By Dov Michaeli MD, Ph.D

It is a well-known phenomenon: people under stress hit the fridge, and gorge on candy and fatty food. A gallon of ice scream in one sitting is not unheard of. But people who think deeply about such things asked themselves: why don’t they (people under stress) gorge on veggies? And what is the nature of the connection between stress and obesity? Is it simply overeating equalsobesity, or is there a deeper connection, involving the brain? After all, stress is a mind thing.

The physiology of acute stress

Almost every physiological action in our body is controlled by two systems: the autonomic nervous system, and the endocrine system.

The autonomic nervous system has this name because it is, well, autonomic: it marches to its own drum, if you will, independently of our whims, wishes or commands. This system is made up of two sub-systems: the sympathetic and the parasympathetic. Basically, they are the Yin and Yang of the autonomic nervous system: the sympathetic nerves secrete noradrenaline, a close relative of adrenaline, and it does everything you’d expect it to do: it accelerates the heart rate, increases blood pressure, in short: it readies the body to react to acute stress situations. My favorite example: you spot a lion coming at you. You want to supply ample blood to your muscles so you can run for your life, or if you are foolish enough, fight the lion; hence the increase in heart rate and blood pressure. The parasympathetic system secretes the neurotransmitter acetyl choline , and it has exactly the opposite action: it slows down the heart and reduces blood pressure.

The endocrine system reacts to stress by releasing two ‘stress hormones’: cortisol from the brain and adrenaline from the adrenal gland. Their action is similar to that of the sympathetic nervous system: increase blood pressure and heart rate.

The other type of stress

So far so good; but how does increased heart rate cause obesity? The answer is: it doesn’t. What I just described is the response to acute stress, and our bodies are well-adapted to handle it. But modern life added another type of stress: chronic stress. And here, a peptide, called neuropeptide Y, or NPY, comes into play. Its existence has been known for several years, but its function was largely unknown. It is expressed throughout the brain, but is especially abundant in circuits that regulate feeding and response to stress. Not surprisingly, like many other brain hormones, it is also secreted in tissues outside the brain that are involved in metabolism; it is secreted by sympathetic nerve endings in adipose tissue. Its function there has only recently been defined by Kuo and his coworkers. It increases adipogenesis (formation of fat tissue) by triggering both the formation of new adipocytes (fat cells) from immature preadipocytes, and by increasing the blood supply to the adipose tissue by formation of new blood vessels (a process called angiogenesis). Even more intriguing: the new fat tissue was not formed just anywhere in the body; it was formed in the abdomen, and specifically around the internal organs of the abdomen. This is exactly the fat distribution that is implicated in the genesis of metabolic syndrome. And to clinch the case: it does it only under severe chronic stress conditions. When mice were subjected to 2 threatening and severe chronic stress protocols, they secreted NPY; when they were subjected to non-threatening mild stress—no NPY. In biological experiments demonstration of a relationship between the “dose” (e.g. severity of the chronic stress) and “response” (e.g. secretion of the peptide), lends credibility to the observation, simply because in biology almost everything is dose-dependent.

Why do we prefer sweets and fats?

The mice in the experiment secreted NPY only if allowed to eat fatty or sugary food. Regular mouse chow did not support secretion of the hormone even under severe chronic stress conditions. We know that high calorie food triggers the reward circuits in the brain. In fact, chronic feeding of high calorie foods activates all the circuits and brain centers that are involved in addiction. That, in turn, induces more eating, which increases the degree of addiction, which… you get the drift. Bottom line: obesity.

The details of the connection between secretion of NPY and high calorie food still need to be worked out. Why didn’t regular, low calorie food have the same effect? What are the specific neural circuits involved in this calorie/reward/peptide axis of evil? What is the mechanism for the specific accumulation of fat around internal organs? Will withdrawal of high-calorie food result in reversal of the accumulation of fat back to normal?

Obviously, many unanswered questioned are triggered by this research. But this is the hallmark of good science: every answer raises many more questions.

In summary

NPY is the link between stress and obesity. Its action:

• Secreted from the sympathetic nervous system only under conditions of chronic severe stress
• Increases adipogenesis by triggering adipocytes formation from preadipocytes, and by increasing blood supply to the adipose tissue
• Secreted only when high calorie diet is available
• Involves the activation of reward circuits in the brain
• And last but not least, it induced a state of metabolic syndrome (obesity, insulin resistance) in the experimental mice.

What is the relevance of this research to human obesity/metabolic syndrome?

Obviously, this phenomenon needs to be demonstrated in humans. Demonstration that NPY levels are markedly higher in chronically-stressed individuals will be a big step forward. Inhibition of secretion of NPY through drugs or stress reduction techniques will add weight to the hypothesis.

The big prize: demonstration of weight reduction through reduction of NPY secretion will be a boon to us and to our strained health care budget.

Here is a thought that may have occurred to you: can our increasingly stressful lifestyle be partly responsible for the obesity/metabolic syndrome epidemic?

Another thought: rather than wait for the results of these experiments to yield the ultimate proof, why not toss out all the sweets and high calorie foods, and stock the fridge with “good for you” veggies? No activation of the reward system in your brain=no NPY secretion. Not very appetizing solution, I know. I’d rather wait for the results of the human experiments, and then decide.

Epilogue

My estimate is that to carry out the required experiments in humans would cost about $10-20M. To develop and clinically test an NPY inhibitory drug could cost anywhere from $50-100M. Can the health care mavens quickly calculate what would be the ROI (return on investment) on this sum?

