Search for tag: "bariatric"

Interviewer: After a person has experienced major weight loss, either through lifestyle changes or something like a bariatric surgery, you may be left with a bit of excess skin that just won't seem to go away. And there are a few surgical options available to help remove that skin. Dr. Brad Rockwell is a professor of plastic surgery at University of Utah Health.

Now, Dr. Rockwell, when it comes to the excess skin from weight loss, how common is it for someone to have excess skin that just won't seem to go away?

Dr. Rockwell: Oh, virtually 100%. Unfortunately, as we get older, our skin loses some of its collagen, loses some of its elasticity, and the skin will become loose. So, even at certain ages of maturity, even if someone is not overweight, they will still have some lax skin in their abdomen. For everyone that's lost weight, virtually 100% will have some extra skin that could be improved with abdominal surgery.

Interviewer: So the surgery is an abdominoplasty, correct?

Dr. Rockwell: Correct.

Interviewer: And it's my understanding that there's a gradation of how much skin, and that kind of relates to what kind of surgery that you as a plastic surgeon would perform. Why don't you walk me through some of these treatments and kind of walk me through how they work and what a patient could expect?

Dr. Rockwell: There's the standard abdominoplasty. The non-medical term for that is tummy tuck. That's also essentially one of the main components of a Mommy Makeover. But it's just loose skin in the abdomen. In addition to the loose skin, usually the muscles beneath. If it's in a female who's had a pregnancy, the muscles will be a little loose. The skin may have some redundancy.

And the standard abdominoplasty or tummy tuck will remove skin in the lower portion of the abdomen. The skin that is higher on the abdomen is stretched to close where the skin was removed. And in addition, the six-pack muscles or rectus muscles are tightened and that will narrow the waist.

Interviewer: Okay. So it's not just the skin that you're operating on. It's also the muscles underneath?

Dr. Rockwell: Right, by tightening the underlying muscles. No muscle is cut. No muscle is thrown away. The muscle is still fully functional. There's some experimental evidence that actually shows the tone in the muscle is increased and athletic performance may be boosted a little by tightening the muscles. But the muscle is tightened. That will narrow the waist and that actually allows more skin to be removed because the inside becomes a little smaller.

Interviewer: Ah, got you. So what's the next stage of treatment?

Dr. Rockwell: So the standard abdominoplasty that we just talked about will pull the skin from the upper portion of the abdomen down lower and remove skin in the lower abdomen. Some people who have lost more weight will have a vertical skin redundancy and also a transverse skin redundancy. So the skin can be tightened by pulling it down, and the skin could also be tightened by pulling each side towards the middle of the abdomen.

The standard abdominoplasty leaves a longer scar in the lower abdomen. It goes from one hipbone to the other hipbone. The second stage does everything that a standard abdominoplasty would do, but in addition tightens skin from side to side, and that leaves an additional scar along the vertical midline of the abdomen. It goes from the bottom of the breastbone down to the pubic bone.

Interviewer: Okay. And so that's for, say, someone who has additional excess skin on the sides, love handle area, or . . .

Dr. Rockwell: It would be someone who's probably lost 50 pounds or 100 pounds. Standard abdominoplasty, maybe the people haven't lost weight. Maybe they've actually gained a little bit of weight from their younger days.

So this second stage, which is also called a fleur-de-lis, which is a French term, that will tighten side to side. And most of those people have lost probably 50 to 100 pounds.

Interviewer: And so as we go onto the last stage, this is for people who have lost a lot of weight. Tell me a little bit about this Stage 3. And I hear that it was a procedure that was developed by someone from the University of Utah?

Dr. Rockwell: Yeah. So the third stage is called a corset abdominoplasty. Dr. Alex Moya, who was a plastic surgery resident at the University of Utah in the early 2000s, now practices in Pennsylvania, and he developed this surgery.

So it incorporates everything that a standard abdominoplasty would do and everything that a fleur-de-lis abdominoplasty would do. And in addition, he pulls skin from the upper portion of the abdomen up towards the chest. The downside of it is it adds a scar right under the chest, or in women right under the bottom of the breast. But it allows even more skin to be removed compared to the other two options.

Interviewer: When it comes to deciding which surgery to do . . . I've heard you kind of discuss it depends on how much weight has been lost, how much excess skin. How much does the scarring come into that decision-making?

Dr. Rockwell: For most of these people, scarring is a secondary concern. Removing the extra skin is more of a concern. Obviously, if someone is in clothing, the scars are not visible at all.

And the majority of people who have the fleur-de-lis abdominoplasty or the corset abdominoplasty may not be on a beach exposing their abdomen. They may have little more modest clothing to cover it up, and then the scars would not be visible at all. But even if they're in that clothing and had not had surgery, the redundant skin and the rolls of extra skin would show through their clothing.

So, for most of these people, the priority is removing as much skin as possible, and the secondary concern would be the scarring.

Interviewer: So, for patients that are choosing to have this procedure done, is it an outpatient procedure? Are they in the hospital for a few days? And how long does it take to get back to your day-to-day life?

Dr. Rockwell: So just about everyone that has any of the three versions of a tummy tuck that we have discussed, it would be performed as an outpatient. The reasons to stay overnight would usually not be specifically related to the involvement of the surgery, but would depend on pre-existing medical conditions.

So if someone had lung trouble or heart trouble and their lung doctor or heart doctor might say, "You need to be monitored overnight in the hospital after that surgery," that would be the reason to stay. But most of them, it's an outpatient operation.

