Category Archives: Morbidity

Addiction: Twenty-first Century Style

Posted by on November 19, 2013 Comments Off on Addiction: Twenty-first Century Style

Technology is wonderful, ever moving forward. Now that cigarettes and other tobacco products have been thoroughly discredited as nothing more than a dirty 20th Century addiction, the purveyors of nicotine addiction have developed the e-cigarette for the 21st.

None of that harmful tar. None of that distasteful, annoying smoke. Just pure pleasure, as innocent as sucking a straw.

The Food and Drug Administration (FDA) is not convinced and is expected to issue regulations shortly.

E-cigarettes are a battery-powered device, about the size of a cigarette, that heats a nicotine-laced liquid into a vapor to be inhaled.

First, the FDA will not be able to regulate e-cigarettes as medical devices. That was decided by the DC Court of Appeals in Sottera, Inc v. FDA at the end of 2010. That means that restrictions will be similar to tobacco products rather than to nicotine patches.

Second, there will be considerable debate about the relative safety of e-cigarettes. While it is true that the tar and smoke is missing, it is unclear what the effects of the vapor components are both or the “vaper” and those around him.

A 2012 study at the University of Perugia (Italy) concluded:

The e-cigarette seems to give some advantages when used instead of the conventional cigarette, but studies are still scanty: it could help smokers to cope with some of the rituals associated with smoking gestures and to reduce or eliminate tobacco consumption avoiding passive smoking. However, the e-cigarette causes exposure to different chemicals compared with conventional cigarettes and thus there is a need for risk evaluation for both e-cigarettes and passive steam exposure in smokers and non smokers.

In August, 2013 respected researcher Igor Burstyn of the Drexel University School of Public Health issued a study financed by The Consumer Advocates for Smoke-free Alternatives Association (CASAA), an advocacy organization of the e-cigarette industry. Burstyn’s work and presentation is rigorous, but it is a technical study, not the peer-reviewed journal article considered the gold standard among researchers. While finding that the contaminants are generally safe, Burstyn:

  1. does not evaluate the risk of nicotine exposure to the person “vaping.”
  2. notes the difference in standards between exposure to a willing user and more stringent standards for an unwilling bystander.

Burstyn report

This approach to secondhand vapors provides a legal and philosophical foundation for applying existing tobacco regulation to the newer nicotine delivery systems.

Third, the e-cigarette industry is following the lead of the tobacco industry in its advertising. Note the remarkable parallels in Cigarette Flashbacks, a presentation by three Democratic members of the House Energy and Commerce Committee.

Fourth, there is widespread concern about the marketing and increased consumption of e-cigarettes by teenagers. Ninety percent of adult smokers had begun smoking in their teen years. The issue is well summarized by Health.Howstuffworks.com Flavoring the vapor with chocolate, caramel, strawberry, and bubble gum suggests a conscious attempt to lure youth into early addiction for later profits. Similar concerns have been expressed about the flavorings in hookah smoking as well. The Centers for Disease Control and Prevention recently issued a report on the percentages of teenagers using flavored tobacco products, nearly half of the consumption is flavored.

In the Jewish tradition, consumption of dairy and meat products together is forbidden. Technically, it would be permitted to have soy cheese on a hamburger, but the rabbis have forbidden that as well, because the appearance of violation by believers might encourage others to violate the prohibition.

It is clear that the appearance of smoking cigarettes should be treated no differently than the consumption of cigarettes. The difference between suggesting “Reach for a Lucky instead of a sweet,” and “E-cigarettes have no tar or smoke,” is minimal.

The FDA should treat e-cigarettes as tobacco products, and the several states should follow the examples of Utah, North Dakota, New Jersey, Arkansas, and the District of Columbia in banning indoor use in public places. Additionally, sales to minors should be banned as well as Internet sales since age-verification is not possible on line. In short, we need to bring these products under the same regulations as their tobacco cousins–NOW.

What we almost know

Posted by on September 25, 2013 Comments Off on What we almost know

The impact of intestinal flora on health conditions is known, thus fecal transplants for numerous conditions. Last week I wrote about an experiment with mice verifying the impact on obesity.

As a consequence, there are numerous products being marketed as “probiotic.” We have no idea whether those products are helpful, harmful, or simply benign.Bacterial flora are an instance where we know some bacteria are essential, and we know some can be added beneficially, but we do not know which ones to add. There are promising studies with lactobacillus acidophilus shown: lactobacillus We almost know about GI flora, but not quite enough yet.

