Category Archives: Prevention

Getting your teeth into health care

We all know the reasons for going to the dentist regularly:

  1. Early detection (cavities, gum disease, oral cancer, bruxism)
  2. Checking existing fillings for structural weakness or peripheral decay
  3. Review of oral health practices

These are dental reasons, but there are other reasons as well.

The relationship between dental health and other medical health is not a new concept, with studies going back to the 1980’s. For example, the statistical relationship between heart attacks and poor dental health was noted in a 1989 Finnish study.

Managed care organizations have a strong financial incentive to lower health care costs. Healthier members have lower medical costs, so improving the health of members is an attractive alternative to cutting benefits in order to lower costs.

Aetna has been a leader in “Dental-Medical Integration” (DMI) as an approach to that end.

A study in 2006 found significant relationships between treatment for gum disease ( a proxy for having gum disease) and higher medical costs for cardiovascular, cerebrovascular, and diabetic conditions, heart, stroke, and diabetes, respectively.

In 2009, Aetna reported considerable success in getting dental care for at risk members:

In 2008, nearly 67,000 medically at-risk members sought dental care after being enrolled in Aetna’s Dental Medical Integration program. At-risk members are identified as those with diabetes, heart disease and pregnant women who have not seen a dentist in 12 months or more.

A 2011 University of Pennsylvania study in collaboration with Cigna Dental established lower medical costs two years after periodontal (gum) treatment:

2011_UPa_Dental

Earlier this month Aetna reported:

  • Lowered their medical claim costs by an average of 17 percent
  • Improved diabetes control by 45 percent
  • Used 42 percent less major and basic dental services
  • Required 3.5 percent fewer hospital admissions year-over-year compared to a 5.4 percent increase for non-members

With the caveat that the Aetna programmed targeted individuals with particular diagnoses who had not seen a dentist in a year, we are nonetheless facing an important question:

Is it time to end the division between dental and medical insurance, treating health care for the mouth as a medical specialty like others, and dentists as medical specialists like others?

Competition, Cooperation, and Health Care

Maybe it’s the days of endless government shutdown. Maybe it’s the days of endless rain.

Writing about any of it comes hard to me. I am uncharacteristically quiet and reflective.

We live in a society built on competition. The economic system creates wealth and rations scarce resources through competition. Democracy is a competition for the support of voters. And, no society is more sports-minded than we are, with giant arenas and stadiums for a variety of sports, each with millions of followers.

However, all of this competition occurs in the context of a society. A society implies certain shared values, a modicum of cooperation, and concern for other members of the society, if not for their own sakes, then for the sake of the society.

Consequently, a competitive society is one with built-in contradictions. At the extreme, economic competition results in great wealth, poorly distributed, and concentrated in the hands of the few. At the extreme, political competition, like sports competition, requires that victory trumps all ethical considerations, including the needs of the society or sport.

On the other extreme, a completely cooperative society, devoid of competition, sharing things equally, is unlikely to thrive. As our conservative friends point out, the incentives for wealth creation and technological progress based on expenditure are likely to be lacking. In addition, there will be free riders, people who wish to partake without producing.

The political and social pendulum in the United States often swings between competition and cooperation, between liberty and equality. At this point in time, it seems to me that we have swung a bit too far toward competition. We have a Congress that cares more about the next election and scoring political points than public policy; we have a Speaker, who should know better, but is more concerned about the challenge to his leadership than the American economy.

Behind it all are two ideologies that seem singularly unconcerned about any impact, other than how a position is measured against the yardstick of a belief system, a non-religious libertarianism allied with a particularly narrow version of Christianity, aligned together in opposition to government initiatives, despite their obvious contradictions. It is a characteristic of ideology and utopia, as Karl Mannheim called the narrow beliefs of the present and the future, that purity of belief surpasses any human need.
ideology and utopia

Combining these strong ideological commitments with the political system results in the political impasse we are experiencing. Closed belief systems can rationalize economic collapse as a necessary, ultimate good, so compromise is not only unnecessary from that perspective, but traitorous. As Eric Hoffer put it,

It is the true believer’s ability to “shut his eyes and stop his ears” to facts that do not deserve to be either seen or heard which is the source of his unequaled fortitude and constancy. He cannot be frightened by danger nor disheartened by obstacle nor baffled by contradictions because he denies their existence

So, the campaign against the program of our current President can pivot from health care to spending to entitlements, but is consistently against the President and his positions. When the economic consequences of the shutdown and the debt limit crisis are tallied, they will say, “See, we told you that the Affordable Care Act would destroy the economy.”

