Category Archives: obesity epidemic

Weight Watchers catches on…

Bbrrrrrrrrrr!!! Mid Ohio has gotten down right cold!! Hope it’s toastier where ever you are! Check out what the mornings bring:

Told you so…COLD!!! I guess being a Southerner for 18 months did turn me into a wimp!! ๐Ÿ˜‰

Before I gush about an awesome fall recipe I tried, read about changes coming to Weight Watchers.

Weight Watchers in the UK has launched a new program that includes “ProPoints” that will take into account protein, carbohydrate, fiber, and fat. According to the Grocer, a British news outlet, calorie-counting as previously endorsed by Weight Watchers has since been proven “inacurate” and “outdated”. The new Weight Watchers program in the UK also gives participants “real living” points that can be used on occasional treats and alcohol. No details on the new US Weight Watchers program are available as of yet.

While these changes in the UK program are vague, they seem to be working in the right direction. In recent years, types of calories are being examined more closely. In other words, all calories are not made equal. In theory, all calories are made equal — a calorie represents one unit of heat equal to the amount of heat required to raise the temperatiure of one kilogram of water by one degree — but we all know that calories “spent” on empty calories like alcohol and simple sugars are not ones well spent as they provide no nutritive value. While Weight Watchers has made strides to encourage members to utilize their points appropriately, that has not deterred some individuals from the Cheeto and turkey hot dog meal plan. I would know, because that was me…10 years ago. One can quickly learn that you can eat what you want, as long as your points are within your target range, and lose weight. However, Weight Watchers is wisening up to see that while people are losing weight, they are not doing so appropriately.

The new program sounds more sound in that is will take into account ALL macronutrients — the components that make up calories in foods: carbohydrate, fat, and protein. I would venture to guess that the new program will also set goals for macronutrient composition in the diet (i.e. a balance between carbohydrate, fat, and protein). We shall see what Weight Watchers has up their sleeves, but I do see some changes in the program for the better. But, of course, a visit to your friendly neighborhood dietitian is always best!

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And on to the eats! ๐Ÿ˜€

I saw this recipe on Erin’s blog and I knew I had to try it. Butternut squash and cannellini beans…what a perfect fall dish!

Butternut Squash Cassoulet with Bacon and Roasted Garlic adapted from Cooking Light and The Healthy Apron

1 whole garlic bulb (about 9 cloves), chopped
2 oz. (4 slices) turkey bacon, chopped
2 large onions, vertically sliced
1 Tbsp olive oil
2 Tbsp white wine (I used red because it was open, worked great!)
1 Tbsp white wine vinegar
2 lbs. butternut squash, peeled and cut into 1/2 inch cubes
1/2 cup organic vegetable broth
1/2 tsp fresh thyme
1/2 tsp kosher salt
1/4 tsp coarsely ground black pepper
2 cans cannellini or great northern beans
1 bay leaf
2 slices Italian or sourdough bread
2 Tbsp freshly grated Parmesan
1/2 teaspoon olive oil
Chopped fresh parsley

Directions:

Sautรฉ bacon in large skillet or Dutch oven ~5 minutes or until crispy. Set aside.

While bacon cook, process bread pieces until course crumbs, add Parmesan, and 1/2 tsp olive oil. Set aside.

Drain fat from skillet and clean or use a separate skillet. Sautรฉ onion in 1 tablespoon olive oil ~5 minutes. Reduce heat to medium low, sautรฉ another 10 minutes. Deglaze the pan with 2 tablespoons wine, cook ~15 more minutes or until onions are softened and brown. Keep stirring frequently. Remove from heat and add 1 tablespoon white wine vinegar.

Preheat oven to 375หš F.

Mix your onion mixture, garlic pulp, bacon, squash, broth, spices, and beans, in a large bowl and stir well. Transfer to a large casserole dish. Sprinkle with homemade breadcrumbs.

Cover and bake at 375หš F for 1 hour and 5 minutes, or until squash is tender. (Remove cover the last 15 minutes of baking to brown the topping). Discard bay leaf and sprinkle with parsley. Serves 8.

