Place comment_Layout 1 16/11/2011 09:36 Page 1 COMMENT 39 Getting to a better ‘PLACE’: helping patients counter obesity by achieving enduring lifestyle change ROGER KIRBY, MICHAEL KIRBY, PETER AMOROSO, BEN CHALLACOMBE, PROKAR DASGUPTA, CULLEY CARSON III AND JOHN M. FITZPATRICK In the domain of public health, common sense is not always common practice. How best then to enable patients to act on the advice that they have constantly heard, but find hard to actually carry out? besity, especially male-pattern modifications that can help to Oabdominal obesity, is strongly achieve, and maintain, significant correlated with hypertension, diabetes, weight reduction. dyslipidaemia and consequent cardiovascular risk.1 It is also linked with We advise our patients to ‘get to erectile dysfunction (ED) and increased risk a better PLACE’ and achieve the of benign prostatic hyperplasia (BPH), as balance between energy intake well as greater morbidity after treatment and calorie use that provides for prostate cancer.2 Although diets the key to weight reduction. low in carbohydrates and energy-rich A mnemonic of five simple rules fats are often successful in achieving acts as an aide mémoire for both clinician weight reduction, their impact is often and patient (Figure 1): Figure 1. Getting to a better PLACE disappointingly short-lived, so that their (patient handout available from long-term efficacy is limited. A urologist is ortion control. Generally speaking, the www.trendsinurology.com/patientinformation) frequently the first clinician that a patient, Pportions of energy-rich foods, eaten especially a middle-aged male patient, both at and away from home, are much comes into contact with. Urological larger than actually required. The specialists are therefore in a unique overweight individual should be position, not only to assess the presenting encouraged to eat smaller portions, urological problem, often BPH and/or ED, without necessarily clearing his plate, and but also to draw the patient’s attention to resist the temptation to indulge in a to his abdominal obesity and inspire second helping. This can help to reduce him to make the sustainable lifestyle energy consumption. This article was originally published in BJU Int 2011;107:873–4. Roger Kirby, The Prostate Centre; Michael Kirby, The Prostate Centre; Peter Amoroso, The Prostate Centre; Ben Challacombe, The Prostate Centre, London; Guy’s Hospital, King’s College London, King’s Health Partners, London; Prokar Dasgupta, The Prostate Centre; Go to the Trends website to view Guy’s Hospital, King’s College London, King’s Health Partners, London; Culley Carson III, Roger Kirby’s video on ‘Getting to University of North Carolina, Division of Urology, Chapel Hill, NC, USA; John M. Fitzpatrick, a better PLACE’ The Mater Misericordiae Hospital, Dublin, Ireland (www.trendsinurology.com/videos) TRENDS IN UROLOGY & MEN’S HEALTH NOVEMBER/DECEMBER 2011 www.trendsinurology.com Place comment_Layout 1 16/11/2011 09:36 Page 2 COMMENT 40 ose the booze. Cutting back, xercise every day. Emerging literature regulatory loop with three distinct steps Lwithout necessarily cutting out Ehighlights the need to incorporate has been identified: altogether, regular alcohol in the evenings physical activity into every strategy 1 a sensor (leptin production by adipose is another excellent way of reducing intended to prevent weight gain as well cells) monitors the size of the adipose energy intake. Alcohol not only provides as to maintain weight loss over time.6 tissue mass calories in its own right (around 100 Furthermore, physical activity needs to 2 hypothalamic centres receive and calories per glass of wine, for example), be part of any plan to lose weight.7 The integrate the intensity of the leptin but also encourages the recipient to stimulus of exercise provides valuable signal through leptin receptors consume extra food by, for example, metabolic adaptations that improve energy 3 effector systems, including the finishing up the bottle of claret with and macronutrient balance regulation. A sympathetic nervous system, control a generous helping of cheese and tight coupling between energy intake and the two main determinants of energy biscuits. While moderate alcohol intake, energy expenditure has been documented balance, namely energy intake and especially red wine, may be mildly at high levels of physical exercise, energy expenditure.10 beneficial, consuming larger quantities suggesting that exercise may improve on a regular basis not only encourages appetite control. Regular physical activity Although some urologists may feel abdominal weight gain, but also also reduces the risk of stress-induced reluctant to venture outside the comfort disturbs sleep patterns and may weight gain and improves