What’s Your Mantra?


Religion as known this for millennia. Chants are a powerful way to train the mind. For weight loss and wellness to be a maintained we have to change our lifestyles for the long-run. The change needed is antithetical the direct our society wants us to live.  The choice infrastructure of our society is such that we consume more than we think.

Our society is functionly illerate, we read without comprehension and are easily misled, by the “shiny” toys being sold. Mantras are one of those shiny toys, but there is ample evidence to suggest there is power there.

Every time I am tempted to make the wrong food choice I repeat my mantra, “I will eat well today.”

What’s your mantra? Find one and say it often.

Bad Advice


Bad advice is everywhere. It is your job to find it and discard it. In the world of diet and weightloss, poor quality information is a scourge.

If we don’t want to be trapped by the purveyors of “crap” we need to educate ourselves. Read, read and read some more. Making better choices is about high-quality data. Learning how to find high-quality data is key, not just for diet but for life in general.

With that in mind start here. Go to google and read about insulin and read about sleep quality and quantity. Only after we are convinced of the validity of the information I am presenting will you own it and follow it.

Without ownership, it is too easy to be lead astray. Keep focused, keep learning and just do it.

Let’s Eat


How we eat and what we eat is crucial to managing our weight. The current advice is skinny on facts and heavy on opinion. The myths and folklore that surrounds food are killing us.

I suggest, and the data are supportive of a low-calorie diet that is overweighted with plant-based components.

Divide your plate into fourths. Half should be leafy vegetables. One-quarter fruit and the final quarter a protein option. Each component should be no larger than your fist.

Can You Cure Your Diabetes?


I have been talking to anyone who would listen about weight management and well-being. The number one health threat in the coming century is obesity. Obesity too often is seen as an attractiveness quotient. The impact of obesity far exceeds just outward appearance. Obesity puts us all at increased risk of various diseases.

The disease risk is seen by many as a problem only in rich countries, but we are all getting more affluent. Poverty around the world has precipitously fallen over the last half-century, and conversely, obesity has increased. These changing patterns have given more options as to the content of the diet to many more people around the world. The current food trends have many focused on organic and “all-natural,” both foci have no real meaning and have allowed food companies and business interests to extract money from us without providing improved health options. The real problem is not chemicals or GMO’s. It is calorie count.

There are very few instances where increase bodyweight is not a direct factor of increase caloric consumption. Calories count. Understanding the science of digestion and how the body uses the food inputs is great; however, that understanding is only beneficial if we can count. Yes, counting calories matter. Bodyweight control is a math problem. Unfortunately, both popular and fringe food media have sold us out to commercial interests. Those interests are not limited to mega-corporations, but also to the feel-good all natural con artists. These people are leeches on an uneducated distracted society. Has America become less obese over the time that the all-natural, organic crowd has risen to prominence? Some will answer by saying that not enough people have changed to this new way of eating. Unfortunately, too many have. Too many have made poor choices. These are our bodies let’s educate ourselves and take full control. Do not be misdirected.

How do we get control? Let’s just do it! We need to change how we eat. The rapid rise in obesity is leading to an increase in diabetes and is increasing cancer risk. Consider the increase in breast cancer and the concomitant rise in obesity. The evidence may only the coincidental but needs closer examination. We cannot wait for some magic pill.

I have seen enough clear-cut evidence. Obesity is a health risk. How we handle it will have a profound impact on the prospects of our country. I am starting a journey today. I will get to my idea bodyweight before the year is out. I will give daily specific advice on how to get there to anyone that asks. If you have diabetes, you can reverse and control your disease with diet only.

If you are ready for the hard work and the joy of success, join me. I will share my daily routine. Let’s lose some weight, feel better and cure your diabetes.

I Know How To Save The Planet!


Every year Americans get larger. We are getting fatter, and we care less about the health risks. As a physician, I can see the effect on health, but societal pressure is going opposite to the medical evidence. The science is being ignored to spare the feelings of the obese.

As we spare the feelings of the obese, we are doing several things that will harm us all. We are making obesity socially acceptable and have gone further to pretend that highlighting obesity is the same as racist speech. It is not. As obesity increases in prevalence, the conditions that create obesity are becoming normalized. In the long term, this impacts our children and leaves them with a lifetime of obesity. Obesity may become socially acceptable, but it is not medically sustainable. We need to take better care of our citizens and start by telling the truth. Obesity is the most destructive disease to Americans. We will be paying in ways not yet foreseen.