Interviewer: After they get home, what is the recovery time, and what are the steps of recovery, and how long will they expect to be recovering for?

Dr. Rockwell: So if someone has a desk job, they would probably be able to return to a desk job after two weeks. If they have a job that's a little more physically demanding, maybe three weeks.

In tightening the muscle, there's a six-week recovery period to resume exercise. Where the muscle is tightened, it takes six weeks for the muscle to heal where someone could attempt to do a sit up. So the long point of recovery would be six weeks to resume exercise or six weeks to lift more than 10 to 15 pounds.

Interviewer: So, for patients that might be interested in a procedure like this, what should they be looking for when it comes to choosing a good surgeon who will be able to give them the best results possible?

Dr. Rockwell: So none of these options of an abdominoplasty are small operations. They usually require between three and maybe six or seven hours in the operating room. So you want to make sure you have a qualified surgeon.

The best level of qualification that the public could find out about a surgeon is to make sure the surgeon is board certified. And for this type of surgery, make sure they're board certified by the American Board of Plastic Surgery. There are non-plastic surgeons who offer this surgery, but their background training would not be as rigorous as a board-certified plastic surgeon.

Interviewer: And I guess the last question is what are some of the positive results that people see? Are most people happy with the procedure? What can a patient expect after they're all healed up and back to their lives?

Dr. Rockwell: Yes, I think universally the patients are happy. The extra skin is gone. The satisfaction is largely patient-derived where the abdomen is closed. There's not a lot of positive reinforcement from other people because other people aren't seeing it.

But the patient himself or herself just feels much better. Their confidence increases. They find clothing will fit differently. They can buy clothing more easily because they're more a standard size. And if exercise is an option, that extra skin, extra fat is not there, and just normal everyday moving around is easier and exercise is easier.

Dr. Jones: So you've been very successful at achieving your weight loss goal. Congratulations. But you don't fill out your bra anymore. What is that about?

Most women who undertake a significant weight loss through diet or through weight loss surgery are hoping to lose fat. That's the part of the body that we don't need so much. We don't want to lose a lot of muscle when we do a weight loss thing. But some parts of our body are mostly fat, and that would be our breasts, and weight loss may lead to a body change that isn't welcome. So what can we do about that?

Today, in the virtual Scope Studio, I'm talking with Dr. Cori Agarwal. She is a plastic surgeon who specializes in aesthetic and reconstructive surgery at the University of Utah, and she has an interest in helping women find the body that they're looking for.

So I have some questions about this, because this is a really interesting topic for people who have really undergone a basic transformation of their body, whether it was 30 or 50 pounds, or they lost baby weight and the baby and then they nursed and so their body isn't the same. After substantial weight loss, women may find their bodies change in ways that they hadn't anticipated. Can you talk about weight loss and how it affects breast structure?

Dr. Agarwal: I think that's a really overlooked conversation when people set out to lose weight. They're really focused on health and kind of the getting back to feeling more active. And sometimes it's a surprise when there's this negative effect on specifically the breasts.

The breasts, as you mentioned earlier, are made up of quite a bit of fatty tissue, and that really varies person to person. But I'd say most women, especially as we age, the breasts become more and more percentage of fat. So when you lose weight all over your body and you lose fatty weight, naturally some amount of that is going to come off of the breasts. And you don't always know until you're there. So, for some women, it's just a minor effect. And for some, it's completely deflated after the weight loss.

Dr. Jones: Oh, deflated. I mean, it's hard enough getting older and if you've had babies, but to have . . . even that word deflated, that would have me rushing to you to get some help.

Dr. Agarwal: Well, I was going to say the deflation, it's really important to think of it in two areas. There is the loss of volume, so the loss of this fat where you really just lose the size of your breast. And then there's the deflation, the sagging of the skin where the nipples kind of point down and everything stretches down.

And those two we really think of separately and independently. When we talk what options there are for rejuvenating and filling the breasts, we really think of the sagging and the loss of volume separately, because not every individual has as much sagging or as much loss of volume.

Dr. Jones: When you said there are really two parts to two different kinds of changes that happen with weight loss, there's sagging and then volume, what are you going to do? What are the procedures here that you're going to undertake with this woman?

Dr. Agarwal: There are really two main objectives. And one is to fill the volume to the size that was lost. And for some women, they want to be a little bit smaller than they were to start. Some want to be a little bit bigger. And to fill that volume back, to restore that deflated volume, the mainstay operation is a breast augmentation, and that's placing an implant in the breast usually behind the muscle to regain the volume.

However, if the skin has at the same time sagged, which it usually does, in the process, there needs to be a skin tightening procedure done at the same time. And that's called a mastopexy or breast lift.

Now, these can be done independently. Someone may just want the lift. They might like the size that they've ended up, but everything's just droopy. So we'll just do the breast lift. And then more commonly, we will offer and recommend a lift with an implant, because in most people, I think both of those processes are happening. That's something that's very individualized, but I think it's important to think of those two separately, the lift and the augmentation.

Dr. Jones: And so, rather than some people thinking they're just going to have a little incision somewhere and something is going to be slipped in and pumped up or something, you're really going to have to remove some skin and maybe lift the nipple.