Nutrition Information (per serving): 215 calories; 4.5 g. fat; 6 mg. cholesterol; 444 mg. sodium; 33 g. carbohydrate; 7.9 g. fiber; 9.9 g. protein

Result: I am BLOWN AWAY at how flavorful and delicious this cassoulet was. I knew it would be good, but it far surpassed my expectations. I ate this as a meal, but I think I would add goat cheese for a main course next time. I think that creamy richness would pair perfectly with the sweet, soft squash and the hearty beans. If you don’t have time to make homemade breadcrumbs, use Panko or just regular breadcrumbs…either would work just fine and be a time-saver! I am glad I halved the amount of beans…4 cans just seemed like a lot! I love beans, but I much prefer the squash to be the dish’s super star! The dish is a nice balance between carbohydrate, protein, and fat and is loaded with fiber while being low in calories. A winner all around! Enjoy!

Trivia question answer: the #1 most requested pizza topping in the U.S. is PEPPERONI! Most of you guessed it, kudos! I honestly thought it was sausage and no one else guessed that, oops! ๐Ÿ™‚

Thanks for your great Q&A questions! If there are any others, send them over to me PreventionRD@gmail.com! I will post a Q&A next week, and keep a look out for Mr. Prevention’s cameo appearance post next week, too! ๐Ÿ˜‰

Question: What do you think about the changes Weight Watchers is making to their program? Are there any other changes you would like to see?

I would love to see sodium and saturated/trans fat included in the Weight Watchers program.

I am off to an all-day meeting with renal dietitians from all over Ohio! Should be a great day packed with lots to learn!!

Happy day-before-Friday!


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Filed under blog topic request, carbohydrates, Cooking Light, dialysis & kidney disease, diet, dietitians, dinner, fiber, fruits and vegetables, garlic, healthy cooking, herbs, hydrogenation, obesity epidemic, pizza, protein, recipe, saturated fat, sodium, trans fat, vegetarian, weight loss, work

high fructose corn syrup to be renamed corn sugar?

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High fructose corn syrup (HFCS) consumption is at a 20-year low with more than half of Americans believing corn sugar poses health risks. Consumers have become label-savvy when it comes to picking out HFCS on an ingredient list and companies including Gatorade, Sara Lee, Hunt’s ketchup, and Thomas English muffins have publicly removed HFCS from their ingredients.

HFCS has been around for decades and is the cheapest and most shelf-stable form of sugar on the market. HFCS is made by changing the glucose in cornstarch to fructose (a sugar naturally found in fruits) and the result is a combination of glucose and fructose, just like sugar. HFCS comprises just over half of the added sugars in our food supply but American’s consumption of sugar is up 50% from the 1970’s. It’s clear what’s really the problem, no?

Sweet Surprise is a multi-million dollar campaign put out by the Corn Refiners Association who have aired new commercials refuting any difference between corn sugar and cane sugar. That video can be viewed on the right side of the page.

A few other commercials have been put out by Sweet Surprise, and it’s definitely worth taking a few seconds to view them.

The Corn Refiners Association is petitioning the Food and Drug Administration (FDA) to have the name high fructose corn syrup changed to corn sugar. This is a potentially brilliant endeavor. When low erucic acid rapeseed oil was renamed canola oil, sales went up. Nothing about the product changed other than its name, and consumers bought it. Pun intended ๐Ÿ˜‰

The difference in fructose/glucose composition of HFCS compared to sugar is negligible and to date there is no resolute data supporting the dangers of HFCS over sugar on “weight hormones” such as leptin, ghrelin, and insulin. Some rat studies have shown that HFCS promotes obesity more so than other sugars, but other studies have negated the very same claims. Basically, there are no definitive answers in the science world…yet.

It seems as though consumers want an “all-natural” sugar that offers sound nutrition and is “healthy” in abundance. Bottom line: sugar is sugar and should be used in moderation. Unlike the Sweet Surprise videos portrait, moderation is NOT in the form of Kool-Aid and sugary breakfast cereals…there are much better alternative out there. And whether Starbucks baked goods are made with HFCS or cane sugar, they will contain the same number of calories and have identical nutrition stats. Americans simply need to get down to business and limit ALL sugars and processed foods.

I would urge consumers to not get caught up in the gimmicks surrounding such issues. Why not assess labels for the lowest sugar content (grams per serving) rather than purchasing a high sugar product just because it contains sugar and not HFCS?

Is HFCS safe? I think so.
Is it the most “natural” sugar available? Nope.
Is HFCS over-used? I think so.
Is HFCS to blame for America’s obesity epidemic? I don’t think so.