health-related zone of their urological expertise, the jeopardise liver function. quality of life.8 The ideal time to do wellbeing of the patient as a whole, and exercise is first thing in the morning not simply his prostate, is surely their xe the snacks. Eating in between when insulin and glucagon levels are low: clinical responsibility. Moreover, there is Ameals, especially foods high in this encourages fat burn and increases now evidence that reduction in abdominal energy but low in micronutrients, is metabolic rate for up to 18 hours girth not only reduces cardiovascular risk, associated with overweight and afterwards, promoting weight reduction. but can also improve ED,11 a condition that obesity.3 It has become customary drives many men to seek urological help. these days to eat fast foods while One additional strategy to recommend is Although, of course, we should still retain walking around shopping, and the to Sleep more (in order to get to better Hippocrates’ imperative to ‘first do no scent of, for example, doughnuts baking PLACES), since chronic lack of sleep has harm’, perhaps a maxim for the 21st makes them difficult to resist.4 There is also been shown to be associated with century should instead be ‘first do some evidence that limiting consumption of problems of overweight and obesity.9 good’. Encouraging our patients to adopt a sugar-sweetened beverages and snack Patients should also be advised to eat and healthier lifestyle in order to reduce their foods (defined as high-fat, energy-dense drink less alcohol in the evening, and get waistline measurements would be a very foods) may be associated with a reduction to bed earlier. A memorable maxim is to good start.12 However, before we offer in the risk of obesity. practise 7/7/11: that is, exercise before advice to our patients to get to a better 7am, eat in the evening before 7pm and PLACE, we had better make a start by ut the carbs. Consumption of sugar- get to bed before 11pm. making sure we get there ourselves! Csweetened beverages, particularly carbonated soft drinks, may be a key With modern environments promoting Acknowledgements contributor to the epidemic of overweight overeating and sedentary behaviour, a Prokar Dasgupta acknowledges financial and obesity, by virtue of their high added chronic minor imbalance between energy support from the Department of Health via sugar content and low satiety value.5 intake and energy expenditure inevitably the National Institute for Health Research Processed white bread in the form of leads to progressive obesity. Eventually a (NIHR) comprehensive Biomedical Research sandwiches with high-fat fillings should balance is reached and weight stabilises, Centre award to Guy’s and St Thomas’ also be avoided. Fast foods, such as because the adipose tissue mass is ‘sensed’, NHS Foundation Trust in partnership with hamburgers and accompanying fries, are moderating energy intake. The cloning of King’s College London and King’s College packed with starch, fat and salt, and the ob gene and the identification of its Hospital NHS Foundation Trust. He also sweet chocolate snacks produce rapid encoded protein, leptin, has elucidated the acknowledges the support of the MRC insulin release. These result in the laying system signalling the amount of adipose Centre for Transplantation. down of body fat and the stimulation of energy stores to the brain. Leptin, a the appetite centre, with consequent hormone secreted by fat cells, acts via Declaration of interests: none declared. craving for another high-calorie, sugary hypothalamic receptors to inhibit feeding or starchy, fatty fix. and increase thermogenesis. A feedback Continued on page 43 www.trendsinurology.com TRENDS IN UROLOGY & MEN’S HEALTH NOVEMBER/DECEMBER 2011 BJUI review Sep Oct_Layout 1 15/11/2011 15:14 Page 2 JOURNAL REVIEW 43 anaesthetic (n=110). Using a rigid metric should be helpful for urologists when that is necessary, combined with ruler, three penile measurements were taken: counselling patients. sex education. flaccid pendulous penile length, flaccid This study establishes a reference penopubic penile length (to the pubic arch) Khan S, Bhaskar S, Lam W, Donat R. range for adult Caucasian male genital and stretched flaccid penopubic length. In Establishing a reference range for size in the UK using penile length addition, testicular size was measured using penile length in Caucasian British men: measurements. The data demonstrate an an orchidometer. The patient’s age and the a prospective study of 609 men. BJU Int average flaccid pendulous length of 8.7cm reason for referral were recorded. Statistical 2011. doi: 10.1111/j.1464-410X.2011.10338.x and a stretched flaccid length of 14.3cm. analysis was carried out using Pearson The authors advise use of the