Tag Archives: obesity

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.

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.

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.

Illusion and Health

Posted by on June 24, 2013 Comments Off on Illusion and Health

A recent University of Texas study about the gap between perception of adequate exercise and optimal diet and the reality of an individual’s regime sent me googling.

I remembered a similar meme about body image. My memory was that men do not see how fat they are, and women imagine themselves fat when they are not, leading to anorexia.

Here are a few of them, and there are no doubt more:

Those studies raised an important question: how do reality and perception diverge when it comes to health?

So, let’s look at the University of Texas study from the Journal of Women’s Health, entitled Lifestyle and Cancer Prevention in Women: Knowledge, Perceptions, and Compliance with Recommended Guidelines.

Among those who believed that good diet and physical activity prevented cancer, the study found discrepancies (I have color-coded them) between what they believed they were doing and were actually doing as shown in the following table:

Women's Perceptions JWH 20130610

It can be seen that while 85 percent believe they are consuming a healthy diet, only 8.5 percent are eating an adequate amount of fruits and vegetables. While 73.1 percent reported engaging in physical activity to prevent cancer, only 31.5 percent were active enough to have a positive impact.

The study found that the significant predictors of the discrepancy were education, and to a lesser extent race-ethnicity independent of education. While the authors speculate about the reasons for those findings, they are clear and unambiguous about the implications, which I quote at length with the footnotes removed:

This finding has important public health implications. The first implication is that women in the current study reported understanding that engaging in regular physical activity and eating a healthy diet are important behaviors for cancer prevention. Thus, media campaigns and targeted public health messages should focus on the importance of specific frequencies and durations of recommended behaviors (i.e., 5 a Day for Better Health), and place less emphasis on the general importance of health behaviors. This may help attenuate the “underdosing” observed in the current study. Current public health efforts are focusing on making community-wide changes to reduce obesity and improve health.19 These efforts may be enhanced by promoting awareness of potential discrepancies between perceptions of behavior and actual behavior and by highlighting practical ways to integrate specific cancer prevention behaviors into daily life at adequate levels. Furthermore, they should consider the imbalance between educational resources for healthy eating and physical activity and barriers to these behaviors (i.e., society encourages the overconsumption of unhealthy food; low access to fresh produce and places to exercise safely sometimes exists). Given that women often serve as “gatekeepers” of health behavior within their families, efforts to address these discrepancies among women may ultimately have a positive downstream effect on men and children. Because dietary habits are often solidified in childhood, the discrepancies observed in this study could potentially set children up for a lifetime of poor health behaviors. These findings add to the body of existing literature indicating that although health-relevant knowledge and attitudes are generally positively associated with the practice health behaviors, the associations are only modest.

Results further indicated that the observed discrepancies for diet and physical activity were significantly more common among women with less education and among members of racial/ethnic minority groups. This is consistent with a large body of research supporting a social gradient in health (i.e., lower socioeconomic position and minority status are associated with poorer health behaviors and poorer health outcomes). One explanation for this is differential exposure to obesogenic environments. That is, individuals with low socioeconomic status and racial/ethnic minorities have less access to healthier foods such as fruits and vegetables due to higher cost and lower access to grocery stores that carry fresh produce. They also have fewer safe places to engage in physical activity. These women may be particularly vulnerable to perceiving that they are engaging in specific diet and physical activity behaviors to help prevent cancer. However, they may lack the opportunity to fully engage in preventive behaviors, thus failing to engage in such behaviors with sufficient frequency and duration to reduce their cancer risk. Such women may need to be specifically targeted for intervention and may benefit from tailored messages and interventions regarding diet and physical activity.

Do we not all know friends and family and clients who believe they are eating well and exercising adequately, but do not understand why their weight keeps rising, with the attendant complications? Our challenge as a society is not only to find ways of addressing the health problems that are undermining our economy and personal functioning that underpin our nation, but to communicate those findings in a way that is unambiguous and specific. The challenge of communicating the findings of a solution to the public health issues may be even more daunting than isolating those causes.