I think this debate is very interesting, and I’d love to hear your thoughts.

Question: Do you think HFCS is worse than sugar? Do you avoid HFCS? Why or why not?

Credible, wonderful sources:
Journal of Nutrition, Misconceptions about high-fructose corn syrup… American Journal of Clinical Nutrition, High-fructose corn syrup, energy intake, and appetite regulation

P.S. Thanks, Kerstin for such a wonderful topic request!! ๐Ÿ˜€

Down with too much sugar,

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Filed under blog topic request, obesity epidemic, sugar substitutes, Uncategorized, US health care, weight gain

Don’t judge a recipe by its looks…

Kerstin’s blog, Cake, Batter, and Bowl, is one of my favorites. Her recipes always look fabulous…and healthy! Easy on the budget, too, as she provides the cost per serving for every recipe. What a saint, huh!?

When I saw this recipe, I knew I had to make these muffins. Especially since berries are slowly creeping up in price and starting to lose their prime-season sweetness and quality. I will forewarn that these muffins take a bit of time to concoct, but the result is well worth the wait. My father-in-law loved these muffins and gave them a definite 5-star rating. Everyone else enjoyed them, too…especially warm ๐Ÿ™‚

Berry Muffins very slightly adapted from Cake, Batter, and Bowl

3 cups strawberries, hulled
2 cups blueberries
3/4 cup granulated sugar
1/4 cup canola oil
1/4 cup low-fat buttermilk
1 large egg
1/2 teaspoon vanilla extract
1 1/4 cups white whole wheat pastry flour
1/2 teaspoon baking powder
1/4 teaspoon baking soda
1/2 teaspoon salt

Directions:

Preheat oven to 350หšF. Line a 12-cup muffin pan with cups. Place 2 cups strawberries and 1 cup blueberries in a food processor and pulse until smooth. Place berry puree in a small nonstick pan and cook over medium heat for 20 to 25 minutes or until reduced to 1/2 cup, stirring occasionally. Remove from heat and let cool to room temperature.

Mix cooled puree, sugar, oil, buttermilk, egg, and vanilla extract in a large bowl until smooth. Stir in flour, baking powder, baking soda, and salt. Coarsely chop remaining 1 cup strawberries and fold chopped strawberries and remaining 1 cup blueberries into the muffin batter.

Scoop muffin batter evenly into the 12 prepared muffin cups. Bake at 350หšF for 24 to 28 minutes or until a toothpick inserted in the center of the muffin comes out clean. Makes 12 large muffins.

Nutrition Information (per muffin): 172 calories; 5.5 g. fat; 18 mg. cholesterol; 109 mg. sodium; 30 g. carbohydrate; 3.1 g. fiber; 1.1 g. protein

Result: Mmmmm mmmm good! These muffins provide at least 1/2 serving of fruit, and I think that is just awesome! I love the fiber content and low calories and sodium for muffins, too.

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Thank you for all the chili recipes for the Prevention Chili Contest! I’m sorry I couldn’t accept more than 12 recipes — we would’ve been eating chili through Easter if I didn’t put a cap on the entries!! ๐Ÿ˜ฆ I really appreciate all of the participation and look forward to a fall season of football and chili! ๐Ÿ˜€

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In the news…

Oral sprays and inhalers may replace traditional syringes for insulin administration among diabetics.

Starting January, South Carolina residents with the state health plan will be eligible to receive gastric bypass or LapBand weight loss surgeries.

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And Miss Lily wanted to show off some cuteness today…

And some cuddles with daddy…Awwww ๐Ÿ™‚

Question: Do you think weight loss surgery should be covered by insurance? Do you think a portion of the cost should be covered? If so, what percentage?

A co-worker asked me this question yesterday and having working in bariatrics, I’ve seen the good and the bad outcomes of bariatric surgery, and most of it depends on the readiness for change on the part of the patient, as well as their support system in and out of the health care setting. I do think it’s appropriate for insurance companies to set up guidelines for weight loss surgery candidates (e.g. BMI > 50) to help offset future health care costs of chronic diseases, such as diabetes, a very costly disease. But I can’t decide if I consider bariatrics “prevenative” or “reactive” health care — I can see arguments both ways. Just curious as to everyone’s thoughts!

Have a wonderful day!