Politicians of all wings, parties and beliefs routinely employ spin–stretching the truth to make their points; however, at some point the distance from the truth is sufficient to call “spin” an outright falsehood. An example, in health care, was the charge that Obamacare mandated “death panels.” (Physicians routinely discuss end-of-life issues with their patients. The proposal was that they be reimbursed for the time so spent.)

As Mark Twain put it, “A lie can travel half way around the world while the truth is putting on its shoes.”

When confronted with an obvious falsehood or exaggeration, the honest person faces a dilemma: does the speaker/writer truly believe what is written, or is that person cynically exploiting the ignorance of others?

Here are some of the arguments about the Affordable Care Act that have been dragged into debate about fiscal policy, the Federal budget, and the US statutory debt limit.

  1. Congress has exempted itself from Obamacare.
    The fact is that Congressional employees will be shopping for health care on the exchanges rather than receiving employer-provided health care as would most businesses with a comparable number of employees. As employees, they will receive an employer contribution that reduces the monthly premium cost.
  2. Large enterprises have been made exempt from the mandate to provide coverage so individuals should be exempt as well.
    Large enterprises are still required to provide health insurance coverage for their employees as scheduled; however the Justice Department will not be imposing penalties immediately. Furthermore, the individual mandate is an entirely separate issue–it is the linchpin of eliminating denial of coverage for pre-existing conditions. Without it, no one would buy health insurance until they needed it, with the assurance that their health condition could not be denied.
  3. Health insurance premiums are going up because of Obamacare.
    With the exception of the past 3 years, health insurance premiums have been rising by double digit percentages each year. The rise slowed because of the deep recession we are emerging from. Health insurance premiums will continue to rise, largely driven by technology (MRIs are expensive), now that the recession is almost over. Furthermore, premiums may seem very high to individuals who have not been able to or been interested in purchasing insurance until now. Health insurance is expensive.
  4. Companies are letting full-time workers go and hiring part-time workers in their place.
    1. Many individuals choose part-time employment over full-time employment. So, the only concern should be involuntary part-time employment rather than all part-timers.
    2. There has generally been a rise in part-time employment during economic recessions. The recent recession is no different.
    3. Many new jobs are coming into the economy to help with Obamacare, as well as new hires in the private sector to meet the needs of the health care law mandates for preventive care and individual coverage.
    4. [It should be noted that individuals concerned about employment issues would never close the Federal government or permit it to be closed, since the loss of spending by Federal workers ripples through the labor market as business owners determine whether to take on new hires, and the lack of Federal issuance of permits in several areas e.g. a Vermont micro-brewery, adversely impacts employment.]

    And as I was reflecting upon the original conundrum, how to reconcile cooperation and competition, liberty and equality, while retaining the best of both, I came across a quotation from Milan Kundera,

    kundera

    “Too much faith is the worst ally. When you believe in something literally, through your faith you’ll turn it into something absurd. One who is a genuine adherent, if you like, of some political outlook, never takes its sophistries seriously, but only its practical aims, which are concealed beneath these sophistries. Political rhetoric and sophistries do not exist, after all, in order that they be believed; rather, they have to serve as a common and agreed upon alibi. Foolish people who take them in earnest sooner or later discover inconsistencies in them, begin to protest, and finish finally and infamously as heretics and apostates. No, too much faith never brings anything good…”

    The Roman playwright Terence wrote “Ne quid nimis,” alternatively translated as “Nothing in excess,” or “All things in moderation.”
    Terence

    Moderation isn’t sexy or attractive. It doesn’t cause the adrenaline rush of ideological combat. But, I think it is the medicine we need now.

    Moderation in politics, moderation in spending, moderation in punditry. Here’s to moderation!!