There are other topics where we are at a similar place. We know a lot about what mental illness is and isn’t. We know that increasing serotonin in the interstitial spaces of the brain helps with depression and that too much serotonin is associated with schizophrenia. As of this point, however, we don’t have imaging or blood tests or biopsies that will tell us who is mentally ill–we use written testing and observation not laboratory tests to diagnosis it. When physicians attempt to treat it, it is largely a matter of trial and error. We do not know beforehand whether a particular selective serotonin re-uptake inhibitor (SSRI), such as fluoxetine or venlafaxine will work with an individual, or if any SSRI will work. Some people will do better with buproprion, which uses a different mechanism. Others will do better with a serotonin–norepinephrine reuptake inhibitor (SNRI) such as duloxetine. Others will experience no clinical effect at all. We almost know about mental illness, but not quite enough yet.

These examples lead to a more general question about what we know and do not know. It is usually phrased as “nature vs. nurture,” but it is really genetics vs. environment. I am not sure if the the “versus” between them is appropriate–something else I do not know–as it is the relative interaction of the two rather than a false choice between them that is a more likely source of the truth about who we really are.

Researchers often conduct identical twin studies, controlling for genetic variation by comparing the environmental impact of twins with nearly identical DNA. Molecular computer graphic of DNA double helix However, the studies are limited: it is intriguing if they both smoke the same brand of cigarettes or like the same foods despite very different upbringings, but it does not neatly tell us which behaviors are genetic and which are environmental.

Similarly, we know that 3/4 of children of two bi-polar parents are likely to have bi-polar disorder, which seems to indicate a Mendelian genetic inheritance, but we only almost know about the inheritability of mental illness, not quite enough.

Even where we know that a trait is inherited, we often do not know what genes or constellation of genes are associated with a given, visible trait. We almost know about the human genome, but not quite enough yet.

As scientists or those of a scientific bent, we are obligated to say what we know and what we don’t know, being able to distinguish the difference. It is not always an easy distinction to make, but is central to our effort to know more, and eventually know enough.

Learning about fat people

Posted by on September 16, 2013 Comments Off on Learning about fat people

When I was growing up, I had a first cousin who was morbidly obese, long before the efforts of the rest of the country to catch up with her. Her failure, and it was considered a failure, to lose weight was seen as evidence of a moral failing, a lack of willpower, only slightly less pejorative than the sin of gluttony in earlier times. There was some vague talk that she might have some hormonal imbalance, but it was clear that all around her considered her problem to be predominantly one of willpower.

Both alternative and scientific medicine have taken a recent interest in gastro-intestinal (GI) flora, or “gut bacteria.” The alternative medicine folks have favored “probiotic” supplements and yogurts fortified with bacteria. The probiotic movement began with Nobel laureate Elie Metchnikoff, known as the “father of probiotics,” who believed that longevity of rural Bulgarians and Georgians could be attributed to their consumption of fermented milk products.
Metchnikoff

Consideration of the impact of GI flora on diarrhea is not really new–a half century ago I can recall being given lacto-bacillus pills to counter the gastric distress resulting from penicillin. It is the potential impact of bacteria on obesity that is notable in the current focus. Recently National Public Radio (NPR) interviewed Jeffrey Gordon, a microbiologist and director of the Center of Genome Science and Systems Biology at the Washington University School of Medicine in St. Louis.

While I hope you will either listen to the embedded audio clip (about 12 minutes) or read the interview transcript, the short version is that there the research shows a recursive feedback loop between how the bacteria impact our appetite and how what we eat impacts the bacteria that are in our intestines. By eating the right or “lean” foods, we encourage the bacteria that help us maintain our weights at a healthy level. Now, there has been some experimentation with fecal transplants, having a similar aim, but that does not seem to be for everyone–particularly those of us who would be grossed out by the very idea. Eventually, we will probably have probiotics, which, combined with proper diet (they need to be fed or cultivated in our gut), can be delivered to our intestines in pill form, or at least a suppository rather than a fecal transplant.

Over time my cousin became estranged from nearly everyone in the family and died a few years ago, not having been seen by any family members in decades. Waxing philosophically, I cannot help but wonder how different my cousin’s life might have been had she been born a half-century or better a century later. And, I wonder how different my father’s life might have been had he survived his first heart attack and lived to see statin drugs.