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Filed under challenge, chronic disease, diabetes, dog, obesity epidemic, pets, recipe, Uncategorized, US health care, weight loss

My New Job: End Stage Renal Disease

My new job is in renal dietetics and I will be working as a dietitian in dialysis facilities caring for those with End Stage Renal (Kidney) Disease (ESRD). Chronic Kidney Disease (CKD) is the declining function of the kidneys and affects more than 26 million Americans, or 1 out of ever 9 adults. As kidney function declines, CKD progresses and when the kidneys perform at about 10% capacity, a patients is considered to have ESRD, which requires transplantation or dialysis to stay alive.

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What is dialysis?

There are two types of dialysis: hemodialysis and peritoneal dialysis. I will be working in hemodialysis and will expand on that type, but you can read all about peritoneal dialysis. Hemodialysis is traditionally performed in a dialysis clinic where patients come 3x a week (either Monday, Wednesday, Friday or Tuesday, Thursday, Saturday) and are dialyzied (blood filtered) for 3-4 hours through an access site, typically on their arm.

What do the kidneys do?

The kidneys perform a lot of vital functions of the body including filtering the blood to remove waste (e.g. urine) and the release of hormones which regulate blood pressure and bone health. When the kidneys lose filtering capacity, vitamins and minerals build-up in the blood at toxic levels. Micronutrients such as potassium, sodium, phosphorous, and calcium can cause fatalities in renal patients if not controlled in the diet. The diet is hugely important to follow for renal patients.

Why do the kidneys fail?

Chronic uncontrolled blood pressure, chronic uncontrolled diabetes, glomerular disease, and other complications such as polycystic kidney disease, drug abuse (prescription and illicit), poisons, and trauma. The rate of ESRD is increasing due to the increase of obesity and associated co-morbidities such as diabetes and hypertension.

What diet do dialysis patients have to follow?

Foods that are commonly omitted or limited from the renal diet include: beans, peanut butter, nuts, many cereals and grains, all dairy products, colas, processed meats, orange juice, oranges, bananas, tomatoes, tomato products, kiwi, pears, melon, dried fruits, potatoes, squash, avocado, mushrooms, pumpkin, chocolate, and WATER and all other fluids.

However, the renal diet is highly personalized to a patient’s needs based on their labs and may be changed on a frequent basis.

Renal diets need to be very high in protein — about 95 grams (for a 150 pound adult) or 140 grams (for a 220 pound adult). And because processed meats, beans, and nuts are discouraged in the renal population, fresh meat and eggs are the only sources of high biological value protein (HBV). A renal patient requires significant amounts of protein due to protein loss during dialysis, as well as a decline in the body’s ability to make amino acids (protein in the body) due to CKD.

What if a patient doesn’t eat enough protein?

Albumin is a protein made by the liver. This lab value has the strongest correlation to morbidity (illness) and mortality (death) in the renal population. In addition to drug therapies, the diet is the best way to elevate albumin levels.

This is a perfect example of why I support all food groups. A vegetarian/vegan would not fare well on dialysis based on their food preferences. Simply, there are NO methods available to achieve neither adequate intake, nor intake from high biological value proteins.

I hope this gives an idea of what my new job entails. Today I meet the entire patient care team: nephrologist, charge nurse, social worker, and me, the dietitian. We have rounds starting…soon! Better jet! ๐Ÿ˜€

But first a quick Lily picture. On our way to the dog park yesterday…

Question: Knowing what a renal diet aims to limit or eliminate, what would you have the most trouble omitting?

I think limiting fluids, tomato products, and bananas would be the hardest for me!

P.S. I am a writer for the Examiner in Columbus! I cover cooking! It’s been a slow start simply because I haven’t had time or Internet, but I look to put out a lot more articles soon! ๐Ÿ˜€

Happy Monday,

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Filed under chronic disease, diabetes, diet, dietitians, Examiner, fruits and vegetables, hormones, hypertension, meat consumption, obesity epidemic, physicians, protein, sodium, vegan, water, work

7 foods in question

Happy Friday! ๐Ÿ˜€ Bring on the weekend, right?!