By Dov Michaeli MD, Ph.D

Phew…that was something. We ate and we ate, and drank and drank—I thought we are going to burst. Literally. I hope everybody in our Thanksgiving party (over 30 people) survived intact. Being a doctor, and a worrier, the thoughts of what could go wrong were never quite banished by the pleasures of gluttony. What dangers were going through my mind?

The burst stomach

Have you ever seen a snake swallowing a whole turkey? You can actually see the poor creature traveling through the long intestines of the tubular glutton. Well, a burst stomach is extremely rare, and happens only in rare conditions where the brain center controlling hunger and satiety is malfunctioning. Normal stomach capacity is about 8 cups, although it can range form 4 to 12, according to Dr. Edward Saltzman of Tufts Medical School, quoted in a New York Times article on the hazards of Thanksgiving. But for us regular gluttons, there are more common dangers lurking in stuffing our faces.

Heart attacks

This is probably the most serious problem of serious overeating. Here is what happens:

A normal meal of about 1500 calories sits in the stomach 1-3 hours, depending on the amount of fat in the diet; fat slows down stomach emptying. How is this night different from all other nights? The average American consumed yesterday 4500 calories and 229 grams of fat, according to the Calorie Control Council (full disclosure: they represent the makers of low-calorie foods). The average time to empty this humongous amount of fatty food is 8 hours. This in itself can cause only a sensation of fullness (loosen your belts) and flatulence (leave the room, please). But what goes on in your physiology is more serious: in order for the stomach and intestines to perform their job, they get an increased supply of blood coursing through the arteries and veins that supply them. This blood is diverted from vital organs such as the heart (vital for all of us) and the brain (less vital for some people I know). Now if instead of 1-3 hours the blood has to take an 8 hour detour, and a lot more blood diverted, to boot, and you can see the stress the heart and the brain are undergoing. In fact, if the blood supply to the heart is marginal to begin with, this massive diversion of blood volume will tip the balance and result in a heart attack.

To add insult to injury, the high fat content in a typical Thanksgiving meal results in a massive influx of lipids and triglycerides into the blood. This situation, called hyperlipidemia and hypertriglyceridemia, causes an increase in platelet aggregation. Those tiny cells, when sticking together to form a platelet clot, can cause blockage of the coronary precipitating, yes you guessed it, a heart attack. The combination of reduced volume of blood flow to the heart, and the increase in blood coagulability is more than additive; the risk is not 1+1=2, it is more like 1+1=10.

The gall of it all

In order to absorb dietary fat our digestive system needs to break it up into microscopically small particles. This is accomplished by the bile, a juice flowing from the gallbladder. Sometimes, the solids in the bile precipitate out and form gallstones. They can then occlude the bile duct, the narrow outlet from the gallbladder to the small intestine. When there is a lot fat in the diet, the hormone chlecystokinin signals that a large amount of bile is required. But if the bile duct is occluded the bile backs up, and the result is excrutiating abdominal pain that may mimic the pain of a heart attack.

What about the brain?

Here the consequences can be just as serious. The reason we feel drowsy after a heavy meal is that blood supply to the brain is reduced. This in itself never killed anybody. But add to this the amount of alcohol we consume with the meal—and put us behind the wheel, and you can see why the accident rate is sky high and Highway Patrol is out in force on Thanksgiving Day.

Before you rush to your computers to berate me for omitting your favorite culprit or theory, here is one subject you shouldn’t bother about: the urban legend that the amino acid tryptophan is the culprit of the meal-induced drowsiness. Tryptophan is indeed the precursor of melatonin, the sleep-inducing hormone. But the amounts required to increase significantly the level of melatonin are much higher than even the most outrageously gluttonous feast can provide.

Now that I told you how badly we behaved yesterday, did I restrain myself? As they say in New York, fuggeddaboudit; I stuffed my face and enjoyed every calorie of it. Today, though, starts the hard task of atoning for my sins. But I enjoyed it while it lasted. I hope you did too.

Dov Michaeli MD, Ph.D is in the biotech industry.

by Pat Salber

AGEs stands for “advanced glycation end products.” AGEs are promoters of high oxidative stress and, as such, they are known to play an important role in the development of cardiovascular disease in diabetics.

AGEs are produced by our bodies internally under certain conditions, such as hyperglycemia. They are also present in fairly high amounts in the typical Western diet. Research published in the Journal of the American Diet Association (Goldberg et al 2004) and in Critical Review of Food Science and Nutrition (O’Brien and Morrissey 1989), show that AGEs are present in high levels in dietary mixtures of proteins, lipids, and sugars processed under elevated temperatures, such as broiling, roasting, or grilling.

According to an recent article in Diabetes Care (October 2007), a single ingestion of a drink high in AGEs results in an immediate impairment of a normal blood vessel function – known as “flow-mediated dilation” or FMD. FMD is the expected dilation of arteries that occurs as a response to decreased blood flow (aka ischemia).

Impairment of FMD is widely accepted as an early indication of endothelial dysfunction, a precursor to atherosclerosis. It is postulated that repeated disturbances of endothelial function over time may lead to cardiovascular disease both in diabetics and non-diabetics.

The authors of the study, Jaime Uribarri and colleagues, had previously demonstrated that a diet rich in AGEs impaired FMD, however, because that diet also contained other substances that can cause the vasodilatory defect, they wanted to repeat the study using a “food” that was “free of carbohydrates or lipids or other known vasoactive substances.”

