By Dov Michaeli MD, Ph.D

In 2005 National Geographic magazine had a fascinating article by Dan Buettner, about the “Blue Zones”, areas where people live to the ages of 90, 100 and older. These areas included Loma Linda, CA, Sardinia Italy, Okinawa Japan, and the Nicoya peninsula in Costa Rica.

He followed up his trip to Costa Rica with a more extensive visit, including a team of researchers, in 2007.

One of the pitfalls of studies of this sort is the verification of claims of age. For instance, a claim that made a big splash in the media several years ago concerned Bulgarian villagers who claimed that their secret to longevity is eating yogurt. A craze of yogurt swept the U.S. following publication of this story, which I am not sure has completely disappeared. That "study" was discredited because of the lack of age documentation and the exaggerated claims of extreme age because of the social benefits it provided. But in the case of Buettner’s expedition in Costa Rica, birth certificates, as well as records of the University of San José C.R. were used to verify the claims of age.

What they found

Actually, nothing extraordinary; their findings strengthened findings of other studies.

• Have a strong sense of purpose. Costa Rican centenarians have a clear mission in life, what they call plan de vida. They feel needed and want to contribute to a greater good. Interestingly, this was the salient finding in the Okinawan centenarians as well.
• Drink hard water. Nicoyan water has the country’s highest calcium content. We know from other studies that calcium is important not only for maintaining strong bones, but also for maintenance of cardiac health. There is also accumulating evidence that calcium is important in reducing the risk of colon cancer.
• Keep a focus on the family. Nicoyan centenarians tend to live with their families, and children or grandchildren provide support and a sense of purpose and belonging. Again, identical to the Okinawan centenarians.
• Eat a light dinner. Eating fewer calories appear to be one of the surest ways to add years to your life. Nicoyans eat a light dinner early in the evening. Many studies in animals amply documented the effect of caloric restriction on longevity. Their traditional diet of fortified maize and beans may be the best nutritional combination for longevity the world has ever known
• Maintain social networks. Nicoyan centenarians get frequent visits from neighbors. They know how to listen, laugh, and appreciate what they have.
• Work hard, physically. Centenerians seem to have enjoyed physical work all their lives. They find joy in everyday physical chores.
• Get some sensible sun. Nicoyans regularly take in the sunshine, which helps production of vitamin D. This vitamin is crucial for maintenance of strong bones, a healthy heart, and reduced risk of GI cancers. Of course, you’ve got to be sensible about it; stay too long in the sun and your risk of developing skin cancers, including melanoma, goes up significantly.
• Embrace a common history. Nicoyans are aware of their roots and their spiritual traditions. This is another factor in maintaining their low-stress life.

So there you have it. Don’t overeat, exercise, and don’t worry—be happy.

Oh yes, one more thing which the Nicoyans did not tell us: choose your parents very carefully.

Brian Klepper 

I was on the phone with my good friend, fellow TDWI columnist Bill Bestermann MD yesterday.  Dr. B, a preventive cardiologist who is passionate about the underlying mechanics of cardiovascular disease and the horrific toll the American diet and lack of exercise is taking on everyday people, lives in spectacularly beautiful, rural Kingsport TN. He told me he was driving through town, channel surfing on his radio, and he happened upon the station that broadcasts information for the local schools. They were announcing the menu in the school cafeterias. He said it was appalling. "Honeybuns and processed foods. It was all the stuff I tell my patients to avoid."

Never one to shrink from suggesting that other people embark on courageous courses of action, I urged him to ask for a meeting with the School Board to lay out what the long term effects of this diet are on the children of the region. "Think in terms of leveraging your credibility as a trusted authority," I advised.

Many school boards have defaulted to whatever's most financially expedient in their school cafeterias. They take money from junk food companies and, in exchange, give the firms free access to the kids with vending machines and ads. They ignore the rising tide of obesity and chronic disease that threatens the kids and their future.

Imagine if a doctor or, better yet, a small army of local doctors, waltzed in and explained the impacts of the school menu to the Board and, if possible, the community, through the local newspapers, TV and radio stations. Then they could make recommendations for a diet that would be acceptable to kids while providing actual nutrition. (And while they're at it maybe they could explain why getting rid of gym and other physical activities is moronically penny-wise and dollar foolish.)