Dr. Agarwal: Right. I think that's often a surprise for women because they think, "Well, this is just like a deflated balloon. I'm just going to fill up the balloon," but they haven't really noticed how far things have stretched. And we really have to have an honest conversation about what it will look like with just the implant, or if you really want or would recommend a lift along with that implant.

Dr. Jones: So what are the options for women who would choose breast surgery? Do you call it aesthetic or cosmetic, or in this case, is it really reconstructive and is it paid for by insurance?

Dr. Agarwal: That's a really important thing, and so many things are blurred in the world of plastic and reconstructive surgery. A lot of things that we do that are reconstructive really are also cosmetic, and there is a blurred line, especially when it comes to the breast.

So when we talk about the words cosmetic and reconstructive, what we're usually getting to is "Will insurance pay for it?" Because if insurance sees it as cosmetic, then even if we think it's really truly a reconstructive thing, building your body back, we have to call it cosmetic. And the sad truth is that for most breasts that have sagged or lost volume almost all the time will be considered cosmetic by insurance companies and is not covered.

Dr. Jones: Well, for women who part of their weight loss journey has been becoming really active, and now they have breasts that don't want to stay where they want to put them, that ends up getting in the way of their being the physically active person that they have to be if they're going to maintain their weight loss.

Dr. Agarwal: Right. And we do try to make those arguments to insurance, but I think that it's just outside the scope of what we can declare medically necessary for the breast. Breasts sag for so many reasons. Pretty much anyone who has gone through a pregnancy and nursed a baby, even just age, breasts just sag almost 100% of the time. And so I think that's just beyond what we can argue for insurance to cover.

Dr. Jones: Knowing that many people who lose weight gain it back again, is there any recommendation about waiting for weight to stabilize for a while before considering breast augmentation? I mean, we've all watched the successes and failures on "The Biggest Loser," and some people are back right where they started from within a year or two. So how do you counsel people in terms of when they should consider this reconstruction?

Dr. Agarwal: I think as a general rule of thumb after a lot of weight loss, we'd like people to maintain their weight for about six months. If it's just a quick diet that's severe and maybe they're going to bounce right back in a couple of months . . . but by six months of sustained weight loss, most people are pretty steady in their weight. So that's the general recommendation, but of course, it's very individualized.

Dr. Jones: Right. And can this surgery be part of a larger surgery? So you certainly know people who have maybe had bariatric surgery and they lost 150 pounds, and now they have sagging not just in their breasts, but throughout skin, all over their body, which becomes a significant issue in just terms of staying healthy. Can you do redundant skin reduction at the same time that you do a breast surgery, or are these staged at different times?

Dr. Agarwal: I think both are true for each individual. When we're thinking about doing reduction of skin, tightening of skin after a lot of weight loss, safety is the main priority. We want to limit the amount of time under anesthesia for any individuals. So if they came in and said, "I want my breasts and my belly and my thighs and my back," we really have to slow it down and say, "Okay, what's the most important thing here? Can we combine it with something else?"

We try to limit the surgery time somewhere between three and six hours. And so we can do sometimes breast work with something else, but depending on what other areas are the priorities, it's very common to stage this.

But that's the conversation we have after we get to know the patient and see how healthy they are, how prepared they are for a long recovery. So it can go both ways.

Dr. Jones: So when you say how healthy they are and how emotionally prepared, it's hard when you have just a few minutes to get to know someone. And I know that sometimes before people undergo bariatric surgery, they might actually see a behavioral psychologist. But how do you get to know people to know that this is the right thing for them to do and they're not just seeking something that's really unobtainable? How do you set realistic expectations about what they're hoping for?

Dr. Agarwal: This is really important. We spend a lot of time . . . I'd say the first visit is usually about an hour. And during that time, a portion of it is talking about the surgery and evaluating them. But a big part of it is talking about how they've gotten to that point, how they feel, what their expectations are, and then their social support. I think social support is critical when you talk about getting through a big surgery like that. And so we'll make sure that they've really thought through who needs to help them, someone to help with the children, someone to help with themselves and their work. So that first visit, we do a fair amount of that really trying to get to know someone.

And you're right, it's only one visit, but usually we have another one or two visits after that before surgery and really get to these critical questions of whether they've thought this through and have the support on the other side. Some will have to really set realistic expectations, that you will not have a 20-year-old body after this, but you will have this and you won't have that. So we try to be really realistic and not try to sugarcoat it or make it seem better or easier than it will be.

Dr. Jones: Right. Well, I would think that most people having gone through . . . particularly if it was significant weight loss, they've been with this body for a while and they know what they're looking for, and I bet you they're mostly pretty realistic. They're not coming in with perfect breasts hoping for more perfect breasts.

Dr. Agarwal: I wish that was the case in everyone. I think there are certainly a lot of women who are exactly in that category, but there are a lot of people who still . . . maybe it's a lot of the TV shows out there, but there is an idea that there's some magic that happens and some Photoshopping. I do think we have to ground them sometimes if maybe what they've been seeing isn't realistic, because . . .

Dr. Jones: I've seen some of those YouTube videos, the befores and the afters, and I look at the afters and say, "How can she have lost 150 pounds and have breasts and legs that look like that? Is that real?"

Dr. Agarwal: Exactly. So you have to take a lot of it with a grain of salt, and so that's the job. I think that that's the consultation. You're not going to know that before really meeting with your surgeon and understanding what can be achieved.

