Can't Lose Weight? Count LIQUID Calories!

Many times when people are frustrated with weight loss, they look and look again at their food records and insist that they are eating only healthy food in small portions, yet the scale wont budge. There are certainly multiple reasons for this, not the least of which is the scientifically proven human tendency to record LESS than we consume and MORE than we exercise. It's not purposeful cheating, but small things such as forgetting the handful of M&M's off a co-worker's desk, or chips at a Mexican restaurant (we didn't ORDER chips, right?) or assuming we must have walked "at least a mile" during the day (without counting steps on a pedometer.)

My focus today, however, is on the portion of calories that we all tend forget- the LIQUID calories! Yes, Virginia, the liquid calories count, too...and often way more than you'd expect. Let's review some common ones:

Soda: 1 can of Coke is 140 calories
Starbucks:Tall Cafe Latte with Nonfat milk: 126 calories (Grande: 168 )
Caramel Frappuccino Blended Coffee with whipped cream: Brace yourself- 430 calories!! (Note a McD's Quarter pounder is 410)
Wine: 4 oz- a HALF CUP- glass of Chardonnay~90 kcal. MEASURE your glass once- most of us drink at least 6-8oz- check the picture above!
Frozen Margarita: 180 kcal for 4 oz...but most Margarita glasses hold 12 oz, which is over 500 kcal!
GATORADE: 12 oz is 310 kcal.

Recognize that 3600 calories equal one POUND, which means your simple morning coffee may be adding a pound or more per month. Or your workout drink, ironically, can easily do the same.

BOTTOM LINE: Focus on WATER the most, and low or no calorie drink options if you are trying to lose weight!

On Blood Thinners? READ THIS!

Typically when there is a drug recall, it is not too serious. The last several that I have noted were voluntary recalls by the manufacturers, and there were no adverse patient outcomes even reported. This one, however, could have immediate and disastrous consequences.
Warfarin (Coumadin) is a blood thinning agent that many people take to prevent blood clots. We use it in the treatment of atrial fibrillation, pulmonary embolisms and deep vein thrombosis (clots in your legs that can go to your lungs) as well as with patients who have artificial heart valves. Patients who take this drug must have their blood drawn regularly to make sure that they have proper drug levels in their system. Too much warfarin can cause bleeding- from a nuisance of easy bruising or bleeding gums, all the way to a serious bleeding event in your brain- a stroke.
The FDA and Usher-Smith Laboratories have issues a recall on Warfarin Sodium Tablets (Jantoven), 3mge. A bottle of the drug was found to have 10mg pills mislabeled as 3mg, which means the patient could potentially receive three times their appropriate dose. While there has only been one bottle identified so far with this risky error, they have appropriately recalled the entire batch.
The 10mg pills are white, and easy to tell apart from the 3mg ones, which are tan. There are also different markings on the pills, but most of us do not routinely check the fine print.
With concern for patient safety, the company has admirably voluntarily recalled their other products from that same packaging line over a six month period, including these medications: Amantadine, Amlodipine, Androxy, Baclofen, Bethanechol, Jantoven® and Oxybutynin.
BOTTOM LINE: Check your prescriptions if you are on any of these medications to be sure you've got the correct dose, but more importantly, BE AWARE of the color and shape of your prescription medications, and QUESTION the pharmacy when you notice a change! Most of the time it will be a change in brand- likely to a different generic- but ASK and BE SURE!

Heart Disease in Women- New AHA Guidelines

The American Heart Association has recently published an update to their Guidelines for the Prevention of Cardiovascular Disease in Women, so I thought I would highlight a few issues that may surprise you. Did you know that women are more likely to have a stroke than a heart attack? My patients with risk factors such as high blood pressure or high cholesterol worry far more about having a heart attack than having a stroke, yet at every age, women truly are more likely to suffer a stroke. (The opposite is true for men.) Sadly, in the United States, one woman dies every minute from cardiovascular disease.

The numbers of young women (aged 35-54) dying from cardiovascular disease is rising, paralleling the rise in obesity in our country. Now 2 of 3 women over the age of 20 are overweight or obese. This is why I spend so much time counseling patients and blogging and talking about weight loss and healthy lifestyle changes!

Women who had any pregnancy related complications such as premature birth, pre-eclampsia or gestional diabetes are now known to have higher risk of future cardiovascular events- possibly doubling their risk- despite blood pressures and sugars returning to normal after childbirth. We need to treat these women more aggressively to reduce their risk factors both with behavior modification and with medications.

BOTTOM LINE: Women, recognize that YOU are at risk for strokes and heart attacks as much, if not more than the men you are worrying about! Schedule a check up with your family doctor today.