The science is clear. The medical observations are in, and obesity is not an acceptable fashion statement. It is a disease state. Like smoking, no amount of obesity is without consequence. All obesity will cause medical damage. The only question need is, how much. Many will have long lives in spite of their obesity, but the facts are clear. They could have had better lives. The sad news is that obesity is not a personal disease, it is a societal disease. We have an epidemic.
The epidemic is that of the whole organism. The organism is humanity. As the maldistribution of food resources leads to obesity all over the world, the entirety of the planet will suffer. There is a need to clear and plant; rare and kill more animals. This race to produce more food is destroying not just our bodies thru obesity but is destroying the biosphere.
As we destroy our planet’s ability to sustain us, we are killing ourselves. How we handle food is not a personal matter, it is a species matter. The capacity of our planet is finite. We live on a rock covered with a small volume of air and water in a giant vacuum. If the potable water runs out, or the breathable air disappears we have no place of refuge.

All of us can directly impact the planet. We can eat less. The science is clear. If we eat organic or non-organic, there is no difference. We need to eat less. There is no superfood. There is food. No matter the nutrient content, excessive quantity has the same result, obesity.
Eat less and leave a healthier planet for our children. Teach our children to eat less and save the planet for our grandchildren.

Eat better.

Happy Father’s Day.


Maintaining a healthy weight in our culture is becoming more difficult. Just look at the people around you. Most of us are overweight. As the epidemic of obesity continues to grow, we seem to be less concerned. We seem to be more concerned about the consequences of fat shaming and not on the fact that life expectancy in some segments of the population is declining. Obesity is primarily a disease of excess compounded by a lack of insight.

If we want to change the trajectory of this epidemic, we need first to acknowledge that there is a problem. As I have gained several kilograms over the last few months, I’ve had to confront the trip wires in my life. It seems to me that we all need to honestly evaluate the obstacles preventing us from maintaining a healthy weight.

Let’s challenge our obstacles and surrender to the facts. 1. I’m making poor food choices 2. The people around me are allowing me or encouraging me to eat poorly 3. I don’t recognize appropriate portion size 4. I eat too much and too often 5. I buy too much food 6. I move too little 7. Everything I believe about exercise is wrong 8. Dessert is food 9 Calories matter.

My simple advice, which I should take myself. Stop listening to the people in your life who overeat and are always complaining about their weight. Stop eating out. Eat whole foods. Eat a plant first diet. Remove the highly processed carbohydrates. Eat less often. Count your calories. Sleep better. Stop worrying about what you will look like after you have lost the weight.

Dads, be an example to your family. Be disciplined and eat better.

Happy Father’s Day.

 

POSTOPERATIVE DELIRIUM


Life expectancy in the USA as of the most recent data is 78.61 years. Along with longer life span we have a every increasing number of surgery. With out-patient surgery rapidly growing year over year. The population over 65 years are living a more active life still and are requiring more surgical intervention. Our peri operative technologies have improved to allow us to provide safer care to those at the extremes expectancy range. WIth this improvement and comes many additional questions. The question of post op delirium continues to be a problem and will increase as the populations ages and more surgical procedures are available.

How the older patient is cared for in the peri operative time frame is and will continue to be of special concern to themselves, families and increasingly to payors. The process of getting from diagnosis to the surgical suite is basically divide in 2 routes, either via he emergency room or the physician office. The peri operative preparation is as import as the intra operative care and involves many, however as an Anesthesiologist i will present the process from my vantage point.
The care of any patient starts with the basics, taking a good history. For all patients under the care of an anesthesia provider taking a focused and directed history is vital to the safe delivery of appropriate care. For the older patient extra attentions should be placed on history of delirium in the post operative period which i would suggest should be considered to include the first 24 hours post PACU discharge. Other vital components to evaluate include vision impairment and hearing loss. For the visually impair consider how soon after arrival in PACU to return glasses. For the hearing impaired do they use hearing aids, can they be left in for the procedure. Does the patient lip read. Even for those that do on lip read, looking directly at them, speaking clearly with proper enunciation without shouting works very well to transmitted data.

