Weight Loss Motivation: Look In The Mirror And Say "Damn You's A Sexy Person!"

I know that there are many of you out there who have given up on losing weight. You know what I’m talking about. That feeling deep inside that tells you that you will always be overweight. Once in a while you may make an attempt to change. You say things like “I’m really gonna try” or “I’ll do my best. That’s all I can do”. It doesn't sound like you believe.


That’s one part of your life that you don’t like to talk about because it reminds you of that sense of defeat. Or may be you talk about it everyday! You are constantly on a diet. People roll their eyes up when they hear about your latest attempt and they don’t even hide it from you anymore.

You are successful at work, have wonderful friends and a loving family but cannot conquer your inner self.

What motivates you to want to lose weight? Is it to be healthier? Is it to look good? Appear more attractive to potential partners? Maybe your family members are nagging you? Does your doctor bring it up in passing and try to guilt you into eating healthier and going to the gym?

I think the greatest motivation is to look in the mirror one day, not at the shape of your body but deep into your own eyes. Knowing that you have control over your mind and your body. After achieving what was seemingly insurmountable, you will feel like you can take on the world. No matter what it throws at you.

Motivation refers to the psychological forces or energies that impel a person towards a specific goal. Everything that we have mentioned so far falls under the category of extrinsic motivation. What that means is that we start to restrict our calories and physical exercise because we want to achieve weight loss and everything that we think will come with it, and not because we are particularly fond of eating healthier or going to the gym.

That’s a great way to start but as we move through this journey, we will explore ways to incorporate tools to achieve intrinsic motivation. We hope to be in a place that we derive satisfaction and enjoyment inherent in healthy living habits.

I am inviting you to start believing again.

I would like to introduce you to a recently started internet service. Someone described it once as a personal spa for the mind! At this time we will use it for its meditation and affirmation tools. Go to meisalus.com and click on inspirational videos. Under the weight loss tab watch and listen to some of the featured videos. Listen with headphones for full effect. Keep yourself motivated daily.

Remember! Until next time keep recording what you eat. It’s a crucial aspect of self monitoring.

"Lose Weight The Easy Way" and next week "Get Rich Quick, Doing Nothing"

The hunger center in my brain wasn’t very active when I was a child. It didn’t need to be. I gave it everything it wanted and more. Way more. It would only be time to leave the dinner table when the stomach pain overtook the desire to consume more food.
This along with an innate dislike of too much physical activity led me down an inevitable path which was to be known as the chubby one throughout my childhood. I know, the story is sad and you are probably trying to hold back tears but let them flow because there is more. Even now as I am in my early forties, kind relatives remind me at every opportunity of my childhood fondness for all things edible.

Any lesser man would have been left with a life long sensitivity towards his weight. But not me. No sir.

I have however, purely for professional growth had the opportunity to study and observe various weight loss measures. I have seen some amazing success stories that have proven the most reasonable approach to be the right one.

This approach is based on consuming fewer calories than you expend which is an elaborate way of saying eating less than you burn off. This is GUARANTEED! to cause weight loss. I wish that what I just said was as profound as I tried to make it sound. The importance of my statement is not that it offers a new way to lose weight but its promise to be an equal opportunity method. No matter who you are if you consume less than you expend, you must and will lose weight.

Our task for today is to find out as much about ourselves as possible;

First lets see who is at risk for complications of being overweight and obesity and needs to consider weight loss. Go to BMI Calculator and by inputing your height and weight calculate your Body Mass Index (BMI). A BMI of 18.5-24.9 is considered normal. If your BMI is less than 18.5 you are considered underweight. The following are the various stages of being overweight and and their corresponding BMIs and risks of medical complications such as type2 diabetes, high blood pressure and heart disease;

Overweight: BMI 25.0-29.9, Increased Risk

Obesity(Class I): BMI 30.0-34.9, High Risk

Moderate Obesity(Class II): 35.0-39.9, Very High Risk

Extreme Obesity(Class III): >40.0, Extremely High Risk

Realizing that you are overweight or obese is not going to be the best news that you've had today but burying your head in the sand is not the solution either. Recognizing the task at hand is the first step towards resolving it.

Second, are you ready to get started today?