Dr. Jones: I want to thank you because I hadn't really thought about this one. Certainly I've had patients over the years who were thinking about bariatric surgery, and I didn't really take them through all the steps that this will happen when you get there. You will get there, but then this may happen. It may not. So I want to thank you for giving us some insight.

And for women who've taken the big steps to make a big positive change in their body through weight loss, there are sometimes still steps to take to feel like yourself again. You're not alone and there are options and procedures that can help.

I want to thank you, Dr. Agarwal, for joining us. And thanks for everyone who's listening on The Scope.

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Scot: All right, Troy, this is your show. Go ahead. I'm just kidding.

Troy: Don't put me on the spot like that, man. You know I don't know what to say.

Scot: All right. Here we go. "Who Cares About Men's Health," providing information, inspiration, and motivation to better understand and engage in your health so you feel better today and in the future.

Got some guys here that care about our health. We're proud to say it too. My name is Scot Singpiel. I am the manager of thescoperadio.com, and I care about men's health.

Troy: And I'm Dr. Troy Madsen. I'm an emergency physician at the University of Utah and I care about men's health.

Thunder: I'm Thunder Jalili. I'm a professor in the Department of Nutrition and Integrative physiology, and I care about men's health.

Scot: All right. Today on the show, what's wrong with a few extra pounds? Is that a bad thing or not? We're going to talk about your diet, your nutrition, that extra weight you may be carrying around, and how that could impact your health today and in the future as well.

So, right after the holidays, and you tune in to your favorite podcast, "Who Cares About Men's Health," and boom, this is the topic we choose. I'm sure you're like, "Thanks, guys. I just got done gluttonizing from Halloween through New Year's and this is when we're going to talk about a few extra pounds?"

So, Thunder, from a nutrition standpoint . . . we talk about proper nutrition and exercise in the core for health now and later. And one of those reasons is to keep your weight within a healthy range. But why does that matter? We've learned that knowing why we do things is important for us to actually follow through on those things, so what's wrong with extra pounds?

Thunder: Well, there are several health risks associated with extra pounds. I think the one that most people know about is the fact that it increases your risk for diabetes. And it's actually the weight gain that happens around the middle, so around the belly. That's kind of the worst kind in terms of increasing diabetes risk.

And that happens to affect men more than women. So as a guy, when you see the belly start to get bigger, which happens after the holidays, that's not always a good thing.

With women, the risk is a little less, they tend to gain weight in different places, more around the extremities and the legs and the rear end. And that's not as bad as far as diabetes risk. So that's the main one.

And then the other one that has been getting more attention lately is actually the fact that obesity is related to cancer risk. So it turns out that that's another risk factor for cancer, is obesity.

And there's now some work that's actually being done in our department trying to also establish a link between metabolic syndrome, which is what happens when people gain weight, and having that be the link to increased cancer risk.

Troy: So, when we talk about a few extra pounds, Thunder, are we talking like, "I just did not do super well eating over the holidays. I put on five pounds"? Are we talking 10 pounds, 20 pounds, or we're talking BMI, looking at that? Anything that you can put there in terms of a cutoff where you really see that risk?

Thunder: Yeah, so if you want to just take the straight clinical approach, BMI, the cutoff where you start to see increased health risks is a BMI of 25. Twenty-five to like 29.9, that is the range that is called overweight. That's where you see these health risks go up. Obviously, the greater the BMI, the more those health risks go up.

To translate that into pounds, what does that mean? Because most people are not quite sure how to make a connection between, say, a BMI of 27 and extra pounds. It's an easy calculation to do. There are lots of online calculators that can help you do that if you want to go in and type in your body weight and your height and it can spit out your BMI. But in general, if somebody is probably 15 to 20 pounds over their ideal body weight, their BMI is going to be in a range that's going to be around that kind of mid-27 or so. And that's where the health risks are going to increase.

But I encourage everyone to go online, find one of those BMI calculators, and try it out. It's good to know where you're at.

Scot: So I'm standing in front of the mirror right now looking . . .

Thunder: Always a bad idea.

Scot: Well . . . I'm looking at my stomach. Is it just the front part of my stomach or the love handles/muffin top? Does that count? What are we talking here?

Thunder: Yeah. It's all there. It's everything.

Scot: Okay. Allow me to put my shirt back on and back away from the mirror slowly now at this point.

Thunder: And mostly the abdominal obesity that is the subject of concern, that is kind of the front, like as your belly protrudes out. Love handles are a bit more subcutaneous, and that's not quite as bad. If you think about like the anatomy of the body, the fat that's packed in around the intestines and the organs, that's the kind that is more associated with diabetes risk.

Scot: So you talked about metabolic . . . what did you call it? Metabolic disease?

Thunder: Metabolic syndrome. Metabolic syndrome is three out of the following five conditions. Either somebody has kind of high blood pressure. Maybe not the blood pressure that we would classify as classic high blood pressure, but that borderline high blood pressure. They may have slightly elevated cholesterol. Again, on its own, maybe it wouldn't be the first thing of concern, but it's elevated more than normal. They may have slightly higher blood glucose levels, which is indicative of pre-diabetes. And they probably have extra weight around the middle, around the belly that we were talking about. And they may have more fat, which we call triglycerides, in their bloodstream.

So, if somebody has three out of those conditions I described, or more, then we would say they have metabolic syndrome.

If somebody has this undiagnosed hypertension, maybe they're running around with a blood pressure that's 5 or 10 points above what we would classify as normal and that would maybe fly under the radar when they would go get a health screening or whatever, but over time, that can increase risk.