Physicians shouldn't underestimate their power in this. While physician credibility has waned in recent years as the health care crisis has intensified, a 2003 study found that Americans still trust their physicians more than any other relationship outside of family.

It's not like this is a small problem. In my talks I flash my favorite obesity slide, an image generated by the gifted illustrator Wellington Grey. (When it comes up on the screen and the audience begins to absorb it, you can always hear embarrassed laughter ripple through the crowd.) It shows the percentage of adults over age 15 in a variety of developed countries with a body mass index over 30 (that is, who are obese). Americans, at 31%, are far and away the fattest people, with Mexico and the UK trailing distantly at 24% and 23%, respectively. The French, Austrians and Italians are at 9%, and the ridiculously trim Koreans and Japanese are at 3%.

This slide tells us everything we need to know about America's future competitiveness. If obesity is a general predictor of health, health is related to productivity and productivity to competitiveness, we're toast.

To turn this around, we need leadership. If not from doctors, our most trusted professionals, then from whom? This is really a problem that local medical societies ought to wave the flag on. It might create the impetus for real change, and remind people that their doctors do really want what's best for us all.

Brian Klepper 

Some things are timeless. I remember watching Jack La Lanne, the TV health fitness evangelist, when I was a boy, 45 years ago. My Mom would turn him on, and would occasionally bend and stretch with his show. You couldn't help but admire his strength and vitality. It was clear he was doing something that everyone ought to do.

It turns out, of course, that his advice - exercise and diet - was solid then and is solid now. Now 93, Mr. La Lanne's life and achievements are chronicled in, of all places, the Costco Connection. If nothing else, in checking out this article you'll learn, for example, that in 1956, at age 42, he set a new world record by doing 1,033 pushups in 23 minutes on the TV show You Asked For It. Or that in 1984, at age 70, handcuffed and shackled, he swam 1.5 miles in the Long Beach, CA harbor, towing 70 boats carrying 70 people.

Stunts aside, its worth getting a glimpse of this remarkable individual, equal parts health expert, showman and true believer, who by discipline and saavy introduced the American public to the idea that everyone could be fit and healthy. Be sure to look for the photo of him exercising on a common chair, conveying that no special equipment is needed, that anybody can get down to business.

Like an even earlier fitness guru I pointed to last August, Bernarr Mcfadden, "The Father of Physical Culture," Mr. LaLanne's life is an inspiration to us all.

By Dov Michaeli MD, Ph.D

“Go to the ant, my son

Observe her ways

And wisen”

King Solomon, Proverbs (free translation).

Undoubtedly you have seen pictures of those emaciated characters who practice calorie restriction in the name of living a long, long life. The normal daily diet of an adult male contains about 2000-2400 calories. The ‘calorie restriction’ people limit their diet to about half of that. They may live longer, but are they happier? Hard to tell; they are going to die hungry but maybe also happy, for the ordeal is finally over.

One of the organisms that provided the ‘intellectual’ basis for this cruel and unusual experiment in long living is called C. elegans.

Where in the world is C. elegans?

Caenorhabditis elegans (Caeno, recent; rhabditis, rod; elegans, nice), is a free-living, non-parasitic soil nematode that can be safely used in the laboratory and is common around the world. It is small (about 1 mm in length) and has a short life cycle. From egg to egg takes about 3 days, and its life span is around 2 to 3 weeks under suitable living condition. What is unique to this organism is that wild-type (normal, non-mutated) individuals contain a constant 959 cells. The position of cells is constant as is the cell number. Moreover, it is transparent. It is easy to track cells and follow cell lineages. This provides a great tool for research on how genes influence cell fate. These traits enable the study of the biology of a single cell in an intact, living organism.

The genome size of C. elegans is about a hundred million base pairs. This is approximately 20X bigger than that of E. coli and about 1/30 of that of human. But, as its genome is surprisingly similar to that of humans (40% homologous), C. elegans became an attractive organism in the study of human biology and diseases.