The researchers created the high AGEs food by combining caffeine-free Coca-Cola light with glucose and concentrating it by a rotary evaporation process. The article states that the resultant beverage is AGE-rich, but free of glucose or lipids (it’s not clear to me what happened to the glucose they added to the diet Coke—but heck, I am not a chemist so I just have to take the researchers word for this.)

Anyway, 44 diabetic subjects and 10 non-diabetic subjects got to drink this concoction to see what it did to their FMD. It turns out both diabetics and non-diabetics had a reduction of FMD after drinking the AGE-rich drink. There was no change in FMD when the subjects were asked to drink water.

The authors speculate that ingestion of diets rich in high-AGE foods could, over time, cause multiple insults to the body’s blood vessels and, eventually result in permanent endothelial dysfunction and overt vascular disease.

An accompanying editorial by Dandona et al, in the same journal point out that a reduction in FMD has been associated with an increase in cardiovascular risk. And that multiple studies over the past 10 decade have shown associations between diet and alterations in FMD. One study cited in the editorial (Plotnik et al, JAMA, 1997) documented a predictable reduction in FMD related to eating high-fat, high-carbohydrate fast food. This was prevented by pretreatment with antioxidants.

We are just beginning to scratch the surface of the relationship between ingestion of certain macronutrients and the relationship to insults to the vascular system. Although we know certain foodstuffs, such as saturated and trans-fats, are bad for us, this new line of research on AGEs opens up a whole new avenue to explore – the relationship between how we combine foods, process and cook foods and their impact on our vascular (and thus our entire body’s) health and well-being.

I look forward to exploring more research on this fascinating and important topic.

by Pat Salber

Perhaps the folks over at Hardee's fast food haven't heard the country is in the midst of an obesity epidemic.  They have just unveiled a new breakfast offering, the Country Breakfast burrito.  It consists of a two egg omelet filled with bacon, sausage, diced ham, cheddar cheese, hash browns and sausage gravy.  Surrounding this protein load is a flour tortilla.  The burrito weighs in at 920 calories.  That's right, 920 calories, about half of what you should ingest in a day.  This little baby also has 60 grams of fat.  All those calories and all that fat will only set you back $2.69.

According to a story by the Associated Press, Brad Haley, Hardees' marketing chief, says that the burrito offers the sort of big breakfast item normally found in sit-down restaurants with an added advantage.  "It makes this big country breakfast portable," he said.

Other Hardee offerings include the Monster Thickburger, a 1,420-calorie sandwich that contains two 1/3-pound slabs of beef, four strips of bacon, three slices of cheese and mayonnaise!  Want a healthy alternative?  Try the Hardees' chicken salad --it is only 1,100 calories and 83 grams of fat.  Supposedly, the chain does offer some low-calorie options, including roast beef and chicken sandwiches.

AP reports that the Center for Science in the Public Interest, a Washington-based advocate for nutrition and health, has called the Hardee's line of Thickburgers "food porn." I love it, food porn!

Jayne Hurley, senior nutritionist at the Center, said the burrito is "another lousy invention by a fast-food company."  The "country breakfast bomb," as she called it, represents half a day's calories and a full day's worth of saturated fat and salt, to say nothing of cholesterol.  "That's all before 10 o'clock in the morning," she said.

Hardees' Haley makes no apologies:  "We don't try to hide what these are," he said. "When consumers go to other fast-food places they feel like they've got to buy two of their breakfast sandwiches or burritos to fill up. This is really designed to fill you up."

Way to go, Hardees.  Keep on fillin' us up.

By Dov Michaeli MD, Ph.D

Some of the health advice we come across in the media and the internet is so outrageous it borders on quackery; no, it is quackery. If it wasn’t so dangerous it would be hilarious. So I thought we should all share in the hilarity. But before we proceed, a disclaimer: the following is based on actual Q and A, but the author took  literary license to highlight their innaneness (there, I finally got to use this word). So here goes:

HEALTH QUESTION & ANSWER SESSION
Q: I've heard that cardiovascular exercise can prolong life; is this true?
A: Your heart is only good for so many beats, and that's it... don't waste them on exercise. Everything wears out eventually. Speeding up your heart will not make you live longer; that's like saying you can extend the life of your car by driving it faster. Want to live longer? Take a nap.

Q: Should I cut down on meat and eat more fruits and vegetables?
A: You must grasp logistical efficiencies. What does a cow eat? Hay and corn. And what are these? Vegetables. So a steak is nothing more than an efficient mechanism of delivering vegetables to your system. Need grain? Eat chicken. Beef is also a good source of field grass (green leafy vegetable). And a pork chop can give you 100% of your recommended daily allowance of vegetable products.

Q: Should I reduce my alcohol intake?
A: No, not at all. Wine is made from fruit. Brandy is distilled wine, that means they take the water out of the fruity bit so you get even more of the goodness that way. Beer is also made out of grain. Bottoms up!

Q: How can I calculate my body/fat ratio?
A: Well, if you have a body and you have fat, your ratio is one to one. If you have two bodies, your ratio is two to one, etc.

Q: What are some of the advantages of participating in a regular exercise program?
A: Can't think of a single one, sorry. My philosophy is: No Pain...Good!

Q: Aren't fried foods bad for you?
A: YOU'RE NOT LISTENING!!! ... Foods are fried these days in vegetable oil. In fact, they're permeated in it. How could getting more vegetables be bad for you?

Q: Will sit-ups help prevent me from getting a little soft around the middle?
A: Definitely not! When you exercise a muscle, it gets bigger. You should only be doing sit-ups if you want a bigger stomach.

