Monday, July 2, 2012

Timing is Everything - Lessons From Caddyshack

Reading the Allen’s story, I am reminded of many of the important lessons I learned during my medical education.

Some lessons I learned as a student, some as a resident, but one lesson I learned from Caddyshack. That’s right. Caddyshack.

Now, I realize that many women in my life collectively roll their eyes when I start quoting movies with my friends. It’s a guy thing. We can’t help it. The quotes make us laugh. They give us a bond. And yes, they can make us annoying…..

“Spalding, get your foot off the boat.”

“Oh, this is the worst-looking hat I ever saw. What, when you buy a hat like this I bet you get a free bowl of soup, huh? Oh, it looks good on you though.”

But sometimes there is great wisdom in the stupidity, and that is where I learned an important medical lesson….

“We're about to tee off now so call the hospital and move my appointment with Mrs. Bellows back 90 minutes...Just snake a tube down her nose and I'll be four or five hours”
said Dr. Beeper.

Caddyshack Lesson from Dr. Beeper: Don’t be like Dr. Beeper. Take the time to do things right.


Flash forward now to 2002. The setting is a tour of a hospital that is recruiting doctors to train in the field of Reproductive Endocrinology. If this were a movie, I’d be the guy on the tour who was not impressed. In fact, I was disgusted. I told myself, these are people I will never work with. I was interviewing for fellowship training in Reproductive Endocrinology and Infertility.

I was with several other applicants taking a tour of a very well respected program when one of us asked the doctor leading the tour about doing fertility procedures on the weekends. The doctor told us, seemingly proudly, that they didn’t do much on weekends. He said they could always tweak a woman’s treatment to delay ovulation or to do it a little earlier than usual so that weekend treatments could be avoided.

The tour went on, but there was at least one less applicant for fellowship at that program. I don’t know if my face showed it, but I burned on the inside hearing this. Having been a fertility patient, it was very disappointing to hear a fertility doctor say that he was willing to sacrifice a patient’s chances of success just to make his life easier.

It is a common source of amazement to my friends and to patients that we see patients on weekends and even most holidays if they are bleeding in pregnancy, or in the middle of treatment cycles. But if you don’t do that, you may be decreasing a patient’s chance of success. It’s good to know that people appreciate the steps we take to maximize their chances of success. It is almost always interpreted as an act of kindness. Which I guess it is.

As the Dalai Lama says, “Be kind whenever possible. It is always possible.”

Big Hitter, the Lama.

Friday, March 9, 2012

Weight Loss Quiz

A) How many meals and/or snacks do you eat in a day?
  1. 5
  2. 4
  3. 3
  4. 2
  5. 1
  6. Some days I don't eat at all

B) Do you count calories?
  1. Yes (I know exactly how many calories I eat because I weigh or measure my food and read food labels.)
  2. Yes (but I estimate)
  3. Sometimes
  4. No…. and what is a calorie exactly?

C) When you eat at a restaurant, how to you pay for food?
  1. Nearly always in cash
  2. Both cash and credit/debit card nearly equally
  3. Credit cards or debit card nearly always

D) Which best describes the way you eat a meal?
  1. I am painfully slow to the point that I annoy others.
  2. I have a leisurely pace to meals, because I enjoy the time at the table.
  3. I am a relatively fast eater.
  4. I eat with no wasted motion, and only put a utensil down to change to a different one.
  5. Very fast.
  6. Like I’m in a competition.

E) When you go to the movies, what describes your snack habit?
  1. I don’t ever snack at the movies.
  2. I buy something small, with a low calorie content.
  3. I buy the value bucket and drink, but only have a few bites and leave the rest to my companion(s).
  4. I buy the value bucket and drink, even if I don’t finish it all.
  5. Love the value bucket and may get a refill.

F) When you go to the grocery store do you?
  1. Nearly always pay with cash.
  2. Usually pay with a check.
  3. Usually use a debit or credit card.
  4. Nearly always pay with a debit or credit card.

G) When you go to the grocery store, which best describes your shopping habits?
  1. I have a list and I’m sticking to it.
  2. I mostly stick to my list but usually see some things I forgot to list.
  3. I wing it.

H) How much television do you watch?
  1. Less than 30 minutes a week
  2. 30 min to 1 hour a week
  3. 1-2 hours a week
  4. 2-3 hours a week
  5. More than 3 hours a week

I) Do you eat/snack in front of the TV?
  1. No
  2. Rarely
  3. Usually. I fix a plate or bowl just for myself and don’t refill it.
  4. Usually. And I get seconds or refill when empty.
  5. Yes, and I bring the bag so I don’t have to make second trips to the kitchen.

J) When do you decide you are finished with a meal?
  1. When I am no longer hungry.
  2. When I am satisfied, but not full.
  3. When I’m full.
  4. When I’m worried I might pop.

