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Normal Weight Obesity: Are You at Risk?

>> Sunday, May 30, 2010

As excess body weight is such a common condition, a simple, easily obtainable measure of body 'fatness' is necessary to quickly assess whether an individual is overweight. As such, the Body Mass Index (BMI) is widely accepted as the most appropriate measure of body fat, with a BMI threshold of 25 kg/m2 set for overweight, and a threshold of 30 kg/m2 set for obesity (you can calculate your own BMI in the right hand column here). However, a recent systematic review suggests that the use of BMI fails to identify half of individuals who have an excess of body fat.

This has led to the coining of a new term, called Normal Weight Obesity or NWO. This refers to individuals who fall into the normal weight zone for BMI, but who have an excess percentage of body fat. NWO individuals have an increased risk of metabolic syndrome, high cholesterol, and high blood pressure. Of great concern, a recent study has demonstrated for the first time that NWO women are at a 2.2-fold increased risk of death from cardiovascular disease.

The question is, how can we detect NWO? Body composition and body fat percent can be assessed by a number of different methods. The simplest of these methods are measures of skin fold thickness (where your skin gets pinched gently between calipers) and bioimpedance (scales that send electrical currents through your body). A more accurate measure is a DEXA scan (pictured above), which is the same machine used for detection of osteoporosis. DEXA scans are not covered by Canadian health care for assessment of body fat, though some insurance providers in the US are covering them for body composition assessments (the cost is about $100 USD). The criteria to define NWO is debated as well; the most accepted definition is that put forth by the World Health Organization: >25% body fat for men, and >35% body fat for women.

For the time being, bioimpendance scales are probably the most accessible method for finding out your own body composition. Many doctors' offices have these, or alternatively, they can be purchased for personal use. Although they are not exceptionally accurate, they may be of value to follow your change in body fat percent with time, as you engage in a dietary weight loss or exercise program.

The discovery of NWO teaches us once again about the importance of body fat as a metabolic organ, and the importance of leading a healthy, active lifestyle to not only maintain 'normal' weight, but also to keep lots of lean, metabolically healthy muscle tissue on board.

Dr. Sue © 2010


Deb's Stuffed Peppers!

>> Saturday, May 22, 2010

Mmmm..... right from the kitchen of my best friend comes a deliciously healthy, high protein meal! The caloric price tag is low at under 250.


  • 6 bell peppers - 2 red, 2 Yellow, 2 Orange
  • 1 tablespoon olive oil
  • 1/2 cup chopped onion
  • 1/2 cup chopped celery
  • 1 can (19.5 ounces) diced tomatoes
  • 1 can (8 ounces) tomato sauce
  • 1 clove garlic, crushed
  • 1 teaspoon dried leaf oregano
  • 1/2 teaspoon dried leaf basil
  • 1 teaspoon salt, divided
  • 1/2 teaspoon ground black pepper, divided
  • 1 egg white, lightly beaten
  • 1 1/2 teaspoons Worcestershire sauce
  • 1 pound extra lean ground beef
  • 1 cups cooked long-grain brown rice
  • shredded low fat cheddar cheese


Cut tops off peppers; remove seeds and membranes. Rinse the peppers under cold water. Place peppers and tops in a large pot; cover with water. Bring to a boil; reduce heat, cover, and simmer for 5 minutes.(you may have to do this in 2 batches if your peppers are bigger than your pot.) Drain peppers and set aside. Dice the celery and the onion.

Heat olive oil in a large skillet over medium heat until hot. Sauté the crushed garlic, chopped onion, and chopped celery for about 5 minutes, or until vegetables are tender. Add tomatoes, tomato sauce, oregano, basil, half of the salt, and 1/4 teaspoon of the pepper. Simmer for about 10 minutes.

In a large mixing bowl, combine egg white with remaining 1/2 teaspoon salt and 1/4 teaspoon pepper and Worcestershire sauce. Gently stir to blend; add ground beef, cooked rice, and approx 3/4 of the tomato mixture you just made. Mix well. Place the peppers in a cassorole dish standing up and stuff the peppers with meat mixture until 1/2 way full. Then add a tablespoon of your shredded cheese and fill the rest of the pepper full with the meat mixture. Use the 1/4 remaining tomato mixture and divide it 6 ways to spoon some on top of each pepper. Put pepper tops on the peppers. Bake at 350° for 65 minutes. Top each stuffed pepper (under the cap) with a little of your shredded cheese a couple minutes before the peppers are done and bake until the cheese is melted.


Makes 6 servings.