Are you ready to tackle this issue once and for all? Why do you want to lose weight? What are the things that make it hard for you to start? Can you commit to 15-30 min a day to this process?

Third, we need a very clear idea of what we are eating before we can think about modifying it. There are online calorie counting sites available with smartphone applications. The one that I like is dailyburn.com.
Sometimes just realizing how many calories you are ingesting is enough to start the process of modification. Before we talk again you must become religious about tracking how many calories you are eating. The site has thousands of food item entries including ones from restaurants. You must be careful as we tend to underestimate our portion sizes. This time, stay true to this endeavor and you may be surprised at the results.


We will base our approach on the American Gastroenterological Association Medical Position on Obesity. You will need a medical evaluation before we can proceed from this point. This may include history taking, physical examination and possible lab tests which may elicit obesity related health risks. You must notify your medical provider of your intention to embark on a dieting regimen involving calorie restriction and increased physical activity.

I saw an ad for a smoking cessation aid that said "never quit quitting" and something similar needs to be our moto. Despite the title of this post, this journey will be hard and at times you will falter. It doesn't mean that your body is immune to this way of life. It means that we regroup and start again. Not in six months, or next new year's day but tomorrow or in a week.

Over the next couple posts I will try to go in a little more detail about the different aspects of this approach. Feel free to comment and even help us come up with a slogan or a name.

Mammograms, Evidence Based Medicine, Media, Politics,...

In 2002 the researchers of the WHI (Women's Health Initiative) held a press conference to announce to the world the results of their study. This was before any of their peers had a chance to review their results. They told us that they had prematurely halted the study on Hormone Replacement Therapy (HRT) because they had found a significant increase in the risk of heart disease, breast cancer and stroke in the treatment group.
The radio, TV and the internet were ablaze with outraged women that felt betrayed by their physicians who had obviously given them these poisonous pills for years. Many of my patients called our office to inform us that they were stopping their HRT. More than a few however called back a couple of months later to tell me that they were restarting them as life was unbearable with constant hot flushes, night sweats and mood swings.
Fast forward a few years and now these wonderful and informative studies have had a chance to be peer reviewed and a consensus has emerged.
There is no increased risk of the conditions mentioned above for about the first five years after menopause starts. The recommendation now is to only prescribe HRT to alleviate menopausal symptoms and at the lowest dose and for the shortest period of time (usually three to five years). These guidelines for some reason did not grab any headlines. If only we could convince a celebrity to say you could have wonderful sex, all day long if you take HRT according to these recommendations.
It appears that the history is repeating itself. The U.S Preventive Services Task Force (USPSTF) has recently issued its recommendations for screening for breast cancer. You cannot escape the headlines on TV, radio and newspapers. Blogs are also of course full of opinions on the matter. The fact that the American Cancer Society, American College of Obstetricians and Gynecologists and surprisingly! American Society of Radiologists have come out against these recommendations has only added fuel to the fire.
The major changes to the current practice are;

1. For women aged 40-49 individualize decision to begin biennial (every two years) screening according to the patient's context and values (family history, other risk factors, patient's desire, ...)
2. For women aged 50-74 screen every two years.

Again, as was the case with the WHI study the USPSTF have done a great job in studying the merits, risks and benefits of a very common screening program. Where this effort has failed, through no fault of its own is that it never had a chance to be appropriately peer reviewed and a consensus to be reached. This should have been done before the media had a chance to make a mockery of it and the Congress to feel obliged to step in.
A screening program must meet the following criteria;

1. The disease in question should constitute a significant public health problem, meaning that it is a common condition with significant morbidity and mortality.
2. The disease should have a readily available treatment with a potential for cure that increases with early detection.
3. The test for the disease must be capable of detecting a high proportion of disease in its preclinical state, be safe to administer, be reasonable in cost, lead to demonstrated improved health outcomes, be widely available, as must the interventions that follow a positive result.

Adequacy of a screening test should not be based on anecdotal evidence or questionable expert opinions. Everyone can remember an uncle or a grandfather that lived to be ninety despite smoking a pack a day. It doesn't make smoking safe. This brings me to my favorite Hippocrates quote;
"There are in fact two things, science and opinion the former begets knowledge, the latter ignorance."
My patients have started asking me about these new recommendations and for now I'm telling them that I'll wait for the dust to settle and for knowledge to overcome ignorance.