Q: Is chocolate bad for me?
A: Are you crazy? HELLO . Cocoa beans! Another vegetable!!! It's the best feel-good food around!

Q: Is swimming good for your figure?
A: If swimming is good for your figure, explain whales to me.


Q: Is getting in-shape important for my lifestyle?
A: Hey! 'Round' is a shape!


Well, I hope this has cleared up any misconceptions you may have had about food and diets.

Finally, an exercise regimen I found in a Man's Health magazine. I have been following it religiously:

You have to give this a try, it really works.

This exercise is suggested for mature adults, to build muscle strength in the arms and shoulders. It seems so easy, so I thought I'd pass it on. I suggest doing it three days a week.
Begin by standing on a comfortable surface, where you have plenty of room at each side. With a 5-lb potato sack in each hand, extend your arms straight out from your sides and hold them there as long as you can.

Try to reach a full minute, and then relax.

Each day, you'll find that you can hold this position for just a bit longer. After a couple of weeks, move up to 10-lb potato sacks. Then try 50-lb potato sacks and then eventually try to get to where you can lift a 100-lb potato sack in each hand and hold your arms straight for more than a full minute. (I'm at this level)

After you feel confident at that level, put a potato in each of the sacks.

And remember:

"Life should NOT be a journey to the grave with the intention of arriving safely in an attractive and well preserved body, but rather to skid in sideways - beer in one hand - chocolate in the other - body thoroughly used up, totally worn out and screaming "WOO HOO, What a Ride"

Dov Michaeli MD, Ph.D is in the biotech industry and is a nut when it comes to diet and exercise.

By William H. Bestermann Jr. MD

Type 2 diabetes is a condition that costs Americans terribly in terms of death, disability, and health care expenditures. This chronic condition is a vicious cycle type of illness. Glucose control tends to deteriorate over time. Most of these patients also have problems with blood pressure and cholesterol. Only about a third of type 2 diabetics have their pressure, sugar, or cholesterol under control as individual risk factors. Only 7% have all three risk factors controlled simultaneously to conservative goals. This sad fact has dramatic consequences. The lifetime risk of a diabetic having a heart attack or a stroke is 80%. For each risk factor that is controlled to goal using the right medication, the risk is reduced by roughly half—so when we control pressure, sugar, and cholesterol the risk is reduced from 80% to 40% to 20% to 10%. Now maybe the risk is not really 10%, but it is very dramatically reduced and in 10 years of experience with 450 diabetics, I believe that I have seen a very important reduction in vascular events that has been achieved by aggressively controlling these risk factors..

Everything bad that happens to a diabetic is fundamentally arterial or vascular. Obviously the heart attacks, strokes and amputations are vascular, but even the kidney, nerve and eye damage relate to arterial damage as well. So the target here is not just the sugar or the cholesterol. The fundamental question is “how do we lower the sugar, cholesterol and pressure with the maximum benefit on the artery?” Furthermore, how do we accomplish this in such a way that the patient’s life is minimally altered and this is sustainable.

In this post, I will focus on sugar control. Everyone agrees that type 2 diabetes is at its core a life-style illness. As one of my colleagues in South Carolina said: “There is nothing that we can do for diabetes that you cannot outrun with a spoon.” In other words, if the patient does not make some effort with diet and exercise, it is difficult and perhaps impossible to get risk factors to goal. I have controlled the sugar in disabled patients, but it is more difficult. Type 2 diabetes is a disease of elevated blood sugar. It is self-evident that sugar consumption must be limited. Less widely appreciated is the impact of starch or carbohydrate consumption. Processed starch becomes sugar in 2 minutes once it is consumed. When a person eats 100 calories of white rice, in 2 minutes it is just as if he took a spoon and ate 100 calories of sugar out of the sugar bowl. The less processed a carbohydrate, the more slowly it is consumed.

Some understanding of nutrition is vital. Formal dietary instruction by a certified diabetic instructor is helpful but I see substantial variation in what patients are told. As a practical matter I have found the South Beach diet to be very useful and just bought the book for a friend at Walmart for $12.00. I have recommended that diet for patients and found it very effective with sustainable effects on weight and sugar control. Dr Agatson, the author, is a cardiologist famous for developing the cat scan calcium score we use to determine cardiac risk. He teaches two very important concepts. First, we have to learn to limit starch and to eat our starch in the form of whole foods. Second, we need to limit fats, especially animal fats and trans fat. This program is attractive because it is effective, widely available, and supported by recipe books and pre-packaged items.

Next we come to drug therapy. Doctors are trained in the treatment of diabetes with medication by learning about all of the medications that are available, and then they are left to decide which of these many medications they will use and in what order. There are several different classes of oral drugs with multiple drugs in each class. There are multiple types of insulin with differing durations of action. There is no real protocol that is universally agreed upon as best practice.

Type 2 diabetes is the later stage of the metabolic syndrome. Most type 2 diabetics have been metabolically abnormal for decades. They have been resistant to the effects of insulin for years and just before they become diabetic they have been maintaining their normal sugar by producing levels of insulin in the blood that are three times normal. As time goes on they are unable to sustain that level of insulin production and when insulin levels fall the sugar begins to rise. At the time of diagnosis, insulin production has fallen by 50% and the loss of the ability to produce insulin is aggravated by poor sugar control—a built-in vicious cycle. When it comes to diabetes, we just do too little too late.