It seems that much of our survival depends upon living just long enough for technology to address a mortal weakness in our genome. Nonetheless, it is encouraging to note that promising approaches to obesity may make it seem like nothing more interesting than a historical healthcare statistical blip rather than the crisis it appears to be as we live with it and address it.

Three research pieces with a lot of heart

Posted by on September 10, 2013 Comments Off on Three research pieces with a lot of heart

Often the most heartening news comes from health research. The past couple of weeks have revealed three worthy of note. All three involve prevention measures, two before a heart attack, and one after.

First, the US Centers for Disease Control and Prevention estimate that 200,000 deaths from heart attacks can be avoided annually. The preventable deaths are concentrated in three areas.

The first area is age, where preventable deaths are concentrated in the 45-64 age cohort.
Preventable deaths by age

The second area is race, where African-American men are at the highest risk of preventable death, 143 out of 100,000.

Preventable deaths by race

Finally, the deaths are concentrated geographically in the South-Central Region.
Preventable deaths by region

Second, a study from Britain and India, published in the Journal of the American Medical Association (JAMA) found that a single pill or “polypill” with fixed doses of aspirin, anti-hypertensive, and cholesterol-lowering drugs was statistically more effective than offering separate prescriptions. While physicians point out that this approach limits flexibility, greater variation of dosage combinations in polypills is a promising approach.

Polypill study

Third, a study in JAMA Internal Medicine found that even after a heart attack, better diet, as measured with Alternative Healthy Eating Index (AHEI 2010), resulted in lowered mortality.

The good news is that either before, or failing that, after a heart attack, the good practices of medication adherence and reduction of risk factors such as poor diet, can improve our survival as individuals. Furthermore, we can move the needle in a better direction by focusing our educational and interventional efforts on those under 65, African-American, residing in the South-Central United States.

Herd Immunity — How vaccines avoid thinning the herd

Posted by on September 3, 2013 Comments Off on Herd Immunity — How vaccines avoid thinning the herd

Part of the difficulty in making a case for universal vaccination against dangerous disease is a lack of understanding of probability. Since there are few certainties in life, except its eventual end for individuals, we are constantly calculating probabilities. What is the probability that I will get to the other side of the street before that oncoming car arrives? What is the probability that the wheel stop on my number or that I will draw the card needed to complete my hand? What is the probability that the game I am going to attend will occur or get rained out? And, of course, what is the probability that the suggested intervention will cure my disease rather than kill me or leave me permanently debilitated?

Some probabilities are more difficult to calculate than others: what are the odds that I will die from prostate cancer, and what are the odds that the operation will leave me impotent? how do I calculate the best course when my choices are an operation with an 80 percent success rate that leaves another 15 percent paraplegic and 5 percent dead? How about the same operation with 93 percent success, 5 percent paraplegic, and 2 percent dead?

The more complex the alternatives, particularly when they are being balanced against complex outcomes from non-intervention, the more difficult it is for us to make a rational decision.

That leads to a discussion of vaccination. Let’s consider a disease such as smallpox, which has killed 100s of millions of people. Not everyone got smallpox. Not everyone who got smallpox died from it–estimates are that about 30 percent, or 3 out of every 10 died. Now, consider that not everyone who gets a vaccination gets 100 percent immunity. Some people get partial immunity. Some very small percentage may not produce antibodies in reaction to the vaccine. Some people actually die of the side effects of the vaccination.

As an individual, you might think, well, it’s not great but 70 percent odds of surviving are better than none, and maybe it will miss me altogether, so why should I vaccinate? Of course, smallpox has been eradicated, and we don’t have to make that kind of determination any more since the dangers of side effects from the vaccination exceed the danger of contracting smallpox, particularly in the United States where the last documented case appeared in 1949.

If you were a free individual, not part of a society, not part of the possible transmission stream of a disease, then no one is likely to care too much what you decide? However, if you are reading this, you are part of a society providing this message to you via a societal mechanism. As part of that society, you have obligations to others in the society, including children, yours and others, who once were considered private property but are now considered individuals with rights, albeit limited compared to adult rights.

The concept of “herd immunity” goes directly to the questions posed and to your obligations within the society.