How Can I Get Pregnant?...NOW!

The glint in the husband’s eyes is unmistakable as I explain the frequency with which the couple needs to have sex to increase the likelihood of getting pregnant. My patient on the other hand looks a little more skeptical. It is as though she wants to make sure this is not the result of some male conspiracy or that her spouse didn’t call me before the appointment to arrange for this advice!

For numerous patients, planning a pregnancy is a conscious decision that usually leads to behavior and lifestyle modifications. It is however unlike most other conscious decisions in our lives in that we have less control over when it may happen.

“Finish college at 21. Take a year out and travel before graduate school. Get married at 26. Get stabilized at work and married life for one to two years. Get pregnant around August so can have baby in Spring and not be pregnant when it is too hot outside!” This is how many of us try to plan our lives and for the most part we manage to stick with the agenda until it comes to the last item on the list. This lack of control can lead to anxiety and feelings that something must be wrong.

The scenario can be a familiar one. The first month is all very exciting. The couple have sex as they are advised. They both try to delay doing the home pregnancy test until at least an hour after she would have expected her period to come. Most however can’t even wait that long. They start a day or two before. Squinting their eyes as they look closer at the test strip for any faint positive signs. Then they reassure each other that they tested too early. I bet one or both of them later goes and retrieves the test strip from the garbage can just to make sure. The disappointment is clear when her period starts.

By the third month, the excitement of having sex prescribed by your doctor is all but gone. Instead, having sex is about achieving results. It is about ovulation kits, temperature spikes and the consistency of cervical mucus. All of which are, no doubt, very well known aphrodisiacs!

Anxious thoughts and insecurities begin to creep in. She feels less of a woman and him less of a man. “Maybe you need to relax. You’re too stressed.” “Maybe you need to take this more seriously". "What if something’s wrong?"

Most pregnancies happen during the first six months of trying to get pregnant. Overall, after 12 months of unprotected sex, approximately 85 percent of couples will become pregnant. Over the next 36 months, approximately 50 percent of remaining couples will go on to conceive spontaneously. This entire group is considered to have “normal fertility”. The approximately 10% that are remaining may need evaluation for decreased fertility.

Having this knowledge doesn’t necessarily make dealing with disappointments any easier. It is important for a couple to sit down before they start and discuss their approach and their goals. Having a strong foundation built on communication and mutual support will certainly help. It is important to include your healthcare provider in your discussions. He or she can make sure that you are in optimal physical and emotional health before starting on this very exciting journey.

Miscarriage- Tragedy of Now...Hope for the Future

My heart sinks almost immediately after I start the trans-vaginal ultrasound. I desperately look for a flicker or a movement where the heart beat would be.

At the same time my mind is rehearsing what I may have to say. “I’m sorry but the pregnancy has stopped growing”. No, that doesn’t make sense. “I’m sorry but the baby has passed away”. Don’t like that either.

What do I say? She should be about 7 weeks pregnant. Just missed her period a couple of weeks ago. Like most couples they didn’t want to allow themselves to get too excited. I am sure however, that like most couples from the moment the home pregnancy test gave them the positive signal, the cautious day dreaming began. What names for boys and girls? Which color for the baby’s room? Daycare or babysitter at home?

“I am very sorry but I don’t see a heart beat on ultrasound today”. I then explain the miscarriage process but mainly try to listen.

This is not something that is usually taught very well in medical schools. I made mistakes at the beginning of my career and placed my foot several times in my mouth before settling into what I know now.

What I have learned over the years is to separate the tragedy of the moment from the hope for the future. Too many people resort to minimizing the emotional effects of an early miscarriage as a way to comfort the grieving couple.

All the stages of grief apply to an early pregnancy loss, from denial and guilt through to acceptance and hope. It is not unusual to feel isolated with these emotions because the couple may not know anyone else who has had a miscarriage. It is not exactly a topic that comes up often during dinner parties and family gatherings.

Unfortunately miscarriages are very common. Approximately 15% of known pregnancies will end up in a miscarriage. However if you include all the pregnancies that are lost before a woman even misses a period, the number is a staggering 50%. Most of these are due to chromosomal abnormalities which are sporadic in nature. This means that in most cases it appears to be a chance event.