In recognition of this fact, there was a recent consensus algorithm published in Diabetes Care. This is a joint statement from the American Diabetes Association and the European Association for the Study of Diabetes. They emphasized the importance of diet and exercise as first therapy. Most notably in my view the authors went on to say, “The authors recognize that for most individuals with type 2 diabetes, lifestyle interventions fail to achieve or maintain metabolic goals, either because of failure to lose weight, weight regain, progressive disease, or a combination of factors. Therefore, our consensus is that metformin therapy should be initiated concurrent with lifestyle intervention at diagnosis.” Most medications for diabetes cause weight gain. Metformin has modest effects in assisting with weight reduction and it is the only medical treatment for diabetes that is proven to lower the incidence of heart attack and stroke by 40%. That effect is on a par with the best cholesterol and pressure treatments.

If treatment with metformin fails, it is generally because insulin production is at least relatively inadequate. The most effective and rational next step is to instruct the patient in a self-adjusted insulin shot using Lantus or Levemir. In the protocol I use, the patient is able to rapidly bring the sugar safely down and most patients are at goal with this reasonably simple approach. It seems to me that the proven vascular benefits of metformin would be preserved in these patients since all we are doing is replacing insulin that they cannot make themselves. Most patients are really surprised at how easy this is to work with and how much better they feel when their sugar is controlled.

Brian Klepper 

Over at Health Care Policy and Marketplace Review, the always insightful Bob Laszewski drew my attention to the release of a new report from The Trust for America's Health , F as in Fat: How Obesity Policies Are Failing in America. This 120 page document, funded by the Robert Wood Johnson Foundation, provides an update on how obesity is ravaging America's health and productivity.

The facts about America's obesity problem aren't new.  They continue to be grim and worsening:

• Two thirds of American adults are now overweight or obese.
• Adult obesity rates exceed 20 percent in 47 states.
  
• In the past year,  the obesity rates increased in 31 states; no state improved
  
• Obesity is at the root of an array of our most expensive major diseases that will generate huge costs for care and lost productivity.
• 85 percent of Americans believe obesity is a national epidemic.
• So far, neither Congress nor our nation's business leaders have recognized this problem as a priority or developed a comprehensive plan to combat it.

Mr. Laszewski rightly argues that the insidious nature of this problem warrants national action, and that we should develop a pro-health/anti-obesity campaign that follows the example of the very successful anti-smoking campaign a few years back. Absolutely true.

While The Trust for America's Health (TFAH) report is honest and an honorable effort at consciousness-raising, I'm afraid I found their approach and call-to-action disappointingly vanilla and almost certainly ineffectual.  TFAH focuses primarily on describing community-based programming that might promote healthy habits and discourage bad ones.

This is fine, I guess, as far as it goes, but it is a form of passive resistance that doesn't really acknowledge or address corporate money and influence as at least partial roots of the problem. Except for a couple quick references, this report doesn't really dwell on the fast, prepared and junk food industries, on the advertising techniques used to seduce children and adults, or on the business leadership that will be required to turn this around.

Mr. Laszewski refers us to the work of Ken Thorpe, an Emory University health economist who has done a good deal of work on the relationship between obesity and health care cost. He quotes Dr. Thorpe:

"The obesity epidemic has caused a tenfold increase in the nation's private health insurance bill for conditions related to being overweight, according to a self-funded study by researchers with the Emory University Rollins School of Public Health. According to the study the cost of treating conditions linked to obesity increased from $3.6 billion to $36.5 billion between 1987 and 2002. The study concludes that the best way to lower healthcare spending is to target the rise in population risk factors -- especially obesity."

"Current approaches to controlling healthcare costs are not working because they ignore the true drivers of those costs,' Dr. Thorpe says. 'Increases in the number of people getting treatment for serious health problems like diabetes, heart disease, high cholesterol and mental disorders are directly linked to population increases in obesity. If insurers and employers are serious about reining in health care spending, then obesity prevention should be at the top of their agenda."

In a recent post, I recounted how a good friend, a preventive cardiologist, told me that, when it came to my body's propensity to lay down plaque in my vessels, I wasn't taking the problem seriously. That woke me up, and I've made a lot of efforts since then to turn the problem around.

The junk food problem is obvious and, in a sense, no less dangerous to the nation's welfare than if it were crack cocaine. It will drain our financial resources and cripple the nation's ability to be productive. Under our form of government, where lobbying dollars drive how policy works, the answer is clear. Our business leaders can take this problem seriously, overwhelm the food industry's behaviors, and reshape policy to diminish the impact of advertising and make healthy living a positive cultural value. Or we can surrender the nation to the pushers who feed our addiction. It really isn't a lot more complicated than that.

I have spent a good deal of my career synthesizing the terrific information created by researchers and translating it to decision-makers. At some point, problems and their solutions become extremely well understood, and further efforts to describe the problem are, in a sense, superfluous.

Like the larger health care crisis, the obesity crisis is now very well understood. While updates on the status of the issue are always welcome, what is really needed is a deeper understanding of the problem's power dynamics, and the formulation of mobilization plans to address them. If we don't intend to address the obesity problem directly - at the level of corporate power and influence - then all the updates in the world won't matter.

Brian Klepper (904.246.9643 o, bklepper@gmail.com) is a health care analyst and advisor based in Atlantic Beach FL. 

by Pat Salber, MD

While not nearly as high profile as TV’s “The Biggest Loser,” the National Weight Control Registry has helped researchers gain a better understanding of what it takes to lose a significant amount of weight (at least 30 pounds) and keep it off (for at least a year).