Scot: Is the fat the cause of these things starting to happen, or is the fat the indication these things are going to happen? Does that make sense? Because the fat is an indication of a lifestyle that somebody has maybe been doing that is not the healthiest.

Thunder: Yeah. I would say the fat is an indication of the lifestyle that can affect some of those factors, because we know lifestyle is involved with cholesterol or hypertension or, obviously, blood sugar. So, if somebody is gaining weight, for me, and Troy can chime in on this, that's the first kind of warning sign, "Let's take a closer look and see what else happens to be there."

Troy: Yeah, exactly. And I think you're right, Scot, and obviously, Thunder. Yeah, it's one of those things where is it a chicken and egg thing? Is it because these other things are going on? But my understanding is they're all interrelated. Yeah, one may cause the other, but then the other is there, and then it feeds into the other thing.

So I do think that putting on that extra weight, and obesity is going to make you more likely to have that blood sugar that's going to be a little bit too high. And then often, once you get into more of the diabetic issues, then you're going to see more high blood pressure with it and heart disease and all that as well.

So, yeah, it's hard to say if one is definitely the thing that precipitates everything else. But I think definitely the obesity is something that really gets that ball rolling, especially if you've got any sort of genetic tendency toward these things or any sort of just mild underlying issue. It's really going to push that forward to where it gets much more severe.

Scot: It sounds like those video games where you have to string together moves, and you get times two, times three, times four, times five. It sounds kind of like that's what this is, except for not in a good way.

Troy: Yeah. Exactly. If you're already struggling with your genetics, and then you have a tendency toward high cholesterol or toward high blood pressure or diabetes, and then you throw in obesity, you're right. It just makes that snowball and take off.

Scot: What is the turnaround for somebody that has found themselves in a range that's concerning? They've gone online, they did the calculator, they figured out their BMI. How do you start to turn that around? Is it just exercise? Is that what it is?

Thunder: Oh, it's the whole package. It's exercise, and it's what you eat. It's really difficult to use only exercise to control your weight. Unless you're young and you exercise like crazy, then you can probably do it. But if you're a middle-aged guy and you're looking to control your weight or lose weight, you're going to have to bring nutrition into it as well.

Troy: Thunder, what about long-term risk? I've got this BMI calculator up on my computer, and I'm putting in the weight I was five years ago when I was living in California, just living the life of convenience. And every day, there were snacks in the break room, and I was eating snacks, and my BMI was in the 25 to 29 range. How does that compute to longer-term risk? Is my risk dropping immediately as I lose that weight? Or does that time at that range put me at risk of a heart attack in 10 years? Or any idea in terms of what that means longer term?

Thunder: Yeah, I would guess that your risk does drop fairly quickly after you assume a normal body weight or healthy body weight, I should say. So there shouldn't be any reason to say, "Oh, I've already been overweight, so what's the point? The damage is done." I would always try to go towards healthy weight because your risk can always be reduced.

Troy: Again, I was actually a little surprised to put that in. I think at the time, I didn't really realize exactly where I was in terms of BMI, or maybe I justified it or something and I was telling myself it was muscle mass, which it wasn't.

But I'm hoping it's kind of like some of these ads and some of these graphs you see about quitting smoking, about how you may not think that it's making a big difference, but one month after you quit smoking, your risk is dropping. Then you look at that risk drop a year, and then two years out, and it's a pretty dramatic drop in your risk, just with that change. And I imagine the same thing would apply to weight loss as well.

Thunder: Yeah. There have been human studies and animal studies that have found that, where you take an obese animal or human and weight loss occurs, and then you find that their bodily function improved, like their endothelial function in their blood vessels is better, and their insulin sensitivity gets better, and things like that. Yeah, we do have a fair amount of evidence that shows weight loss always results in some sort of improvement.

Scot: I'd like to jump in and say, Troy, at no point have I ever thought that you would have been pushing a BMI that was unhealthy. I need to also confess I had at point . . . maybe now again. Who knows? I had been pushing a BMI that is not healthy, because I would not have considered you overweight. So I think it's good, even if you don't realize, I think your story is really great to maybe check that number out just to make sure, because it can make a big difference.

Troy: It's eye opening. Like I said, I'd never really thought about it until we were just talking now and I thought, "Wow, I wonder . . . well, where am I now? Okay, good." I thought, "Well, where was I five years ago?" And I put it in there and was like, "Wow, I would definitely was in the overweight range."

And it wasn't one of those things where anyone ever necessarily told me, "Hey, you're overweight." People aren't really going to tell you that anyway, hopefully. But I certainly did not think of myself as overweight. So it's a little bit eye opening when you actually plug those numbers in there and see what the results say.

Thunder: Hey, can I add two quick things, as long as we're on the topic of BMI? The thing is, there are so many people in our society who are overweight. Now, I'm making a distinction between overweight and obese. Being overweight is almost normal, really. So the thing is people will say, "Oh, he looks pretty good. Maybe his belly is a little big," but it doesn't register because that's what you see all the time. So that kind of desensitizes us to what overweight actually is.

And then the second point I'll make about BMI is it is just considering your overall body weight. It doesn't discriminate whether that weight is from fat mass or muscle mass. And in the classes I teach, we always do BMI and I come across a fair number of young men who will have kind of a higher . . . like a BMI of 26 or 27, which is in that overweight range, but they're not overweight at all. They're just more muscular than the average person. So you have to keep that in mind, that that can affect BMI, but not in a negative way.