The insulin-like pathway of C. elegans

Among those remarkably human-like genes are the ones that control energy metabolism, and specifically those coding for an insulin-like pathway. Genetic analysis now conclusively demonstrated that several of those genes, when mutated, extended life through reducing the activity of this insulin signaling pathway; in other words, life was extended by reducing the metabolic rate. Conversely, there is now considerable evidence showing that senescence (aging) is associated with increased metabolic rate.

Therefore, a logical conclusion would be that an insulin-like pathway drives senescence in C. elegans by enhancing metabolic activity. Right? Not quite…Genetic manipulation has now demonstrated that it is the insulin-like pathway specifically in neurons, not muscle or other highly metabolically active tissues, that regulate life span in C. elegans. And consider this: in humans the neurons most sensitive to insulin are probably the hypothalamic neurons that regulate metabolism and body weight, destruction of which leads to profound metabolic impairment.

Biology never ceases to confound our most ‘obvious’ theories. Although many hypotheses were offered to explain this unexpected discovery, in truth scientists were stymied.

 A tantalizing clue

In a paper published this week in Nature, scientists from the University of Washington in Seattle reported on an intriguing discovery. They screened 88,000 chemicals for the ability to extend the lifespan of adult C. elegans. They found that a drug that was once used as an antidepressant in humans, increased lifespan by 30%. The drug, a tricyclic, is called mianserin and was marketed as Tolvol, before being largely phased out of the market.

Its mode of action is interesting; it blocks two serotonin receptors, SER4 which signals the presence of food, and SER3, which signals starvation, in C. elegans. But the blocking action of the drug is not equal—it blocks SER 4 (food available) ten fold more than SER3 (starvation). The authors state: “In this way, mianserin might potentially create a ‘perceived’ state of starvation that, despite adequate food intake, would activate mechanisms of lifespan extension downstream of dietary restriction”.

Or in other words: it is not the actual caloric restriction and starvation that is responsible for lifespan extension. It is rather the perception of starvation that causes the brain to activate the mechanisms that lead to life extension. Which may explain the original observation that disruption of the insulin pathway in neurons, and not in muscles or other ‘obvious’ tissues, that leads to prolongation of lifespan.

Another example of mind over body. Or is it perception trumps reality?

Whatever the philosophical musings this experiment evokes, the practical implication is awesome: we won't have to spend a lifetime in starvation in order to live an extra few years. Drugs will be available that would allow us to literally have the cake, eat it and live long enough to tell the tale to our great-great-great grandchildren.

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

"Most heart attacks in women are preventable," is the headline of an article posted on NBC.com.  The article describes a study, published in the Archives of Internal Medicine, that was done by the researchers at the Karoinska Institute in Sweden.  Dr. Agneta Akesson and colleagues looked at the diet and lifestyle patterns of almost 25,000 postmenopausal women.  At the time of enrollment none of the women had heart disease, diabetes or cancer.

The researchers asked the women to fill out "food frequency" questionnaires to identify how often they ate 96 different foods.  The researchers analyzed the data and found four major dietary patterns:

• Healthy - vegetables, fruits, and legumes
• Western/Swedish - red meat, processed meat, poultry, rice, pasta, eggs, fried potatoes, and fish
• Alcohol - wine, beer and some snacks
• Sweets - sweet baked goods, candy, chocolate, jam, and ice cream

Other information collected included family history of heart disease, education level, physical activity, and body measurements.

The women were followed for an average of 6 years.  During that time, 308 women had heart attacks.  The investigators found that two of the dietary patterns (healthy and alcohol) were associated with a decreased risk of heart attack.  Women who drank less than a quarter ounce of alcohol daily (that is just a splash in the bottom of your glass) and ate lots of veggies, fruit, whole grains, legumes, and fish had a 57% lower risk of having a first heart attack.  That is a whopping big difference.

If women added three other healthy lifestyle habits into the mix (not smoking, being physically active, and avoiding too much weight gain), they had a 92% lower risk of heart attack.  In other words, most heart attacks in women are preventable by making healthy lifestyle choices.