Herd Immunity Concept

Those who are vaccinated provide a barrier to illness for those who are not:

Consider:

Assume you have 5 friends who do not know one another, and that everyone has 5 such friends.

Assume that vaccinations give almost 100% immunity and that the corresponding disease gives almost 100% probability of infection if you come in contact with a person who has it.

Now, if 80 percent of people are immunized against the disease, it is quite possible that one of your friends is not immunized. However, if 80 percent of that person’s friends are immunized, there is now only 1/5 times 1/5 or 1/25 = 4 percent chance of the disease vector reaching you. It may be that you friend’s friend has friends with 100 percent immunity, all five of them immunized, and the further you are socially from the source of infection, the lower your odds of becoming infected–even if you are not immunized. You are protected by herd immunity.

However, consider if only 60 percent of people are immunized, then 2/5 times 2/5 is 4/25 or 16 percent chance of becoming infected. That is 4 times your chance of infection from a secondary friend, as in the first example. The degree of herd immunity is a complicated calculation depending upon the percent immunized and the way the disease is transmitted. Your chance of infection depends on those factors as well as your social distance from the source of the infection.

For an animated look at the concept, click on “Play Animation” in the three scenarios of The History of Vaccines: Herd Immunity.

Here are the thresholds for different diseases as estimated by the Centers for Disease Control (CDC):

Herd Immunity Thresholds CDC

Think about flu shots for a moment:

  1. The vaccine is based upon recent mutations of the virus, so you might catch a virus that is not part of the vaccine.
  2. Not everyone gets 100 percent protection from a vaccine–it may be sufficient to protect against some strains and give partial protection against others
  3. In part, because of herd immunity, not everyone exposed to influenza is infected

So, we have friends and relatives drawing the wrong conclusions (e.g. the vaccine caused me to get influenza), based on an association of factors that are coincidental or subject to an alternative explanation, such as a new strain or partial immunity. For most young people, the flu is an occasional inconvenience rather than life-threatening; however, their failure to vaccinate exposes others whom they could be protecting by a simple annual injection. Let’s spread the word–it might not save those young individuals–just an older person, or an asthmatic standing close to them.

Celebrity and science: the vaccination controversy

Posted by on August 19, 2013 Comments Off on Celebrity and science: the vaccination controversy

Bill Maher is witty and funny–particularly if you are not politically or religiously conservative.

However, the closest he will get to being a virologist is when a video clip of him goes viral.

In 2009 he provoked a controversy by tweeting that anyone who got a flu shot was an idiot. In a blog post on November 15, 2009 he backed off a bit, but defended himself by:

  1. I’m a comedian
  2. I tweeted it, didn’t say it on my show.
  3. Saying there are questionable things about vaccines.
  4. Endorsing a group opposing vaccinations.

It was a non-apology worthy of a Washington official. The truth is that while Bill Maher is neither an authority nor an expert on vaccines, he has influence based upon his celebrity. And, as a result, he can influence many people who should get vaccinated but are undecided, as can any other celebrity. After all, who likes hypodermic needles except for the rare needle freak? We all want some cover for deciding to avoid needles.

We may all be grateful that celebrities are not the go-to experts on health care for most parents; however, a 2011 University of Michigan study found that 1 out of 50 parents rely on celebrities a lot for information, and that 1 out of 4 rely on celebrities some.

MichiganVaccineSurvey2011

One of the sources that Maher cited was the National Vaccine Information Center (NVIC). It is reasonable that individuals who have suffered side effects from vaccines or any other medication might band together to ask that there be full disclosure on the risks as well as every effort to promote safety. Unfortunately, NVIC goes a step forward, suggesting that vaccination is a matter of preference rather than necessity. It is a bit like receiving a full glass of water and obsessing about the emptiness between the top of the water and the lip of the glass.

A key paragraph in their statement of purpose:

This traditional paternalistic medical model is increasingly being rejected by today’s more educated health care consumers and, along with this challenge, is also an historic challenge to the supremacy of the allopathic medical model as the only means of maintaining health and preventing disease. The movement toward a more diversified, multi-dimensional model health care system is a phenomenon occurring not only in the United States but in many technologically advanced countries.