“Is it because of something that I did or didn’t do, maybe something I ate?” The feeling of guilt is inevitable. You cannot cause a miscarriage by lifting something heavy or having sex and no it wasn’t that second glass of wine you had before you knew you were pregnant. The list goes on.

As reassuring as it is to know that the woman did not cause this miscarriage, it is disturbing to live with the lack of control. “How can I make sure that this does not happen again?”

There are a few things that can help minimize the risk of having a miscarriage. The most important thing is to be in an optimal state of health. If you have chronic illnesses such as diabetes they should be well controlled. With the help of your provider you can identify any environmental factors such as excess alcohol and cigarette smoking. You will probably need practical help to manage both of these habits.

There are some suggestions that moderate consumption of caffeine may increase the risk of miscarriage in the first trimester.  One cup of coffee a day should not pose an increased risk, as long as you take into account your entire intake of caffeine (including that in caffeinated sodas).

Guess what?! Exercise is good for you! As long as your provider has not identified any reason why you cannot exercise, it has been shown that not only is it safe but it may lower the risk of miscarriages.

Despite all of these adjustments there are a minority of women that experience recurrent early pregnancy losses. The guidelines at this time recommend starting to look for potential reasons after two to three consecutive miscarriages. I’ll leave this topic for another day.

I have been present and shared this emotionally devastating time with a few of my patients. I have also been privileged and have had the pleasure to deliver their healthy newborns sometime later. I cannot help but wish that I had the power to show them the future as a way to ease their pain. But I can't. I know that for now we should mourn the loss.

Labor Pains- Natural Birth? I Hope Nobody Reads This!

If nobody reads this, maybe we can continue to label those women that say they want to have natural birth as a bunch of hippies and wierdos. Then when we fail to provide them with resources to maximize their chances of achieving what they want, we won't feel as bad. Great idea!
If nobody reads this, maybe we can continue to smile knowingly everytime we meet someone who wants to try labor without an epidural.We can continue to make mental bets on how long they will last. After all, what else is there to offer them?
If nobody reads this, maybe when our patients say they want to try natural birth we can go on telling them, "sure just come in on the day and we'll see how you manage!".
Perhaps many of those that want to have a natural birth like the idea of it but don't want to put much time and effort into preparing for it anyway. I tried this philosophy on running the marathon once. It didn't work out too well!
The question is, who has time for all of this when things seem to be working just fine? How can change happen?

If we really wanted to make a change, we would initially create a sense of urgency. Then we would put together a guiding team that would include patients, physicians, midwives, nurses, hospitals etc. (if you can't tell, I've just read "Our Iceberg is Melting" by John Kotter!). The solutions would be decided upon as a TEAM.
Since no one will hopefully reads this, I can be honest and say that many women who choose a non-pharmacologic approach to pain management are often ill-prepared. Some of the ones that succeed look at the pain as a side-effect of a normal process (labor). They may even say crazy things like they felt "able to transcend their pain and experience a sense of strength and profound psychological and spiritual comfort during labor". Yeah! Whatever!
So what are some of the things that we do know about this option?
In contrast to epidurals, the primary goal is not to make the pain disappear. Instead, the woman is educated and assisted by her caregivers, childbirth educators, and support people to take an active role in decision-making and using self-comforting techniques and nonpharmacologic methods to relieve pain and enhance labor experience. If a woman after a few hours in labor decides to get an epidural it is not a sign of failure. For some, just the ability to walk around for a period of time and feel more in control can be very satisfying.
The birth environment and continuous labor support from the father, family member or doula are very important aspects of this approach. A doula that is familiar with the family and the physician can provide tremendous support. A prior meeting or discussion will make sure that everyone shares the same mental model of what to expect when the time comes.
These are some of the options for non-pharmacologic pain management in labor even with the system that we have in place now;
Water Immersion: Many women find the feeling of being immersed in warm water very comforting and relaxing especially in the beginning phases of labor. It has been shown that in "low risk" pregnancies this is a safe practice.
Sterile Water Injection: Also called a "water block", usually involves four small injections in the skin of the back to primarily relieve pain in that area. The injections can be painful but the relief can last 45 to 120 minutes.
Touch and Massage: Women clearly appreciate these and they appear to reduce pain and enhance feelings of well-being.
Acupuncture and Acupressure: As long as this approach is performed by trained practitioners it seems to be safe and provides a great deal of satisfaction to those that have tried it. It remains to be seen how it can be integrated in healthcare institutions.
Hypnosis: Hypnosis used for childbirth is almost always self-hypnosis; the hypnotherapist teaches the woman to induce the hypnotic state in herself during labor. Sometimes her partner is taught to signal her into the hypnotic state. I have seen the positive effects of this technique in my patients that I have referred to Dr Jay Stone. He makes his materials available on line at http://www.drjaystone.com/ .