How Fast Can You Lose 30 Pounds?

You only have to drive around town, flip open a magazine or your computer, and you will see an ad promising weight loss of "30 Pounds in 30 Days". And of course, all you have to do is buy this brand new miracle pill. You don't have to exercise or eat healthy foods. Ready to sign up? I hope not!

Our parents taught us that if it sounds too good to be true, it probably is. Yet, as Americans, we have become so used to instant gratification, we are convinced that somewhere out there exists a pill we can pop for easy, quick weight loss. Let me ask you this- do you think there would be any fat doctors (especially women, forgive my bias!) if such a prescription existed?

So, what is realistic? Well, obviously, it depends on your starting weight. If you are only 20 or 30 pounds overweight, though, a good rule of thumb is a half to one pound per week. It takes a 3600 calorie deficit to lose a pound. Period. If you can burn an extra 250 calories a day (walk 2 -3 miles, for example) AND delete another 250 calories from your usual diet (give up two sodas or one loaded latte per day), then you can expect to lose a pound per week.

Try to look at the big picture. There are 52 weeks in a year. If you make healthy changes such as eating MORE fruits and vegetable servings and moving MORE, you can easily take off those extra 20 to 50 pounds in a year...and KEEP THEM OFF because you did it through small, permanent changes!

BOTTOM LINE: Fast does NOT equal good, nor permanent, weight loss. Realistic, EXCELLENT weight loss is ONE POUND per week, so it will take 6 months to lose 30 pounds.

What Works for Weight Loss? MORE!

MORE, MORE, MORE! That is chant I want you to hear in your head as you focus on FITNESS. Yesterday I talked about MORE fruit and vegetable servings- 5-10 per day. Today let's shift to MORE MOVEMENT.

Many of my patients started 2011 with the resolution to go to the gym EVERY DAY after work. Guess what percentage are still doing that? Hmm...not too many. Why is that? It is a setup for failure. While exercising EVERY DAY is absolutely possible, and indeed, what I do and what I encourage everyone to make a life habit, exercising in a specific place outside your home- like the gym- is very difficult. Say today you wake up and your child has a fever, so you can't leave the house. Tomorrow you have a business meeting in the evening (no time to workout, shower and clean up between work and that meeting) and boom, then it snows/rains/floods...you get the picture!

I think planning a day or two per week at the gym (or the track, or walking the mall) is wonderful, but please, set yourself up for success by having backup plans AT HOME. I am a big fan of exercise bikes and DVDs for this reason. Grab your tunes and/or your dog and head out the front door. Set a timer for 30 minutes, turn on some music, and dance! OR- I got this idea from another woman physician last October- set the timer for 30 minutes, turn on music, and CLEAN YOUR HOUSE- actively! Vigorously scrub the counters, alternate hands, squat up and down unloading the dishes, mop quickly, whatever it takes to keep your heart rate up. Which exercise is best? The one you will DO.
The main idea is to MOVE MORE. Check out my blog on PEDOMETERS- they work great, too!

BOTTOM LINE: Switch your focus to MORE: MORE movement, MORE fruits & veggies!

MORE Ways to Lose Weight in 2011

As promised, in keeping with the new USDA guidelines, I am returning to talk about my MORE philosophy that has helped many patients lose weight. When people decide they want to lose weight, what is the first thing that pops into their mind? DIET, right? So what's next- which foods am I going to cut out of my diet? Followed closely by feelings of deprivation, and then frustration and disappointment when they give in to a craving for that off-limits food.
What if, instead of focusing on LESS, you focus on MORE? I encourage my patients to simply INCREASE their fruit and vegetable servings. The goal is 5-10 servings per day, total, of either veggies or fruit. A serving is what comfortably fits in your cupped hand. Therefore, a salad like the one pictured here is roughly four servings- 2 handfuls of lettuce, one of shredded carrots and one of tomato. Easy, right?

What happens when you focus on MORE vegetables & fruit servings is no secret. You FILL UP on "nutrient dense" foods that are GOOD for you, and eat less of, well, everything else! It tends to be the complex carbs (think breads, crackers, muffins, cookies, chips) that pile on the calories, NOT the fruits, vegetables and protein.
Does this mean you are not "allowed" to eat those complex carbs? Absolutely not! What it means is that you will be focusing on MORE quality in your diet by pushing up those F&V servings, and that typically will automatically decrease your total calorie intake, which POOF- "magically" helps you lose weight.
BOTTOM LINE: It's not rocket science, my friends- simply consume less calories than you burn, and yes, you will lose weight. But do it RIGHT, and make sure you are not skipping any meals, and that you ARE eating foods packed full of vitamins and fiber...our friends, the fruits and veggies.