I left for work at 6:30am yesterday and didn’t walk in the door til 8pm! Loong day! Last evening was the Bariatric Surgery Support Group I lead and the turn out was excellent! My group continues to grow and I have learned SO much! While I think there’s a “right” and a “wrong” candidate for bariatric surgery, the bottom line is that people are going to get weight loss surgery somehow…some way. As a dietitian, it is my duty and my job to help these individuals make the right surgical or non-surgical decision for THEM and to help them adopt lasting lifestyle changes in their eating and exercise habits. It has been very rewarding once I was able to put personal biases aside.

Today I wanted to discuss an article called “The 7 Foods Experts Won’t Eat” [1]. Seven different medical and nutrition experts each listed a different food they strictly forbid in their diet. I thought the list was not only interesting, but controversial and I was curious to hear some feedback from you all! So here it goes…

1. Canned tomatoes shunned by Fredrick vom Saal, PhD, an endocrinologist at the University of Missouri who studies bisphenol-A.

The issue: The resin linings of tin cans contain bisphenol-A, a synthetic estrogen that has been linked to ailments ranging from reproductive problems to heart disease, diabetes, and obesity. Unfortunately, acidity (a prominent characteristic of tomatoes) causes BPA to leach into your food. Studies show that the BPA in most people’s body exceeds the amount that suppresses sperm production or causes chromosomal damage to the eggs of animals [1].

The solution: Choose tomatoes in glass bottles.

2. Corn-fed beef shunned by Joel Salatin, co-owner of Polyface Farms and author of half a dozen books on sustainable farming.

The issue: Cattle evolved to eat grass, not grains [1]. Grain-fed beef have less nutritional value and are higher in saturated fat than grass-fed beef.

The solution: Purchase and consume grass-fed beef.

3. Microwave popcorn shunned by Olga Naidenko, PhD, a senior scientist for the Environmental Working Group.

The issue: Chemicals, including perfluorooctanoic acid (PFOA), in the lining of the bag, are part of a class of compounds that may be linked to infertility in humans, according to a recent study from UCLA. In animal testing, the chemicals cause liver, testicular, and pancreatic cancer [1].

The solution: Pop popcorn in a skillet.

4. Nonorganic potatoes shunned by Jeffrey Moyer, chair of the National Organic Standards Board.

The issue: Root vegetables absorb herbicides, pesticides, and fungicides that wind up in soil [1].

The solution: Buy organic.

5. Farmed salmon shunned by David Carpenter, MD, director of the Institute for Health and the Environment at the University at Albany and publisher of a major study in the journal Science on contamination in fish.

The issue: Nature didn’t intend for salmon to be crammed into pens and fed soy, poultry litter, and hydrolyzed chicken feathers. As a result, farmed salmon is lower in vitamin D and higher in contaminants, including carcinogens, PCBs, brominated flame retardants, and pesticides such as dioxin and DDT [1].

The solution: Switch to wild-caught Alaska salmon. If the package says fresh Atlantic, it’s farmed [1].

6. Milk Produced with Artificial Hormones shunned by Rick North, project director of the Campaign for Safe Food at the Oregon Physicians for Social Responsibility and former CEO of the Oregon division of the American Cancer Society [1].

The issue: Milk producers treat their dairy cattle with recombinant bovine growth hormone (rBGH or rBST, as it is also known) to boost milk production [1].

The solution: Check labels for rBGH-free, rBST-free, produced without artificial hormones, or organic milk. These phrases indicate rBGH-free products [1].

7. Conventional apples shunned by Mark Kastel, former executive for agribusiness and codirector of the Cornucopia Institute, a farm-policy research group that supports organic foods [1].

The issue: Apples are heavily sprayed with pesticides.

The solution: Buy organic. Otherwise, wash and peel apples before eating.

Question: Do you avoid any of these 7 foods, too? Are there any you disagree with? Any changes you may make in your grocery purchases?

I think I will make apples and potatoes 2 produce items I purchase organic. I buy wild-caught fish and grass-fed beef, and I never eat popcorn. Canned tomatoes are a tough one, but if jarred tomatoes are safe…I can do that! And I always buy milk that does not contain rBGH-free.

Any fun weekend plans?

I can’t wait to relax!

Happy weekend!

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Filed under farming, food safety, fruits and vegetables, going "green", grocery store, hormones, meat consumption, microwave, obesity epidemic, saturated fat, work

A whirl wind kind of day…

Yesterday. Phew, it’s over.