Now, it is one thing to say, eat healthy, drink in moderation, exercise and maintain a healthy weight.  It is quite another thing to actually do all of those things over the course of an entire lifetime.  On the other hand, if you look at the amount of money the US (and, indeed, the entire world) spends to treat cardiovascular disease, I believe you would find there is enough there to buy each and every person a personal cook and a personal trainer (I believe this is the secret to Oprah's weight loss and maintenance).

I say this tongue in cheek, but it does make the point that we aren't spending our "health" care dollars on the right things.  We spend generously to fix disease, but we are very stingy when it comes to funding health.   It is time to get this right.  There aren't enough dollars in any treasury to treat all of the heart disease we are going to see as a result of the global epidemic of obesity and physical inactivity.  This must be  a top priority of policy makers and health reformers.  Studies, like the Karolinska study, should be used to promote changes in public policy - such as healthy school foods, ensuring that all neighborhoods have access to fresh fruits and vegetables and that they have safe places where kids and adults can move their bodies (without worrying about getting shot in the process).

Every politician, health reformer, and policy wonk ought to know about this study and others that prove that healthy lifestyles mean fewer heart (expensive) attacks - not just in women, but in men as well.  The bottom line is most heart attacks are preventable!

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.

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.

A recent study from the Mayo Clinic, published in the Journal of the National Cancer Institute (JNCI, vol. 99, p. 825, 2007), looks at the relationship between the use of aspirin and non-aspirin NSAID (non steroidal anti inflammatory drugs) in postmenopausal women and the incidence of death from cancer, heart disease, and death from any cause.

How the study was done

The investigators studied data on about 22,500 women who were enrolled in the Iowa Women's Health Study, a long-term health study of women living in Iowa. Starting in 1986, the women completed surveys periodically about their medical history, diet, physical activity, smoking, and other factors every year until 1992. In that year, the women also reported their use of aspirin and nonaspirin nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. They were then followed, without filling out additional questionnaires, until 2002.

And the results were…

· Women who took aspirin were 13% less likely to die of cancer.

· They were 25% less likely to die of heart disease.

· They were 18% less likely to die of any cause during the study.

· Non-aspirin NSAID had no effect on mortality.

What’s wrong with this picture?

Plenty. Let me count:

1. The study was observational; such studies are fraught with problems, and are not very reliable. For instance, the investigators did not study the effect of aspirin by giving the drug, and following them for the study period (known as a prospective study). They got their data from a questionnaire filled out by the participants.

2. The study started in 1986 and ended in 2002—16 years in duration. And only at one point in time (1992) were the participants asked to recall their aspirin use. The quality of such recall has been shown in several studies as flawed.

3. The questionnaire did not ask about the frequency and dose of the aspirin. And even if they did, such data would have been of questionable utility. Would you trust your own recollection of your aspirin intake several years back? Or even the prior 6 months?

4. The study was restricted to postmenopausal women, mostly white. Does this finding extend to other population groups?

5. Only aspirin had an effect on mortality. Non-aspirin NSAID, such as Advil, Motrin and Aleve, had no effect. This finding is conflict with other studied showing non-aspirin NSAID having a survival benefit similar to aspirin. Both types of drugs have a similar mode of action; they are anti-inflammatory drugs, targeting the same metabolic pathway ( prostaglandin synthesis). If however, this observation stands up to repeat studies, it would be a great contribution, which may uncover some subtle differences of clinical importance between aspirin and other NSAID.

Should you start taking aspirin?

Obviously, this is at best an incomplete study. On this basis alone, it would be inadvisable to start taking aspirin on a daily basis. Admittedly, other studies suggest that daily aspirin is beneficial, to a small degree, in the prevention of breast cancer and colon cancer, as well as heart disease.

But consider these two facts:

· Aspirin is not harmless. It can cause all kinds of stomach problems, like gastritis (inflammation of the lining of the stomach) and ulcer. It can also cause bleeding problems, including hemorrhagic (bleeding) stroke.

· Why take medicine for a 13% reduction in cancer mortality when you can eat well (five helpings of fruits and vegetables a day) and exercise (30 minutes walk, six times a week) and cut your risk of death from breast cancer by 50%! See my earlier post, "Women with breast cancer can lower their risk of dying by 50%." The same type of protection has been shown for colon cancer, and for heart disease.

As far as I am concrned, the choice is obvious.