In short, it is a rejection of science in favor of some other belief system for medical care. The United States makes ample allowance for alternative belief systems; however, alternative behaviors are circumscribed. If you wish religion taught in the schools, you must attend a parochial school, not a public one. Similarly, if you want to attend a public school, then a vaccination prerequisite is reasonable, particularly when you have private alternatives, including home schooling available. Even that stretches the limits, because unvaccinated people lower the safety of everyone. Since vaccines are not 100 percent perfect (and what is in this world?) we depend on an adequate percentage of vaccinated people to prevent an epidemic among those who are only partially protected by vaccines against communicable diseases such as polio, diphtheria, and influenza.

This is “herd immunity,” or:

Indirect protection against disease that results from a sufficient number of individuals in a community having immunity to that disease. With enough immune individuals, the transmission of a disease can be reduced, thus limiting the potential for any one individual to be exposed to it. Herd immunity does not apply to diseases, such as tetanus, that are not spread via person-to-person contact.


One of the best and simplest ways to lower healthcare costs and to improve public health is to increase our rates of vaccination. Consider this: do businesses pay for flu vaccinations because they are loving and generous, or because it will lower absenteeism and paid time off?

All That Jab – one more reason to vaccinate

Posted by on August 12, 2013 Comments Off on All That Jab – one more reason to vaccinate

Those who look toward the scientific for explanations know that only UFOs and and political assassinations attract more conspiracy theories than vaccines do.

The challenge of conspiracy theorists is similar to the challenge of mental illness–no amount of evidence contrary to a deeply held view is sufficient or dissuasive. Astute observations are followed by non-sequitur conclusions, or either-or alternatives with no room for gray in between the black and white alternatives.

Nonetheless there is heartening new evidence that influenza vaccines are benign for pregnant women–or as Reuters put it:

Pregnant women who get flu shots are at no greater risk for complications like high blood pressure, urinary tract infection or gestational diabetes, according to a new U.S. study.

The study of Inactivated Influenza Vaccine During Pregnancy and Risks for Adverse Obstetric Events, which will appear in the September issue of Obstetrics & Gynecology found In this large cohort, influenza vaccination during pregnancy was not associated with increased risks for medically attended adverse obstetric events.

Often such studies are handicapped by small sample bias, not enough people studied to draw a strong conclusion, even if statistically significant. Not the case here, as the authors report that their study group was 74,292 vaccinated females matched on age, site, and pregnancy start date with 144,597 unvaccinated females.

One might ask, “Why bother? So, I get the flu while pregnant–one more nuisance.” The same article in Reuters Health addressed that question:

For a pregnant woman, contracting the flu is “really dangerous,” according to Dr. Laura E. Riley, medical director of labor and delivery at Massachusetts General Hospital in Boston.
Pregnant women with the flu are at greater risk of death, respiratory disease requiring hospitalization and premature labor and delivery, Riley told Reuters Health.
The risk-benefit ratio was already clear, she said, but collecting new safety data is always good.

On the positive side, the benefits of vaccination accrue not only to the mother but to the baby:

“Flu shots protect pregnant women, their unborn babies, and even protect the baby after birth,” Kharbanda said.[lead author Dr. Elyse Kharbanda of Health Partners Institute for Education and Research in Minneapolis, Minnesota]
Babies don’t receive vaccines until six months of age, so they are vulnerable to catching the flu in the first six months of life, he said. But previous studies have found that some of the protection passes across the placenta to the baby and can help shield them from flu after birth.
“What mother doesn’t want to do that?” Schaffner said [ Dr. William Schaffner, chair of the department of preventive medicine at Vanderbilt University Medical School in Nashville, Tennessee]. “There should be no hesitation for women getting the vaccine.”

There is no reason for a pregnant woman not to get vaccinated against the flu; there is every reason to avoid possible consequences of not getting vaccinated; and, if not for you, then for the benefit of your baby, who does not need the flu while getting used to living outside the womb.

Leptin and Ghrelin and Fat, oh my!

Posted by on July 22, 2013 Comments Off on Leptin and Ghrelin and Fat, oh my!

I am so embarrassed.

I have been confusing ghrelin and leptin, as we all do from time to time.

Still, I am very embarrassed.

I know that they are appetite-related hormones, and there was recent news about them. And, it seems I am not alone in the confusion.

But, first let’s go to the news desk.

An international team with principal investigator in the United Kingdom has published A link between FTO, ghrelin, and impaired brain food-cue responsivity in the Journal of Clinical Investigation.