K) How many minutes of aerobic activity do you get per week?
  1. More than 3 hours
  2. 2-3 hours
  3. 1-2 hours
  4. Less than 1 hour
  5. What’s aerobic activity, again?

L) How do you view a meal?
  1. Food is fuel.
  2. Every meal must have balanced nutrition.
  3. Food is something I eat when I get hungry.
  4. Every meal should be a celebration.

M) If you were on a restrictive diet and lost 25 pounds, which of the following describes how you would most likely reward yourself?
  1. I would sign up for a lesson with a personal trainer, yoga, or buy myself some exercise equipment.
  2. I would buy a new wardrobe.
  3. I would buy jewelry or an electronic gadget I’ve been wanting.
  4. I would go to my favorite restaurant and treat myself to my favorite meal.

N) Throughout the day, I drink mostly…
  1. Tap or spring water
  2. Sparkling water
  3. Unsweetened tea (sugar substitute) or black coffee
  4. Diet sodas or coffee with artificial sweetener
  5. Regular sodas, sweet tea
  6. Alcohol (if this was your answer, you’ve got bigger problems than weight)

At the end of this quiz, tally the numbers corresponding to your answers. The higher your number, the worse your habits. Best practices or habits are listed first in the answers. Below, we discuss these topics, one by one.

Answers Explained:

A ) For people trying to lose or maintain weight, it is generally considered better to eat small, frequent meals or snacks than one or two meals a day. Studies which look at body composition find that people who eat less frequently to diet, may lose the same amount of weight as people who eat more frequent meals, but the frequent eaters lost more fat and retained more muscle than those who eat infrequently. Also, if you go longer without food, your basal metabolism slows and you convert more of the calories you do eat into fat. Also, if you skip meals you may be hungrier by the time you do eat, and then you are more prone to over-eating.

B) Weight loss is simple. If you consume more calories than you burn, you will gain weight. If you eat fewer calories than you burn, then you will lose weight. The speed of your weight gain or loss depends on how many more or how many fewer calories you consume during the day. If your metabolism is 1500 calories and you eat 2000 calories per day. You will gain a pound of fat in 7 days. It takes an excess of 3500 calories to gain a pound of fat. It takes a deficit of 3500 calories to lose a pound of fat. If you count calories and see that you are averaging 1500 calories a day and your weight is not budging, then it’s likely that your metabolism is right around 1500 calories per day. Counting calories can help you gauge your metabolism.

C) There are data to show that people who pay with cash, are more likely to make healthy choices for their food. First, they are less likely to order the larger items (with more calories) on the menu. Instead, they are more likely to opt for smaller portions, and skip dessert, or a second glass of wine. People have a harder time parting with cash, and no one wants the embarrassment of running out of it. So, you generally eat smarter and/or less.

D) Fast eaters tend to consume 200 more calories per meal than slow eaters. 200 extra calories per day translates into nearly 21 pounds in a year. Not everyone who is a fast eater will gain 20 pounds in a year, but they tend to fluctuate up and then have to work their way back. If you are a fast eater, put your fork down between bites. Take a sip of water between bites. You’ll eat less. Since it takes 5-15 minutes to feel full, you give extra time to have that sensation catch up with you.

E) We don’t advise buying movie popcorn. In one study, people given small bags of popcorn vs large bags, estimated they at the same amount. However, the people who had the large bags actually ate significantly more without realizing it. In other words, the larger the bucket, the less accurately you are at judging how much you actually ate.

F) Just like going to a restaurant, people who shop for food with cash, tend to make healthier choices. They are also less likely to make impulse purchases. Impulse purchases are rarely things like broccoli and more likely bugle horns or other tasty / fatty treats.

G) This is the best way to eliminate impulse shopping. Impulse shopping tends to result in poor food choices. Make a healthy list and stick to it.

H) The development of diabetes correlates to how much TV a person watches during the average day. The number one cause of diabetes is weight gain. Unless you’re watching on a stationary bike or treadmill….. TV is not good for the waistline.

I) Data show that people who eat in front of the TV are more likely to consume more calories than if they at the same food at a table. Because you are distracted, if you eat from the bag, then you really have no idea of how much you actually ate. If you must eat before the TV, make a plate and don’t refill it. Count the calories.

J) In Japan, the average answer to this question was “When I’m no longer hungry.” Japan does not have an obesity epidemic like that in the United States. If you eat until you are full, that’s at least 200 more calories than if you ate until you were no longer hungry. Again, that’s about 21 pounds a year. Another reason to slow down and stop before you’re full.

K) Exercise is an effective weight loss tool, though not as good as diet alone. Exercise mainly helps people maintain their weight and maintain their weight loss. People who get more than 3 hours of aerobic activity such as running, brisk walking, swimming, have much lower rates of diabetes, hypertension and obesity. They also have less time for TV. They sleep better. They look better. (These are, of course, generalities, but they hold true for the average.)