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

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.

Vaccination–Now and Then

Smallpox was long one of the scourges of humanity, killing millions throughout history. Early attempts were made to combat it through “variolation,”inoculation with the scabs of the disease. Such efforts began at least a thousand years ago in China. ChineseVaccination

Without images to guide us, it is easy to think of smallpox as chickenpox that kills. Not exactly. Besides the fact that smallpox does not concentrate on the torso, the number of pustules seems much more severe to my eye. Here is a child in Bangladesh in 1973 with smallpox. This is what we no longer fear because of vaccination:

Child_with_Smallpox_Bangladesh

Vaccination is relatively new in human history–the United States of America is older. Just before and after 1800 Edward Jenner, noticing the apparent immunity to smallpox of milk maids, experimented with inoculation using the relatively benign disease cowpox to which they had been exposed. It was not until 1840 that the British government routinely provided the means for inoculation, as the medical establishment had been slow to accept Jenner’s findings.

Nonetheless, the disease that killed an estimated 400,000 Europeans annually at the time of Jenner’s discovery, was still able to kill several hundred million in the 20th century.

The last documented case of smallpox occurred in Somalia in 1977. By 1980 the World Health Organisation (WHO) was able to declare smallpox eradicated. Consequently, routine smallpox vaccination was discontinued in the 1980’s as the statistical danger from the vaccination (14 to 52 per million per the CDC) exceeded the danger of the disease.

I would prefer to be able to present a time series of smallpox cases, but have been unable to locate one this week. Failing that, here is the impact of vaccination in the US on numerous diseases during the 20th Century, worth considering when someone questions the value of vaccination.
Vaccination_US_thru1998

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

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.

Disease and National Defense

In Biblical times, where historical accounts and historical myth sometimes mingle, there are accounts of great armies being destroyed by disease. Conflicting accounts of the siege of Jerusalem circa 701 BCE by the Assyrian king Sennacherib are of that nature.

Fast forward two thousand years. Evans, Kleinman, and Pagano write:

In 1334 an epidemic struck the northeastern Chinese province of Hopei. This “Black Death” claimed up to 90% of the population, nearly five million people. The epidemic eventually reached and decimated Tartar forces that had been attacking Kaffa, a Genoese colony on the Crimean Peninsula. In 1347, the departing Tartars catapulted plagueinfested bodies into Kaffa. The Genoese quickly dumped these bodies into the sea, however it was too late. Four ships escaped back to Italy carrying the plague that in just two years killed one-third of the European population.

The relationship between disease and national defense is not a new one in the US. Just a simple web search revealed this 72-year-old article from the American Journal of Public Health on the dangers of venereal disease to military preparedness. Another article in the Journal of the American Medical Association (JAMA) of the same year reports that venereal disease has been a concern of the US Army and Navy since 1778.

There is continued concern about the impact of infectious disease on national defense, for example, the emergence of antibiotic-resistant pathogens and the threat from tick-borne diseases, and from influenza.

Indeed, with anthrax and ricin scares, preventing and managing bio-terrorism is a major part of contemporary national preparedness.

In addition, the Department of Defense is participating in prevention initiatives. As Dr. Jonathan Woodson, Assistant Secretary of Defense for Health Affairs in the Department of Defense, put it:

At the Department of Defense, we’ve moved from a concept of health care to health, meaning that we understand health really is a much more involved concept other than just freedom from disease. It relates to healthy communities and healthy and active lifestyles and also addresses mental wellness and spiritual wellness as well. For us to create a fit and ready force, we need to make sure that we’re paying attention to all these dimensions of health and wellness.

All of these efforts center upon a single premise: national defense depends upon maintaining the health of the civilian and military populations.

That raises an important question: does it matter whether the threat to our health is a foreign enemy, a small band of domestic terrorists, or what we do to ourselves?

As we eat too much, as we eat too much of the wrong foods, as those foods provide biological encouragement to continue those habits, as we exercise too little, and as we create our own national health epidemic, is that not more than what any adversary could do to us?

Or as Walt Kelly’s cartoon Pogo once famously stated: We is met the enemy, and he is us.

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

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.