Dov Michaeli MD, Ph.D

We modern humans have a tough time curbing our appetite. The reason for that is that our primitive ancestors, leading a life of hunters/gatherers (or scavengers, as recent research suggests) did not have a steady, predictable supply of food. So our physiology has evolved to store calories when we could get them, in the form of fat. The need was to maximize conservation of energy (or calories), and an elaborate system has evolved in the gut and the brain to accomplish that.

This state of affairs served our species well until relatively recently. When the industrial revolution arrived about 200 years ago, farms became more efficient and produced more food, people became more affluent working in factories and offices, being able to afford the cornucopia of food and drink. At the same time work, and life in general, demanded less and less effort (or expenditure of calories).The consequences are evident today on every street of the industrial world. Unfortunately, our metabolism has not been able to adapt to this relatively recent change in lifestyle. Such things require an untold number of genetic mutations and take thousands of generations.

Is there nothing to be done about it?

The only way we can change our metabolism is through drugs. So far, all the heavily promoted and hyped diet pills, which are basically attempts to change our metabolism chemically, have been either very limited successes, or total failures. Fortunately, we are a species endowed with a high degree of awareness and the capacity to quickly adapt through changes in behavior. Remember Pavlov’s drooling dog? We are better. Being aware of what triggers our brain to send ‘hunger’ signals allows us to counteract them through behavioral strategies.

The biological clock

No, this is not really a ticking clock; but, biologically speaking, a lot more powerful. A clock is neutral, it just keeps time. There is no inherent functional meaning to 3AM or 3PM. It is us who invest it with the meaning of afternoon or early morning. The biological clock, on the other hand, doesn’t only tell time, it gives time a meaning. For instance, around 6 PM I get terribly hungry. Or around 6:30 AM I wake up regardless whether I got enough sleep or not. And when I travel across time zones, either to Europe or the Far East, my biological clock and my whole physiology still lives in California, and is totally screwed up.

We can see then, that this clock actually controls much of the brain function. One of these functions is the sensation of hunger. I am used to eating breakfast at a certain time of the day, and if I don’t get it I feel that something is missing, I am unhappy and miserable to be around, I can’t function at peak performance. If you think about it, the clock didn’t just control hunger, it controlled mood (great omelet--happy; it’s 11 AM and I haven’t had my breakfast yet--unhappy).

The nice thing about this all-powerful clock is that it can be trained to suit our whims. Try skipping lunch and the first few times will send you trawling for food the whole afternoon. But after a while, your need for lunch becomes less and less urgent until eventually you really don’t feel the need to eat in the middle of the day. But don’t carry it too far. I am reminded of one of my professors at UC Berkeley ( who will remain anonymous for obvious reasons), who studied the metabolic effects of calorie deprivation in the German cockroach (Blatella germanica; and I am not making this up). He slowly habituated the critters to a progressively lower calorie diet. One morning he came to the lab and was dumbfounded to find his meticulously habituated cockroach colony totally, irreversibly dead. Theories as to the causes ranged from the sublime to the ridiculous. To my simple-minded suggestion that they may have died of run-of-the-mill starvation, he responded plaintively,” but they have already got used to it…”.

Sight and smell

Why are the French such foodies? My theory de jour: it’s the presentation. When we walked in the market in Beijing and saw row after row of hanging Peking ducks at the butcher shops, I was mildly disinterested. But when they wheeled in the duck in a fancy restaurant the thing looked irresistably delicious and we devoured the whole thing. How do you think did Ray Croc make McDonald’s such a success? He stood outside a small hamburger diner and took in the smells. He immediately knew that he stumbled upon a winner, bought the restaurant and its formula for Freedom (aka French) fries and hamburger patties, and the rest is, as they say… fat kids with diabetes. Both the rhinencephalon (or the smell center) and the visual cortex communicate with the hypothalamus, the area in the brain that controls hunger, through extensive neural connections.

Don’t eat when you are cold

One of the important functions of our physiology is to maintain normal body temperature. For instance, the shivering response to cold is a way for the body to raise its temperature. Metabolism creates heat, and when we are cold the normal response is to eat more, and more frequently. That’s why we tend to eat more in the winter (and, alas, gain more weight) than in the summer. Can you imagine yourself being ravenous on a 100° day? All I can think of is crushed-ice margaritas.

