experience, one of the biggest challenges in lifestyle change is the process itself. By “process” I mean the daily effort and focus it takes to continue the pursuit of a long-term goal.  Let’s say the goal is to lose weight the healthy way – obviously this takes time, sometimes months. To think of getting there is often overwhelming. To actually do the work is always frustrating.

So, how does one change a long process into a self-propelled and easy one, which like “cruise control” does its own thing? That is when rewards come in.

By reward I do not mean just a pat on the back, I mean a desired and pleasurable “something” to look forward to. One would set a goal, a reward and work towards it. Of course, if your goal is weight loss then food and entertainment centered on food, such as parties or dining out, are not acceptable!  You cannot set a goal to lose 10 pounds and then reward yourself by eating at a fancy restaurant! It does not work.

East River Reflection

Also rewards have to be proportional to efforts put in the process. Following a program for a week does not merit a trip to Europe! Finally, rewards have to appeal to you. What motivates someone else won’t necessarily work for you.

Here is one way to do it. Choose daily, weekly and monthly rewards – and then a final reward for when you reach your goal. Daily rewards should be affordable, hassle-free and, more important, cumulative — meaning that they should add up every day that you stay on your plan. A good example is to put a dollar bill or a marble in a glass jar. As you continue your efforts day after day, the bills or marbles accumulate, giving you a visual reward of your efforts.  Another example is simple check marks on a calendar.  If you have a day when you fail to stay on your plan, then you do not add your dollar bill to the jar or you do not check that mark on the calendar. There is always tomorrow.

I want weekly rewards to be more physical in nature or, when it comes to weight loss, body-related. A massage, a pedicure, a hike in the woods or a weekend getaway all count as a weekly reward.  Rewards do not have to be costly. Planning on having a nice bubble bath or watching a special movie will do the job as long as you do it in the context of a plan to reach your goal.

Hey, it is a start! Daily and weekly rewards go a long way. They become the building blocks of your “change plan.”  Next, I will give you examples of monthly and even bigger rewards.

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“ A Tip To Lose Weight…..That IS NOT True!!”

Monday, November 8th, 2010

I give talks to the general public often. One of my favorite talks is titled “ Ten Tips To Lose Weight…..That ARE NOT True!!” One of these ten myths that I try to deconstruct is the old dogma “a calorie is a calorie is a calorie.” It is not unusual for a person battling weight gain to hear from a dietitian or a physician that slogan implying to lose weight it doesn’t matter what one eats as long as one cuts back on the total calories consumed.

Indeed, outside of our bodies a calorie from orange juice is the same as a calorie from chicken or chocolate. But inside our bodies that old dogma doesn’t hold up. That is because foods are not just consumed, they have to be digested as well. The process of digestion or integration of nutrients into the body is not equally efficient for different food types. For example, fat is 95% efficient. Meaning of 100 calories of fat consumed, 95 calories are stored in the body (mostly in fat cells.) Carbohydrates are about 85% efficient meaning 15% of calories are lost during digestion. Finally, protein is only 70% efficient. Our body cannot store fish, beef or chicken protein. It has to break down all amino acids (the building blocks of proteins) and re-assemble them into human proteins. This process wastes about 30% of the calories consumed from protein. That is one reason that all calories are not the same.

Another reason calories are not equal in our bodies has to do with our metabolism – how our bodies decide to process food at any given time. For example, studies have showed that eating the same amount of calories (in on study of college students it was 2000 calories) in one meal in the morning versus in the evening have different effects on body weight. Eating more of the total intake at night causes more weight gain.

Also, high-protein foods are more satiating than high-carb foods. That is because protein is a strong trigger of the satiety hormone PYY which tells the brain “we ate..” Carbohydrates do not release this hormone as much. Also, different foods influence blood chemistry including inflammation, in variable ways as well.
Finally, the time and the type of food in relation to exercise matter too. We will discuss this important topic soon. But for now, just remember it not all about calories and calorie counting.

Dance at Sunday Market in Paris

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dr yavari

Dr. Reza Yavari M.D. is a Board Certified Endocrinologist and founder of Beyond Care®, a leading preventive care and obesity center located in Guilford, CT. Learn More

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