New USDA Guidelines

On January 31, 2011, the United States Department of Agriculture (USDA) released their updated guidelines for the American diet. A panel of 13 nutritional experts, chaired by Linda Van Horn (who has a doctorate in addition to being a licensed and registered dietician) reviewed the available evidenced-based data regarding the impact of diet on wellness and disease prevention. Their findings come as no surprise, with an emphasis on MAINTAINING a HEALTHY WEIGHT (through calorie balance- energy OUT equalling or exceeding energy IN) and focusing on consuming NUTRIENT DENSE foods and drinks.
What does this mean? In short:
MORE: vegetables, fruits, nuts, seeds, seafood, low- or no-fat milk products, eggs, poultry and whole grains.
LESS: Everything else. Seriously! Less solid fats, complex/refined sugars (crackers, cookies, breads, sweets), fatty meats, and drinks with empty calories like sodas, many fruit drinks and alcohol.

So none of this is shocking. Perhaps the one controversy is the level of salt recommended. The USDA okays up to 2300 mg of sodium for the general population, but the American Heart Association (worried appropriately about high blood pressure) suggests that really everyone should max out their salt around 1500mg. The reality is, however, that if people change their diet from highly processed foods to more plant-based and whole foods, their sodium content will fall as well.

WIth more than 1/3 of American children and 2/3 of our adults falling in the overweight or obese category, the USDA is rightly shifting the emphasis of their guidelines towards calorie balanced diets and LIFETIME weight maintenance, through increasing activity as well as increasing vegetable and fruit consumption. Tomorrow I'm going to return to focusing on the MORE philosophy that has successfully helped many of my patients reach their healthy weights.

BOTTOM LINE: (Straight out of the USDA's Press Release)"The bottom line is that most Americans need to trim our waistlines to reduce the risk of developing diet-related chronic disease. Improving our eating habits is not only good for every individual and family, but also for our country." Cheers.

My Valentine to YOU!

Happy Valentine's Day! I have decided to give you, my patients, AND myself a special Valentine- a free "do-over" for any New Year's Resolutions that have perhaps fallen to the wayside. Did you promise to head to the gym after work three days per week, but now a heavy snowstorm blocked your way for a few days, and you simply dropped the whole thing after missing a week? What about walking your dog each morning- same excuse? In Austin, we had SNOW on the ground last week, but today it is literally 73* and SUNNY, so we need to head back outside.

How about eating more plants and less processed stuff? If the main GREEN in your diet is a Girl Scout Thin Mint Cookie, it's time to focus on more color. Even if your choice today is a chocolate covered strawberry vs. chocolate truffles, take that step and grab the luscious strawberries.

Whatever derailed YOUR good intentions, please use this "get out of jail free" card to cut yourself some slack, and START OVER TOMORROW (or better yet, TODAY!) And if your sweetheart asks what you'd like for Valentine's Day, ask for something that will promote your health, like new work out shoes or clothes, a pedometer, a heart rate monitor, or even a gym membership or an exercise bike! If you are still deciding what to get YOUR Valentine, and he or she hates the idea of exercising and you think a gift like that would offend them, at least choose a pampering gift that wont undermine their weight loss efforts, such as a gift certificate for a manicure or massage.

BOTTOM LINE: Enjoy this Valentine's Day and refocus on your HEART healthy habits for 2011!

An AGGIE Wearing ORANGE? Join Tamika and the Fight Against Cervical Cancer

This week I am talking about HPV (Human Papilloma Virus) and the diseases it causes. The most serious consequence of HPV infection is CANCER, and there are roughly 12,000 American women diagnosed with cervical cancer (caused by HPV) each year.
A couple weeks ago, while I was a guest on a Doctor Radio show that focused on cervical cancer, I met an amazing woman: Tamika Felder.
Tamika was diagnosed with cervical cancer at the very young age of 25, just as she was beginning to enjoy a successful career as a television producer in our nation's capitol. Her treatment included not only chemo and radiation, but also a complete hysterectomy. While friends were planning weddings and baby showers, Tamika was fighting for her life and giving up the dream of having children.
Lucky for the rest of us, Tamika's amazing spirit and talents emerged through her therapy, as she created a nonprofit organization to increase awareness about HPV and cervical cancer. In addition to public speaking, Tamika & Friends offer an online support group for women diagnosed with cervical cancer. Her mission is to spare those women newly diagnosed the shame and isolation that she endured over a decade ago. Click on her website: TamikaandFriends.org and read all the amazing survivor stories! Women from all backgrounds have bonded together to help other women face this challenge.
So why ORANGE? Every cancer seems to have its own color now, and Tamika wanted a color that reflected hope and positive energy, like a sunburst. Why not wear some orange this week, and pass on Tamika's message?
BOTTOM LINE: Cervical cancer is a very serious disease, and PREVENTION plus EARLY DETECTION are key! Remind your girlfriends to SCHEDULE their PAP TEST and get vaccinated against HPV!