In lay terms, as that is my language, what the study found was that individuals with the genetic indicator FTO, known for a tendency to obesity, are less satisfied after eating because of higher levels of ghrelin, a hormone that increases appetite.

Ghrelin has been known about since 1999, and there has been considerable debate about the possibilities of a ghrelin-antagonist to address obesity in a pharmaceutical. The alternative would be a leptin-stimulant as it is leptin that gives us the feeling of satiety after eating.

One of the two approaches, or both, is likely to lead to a very effective pharmaceutical approach to obesity.

But, back to my confusion for a moment. A 2010 Spanish study found that after weight-loss dieting, lower levels of ghrelin and higher levels of leptin were associated with gaining back the lost weight. Furthermore, the ghrelin was significant for men while leptin was statistically significant for women.

Oh, my. I am very confused.

The things we already know–but don’t often do

Posted by on July 15, 2013 Comments Off on The things we already know–but don’t often do

There is the old Middle Eastern story of the one who journeyed East in search of wisdom. He came upon a stone where he read, “Turn me over.”
He picked up the stone and read on the underside: Why do you seek new knowledge when you do not use that which you already have?

A recently reported Swedish study that followed 71,000 individuals over a 13-year period found that consuming less than five daily servings of fruits and vegetables was associated with higher mortality and shorter survival periods. Those eating one serving of fruit daily lived 19 months longer on average, while those eating 3 servings of vegetables lived 32 months longer.

Now by itself, this is not very surprising. We know that heavy meat consumption is linked to colorectal cancer, particularly in combination with genetic mutations, as described in a recent issue of Smithsonian Magazine. So, the possibility that a different diet would be protective, even by contrast, makes some sense.

Fornaciari subsequently analyzed bone collagen of King Ferrante and other Aragonese nobles, revealing a diet extremely reliant on red meat; this finding may correlate with Ferrante’s cancer. Red meat is widely recognized as an agent that increases risk for mutation of the K-ras gene and subsequent colorectal cancer. (As an example of Ferrante’s carnivorous preferences, a wedding banquet held at his court in 1487 featured, among 15 courses, beef and veal heads covered in their skins, roast ram in a sour cherry broth, roast piglet in vinegar broth and a range of salami, hams, livers, giblets and offal.)

In a similar vein, one out of three Americans suffers from hypertension (high blood pressure), a major risk factor for serious cardiovascular events such as stroke and heart attack. A recent study in JAMA showed that 18 months after the beginning of a study in which the experimental group did home blood pressure monitoring along with pharmacist case management, 71.8 percent had controlled blood pressure compared to the control group with usual care at 57.1 percent.

It would be easier if we had pills that would lower our body weight or a vaccination against high blood pressure. We don’t. But we have knowledge that we are not using: walk more, eat less processed foods and more whole grains, vegetables, and fruits, monitor blood pressure and pulse regularly. No, it is not magic–just the best that we can do.

Two things that might help

Posted by on July 8, 2013 Comments Off on Two things that might help

Two recent studies have yielded two tips that might help make your weight loss program work. They are not magic nor pharmaceutical. I confess that they confirm my own biases and experience, which does not make the findings any more valid.

The first study, which appears in the June 26, 2013 American Journal of Clinical Nutrition (AJCN), is a survey of eleven studies on water consumption and weight reduction.

This review found that increased water consumption was associated with greater weight loss. The reviewers conjectured that either the water satisfied hunger cravings, or that the water substituted non-caloric fluid intake for equivalents that might contribute 400-500 calories per day.

The second study, published online June 3, 2013 in the International Journal of Obesity showed a decreased appetite for food following strenuous exercise. The findings from this study are more limited and guarded: it only studied 17 individuals, and ran counter to other studies that showed no relationship.

We need to hope that something will work to help us reverse the trend toward greater obesity. A Rand study by Sturm and Hattori, published online in September 2012 by the International Journal on Obesity showed the accelerated trend toward obesity in the United States beginning in 1987.

Obesity Change 1987-2010

For example, there is a 13-fold increase of BMI > 50 shown by 1200 on the index above.

While the trend in the following table slowed slightly after 2005, there was still an increase of 70 percent increase in those with BMI > 40 so that 15.5 million Americans or 6.6 percent exceeded that BMI.
Obesity 2000_2010

Something has to give–and it better not be more waistlines.