The Registry was started in 1994 by Rena Wing, Ph.D. from Brown Medical School, and James O. Hill, Ph.D. from the University of Colorado. According to the NWCR website, it is the largest prospective investigation of long-term successful weight loss maintenance in the country.  Individuals who meet the criteria of “successful losers” self-report information about their dietary, exercise, and other lifestyle habits. Although not a randomized, controlled clinical study (the “gold standard” in research), there is nevertheless some valuable information to be gleaned from this weight control registry.

According to results reported by lead investigator, Suzanne Phelan, PhD, at the June 2-5, 2007 Endocrine Society meetings in Toronto, 89% of 4,200 registry participants lost weight with diet and exercise. Ten percent used diet alone and 1% exercise alone. The average age of the losers was 47 years old; 77% were female, 95% Caucasian, 64% married and 82% college-educated.

Nearly half the registrants lost weight on their own, not relying on outside help such as weight loss programs or counselors. Strategies included restricting certain foods, such as deserts (87%), portion control (44%); counting calories (43%), counting fat grams (25%), and using liquid meal-replacements (20%).

The August 2007 issues of DOC News, a publication of the American Diabetes Association, reports that Phelan and her team identified a number of other key strategies:

• Low cal, low fat. Participants reported an average energy intake of about 1,300 calories per day with about 20-30% of those calories from fat. To put this in perspective, this is about the amount of calories you get when you lunch on a Big Mac with medium fries and a Coke.
• Lots of physical activity. These losers reported burning about 2,600 calories per week (walking 5 miles or engaging in 30-90 minutes of physical activity per day).
• Limited TV viewing. More than half of the participants watched fewer than 10 hours of TV per week. Only 21% watched more than 21 hours weekly. The average American watches about 28 hours/week. [Note: Not only did these folks have more time to exercise, they also may have been able to avoid the compulsive eating associated with eating while viewing.]
• Frequent self-weighing. Seventy-five percent reported weighing at least once a week. Forty-four percent weighed daily and 31% weekly.   Click here for more information on this important weight control behavior.
• Dietary consistency. Participant tended to eat the same type and amount of food on weekends and holidays as during the work week.
• Limited dietary variety. Many participants restricted their choices within food groups.
• Don’t skip breakfast. Almost 80% of participants reported eating breakfast every day.
• Limited fast food. Participants rarely ate fast food – consuming less than one such meal per week (see bullet one to see why this is important!)

National Weight Control Registry participants did not take their weight loss and maintenance for granted. They had to work at it. But they did report that the perception of the effort required decreased over time. It becomes a way of life.

If you are interested in learning more about the National Weight Control Registry visit www.nwcr.ws/ . If you are a successful loser, consider becoming a registrant - help contribute to our national knowledgebase of what it takes to take it off and keep it off.

Brian Klepper 

How do you live a long life? Take a two-mile walk every morning before breakfast.

Harry Truman
33rd US President, who lived to 88

DAWN, n. The time when men of reason go to bed. Certain old men prefer to rise at about that time, taking a cold bath and a long walk with an empty stomach, and otherwise mortifying the flesh. They then point with pride to these practices as the cause of their sturdy health and ripe years, the truth being that they are hearty and old, not because of their habits, but in spite of them. The reason we find only robust persons doing this thing is that it has killed all the others who have tried it.

Ambrose Bierce, The Devil's Dictionary 

I started taking long walks with my close friend Bob thirty-five years ago when we were students in Holland. We would walk and discuss the things that young people ponder, passing time in the brisk beautiful outdoor landscape of Northern Europe. We always maintained a quick pace, but never minded the effort, because the activity was filled with ideas and always-inviting scenery.

When I returned home, walking was a habit that stuck with me. When Bob and I lived in the same town, we'd get together regularly to walk the dogs. On my own, I found that I could go out for a stroll and think, chewing on whatever I was working on and, getting a little distance from it, find perspective. Elaine and I still walk, constantly, and that's where we get some of our best talking in. Walking has been respite from the rush, a place to hash out conflicts or work out plans, a way to meditate and regain balance.

When I left my post at the University of Florida about 20 years ago and returned home, I traded a landlocked town for the coast. As quickly as I could, I resettled within a few blocks of the beach in a small community on an island off Jacksonville, in Northeast Florida. Then, as now, I was literally within a five minute walk of a 300 foot wide, hard-packed, sugary white sand beach on the Atlantic, stretching for miles both north and south. In addition to the spectacular, always changing beauty of a vibrant seascape - birds, dolphins, turtle nests, fish and other sealife; the boats and ships just offshore; the surf rolling in and lapping the beach - it was perfect terrain for a habitual walker.

Even so, as easily accessible as it is, and though I know lots of people long for just this sort of environment, there have been periods when I lost my discipline, when I took the opportunity for granted and somehow just didn't get around to it.

Then came the moment 5 years ago when I unexpectedly had open heart surgery, a 5 vessel CABG, the result of lousy genes and the gradual relentless buildup of plaque choking off my blood vessels. During the procedure they collapsed and then re-inflated my lungs, and I knew it would take work to ameliorate my shortness of breath. I started walking again immediately, through the halls, on the second day in the hospital following my surgery, and by the time I left 3 days later I was up to walking more than a mile a day.

I continued when I returned home and worked through recovery, and though increasing my distance went slowly, I kept at it. During a follow-up with my surgeon, he commented, "The best thing you can become is a walking fool. It's low impact, steady and its good for you in all kinds of ways, especially with what you're up against."

And then, again, time passed and I got comfortable and distracted. I skipped my walks and then they trickled away, until I was just walking weekends again. I told myself that I was really in OK shape, but the truth was that I put on weight and that I had slipped into a malaise.