Troy: And like I said, that's how I justified it in my mind, but it was not the case.

Scot: I think you know.

Thunder: Yeah, you know. You can borrow Scot's mirror.

Scot: Yeah, it might be 28 and you can tell yourself it's muscle, but I think if it's muscle, you know.

All right. Hey, Troy, since you've got the BMI thing up, why don't you walk us through what that looks like so we all have a better idea of what we'd be getting into?

Troy: I just Googled "calculate BMI" and it took me to the NHLBI, National Heart, Lung, and Blood Institute, to their BMI calculator. I just put my numbers in here. There's a standard and there's metric. We're going to use standard just because we're using feet, inches, and pounds. My height is five feet, and I'm going to put 9.5 inches. Sometimes I will say 5'10", but it's 5 feet, 9.5.

Thunder: Come on. Go for it.

Scot: COVID has gotten Troy down a half an inch.

Troy: I'll be honest here and type 5 feet, 9.5 inches. My current weight it's about 153 pounds. So that puts my BMI at 22.3. The normal range it gives me on here as a normal weight is 18.5 to 24.9. So I'm within that range.

But then I thought back, "Okay, where was I five years ago?" And I peaked out there at 175 pounds. My height was the same. It hadn't changed. Still, 5 feet, 9.5 inches. That's a 22-pound difference. And at that point, my BMI was 25.5. Overweight is 25 to 20 29.9. Although I did not realize it at that time, I was at that time in that overweight range. Surprising for me to think about that because I certainly didn't think of myself as overweight.

Scot: Thunder, let's go ahead and wrap this up. So we've discussed that this is not a healthy thing, that you should try to get back to more of a healthy weight. Exercise is definitely a part of that equation or activity. You should be getting that 30 minutes every day. But unless you're young and exercising a lot, that's not the only thing. So you're going to have to take control of some of the things you're eating.

I think a lot of us realize we're not probably eating the healthiest, and we can make some adjustments. But what are some of the things that you think could make the biggest impact right off the bat? What are some changes that could be made right away that can make a difference?

Thunder: So what I recommend to people, the first thing they should look at is their sugar intake. The reason why I pick on that is because there's a lot of hidden sugar in foods that we don't really suspect. Between drinks, like iced teas and obviously sodas and juices and snacks and things like that, it's just easy to have a lot of that in there.

Scot: All right. So sugars would be one of the first things, the obvious sugars in the sodas, and then the hidden sugars and stuff like sweetened yogurt. Any sort of flavored yogurt that's not a plain Greek yogurt is going to have hidden sugars. Get rid of those. What would be a good Step 2 then?

Thunder: A good Step 2, I would say, is look at the timing of your eating. When do you eat? When do you snack? Things like that. Sometimes people are grazers. They'll tend to kind of nibble and munch the whole day, and that basically puts them in a position where their insulin levels are always high. Insulin is the hormone that's needed to make fat and to store nutrients. So looking at your food habits, your behavioral habits is another way. Maybe instead of eating 18 hours out of a 24-hour cycle, try to eat 8 or 10 hours. That's a great tool to use.

Scot: If you find yourself overweight and you're trying to lose that weight, is that something that you should go to a health professional and should be done under the supervision of a health professional? Or is this something that a person can do on their own safely? What is both of your guys' take on that? Thunder first.

Thunder: I would say if you're just trying to lose 10, 20 pounds, something like that, then just do it on your own. If someone is very obese, with a BMI of over 40, and they're in a position where they have life-threatening conditions, they need to lose 100 pounds or 200 pounds, at that point I would recommend those people get involved with the physician because they need a more drastic weight loss program.

Troy: And it's also worth thinking . . . Scot, you mentioned working with a healthcare professional. If you have just struggled and you can't get the weight off and you're morbidly obese, consider gastric bypass. Consider bariatric surgery. It's been proven it works. It's successful. Most of the time, people are able to lose weight. They're able to keep the weight off long term. Obviously, we want to talk about diet and exercise and everything there. But if this is about really trying to reduce your long-term risk of heart disease, and diabetes, and everything else, and just nothing has worked for you, talk to your doctor. That's something to consider. And for some people, that's what they need and it does the job.

Thunder: Yeah, and I think it's important to make a distinction between someone that's trying to lose 15, 20 pounds versus someone who is 75, 80, 90 pounds overweight, and they have pre-diabetes and maybe they have high blood pressure. So they have documented medical reasons that they need to lose weight to improve those conditions. What we're talking about in contrast is someone who is slightly somewhat overweight, 20 pounds, and they know if they can stay on that road, in 10 years, you're going to have an increased risk of various ailments.

Troy: Exactly.

Thunder: I think that's important for listeners to keep that in mind.

Troy: Yeah, we're not talking about getting in swimsuit shape and getting gastric bypass for that. This is about taking a surgical step to reduce your long-term, very real risk of heart disease and stroke and everything else and serious medical issues, and someone who's been struggling with long-term morbid obesity.

Yeah, this is not really what we're talking about, but, again, getting back to that question of when do you talk to your doctor, when do you think about medically supervised things, I think that's probably more where you may want to look into that.

Scot: Some good lessons. Fat is an indicator that you might have some other health issues down the road. So even if it's just a little bit more than you'd like, perhaps start turning that thing around sooner than later before it becomes much more difficult, because as we've learned today, that extra fat can impact your health in a lot of different ways, including diabetes, and heart disease, and cancer.