Dodge This Bullet...HPV

Yesterday I mentioned that the New England Journal of Medicine recently published a study regarding HPV vaccine efficacy in boys. Today I'd like to explain the study. The title is "Efficacy of Quadrivalent HPV Vaccine against HPV Infection and Disease in Males". "Quadrivalent" refers to the fact that the vaccine targets four strains of the Human Papilloma Virus: strains 6 & 11, that cause 90% of genital warts, and strains 16 & 18, which cause the majority of cervical cancers (roughly 70%).
I'll start by saying that yes, the study was partially funded by Merck, the manufacturer of the vaccine. That being said, I do not feel it negates the study, although obviously it introduces some bias. They took over 4000 boys/young men age 16-26, from 18 countries, and gave half a placebo vaccine series, and half real. The study was double blind (no one knew what they were giving or getting), and randomized (which raises the quality of the study.) Some of the participants were fully screened initially to determine if they already HAD any HPV strains, and others were not. Note that in "real life medicine", we have no way to test people ahead of time to see if they have already contracted HPV.

In the young men with unknown prior HPV status, the vaccine had an efficacy of 60%. In those known to be HPV negative initially, the efficacy was 90%. It is not surprising that the vaccine would appear to work better in those that did not already have some strain of HPV, and this supports the reasons to vaccinate youth BEFORE they are sexually active. I thought it was interesting that they ended up with 1% of the placebo subjects developing genital warts- the same as in the general population. I am encouraged that the incidence in those vaccinated dropped to 0.1%.

The devil is always in the details, and how people pull out statistics. I could note, for example, that 3 patients in the placebo group received gun shot wounds, while only one in the vaccine group did- but obviously the vaccine did not prevent gun shot wounds! The good news here is that true adverse events were minimal and of uncertain relationship to the vaccine.

BOTTOM LINE: HPV vaccination can significantly reduce the incidence of genital warts in young men as well as young ladies, with minimal side effects.

HPV Vaccine (Gardasil)- Don't Forget the BOYS!

I'll bet you could quote the commercial for the HPV vaccine, Gardasil, about choosing to be "one less"- one less woman to get cervical cancer. This is one time where I am pleased that the media is playing a role in pharmaceutical awareness! We absolutely want EVERYONE to know about cervical cancer and the exciting news that we now know not only how this cancer is caused and spread, but most importantly, we know how it can be PREVENTED.

Did you know, though, that this vaccine also protects against genital warts? Two strains of HPV (6& 11) cause 90% of genital warts. Every year there are over a MILLION cases of genital warts in the United States alone. They are COMMON. These warts are transmitted by direct skin-to-skin contact, and though this usually occurs during sex, actual intercourse is certainly not required to pass them on. They are very contagious, with estimates up to 65% transmission. Warts typically recur despite treatment, and frankly, the treatment is unpleasant at best- we burn the warts chemically or with liquid nitrogen. If you've ever had a wart frozen/burned off your knee, you know what that feels like, and the genital area has more nerve endings. Enough said!

While males don't have a cervix to get cancer, they do have other parts that get HPV-related cancers (anal & penile, as well as some head and neck cancers,) although certainly these cancers are less common. Obviously, males can also get genital warts. In my clinical experience, little harms self-image like a young person developing these genital lesions, especially because we cannot simply cure them and make them go away forever.

Gardasil was approved for use in males over a year ago. A study recently published in the New England Journal of Medicine demonstrated that the vaccine had good efficacy in prevention of genital warts in males. More on this study tomorrow...

BOTTOM LINE: PREVENTION is KEY for HPV disease- talk with your doctor (or your child's doctor) about HPV vaccinations for your SONS & DAUGHTERS.

PS. I am NOT on anyone's payroll for this vaccine- but I absolutely do recommend it.

XRAY X-pectations

When you hurt your back (or ankle, or wrist) and head to the doctor, do you expect an x-ray? I find that many patients are surprised if I do not insist on an x-ray for an acute injury. Mind you, I certainly order plenty of x-rays when I believe that the results will change our management (is it a broken bone or a sprained ligament), or even if the results simply tell us what to expect about the time-frame for healing, such as a minor fracture in the foot or toe.