Obesity confusion

Posted by on June 10, 2013 Comments Off on Obesity confusion

We are agreed that obesity is a problem, for individuals and for society.

We are agreed that dieting alone will not help. The latest popular diet approach is part of the background noise not part of the solution. Here is some noise from my Facebook feed as I was writing this posting.

Obesity diet noise

Exercise and dieting combined would work, but is probably beyond the ability of many if not most people facing obesity. Indeed, starting any exercise program may be a challenge to both will and health of someone morbidly obese.

We know that bariatric surgery can work; however, it is invasive, expensive, and there are debates among specialists about what works sufficiently.

Indeed, after Governor Chris Christie of New Jersey announced that he had had a gastric band implanted, there was considerable debate about whether that was sufficient compared to gastric bypass surgery, particularly given the failure rate of the laparascopic gastric band or “lap band.”

There is open debate about whether obesity prevention measures are cost-effective.

As if the problem were not challenging enough, a study has shown that physicians fail to demonstrate to obese patients the empathy necessary to effect change.

Al Lewis argues that many of our workplace wellness programs are ill-conceived and ineffective.

The seriousness of the problem is underscored by a Metlife study showing that obesity contributes $1,723 per person per year to the Medicare budget, or 8.5 percent of the total.

We are not left with a solid place to make a stand against obesity. My plan is to walk a bit more and eat a bit less as I contemplate next steps. What are your thoughts?

Fast food and slow death

Posted by on June 3, 2013 Comments Off on Fast food and slow death

My father returned from a business trip with great enthusiasm for a new food product he had experienced. A company had found the best meat available and mass produced hamburgers, with the mustard, ketchup, and pickle already on the bun. Dad had eaten his first McDonald’s hamburger, more than a half century ago.

He died at age 45 of a massive heart attack, a product not only of McDonald’s and other fast food, but of a sedentary lifestyle, poor heredity, and a 1950’s diet, in which it wasn’t a meal without meat.

He and others who lived through the Second World War had experienced the deprivation of rationing following not long after the Great Depression. Having enough to eat, enough protein to eat, and then seeing opulent food as a sign of material success were all very real to that generation.

The success of feminism led to changes in America’s eating habits. Instead of one partner packing the lunch pail and preparing dinner, both were in the work force, too hurried and harried to spend as much time on meals. Quick meals, whether processed from the grocery store or from a fast food chain, became the norm. In the not too distant future we will learn what the impact has been on gut bacteria that process nutrients and play a role in regulating our weight.

In October 2011 researchers from the University of Michigan, Warsaw School of Social Science and Humanities, and the University of Texas published a study showing significant correlation between national rates of obesity and the density of Subway restaurants in 28 developed nations. Their study ‘Globesization’:
ecological evidence on the relationship between fast food outlets and obesity among 26 advanced
economies found high rates of obesity in countries such as the United States and Canada with high density of Subway restaurants compared to low rates of obesity in countries such as Japan and Norway with low rates.

We can safely assume that it is not Subway alone, but a propensity to support fast food restaurants that is related to obesity. In the study graphic below, the clustering of values along a rising trend line from lower right to upper left, demonstrates the correlation between obesity on the vertical and subways on the horizontal:

Subway_Obesity

Source: Roberto De Vogli , Anne Kouvonen & David Gimeno (2011): ‘Globesization’: ecological evidence on the relationship between fast food outlets and obesity among 26 advanced economies, Critical Public Health, 21:4, 395-402

My father’s generation died sooner, from fatty diets, cigarettes, and a sedentary lifestyle. If anything, computers have made our lifestyles more sedentary, but we know the dangers of cigarettes and saturated fats. We have statin drugs to stave off early death. Now we live longer, die slower, and endure chronic illnesses, such as cardiovascular disease and diabetes.

One of the singular distinctions between children and adults is the ability of adults to postpone pleasure and even endure discomfort in pursuit of a greater good. That may mean planning healthier meals, lighter meals, walking more and driving less. It means, in short, all the things we know we should do but sometimes do not. A long life need not be accompanied by a slow death–if we are willing to act on the knowledge we already have.