Thanks, Thunder, for that great information today, and thank you for caring about men's health.

Troy, are you ready for a new segment idea we're going just kind of float out there and see how it works?

Troy: Yeah, let's do it. Let's start something new.

Scot: All right. As guys, I think . . . at least I can only speak for myself, but I like this feeling of being prepared to handle situations that come up. So, if a situation comes up and I'm out in the world, I'm like, "I know how to help with that."

This is "Who Cares About Men's Health." You are an emergency room physician. So these are going to be a little bit more serious things, but I think I want to call the segment "How Do You Handle It?"

Troy: "How Do You Handle It?" I like it.

Scot: "How Do You Handle It?" We're going to talk about some things that might happen out in the world, and hopefully, you are going to be able to give us some advice on if this happens, how we could be helpful and useful in that moment so we know how to handle it.

Today, I thought it might be fun to do frostbite. Not fun to get frostbite, fun to do frostbite. You think you've had frostbite at one point in your life.

Troy: Oh, yeah.

Scot: Didn't you tell that story?

Troy: It was awful. Yeah. I was nervous. It was bad. It was one of those things. I was out on a long snowshoe run in the middle of winter, and it's like eight degrees out and my feet are covered in snow the whole time, just in powder. And I get up to the point where I'm turning around to come back down, and I think, "Wow, I can't feel my feet, but my feeling will come back as I get closer to home in lower elevation and as things warm up a little bit."

I get home, and I take my shoes off, and I still can't feel my feet. Right now, as I'm talking about it, I still have that sensation. Just thinking to myself, "From the ankle down, I can't feel my feet. This is the weirdest thing."

I peeled my socks off and my socks were pretty much stuck to my feet because they were frozen on my feet. I looked at my feet and it looked like textbook pictures of frostbite. My feet were just white. And I touched my feet and I could not feel anything. I started to feel very nervous. It was scary.

Yeah, I did experience at least some mild frostbite. Fortunately, I recovered from it. But we can talk a little bit more about that process of what I did to treat that and how you do that. But it was a scary experience.

Scot: When you saw that, was there a little bit of a denial? You're like, "I know I'm a doctor. I know I've studied this. I know what it looks like. I'm seeing it on myself. No, that can't be frostbite."

Troy: I usually go one of the two extremes. I'm usually in complete denial, or I go all in and I'm like, "Wow, I have frostbite, I'm going to die, and I'm going to lose my feet." And that's kind of extreme I went to. It was more like, "Wow, should I call 911?"

Yeah, I was nervous. It was one of those things where it was a combination both of being like, "Okay," and then there was a lot of pain following that time. So it was both that pain and then also definitely a high sense of anxiety associated with that.

Scot: Painful. Your feet are white. Those are some of the things to look for. You said there are different degrees of frostbite. So how do you handle it? Cover some of that for us.

Troy: I think one of the important things about handling frostbite is, first of all, if you're in a situation . . . let's say I were up there at the top of my run, and I'm at 9,000 feet, and my feet are in the snow, and I think to myself, "I think I have frostbite." I should not make a fire there and boil water and try and get water hot and try and rewarm my feet because my feet are going to get cold again. You don't want to thaw it out and then have it freeze again. That's the number one goal.

Scot: That's the worst thing?

Troy: Yeah. Don't thaw it out. Do not treat frostbite unless you're in a situation where your feet can stay thawed out. So, if you're up there in that scenario, and you're like, "Wow, I have frostbite," just deal with it and get to a point where you can then be in a safe place and treat the frostbite and not have it refreeze, because that's when really bad damage can happen. That's probably the number one take-home of it.

Scot: All right.

Troy: But then once you get to a point where you can thaw your feet out, or your hands or whatever it is . . . feet, fingertips, toes, those are the most common sites where we see frostbite. The way you want to do it is get a warm bath, about 100 degrees. Something that feels warm to you. You put your hand in the water, and it's like, "Okay, this is warm. It's not crazy hot where it's burning my hand, but it definitely feels warm." And you want to re-warm your feet in that.

Basically, what I did was I took our bathtub, I filled it up, just started running some warm water in there, and I put my feet in there and it hurt like crazy. So as that blood started coming back into my feet and the tissue started to re-warm, it hurt like crazy and it itched. I just wanted to scratch at my feet. It was very uncomfortable.

And that's the biggest thing with re-warming frostbite, is it does hurt. If we see it in the emergency department, sometimes we have to give pain medications with it to help people tolerate that. But you want to just have warm water where you're circulating that water through there. Maybe get the bath full to a certain point and then just keep running some more water in there and go through that process. For me, I did that for about 15 minutes.

Then I looked at my feet after I had re-warmed it, and I actually sent a picture to Laura, my wife, at that point. I said, "I'm a little bit nervous," because it just had this funky, weird appearance like my feet were all bruised as that tissue was re-warming and blood was trying to work its way back in. It was kind of scary looking.

That's often where the damage happens in frostbite. It's not the freezing piece. Usually, the freezing doesn't cause the tissue damage. It's during that re-warming process that it can get damaged.

But I tried just to do what I would normally do with any sort of patient and just say, "Okay, we're going to go through a re-warming process now." I took some pain medication with it too. I took a Tylenol to help with some of the pain I was experiencing.