Nutritional Info per serving:

Calories: 243
Fat: 7.3g
Sat Fat: 2.2g
carbs: 21.1g
Fibre: 3.3g
Protein: 23.1g

Dr. Sue © 2010


Provincial Variation in Accessibility to Bariatric Surgery

>> Saturday, May 15, 2010

At the Inaugural Diabetes Surgery Summit in Montreal last week, it became apparent that there is significant provincial variation in accessibility to weight loss (bariatric) surgery. As Dr. Nicolas Christou of McGill University pointed out, in Canada in 2008, the number of bariatric surgeries performed in each province was as follows:

- Nova Scotia: 28
- New Brunswick: 17
- Quebec: 802
- Ontario: 579
- Saskatchewan: 23
- Alberta: 272
- BC: 160

The reasons for the provincial variation are complex. One interesting phenomenon that was brought up was that in Ontario, patients had previously been funded by the provincial health care system to have bariatric procedures done in the United States - this was a situation that was unique to Ontarians, as no other province provided funding to do this. Due to the enormous expense of sending patients over the border and the potential savings of having these surgeries done at home, the Ontario government provided funding to build access to the service in their home province, to the tune of many millions of dollars in cost savings. As other provinces never had the situation where patients were funded to go south to have surgery, the same financial pressure does not exist to bring the procedure home.

In the mix of the numbers above, other factors have to of course be considered, including population density and surgical expertise available in each province (though with increased provincial funding for bariatric surgery, the surgical expertise would be likely to follow).

Even in provinces with the most accessibility to surgery, however, there is still an enormous shortage of availability country wide, with an estimated fifteen year backlog of patients who would be appropriate for, and benefit from, the surgery.

What can we do? Get out there and talk about it.

Dr. Sue © 2010


The Stigma of Obesity

>> Saturday, May 8, 2010

As Canadians, we are quite proud of our very accepting, non-discrimatory nature. Canada is a melting pot by definition; our culture is defined by the richness and diversity that springs from the assimilation of thousands of cultures from around the world into one country. Many other nations around the world are also very accepting and appreciative of people from diverse backgrounds. Regardless of where in the world you live, stop and ask yourself for a moment - are people as accepting of overweight individuals as they are of indivicuals of a different color, racial, or ethnic background?

Studies have shown that the answer overall is no. As reported by Rebecca Puhl and Chelsea Heuer in the medical journals Obesity and the American Journal of Public Health, obesity discrimination is not just a problem of kids teasing each at school. The problem is rampant in the adult world as well, with 25% of people reporting job discrimination due to weight issues. The majority of overweight adults report weight stigma from colleagues, and nearly half report discrimination on the part of their seniors in the workplace.

Sadly, health care professionals - where the overweight individual should feel they can safely turn for help - are no exception. Several studies have demonstrated that the majority of health care professionals feel that overweight patients are at fault for their weight struggles, and that they lack motivation. Over half of overweight women report receiving inappropriate comments about their weight from their doctors. A somewhat more subtle form of discrimination occurs when an overweight patient is made to feel distinctly uncomfortable at their physician's office, due to lack of equipment (blood pressure monitors, chairs, etc) that can accomodate the patient's size.

It is high time that we as a society (and as a health care profession!) make some drastic changes to these attitudes. Medical professionals should make a point of making all patients feel comfortable, welcome, and accepted in the clinic or hospital environment. From a societal perspective, rather than spending energy on negative endeavors or rude remarks that make overweight people feel badly about themselves, let's generate some positive energy together, and focus on building a happier, healthier, more supportive society!

As discussed in a recent issue of the Canadian Obesity Network's Conduit magazine.

Dr. Sue © 2010


Diabetes Treatment: Is Weight Loss Surgery the Answer?

Canada, like the rest of the world, is caught in a diabetes epidemic. Over 2 million Canadians are diagnosed with the disease, and by the year 2020, those numbers are expected to rise to 3.7 million. This epidemic is paralleled by the high prevalence of obesity, which currently affects 25% of Canadian adults and 10% of Canadian children. One of the treatment options that is being increasingly considered to treat type 2 diabetes in the setting of severe obesity is weight loss surgery.

I attended the First Canadian Diabetes Surgery Summit in Montreal this week, hosted by McGill University, to discuss this very issue. Over two very intense and productive days, a collection of international leaders in the area presented their research and clinical experience to a diverse group including Canadian surgeons, family physicians, endocrinologists, health care professionals, and policy makers. A wealth of learning, sharing, and ideas were generated from this summit, of which I am going to discuss over the course of several articles in the coming weeks. Here are the highlights.

In short, bariatric surgery is a very effective treatment for type 2 diabetes. The results depend on the type of surgery done, but remission rates of diabetes of over 80% have been documented, and sustained for at least 2 years. Much of this success is related to the impressive weight loss that is seen with bariatric surgery, but gut hormone changes with certain types of surgery (such as gastric bypass surgery) play an important role as well.