By the way, while we're on the subject, a SPRAIN happens to ligaments, the tissue that attaches bone to bone. A STRAIN occurs in muscles or tendons (tissue connecting muscles to bones.)

So back to XRAYs. XRAYS look at bones. They do not "see" cartilage, muscles, tendons or ligaments, though sometimes distance between bones suggests lack of cartilage. The vast majority of injuries that send patients to their doctors are not from broken bones, but strains and sprains and spasms of muscles and supporting tissue. As we try to limit both unnecessary radiation and expense, the world of medicine is taking a closer look at when interventions such as taking xrays are really needed to improve patient outcomes. Medical centers are developing guidelines for different injuries that help physicians determine when an xray is truly needed, such as the Ottowa rules for ankle injuries.

RICE: Rest, Ice, Compression and Elevation (plus a bit of pain-reliever/anti-inflammatory medicine such as ibuprofen) go a long way towards treating injuries. Your doctor can show you the best way to compression wrap an extremity, plus possibly prescribe muscle relaxants or stronger anti-inflammatory medicine. Perhaps most importantly, your doctor may prescribe PHYSICAL THERAPY- where you will learn strengthening, flexibility and stability for your injury to fully rehab.

BOTTOM LINE: XRAYS are helpful diagnostic tools for bone injury, but don't assume your treatment of an injury isn't complete without one!

B Vitamins and Omega 3 Fatty Acids vs. Heart Disease

We are always looking for ways to prevent heart disease, the number one killer in the United States. As we gain technology, we are able to look at more and more components in our blood that lead to clot formation and heart attacks. You'd have to be hiding under a rock to not have heard about cholesterol levels, right?

Well, the trick in medicine today is to make sure that we are focusing on PATIENT OUTCOMES more than LAB VALUES. This is the premise behind evidence-based medicine, where we try to look at specific outcomes (did he have a heart attack or stroke) versus did we lower his cholesterol numbers. My patients hear me whine that so many people are willing to spend money on vitamins, supplements and prescription medicines to "lower their numbers" but are NOT willing to change their behavior to eat more fruits and vegetables and to exercise daily. Why do I complain? Because we DO have evidence-based medical data that shows convincingly more exercise and healthier diets not only lower weight, blood sugars and cholesterol numbers, but they decrease the number of heart attacks, strokes and deaths- and isn't that what we're looking for?

Along those lines, a study was published last month in the British Medical Journal that looked at whether or not giving B Vitamins and Omega 3's to patients who had already had a cardiovascular event (heart attack, stroke, or unstable chest pains) would reduce their subsequent numbers of additional cardiovascular events. What they found was that although the supplements worked better than placebo to change some blood tests, there was no difference in actual heart attacks and strokes.

What is the take home message here? Am I saying B Vitamins and omega 3 fatty acids are useless? NO, I am not. It does appear that they don't have great benefit when started AFTER you've already had a heart attack or stroke. Might they help prevent disease in a healthy person? Maybe.

BOTTOM LINE: Let's focus on the common sense changes that we KNOW benefit our health (MORE fruits and vegetables and exercise) and spend less time, money and energy chasing down lab values.

Brand New FDA- Approved Antidepressant

The stock market is very aware that the FDA has approved a new antidepressant (see the FDA News release here)- a drug called Viibryd (vilazodone hydrochloride.) The manufacturer claims that this antidepressant did not cause weight gain, nor did it affect sexual function. If that turns out to be true once large numbers of people are taking the medication, I know I will be flooded with requests for this drug, because weight gain and decreased libido or sexual function are the major complaints that I hear about this class of medications.
Before we all jump on the bandwagon, however, let's go back to a blog I did last week- "Doc, Have you heard of this new drug" and look at the "STEPS" pneumonic.
S: Safety-Side affects appear to be at reasonable incidence, and I cannot find information regarding drug interactions.
T: Tolerability- side effects include "diarrhea, nausea, vomiting and insomnia"
E: Effectiveness-Honestly, I cannot tell from a brief perusal of the medical literature. I found many studies in rats, from the years leading up to the human trials, but only one good size (400 patients) of humans. There was some effect at one week (which is early for anti-depressants) compared to placebo, but no studies yet comparing it to other antidepressants.
P: Price- Don't know yet, but it's a new drug. This means coupons the first year, but a new drug is always a higher price than old ones. The business world, however, is excited and projecting over $2 MILLION in sales.
S: Simplicity- Sounds like it will be once per day, though again, I never found a product information sheet.

BOTTOM LINE: Yes, there is a new antidepressant, which MAY provide good improvement in patients with major depression, while having fewer adverse side effects (weight gain and sexual dysfunction)...but let's not storm the pharmacy yet.