And after I'd done that first 15 minutes, I kind of took 10 minutes off and said, "Okay, we're getting there. I'm still nervous about this, but let's do another re-warming trial in the bath and see how things go." And then I went through that, and after that second 15 minutes of re-warming my feet, things weren't back completely to normal, but I was getting some feeling back in my feet. At that point, the tissue was looking a little more normal, not really that crazy, weird bruise look to it. It's the same process I'd recommend someone go through if this happens to them.

Scot: If you're in a situation where you are at the top or wherever of the 9,000-foot peak, or wherever you might happen to be, is there a point where you just make it your priority that I'm going to stay here until somebody can come get me and I'm going to start re-warming stuff right now?

Troy: No, I wouldn't. Because then you've got hypothermia and everything else you've got to deal with.

Scot: Oh, right.

Troy: If I'd stayed up there . . . like I said, the high that day was in the single digits. And if I'd stayed up there and I'd stopped moving altogether, then I'm risking hypothermia. Then you're risking not only loss of limb, but loss of life. You want to just keep moving. This is going to happen probably when you're somewhere in the backcountry on a hike or snowshoeing or . . .

Scot: Snowmobiling.

Troy: Yes, snowmobiling or something like that. Yeah, don't stay put. Just work your way back and work your way back calmly and recognize that, yeah, you've got some frostbite, but you can deal with it and you can work through it and get things back to normal.

Scot: So the protocol that you would follow in the ER is literally what you described that you did at home You don't have any secret weapon?

Troy: No secret weapon. The treatment for frostbite is re-warming. And it really just comes down to trying to get it re-warmed as soon as you can. You just want to keep re-warming until that tissue no longer feels like a block of ice, that crazy feeling that I felt as I touched my feet where it felt like ice. You want to get it re-warmed to where it feels like normal tissue.

Scot: All right. "How Would You Handle It?" Our very first one on frostbite. How are you feeling about that?

Troy: Feeling good. It's something I think that's very relevant right now. We're going to see, I think, a lot more of these things this winter. Frostbite, potentially avalanche injuries, things like this, stuff that happens in the backcountry because my guess is we're going to see a whole lot more people getting out in the backcountry this winter, just with COVID and everything else. So this is one thing to keep in mind. Know what frostbite is, know how to deal with it, be prepared for it, know what to do if it happens.

Scot: Time for "Just Going To Leave This Here." It might have something to do with health or it could be a random thought that we have.

Just going to leave this here. Troy, do you ever run on the treadmill?

Troy: I do.

Scot: You ever get on that thing and think, "Oh, man, this is a form of punishment"?

Troy: Oh, absolutely. That's why I run outside.

Scot: So I found an article in "The New York Times." The treadmill was once a criminal sentence.

Troy: That doesn't surprise me.

Scot: And there's a picture that shows prisoners on a treadmill in London around 1850. Yeah, the treadmill used to be . . .

Troy: Is a form of punishment.

Scot: It was a form of punishment.

Troy: Probably would be considered cruel and unusual punishment. That's why it doesn't exist anymore. You can't do that to prisoners now.

Scot: You're right, and you shouldn't. If you throw golf on the TV while you have them on the treadmill, that's cruel and unusual. That's like the worst.

Troy: That's awful. Well, Scot, I'm just going to leave this here. I ran across an interesting website recently. It opened my eyes to some very fascinating pedestrian laws. I am very attuned to pedestrian laws because I am often a pedestrian. And when you're a pedestrian, you really feel like your kind of putting yourself out there. I've been in some places as a pedestrian on the road where it's downright scary.

But let me ask you about this, Scot. You've got kind of the crosswalks that are just the two lines going across the road. And then you've got the crosswalks that are like those thick things that look like railroad ties going across the road. Do you know what the difference is in the law with those things?

Scot: I didn't know there was a legal difference. No.

Troy: There is a legal difference. If someone is in a crosswalk when there's just the two stripes going across the road, you just have to wait until they're not on your side of the road and then you can go. If you're at a crosswalk with those big railroad tie looking things, and those are usually school zones, you have to wait until the person is completely off the crosswalk before you can go. Interesting.

Scot: I didn't know that difference. At one point in my life, I had heard that here in Salt Lake, if the pedestrian was in the crosswalk, but they were on the other side of traffic, not my area, even then you were supposed to let them completely clear the crosswalk. But there are actually visual indicators. That's interesting. That's good to know.

Troy: Scot, this came up on a website. Actually, the state of Utah put it together. Some of this may be different state to state, but the website is drivermyths.utah.gov. It kind of goes through some of these things. And some of these are a little tricky. It was a little bit surprising to see what laws are specific to pedestrians in crosswalks and what we really need to be aware of.

Scot: All right. Time to say the things that you say at the end of podcasts because we are at the end of ours. First of all, if you want to get in touch with us, you can do it in a lot of different ways. The way that would be kind of cool is if you called 601-55SCOPE. That's 601-55SCOPE, and leave us a voicemail with your message, your question, your feedback, whatever. But there are other methods as well.

Troy: You can contact us, hello@thescoperadio.com. We're on Facebook, facebook.com/WhoCaresMensHealth. Our website is whocaresmenshealth.com. Also, subscribe anywhere you get your podcasts. We're on Apple, Google Play, Spotify, Stitcher, Pocket Casts, whatever works for you.

Scot: Thank you for listening. Thank you for caring about men's health.