Recently, I had a discussion with a good friend, a preventive cardiologist, who gave it to me straight. I had shared the numbers from my last blood panel. "Look," he said, "you're not taking this seriously. Unless you get your LDLs (the bad cholesterol) down below 60,  you're going to continue laying down plaque, and the risk increases. If you're interested in doing what you can do, you need to get religion on this. Get lean. Eat carefully and ramp up your exercise."

And so I have.

This isn't just theory. Below is a picture from the REVERSAL Trial, led by Steven Nissen MD, chief of Cardiology at Cleveland Clinic. It clearly shows the before and after effects of managing LDL to below 60. After 18 months of the reduced LDLs, there's been a significant opening of the vessel. This is what I'm shooting for.

So we've cut out most breads and sweets. Cookies are out. Our diet is mostly fruits, veggies and fish. Once you get your head around it, it makes sense and you gradually lose the longing for the comfort foods: a milk shake, macaroni and cheese, or a fried fish sandwich.

And then there's the walking. It's a flat 3 miles, 50 minutes door-to-door, down to the lifeguard station on the beach and back, walking fast. Right now, in the NE Florida swelter, I'm soaked through when I return. I do this twice a day. On my suburban beach, around 6AM, there are 200 people out there walking before work. After work, you see  a lot of them again.

 An embarrassing quantity of pounds has melted off. I'm becoming leaner and stronger than I've been in years. The next blood panel will tell. When I'm tempted by some forbidden food, I think of 60 and my will to shrink the plaque that's strangling my vessels.

And I walk.

Brian Klepper 

Here's news to warm the heart of every fast food executive, but that, if the world were a sensible place, should jolt parents, school administrators and non-food industry business leaders out of their nutritional malaise. The New York Times reported this morning on a small sample taste test with 63 children ages 3-5. When presented with different foods - hamburgers, chicken nuggets, french fries, carrots - the kids invariably thought the ones in McDonald's packaging tasted better.

Naturally, the McDonald's people were thrilled, and at the ready with corporate spin. The goal, you see, is to have kids associate good tasting foods with McDonald's, and then McDonald's will gradually introduce foods that aren't so terrible  for them.  Clever, huh? From the article:

Walt Riker, a McDonald’s vice president, said in an e-mail message that “this is an important study and McDonald’s has been actively addressing it for quite some time.

“In fact,” he said, “McDonald’s own ‘branding’ of milk, apples, salads, and other fruits and vegetables has directly resulted in major increases in the purchases of these menu items by moms, families and children.”

This seems like a good time to address people who insist that, if kids are raised right, then they'll make responsible choices. I hope its doesn't rain on your philosophical parade, but so far, it looks like the safe bet is on the people with advertising dollars and the sophisticated techniques for persuasion. McDonald's is winning. Our children are losing.

by Brian Klepper

I routinely hear well-intentioned people say that, if Americans, and most particularly kids, would just become more responsible for their own health and start eating right, then our obesity and diabetes epidemics would turn around.

I don't think this is going to happen, at least not anytime soon. The blunt truth is that, to a large degree, we have an obesity epidemic because Congress ensures that the food industry has free rein with their marketing practices.

Late last year, Pat Salber wrote a post – she had a corresponding video commentary on Medscape – on advergaming. An important study had been released on the Kaiser Family Foundation website that detailed how food companies were using the Web to influence kids' eating behaviors, building on their TV advertising tactics. Here's a quote from the press release:

The report, “It’s Child’s Play: Advergaming and the Online Marketing of Food to Children,” found that more than eight out of ten (85%) of the top food brands that target children through TV advertising also use branded websites to market to children online. Unlike traditional TV advertising, these corporate-sponsored websites offer extensive opportunities for visitors to spend an unlimited amount of time interacting with specific food brands in more personal and detailed ways. For instance, the study documents the broad use of “advergames” (online games in which a company’s product or brand characters are featured, found on 73% of the websites) and viral marketing (encouraging children to contact their peers about a specific product or brand, found on 64% of sites). In addition, a variety of other advertising and marketing tactics are employed on these sites, including sweepstakes and promotions (65%), memberships (25%), on-demand access to TV ads (53%), and incentives for product purchase (38%).

In 2005, Consumers Union issued a report on the food industry's advertising campaigns. That press release headline read:

Certainly, the data say we're losing the war on obesity. Data from two National Health and Nutrition Examination Surveys show that the prevalence of obesity in adults (aged 20–74) more than doubled between the end of the 1970s to the early 2000s (from 15.0% in the 1976–1980 survey to 32.9% in the 2003–2004 survey).

Children and teens also grew significantly plumper. The prevalence of obesity in children 2–5 years rose 2.5 times, from 5.0% to 13.9%; for those aged 6–11 years it nearly tripled, from 6.5% to 18.8%; and for the 12–19 year olds, it more than tripled, from 5.0% to 17.4%.

It's worth noting that, while obesity has intensified throughout the country over the last several decades, certain areas, like the South, are consistently worse than elsewhere. This is traceable in part to regional dietary habits that, of course, long predate the food industry's influence, as well as to the role of poverty.

Percentage of Obese Americans - 2005

BMI > 30, or ~ 30 lbs. overweight for 5'4" person

Source: Centers for Disease Control, Behavioral Risk Factor Surveillance System, 20006 

(If you're interested in seeing the CDC's 20 year (1985-2005) annual trend data on overweight by state, go to http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm, and look for the link that says "Download the Obesity Trends Map." Play the slides in quick sequence. It's very alarming to watch as the entire country lights up, reflecting how quickly we're getting fatter.)