Are we making progress or falling behind?

Posted by on May 27, 2013 Comments Off on Are we making progress or falling behind?

In health care we don’t need to look far for bad news. In the past week, I have read:

  1. The prevalence of diabetes has increases 75 percent from the early nineties to the late naughts. A more extensive discussion (may require free Medscape subscription registration) is at New Statistics Shed Light on ‘Worrisome’ Diabetes Epidemic
  2. Leapfrog Hospital Safety Scores ‘Depressing’
  3. Study finds jump in ER-related admissions

And certainly we could include partisan bickering in Washington among politicians more focused on the next election than any meaningful policy debate or measures.

However, the simple fact is that none of this matters. We have no choice. If we do not adequately address our health care needs, then we will no survive as individuals or as a society.

If that premise, the premise of this blog, is correct, then we must assure access to healthcare for everyone. We must get the public health epidemics of obesity, diabetes, and gun violence, among others, under control.

On this Memorial Day, as we reflect on how many Americans have given up their lives at a young age to protect the American experiment, let us consider our debt to them: we owe it to them to insure that our society does not fail and that individuals not on battlefields do not give up their lives at a young age because they ate too much or someone bought a gun out of fear.

We are Americans: we do not accept failure in ourselves. The rest is trivial distraction.

Bad News for Boomers: Our Parents Were Healthier

Posted by on March 14, 2013 Comments Off on Bad News for Boomers: Our Parents Were Healthier

As Americans we believe in progress, in a better tomorrow, sometimes with a bump in the road or a hiccough, but always a better tomorrow.

The data are in (March 4,2013 edition of JAMA Internal Medicine), and it ain’t happening for boomers. Blood pressure, cholesterol, diabetes, and obesity–all greater than the previous generation.

Boomer_Parent_Comparison_JAMAinternalmed_20130304
Source: The Status of Baby Boomers’ Health in the United States The Healthiest Generation?
Dana E. King, MD, MS; Eric Matheson, MD, MS; Svetlana Chirina, MPH; Anoop Shankar, MD, PhD, MPH; Jordan Broman-Fulks
JAMA Intern Med. 2013;173(5):385-386

Although longevity has risen during the twenty-year gap between the two groups, every other indicator of health, except smoking, has become less favorable. And the pattern is clear.

At the top of the following chart are general measures of health. Then, we can see that lifestyle factors have declined leading to the trends in the last section: declining indicators of cardiovascular health.

We can’t choose to be healthy or not: what we can do is make healthy choices by changing the lifestyle factors.

We are choosing illness at great expense to ourselves, both financially and in quality of life, while continuing to endure longer and sicker lives instead of enjoying healthier lives.

Boomer_Parent_Extract_Comparison

Where are those calories are coming from?

Posted by on February 28, 2013 Comments Off on Where are those calories are coming from?

Hint: it’s fast food. A recent Centers for Disease Control and Prevention (CDC) study found that over a 3-year period 11.3 percent of calories came from fast food.

That surprises no one. There were, however, two interesting points made:

First, while adults have decreased their intake of fast food, consumption by youth has increased. As consumption of fast food declines with age, it is not clear to me whether the decline is true progress or related to the aging of the population.

The second takeaway from the study is more intriguing, as shown in the following summary of study findings:

CDC_NatHealthSurveyNutrition_201302

I have highlighted the finding at the bottom of the graphic.

When it comes to fast food: the more you eat, the more you gain; the more you gain, the more you eat.

If someone told you that the more heroin, opium, etc. you consume the more you want, you would not be surprised.

Are you as surprised as I am to find a study that shows the same is true of fast food?

Since we regulate addictive drugs, there is an argument to be made that addictive substances consumed as food could be regulated as well. I do not know what that regulation should consist of, only that we have a tradition of regulating addictive substances, assuming that the individual is incapable of self-regulation in the face of addiction.

As is frequently the case, the questions that arise are more intriguing and clear than the answers.

Source: NCHS Data Brief ■ No. 114 ■ February 2013