It must be emphasized that bariatric surgery is only appropriate for a very select group of people. The current guidelines recommend bariatric surgery as a potential option for patients with a BMI >40, or a BMI >35 with at least one serious medical complication (such as diabetes), who have failed intensive attempts at weight loss with conventional treatments (lifestyle alteration, medications, etc). Bariatric surgery has a long list of potential side effects and complications that must be seriously considered, and which vary depending on the type of surgery performed. On balance, however, bariatric surgery has been shown to decrease mortality by 28-40% in this population, and as such, may be the most appropriate option for some people.

In Canada, we struggle with very limited accessibility to bariatric surgery. As Dr. Nicolas Christou, one of Canada's leaders in bariatric surgery, pointed out:

  • Based on very conservative estimates that 5% of the 1 million Canadians who fit criteria for bariatric surgery would actually be appropriate candidates for surgery, 50,000 Canadians would currently be candidates for the procedure.
  • Approximately 3,000 bariatric procedures will be done in Canada this year.
  • According to these numbers, then, Canada currently has in excess of a 15 year back log of patients who could benefit from these procedures.

What can we do about this? The problem of course, is funding. Funding for bariatric surgery is extremely limited in Canada, though accessibility does vary greatly by province. Cost analyses suggest that for patients with diabetes, the costs of bariatric surgery to the government are recouped by 26-30 months post operatively, and after that, there are only savings to be had by the health care system due to the decreased rate of diabetes related complications, hospitalizations, and medication requirements of these patients.

On balance, increased accessibility to bariatric surgery in Canada, provided in the appropriate clinical setting by a multidisciplinary, experienced health care team, should be discussed amongst Canadian health care professionals, patients, and the general public.

Dr. Sue © 2010


Kisses of Fibre!

>> Saturday, May 1, 2010

Fiber is a key component of our diet, and most of us don't get enough. There are lots of supplements and high-fiber products out there, but some are definitely better than others. The first question is, how much fibre do we get, and how much do we need?

It turns out that Canadian adults only get about half of the 25-30g of daily fiber recommended by Health Canada. Fiber is found in beans, grains, vegetables, and fruits. Eating a diet that is high in fiber has many potential health benefits, including a decreased risk of heart disease, stroke, and type 2 diabetes, in addition to regulating bowel habits and possibly decreasing the risk of colon cancer.

So what is the best way to top up your fiber intake? One has only to walk down the cereal or granola bar aisle of the grocery store to become instantly innundated with all kinds of labels that claim that they are high in fiber. The key to knowing how much fiber you are getting in 'high fiber' products is to read the nutritional label, as the actual number of grams of fiber in each of these products vary widely.

Here's the skinny on a few of these products:

  • All Bran: Excellent. 1/2 cup contains 90 calories, 12g of fiber
  • All Bran Buds: Also excellent: 1/3 cup contains 80 calories, 11g fiber
    (I'm eating them for breakfast as I'm writing this blog!)
  • Benefibre powder: 2 teaspoons contains 10 calories, 6g fiber
    Uses inulin fiber as its fiber source, which is a natural soluble fiber derived from the chicory root.
  • Benefibre To Go Stick Packs: one stick has 10 calories, 3g fiber
  • Benefibre chewables: 3 tablets contain 3g of fiber (guar gum is the fiber source)
  • Metamucil: 1 teaspoon contains 25 calories, 5g fiber

Not all fiber products are so rich in fiber, however. For example, the high fiber bars don't provide as much bang for your caloric buck:
  • All Bran Bars, have 130 calories and only 4g of fiber
  • While 1 cup of Fiber1 cereal has 210 calories and 11g of fiber, Fiber 1 bars have 140 calories and only 5g of fiber (though the American Fiber 1 bars have 9g of fiber)
  • Metamucil chocolate fiber wafers contain 50cal and 2g of fiber each

Increasing your fiber intake is also beneficial for people trying to lose weight, as fiber helps you to feel full sooner and longer. Remember to factor the calories into your total daily intake! For diabetics, it is also important to read the nutritional labels to evalulate the impact of the carbohydrates in each of these products on your blood sugar.

A final note of caution. Remember the old adage, 'Too much of a good thing'? Overdoing your fiber intake can result in stomach upset, bloating, cramps, and paradoxically, constipation! Increase your fiber intake gradually to reach the above goals will help to avoid these unwanted potential side effects as well.

Dr. Sue © 2010



I am excited that you have arrived at my site, and I hope you are too - consider this the first step towards a Healthier New You!! As a medical doctor, Endocrinologist, and obesity specialist, I am absolutely passionate about helping people with weight management. Though there is certainly no magic cure for obesity, there IS a successful treatment plan out there for you - it is all about understanding the elements that contribute to your personal weight struggle, and then finding the treatment plan that suits your needs and your lifestyle. The way to finding your personal solution is to learn as much as you can about obesity: how our toxic environment has shaped us into an overweight society; the diversity of contributors to obesity; and what the treatment options out there are really all about. Knowledge Is Power!!

Are you ready to change your life? Let's begin our journey together, towards a healthier, happier you!!

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