L) “Live life to the fullest.” This seems to be the message from many food and drink commercials on TV or in print. We’ve come to expect that part of living life to the fullest is having a fabulous meal, with good company. Too often in our busy days, food is one of the only rewards we have time for. But if you are overweight and don’t feel good about your body, can you really say you’re living life to the fullest? Would you trade feeling better all day, for the small burst of fulfillment of a decadent meal? I think most of us would prefer to feel good all day, than to have a small burst of enjoyment followed by regret.

M) Rewards that promote healthy lifestyles are better than rewarding yourself with the things that got you in the shape you didn’t want to be in. Also, if you make exercise a reward, you are more likely to do it than if you regard it as a chore.

O) Drink 64 oz of water daily. Do it. You need it. It’s good for you. Carbonated beverages, even diet ones, can lead to weight gain because they cause your stomach to release a hormone that stimulates appetite. High sugar drinks are generally just empty calories.

Thursday, February 16, 2012

Weighing in on hCG as a Weight Loss Tool

Miracle Drug or Snake Oil?

Flipping through several women’s magazines and magazines which have had specials for women, I have been amazed to see that most weight loss clinics are promoting hCG as a weight loss tool.

I don’t know if they really believe hCG is effective for weight loss, or if they are just responding to public demand for it.

Currently, I have not seen any randomized controlled trial which shows that hCG augments weight loss, except in a subset of patients…. men with low testosterone.

Proponents of hCG was a weight loss tool almost always say a variation of the same thing: hCG is the hormone of pregnancy and diverts mom’s calories to the baby. Some also say it curbs appetite.

Let’s explore this for just a minute. Where is the data that supports these claims? If hCG is diverting colories to the baby, that would mean there needs to be a baby for hCG to work.

Think about it this way. Think of calories as dishes on the countertop of your kitchen. You clean up your kitchen by putting the dishes into the cabinets.

Now think of the dishes as calories and the cabinets as the baby and you as the hCG. How are you (hCG) going to put the dishes (calories) in the cabinet (baby) if you don’t have any cabinets (baby)?

In other words, without a baby, hCG does not have a place to divert those calories to. So the main mechanism touted makes no sense.

Now, I am not an expert in hCG, but I have spent years studying it, mainly as a hormone of pregnancy, as a fertility drug and as a way to boost testosterone. So let me tell you how hCG might work, if it works at all, as a weight loss enhancer.

Before I go further, I must emphasize that hCG plus diet has not been shown to cause more weight loss than diet alone.


hCG is a hormone secreted by pregnancy.

  1. In pregnant women hCG’s the only definitively known function is to increase the
    amount of progesterone secreted by the ovary.
  2. Ovarian progesterone is what keeps a woman pregnant for the first 7 weeks of pregnancy.
  3. After that, the placenta makes enough progesterone to maintain the pregnancy.
  4. Other affects of hCG is that it may enhance a baby boy’s testosterone production to help it develop normally.
  5. hCG is also thought to cause nausea.
How could these natural affects lead to weight loss? Well, if it induces low-grade nausea, some people might eat less. I have yet to hear a proponent of hCG say this is a feature of the treatment.


When used as a drug, hCG does have other purposes and this holds the key to how it is possible that hCG may one day be shown to be a weight loss enhancer. I emphasize might, because no one has shown that it’s effective.

  1. hCG is structurally similar to the hormone LH. In both men and women, LH increases testosterone production.
  2. Testosterone can have positive and negative effects. If it’s too high, women can get facial hair or balding. Men can accelerate balding.
  3. Testosterone is an anabolic steroid that promotes muscle mass.
  4. If muscle mass is created, a person would likely burn more calories due to a higher metabolism.
  5. hCG is commonly used in the fertility setting to promote ovulation. One potential side affect is cyst formation in women.

It is possible that hCG does augment diet. If it increases testosterone and therefore increases lean muscle, someone who loses 20 pounds may lose more fat but keep more muscle. Since muscle weighs more than fat, it is possible that that people who take hCG (while they weigh the same as those who don’t) are actually leaner.

It is essential to point out that this is just a theory! No one has yet to show this in a study. It is quite probable that even if this could be true that it might take a high dose of hCG to accomplish this. Higher doses would much more likely be associated with unintended side effects such as increased facial hair and hair loss.

With so many clinics now offering this therapy, I think it is time for one of them to actually do a well-designed double blinded study (in which neither the doctor or the patient knows if the patient is getting hCG) and see if weight or body composition is different. Only if hCG leads to more fat loss and preserves muscle, could we endorse this treatment.

Until it's proven to work.... we will not recommend it, as many other diet plans have been shown to be safe and effective.

One unintended consequence of the explosion of this diet's popularity is that it has driven up the price for hCG for fertility patients. We don't like that either, but if the diet ever is proven to work, we won't begrudge it.