The reality is that most of us are susceptible to the marketing, and can't withstand the barrage of enticements. And they're everywhere. Every day, Americans are bombarded by come-ons for fast, prepared and junk foods. This diet has become part of many people's regular routine. The industry now vies to subsidize school districts in exchange for the unrestricted ability to advertise, put in vending machines and have their products available in cafeterias. They have developed books for very young children with appealing characters to create brand loyalty early on,

And except for the unhealthy part, what's not to like? These foods are cheap, readily available and, lets face it, all that salt and fat taste really good. Only the most optimistic among us can imagine that, unless something dramatic changes, we'll be able to reverse our love affair with bad food. Nor will any of the other developed and developing countries that all have the same problem.

The food industry has virtually unrestrained promotional access because Congress has willfully ignored their role in the obesity problem, preferring instead to argue that if people were just more responsible as individuals, they'd get this under control. (A quick glimpse of our Congressional representatives shows that, when they preach restraint and self-control, they're talking about us, not themselves.)

 The threats are to the national health and the national pocketbook. At the moment, for example, diabetes and related conditions alone cost Americans about $165 billion a year, about 8 percent of the national health care spend. And we're just getting going. As the population gets fatter, this is going to be a blockbuster national health care problem. Nobody will be able to afford what, in today's terms, we'll be expected to pay to keep all these people alive, semi-well, and consuming.

Congress has good reason to advocate for the food industry, in the form of millions of dollars in lobbying funds that go to buy influence. Skeptical? Go to www.opensecrets.org, the site of the Center for Responsive Politics, a non-partisan group dedicated to accountability in government, and do some checking yourself. Big dollars from the food, beverage, candy and restaurant industries to Congress, part of the larger $2,5 billion dollars that were distributed in 2006 to our 535 representatives. This is the way it is with virtually all special interests. Most effective groups lobby. Why? Because it works!

There are, of course, precedents for change. Congress decided that the tobacco and alcohol industries would be limited in where and how they could advertise, actions that have had profound impacts on America.

It's absolutely in the national interest to turn this problem around. But unless we have dramatic change from elsewhere – chemical concoctions that make junk food taste as good but have no ill effects, or some miraculous national consciousness-raising (Not impossible. Check out the teen fitness program Dance Dance Revolution or consider how the green movement is sweeping across the globe.) – we won't change our obesity and chronic disease problem. To fix that, we'll need a change in how the food industry behaves. And to get that, we'll have to change how our government works.

(The same is true, by the way, for health care reform, but that's another post.)

Brian Klepper is a health care analyst based in Atlantic Beach, Florida. You can reach him at bklepper@gmail.com.

Alli (pronounced "ally") was approved by the FDA in February and will hit the shelves tomorrow.  About half of people in clinical trial studies were able to lose approximately 5% of their body weight in six months.  The medication is supposed to be taken three times a day and will cost about $50 per month. 

Sounds good?  Yeah, but the devil is in the details -- or, in this case, in the side effects.  

This "fat-buster" may not become a blockbuster for its manufacturer, GlaxoSmithKline.  Here's why from an "oldie, but goodie" TDWI post from February 7, 2007:

If you can deal with the "icky" factor, Alli may help you lose weight

Pat Salber, MD

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Is "Accomplia" the next silver bullet in weight control?     (Note:  On February 13, 2007, a U.S. Food and Drug Administration panel Wednesday unanimously rejected Acomplia, a weight-loss drug from Sanofi-Aventis  on concerns the drug increases the number of psychiatric events like depression and suicidal thinking among users.

On February 7, the Food and Drug Administration (FDA) approved the first drug for weight loss that is scientifically proven to be effective to be sold over the counter (AKA OTC). That means you can buy it when and where you want. It also means experts deemed the drug safe enough that mere consumers can decide for themselves whether or not they want to use it.

The drug’s generic name is orlistat. It will be marketed under the brand name of Alli. (Alli?) The brand name of orlistat available by prescription is Xenical. It turns out it Xenical has not been a blockbuster for its company, Roche, despite being relatively safe and modestly effective – the average weight loss is 5-10% of body weight).

Here’s why. orlistat works by blocking the breakdown and absorption of fat from the intestine. If you eat a lot of fat while taking the drug, it does not get broken down and absorbed from your gut. That means it stays inside of the intestines and is eventually passed (if you know what I mean) as a greasy stool that floats in the toilet bowl, generally making a mess. The unmetabolized fat that you ingest can also be passed when you fart (sorry, have flatulence). That means smelly, oily, fecal stains on your underpants. I am sorry to be so graphic, but that is just the way it is. Oh, by the way, if you take orlistat, you also have to take a multivitamin because orlistat-induced fat malabsorption can impair absorption of fat-soluble vitamins, vitamin A, E, D and K.

For some people who are motivated to lose weight, these nasty side effects are enough to make them avoid fatty foods. That is good since fat is the biggest calorie bomb of all of the nutrients we ingest. However, lots of folks continue to eat fat and choose instead to give up the orlistat instead.

The FDA, in its wisdom, has approved over-the-counter orlistat to be sold in 60 mg doses, half of the usual prescription dose of 120 mg – like consumers can't figure out that taking two OTC pills is the same as taking one of prescription dose pills. Duh?

Roche has licensed orlistat OTC, Alli, to GlaxoSmithKline (GSK), a pharmaceutical co