Miss Lily went in for surgery yesterday morning. They ended up not operating on her knee as the x-ray had shown improvement, but they did complete her vulvoplasty. I never knew they did plastic surgery on dogs…but, alas, they do. I have the drugged up puppy and lofty vet bill to prove it! Hopefully this will help decrease or eliminate her infections. Do ladies always have the short end of the stick or what?! ๐Ÿ˜‰

I know Lily has a lot of fans out there, so if you think of it, please do send wishes for a speedy recovery her way. Poor pooch!! She spent most of the evening whimpering and it just about broke my heart.

THEN we found out we had a stray kitten living in our garage — it was hiding in the undersides of our cars. I wonder how many days the kitty has gone to work and back with Mr. Prevention or I!? We coaxed the kitty out with milk and I hope it found its mommy. The kitty was not friendly or socialized, so it was likely a barn cat that wandered too far away.

THEN I watered my booming garden! Check out its growth in the past week or so!

More cherry tomatoes!

THEN I made dinner. I had grocery shopped on my lunch break because I knew my last patient of the day would likely run over. At 10am I was craving taco salad, and so that’s what we had!

deer meat seasoned with taco seasoning
1 home grown cherry tomato
lettuce
corn
Biz’s homemade salsa
2% cheddar cheese
1/2 avocado

Delicious!

THEN I decided I needed to squeeze in a workout while watching American Idol.

Note to self: Running on a full stomach is NOT a good idea.

I made it a whopping 2 3/4 miles before deciding that was enough of that. Bleck!

THEN we watched The Biggest Loser. I had predicted O’Neal to win the at-home prize and Ashley to win it all. I was wrong on both predictions, but it was still a great finale! Darrel looked AWESOME, as did Sherry and Michael…and all the others! It’s amazing what these contestants accomplish in just a few short months.

While in theory I completely oppose the rate at which the contestants lose weight, the alternative is not preferred. The health problems these people face are life-threatening…most of them are a ticking time bomb. Drastic times call for drastic measures and I think the Biggest Loser does do good in helping contestants regain health in a very speedy fashion. It’s easy for those who don’t weight 484 pounds to sit back and disagree with the methods of the Biggest Loser. While I have my qualms as well (lots of them, trust me!), the seemingly insurmountable task set before these individuals is quickly minimized with rapid success at the scale. It’s frustrating to not see results, and a weight loss jump start is what keeps many of these contestants losing weight at home; they find some success at the ranch and began acquiring the tools they need to succeed in their life-long weight loss journey.

Biggest Loser Fans: Who did you want to win the at-home prize? Who did you want to win the grand prize?

American Idol Fans: Team Lee or Team Crystal?

Half way to Friday,

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Filed under dinner, dog, exercise, fruits and vegetables, garden, grocery store, obesity epidemic, pets, physical activity, recipe, running, salad, The Biggest Loser, Uncategorized, weight loss, work

Are we fans of “fat”?

LA Times posted a most interesting article yesterday on celebrities and the battle of the bulge. Rather than shamefully hiding weight struggles from the public eye, celebrities are using their weight struggles as a means to cash in…the big bucks.

Kristie Alley, anyone? Carnie Wilson, yeah?

Great points were made in this article:

1. Even the rich and famous are not immune to the obesity epidemic taking place in our nation — trainers, dietitians, personal chefs, and all.

2. Bariatric surgery does not produce miracles.

3. The traditional “eat less, move more” is…well, boring. Boring in the sense that it won’t earn prime time television airing, but it sure gets the job done.

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Reading this article was timely — my first bariatric patient was implanted with the Lap Bandยฎ yesterday. I’m anxious and excited to see the patient’s progress and wish them all the best!

And if you watch trashy TV like me, you may watch Kendra (but probably not, because it is really, really bad reality TV). And you may have found ex-Playboy Bunny’s post-baby body struggles easy to relate to. I really appreciate Kendra for her “no fuss…take me as I am” approach to…everything! Especially her weight.

Question: Do you tend to “respect” or “disrespect” (for lack of better terms) celebrities for making public their weight struggles? Do you find it easier to relate to those who struggle with their weight or leading a healthy lifestyle?

Thanks for all your anniversary love! ๐Ÿ™‚

Happy day,


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Filed under diet, dietitians, entertaining, news, obesity epidemic, pregnancy, Uncategorized, US health care, weight gain, weight loss, work