Carefully look over medications for hints to treatment for early dementia. Ask about early dementia. What happened after last surgery. Who will be present in the post operative period?

There is no clear evidence that anesthesia specifically is the cause of post operative delirium. The choice of anesthesia should be based on what intervention will provide for the safest working conditions and facilitate a rapid low pain recovery.  For those with dementia the suggestion that regional alone maybe advantageous is not as clear to me as it maybe to others. From my experience regional as the sole anesthetic in a demented even for very minor procedures will be a challenge because of the lack of circumstantial awareness from the patient. The lack of awareness can and often leads to lost of cooperation and increased risk of morbidity to the patient. The primary anesthetic must provide the appropriate working conditions firstly. The demented patient like all patient must first be in optimal surgical condition. General anesthesia is often the most optimal choice. General anesthesia is not one thing but many varied combination of drugs and this is where the judgement of the anesthesia provider can be very helpful. From my vantage point the goal is to provide the most advantageous conditions using the lowest dose of the fewest drugs required. A monitor that was dependable in the judgement of anesthetic depth would be of great utility in the older patient. The BIS monitor is claimed by some to be such a monitor, but many others find it inconsistent and unreliable. I have not seen any evidence that convinces me that it provides and advantage. It may provide some advantage but that advantage is not clear to me. The traditional monitoring of anesthetic depth includes observation of changes in vitals and direct observation of the patient may be insufficient to guarantee adequate depth but is still the best we have. A vigilant provider is still the best monitor. I hope that one day soon we will have an even better monitor. Without that monitor the provider needs to be conscious to balance depth with risks of post operative delirium. The drugs that we use to maintain anesthesia are important potential risk point and one area that is especially concerning are the anticholinesterases. These drugs are used as apart of the cocktail for reversal of paralysis and can cause delirium and should be used with caution. The optimal situation would be to not need them, meaning if necessary we should avoid paralysis. However, if paralysis is needed full reversal should be used because incomplete reversal could make the post operative situation worse. Additionally making sure all our anesthetic if below therapeutic levels before going to the PACU is beneficial.

Once the optimal condition for surgery have been meet and the anesthetic is optimized to decrease the risk of post operative delirium the patient needs to be cared for in a PACU that continues to  optimize recovery. The environment needs to the at an appropriate temperature with appropriate lighting and quiet. Use the minimum required monitors to get the job done. The nurse in the PACU is a vital partner, she needs to orient the patient to date time and location. Orient, orient and orient again. Assurance of adequate hydration, pain control, empty bladder, treatment of nausea if present, prevent hypoxia are all vital. If delirium occurs, low dose benzodiazepine and family at bedside should be considered. The use of regional anesthesia is a great tool to assist the post operative period. I find the most utility of regional in the patient with dementia or at risk of delirium is in its ability to provide significant long-lasting pain control that decreases the amount of opioids needed in the recovery period.
Special attention to the needs of the older patient at risk for post operative delirium is a worthy goal. However, we must not be lead from first principles. We must provide a safe environment for the procedure. With careful planning and attention to detail we may be able to decrease the risks, but we should not lose site of the facts. Fundamentally, there is no good evidence that the type of anesthetic correlates with risk of post operative delirium. The only consistent fact is that the patient has had surgery. Teasing out the specific component of the peri operative environment that increases risk is still some way off. What anesthesia providers need to provide safe conditions that decrease risks based on the evidence we have.

DOCTOR, TAKE A STAND.


The debate around health care in our fair country as heated up again. The strange thing about the process is that the majority of the people commenting already have great insurance. They can afford to pay for great health care. The ACA is flawed and all should admit it, but it is not the cause of the chronic underperformance of our system. We have a closed unresponsive system that is constrained by an ill-informed electorate.

We need to exposed the entire system, both strengths and flaws, to the public. Doctors need to be in charge of care decisions and also need to be cognizant of the economic realities. Patients need to have realistic expectations, which should be set by their doctors.

Doctors need to stop listening to the ill-informed lobbyists. Those lobbyists are not working on our behalf, they are working for other economic interests. Doctors need to stand up and start voting our economic interests because the lobbyist are voting for their own. The interests of the lobbyist only rarely intersect with our own.

Let us take a stand together. Let us take a stand firstly for our patients and secondly for our own self interests.