There are many techniques that can help decrease the pain of labor and sometimes eliminate the need for epidurals and medications. Not all of them may be available or appropriate depending on the risk level of the pregnancy. Most of these methods need a good deal of preparation and time investment by the woman and everyone involved in her care. Although our current system is not fully set up to support these approaches it doesn't mean that they are completely out of reach.

It does seem like a lot of work though! Like I said I'm glad nobody's gonna read this.

Labor Pains- Epidural, Neither Demon Nor Savior

A knight in shining armor, the anesthesiologist gallops away on his white horse after saving yet another lady from the throes of pain!

When the epidural works as it is supposed to this or a similar scene is what comes to mind. The fact that the anesthesiologist is the hero in this scenario doesn't bother me. Really, I'm not jealous! Even though un-scientific polls (conducted by me) show that most women would prefer to see their dentist rather than their gynecologist. I know that I will never experience a gyne exam but less popular than dental work? When I see my dentist I have what seems like a large and noisy Black & Decker drill excavating my tooth, shaking me to the core while flying debris land on my face and glasses. This all as I'm trying to watch Oprah on the tiny sized TV mounted high in the corner. It may be my only opportunity to learn what she is telling my patients to ask me. I'm not angry. I'm just sayin'!

Please ignore my digression. This post is not about exulting the virtues of epidurals but hopefully giving you an idea of what we know of it's benefits and disadvantages and perhaps dispelling some myths.


Lets start with benefits:

Epidurals have been shown to be more effective in relieving pain and have less of an effect on the baby than some of the intravenous medications. Their placement is usually easy and despite some women's fears not very painful. Depending on availability some may be able to walk with the epidural in place but in practice most women rest in bed. There is also the possibility of patient controlled epidurals where you control the amount of medication flowing through the pump.


Now disadvantages:

You may have heard that epidurals slow down the process of labor. This indeed appears to be true. Studies show that it can prolong labor by 40-90 minutes. There are also some conflicting data about the fact that it may increase the need for instrumental (vacuum or forceps) delivery.
A more common but usually minor risk is that epidurals can cause a headache. This commonly resolves within days and rarely requires an intervention called a "blood patch".

There are times that epidurals are ineffective or only partially effective. This does not happen very often but understandably can create a great deal of anxiety and panic. Some of my patients say that they want to be "drugged up" so they won't feel any pain. It is important to emphasize the other options for pain relief and provide tremendous coaching and support in case the epidural is unavailable or is ineffective.


How about myths:

Some of my patients make their minds up very early on that they will not consider an epidural under any circumstances. Unfortunately many times this is not a choice based on accurate information but rather myths perpetuated by friends and family members. One of the most prevalent is that epidurals cause chronic back pain. This has been shown not to be the case. The risk of developing back pain is the same whether you receive an epidural or not.

Another common but erroneous perception is that an epidural may not be placed until cervical dilatation has reached four centimeters. The view of ACOG (American College of Obstetricians and Gynecologists) is that "women in labor should not be required to reach 4–5 cm of cervical dilatation before receiving epidural analgesia".



Epidural analgesia is a safe and effective option for pain relief in labor. You need to approach this choice as you would any other medical procedure. Ask questions, discuss with your physician or midwife and consider the risks, benefits and other alternatives. This post is certainly not meant to be comprehensive but only to provide an overview and a starting point for discussion. In subsequent posts we will look at some other options to consider and they probably will not involve anesthesiologists or dentists!

To look at the ACOG patient education pamphlet on "Pain Relief During Labor and Delivery" go to:
http://www.acog.org/publications/patient_education/bp086.cfm