What can we do?

The answer is: a lot. The biological clock and the relationship between smell, sight and hunger are all subject to habituation, or more plainly—to our will. This is literally the old 'mind over body', and all we need is the will and the persistence.

And yes, don’t forget to heat up the house before you sit down to dinner.

Dov Michaeli MD, Ph.D

The results of the 2007  Food and Health Survey* are in and they show…guess what? Most people want to lose weight. Seventy-five percent of individuals surveyed said they are concerned with their weight. This is up from 66% in 2006. 70% said their reason for making dietary changes is “to lose weight,” and 56% said they are actively trying to lose weight. This is interesting as it seems to reflect reality.  According to the latest scientific evidence, 66% of Americans are overweight or obese.

Where there is a disconnect, however, is people’s knowledge of the relationship between "calories in" and "fat on."  Although 60% of Americans who are trying to lose weight say they are doing so by reducing the number of calories they consume, only 11 percent were able to correctly estimate the number of calories they should consume in order to accomplish that goal. Interestingly, most people underestimated the number of calories they thought they should consume, but that was offset by the 34% of Americans who admitted they actually consume more than they estimated they needed.

It was heartening to learn that most people (69%) say they use food and beverage packaging elements when deciding whether or not to buy and eat food products. However, the most commonly used element was the expiration date. Sixty-six percent said they used the Nutrition Facts Panel (aka the Nutrition Label) and most used the calorie information and the information about fats, particularly Trans fats. The problem is they are not paying attention to serving size – only 49% did so, down from 63% in 2006. Knowing the calories per serving does not translate into decreased caloric consumption if you do not understand serving size.  And, as I have pointed out before, serving size is not intuitive or even easy to understand (how many of us can estimate 1 oz of cashews or 30 grams of Bran Buds?).

Of the 56% of people surveyed who said they were trying to lose weight, 79% said they had increased or began to engage in physical activity; 69% had reduced portion sizes of meals and/or snacks, and 60% had reduced the number of calories. But snacking remains a national pastime with about half of those surveyed saying snacks are an important part of an overall healthful diet. Almost all Americans (93%) eat at least one snack per day with the mean number of snacks being 2.5 per day. Ten percent of those surveyed said they ate 4-5 snacks per day and 7% ate 6-7 per day. Two percent admitted to eating 8 or more snacks per day (how do they have time for anything else??).

Many people perceived foods and beverages to have health benefits, often beyond what medical evidence supports. Specifically, the following percentages of the surveyed population strongly or somewhat agree with the following statements:

• Specific foods improve heart health – 80%
• Specific foods improve physical energy or stamina – 76%
• Specific foods improve immune system function – 71%
• Specific foods improve mental performance – 66%
• Specific foods improve the risk of getting specific diseases – 65%

Can’t you just see the glint in the food manufacturers’ eyes (and the banners proclaiming health benefits plastered all over our food packages)? Food lies masquerading as food science – but, you will have to wait for that is the subject of a post yet to come.

The last item from this survey that I want to mention is that American’s perceived their health to be better in 2007 than in 2006. Thirty-nine percent of those surveyed said their health was “excellent” or “very good” compared to only 33% in 2006. And even more people (58%) said they were “extremely satisfied” or “somewhat satisfied” with their health status – this is somewhat puzzling since that means some people are satisfied with health that is less than “very good.”

So there you have it – a glimpse into how we perceive food, fat, and facts.

*The Survey, sponsored by the International Food Information Council (IFIC) Foundation and organization affiliated and supported by “the broad-based food, beverage, and agricultural industries.” The first survey was produced in 2006 based on a telephone survey of Americans performed in November 2006. The 2007 Survey is based on a telephone survey in March of 07.

Pat Salber, MD

If you liked this post, you may also enjoy reading:

We are fat and getting fatter

Big meals lead to big mistakes in calorie estimation

Living with diabetes can be tough. There is so much stuff to learn and so many things to do. It can be hard to keep track of everything. And, it can seem overwhelming, particularly around the time you are first diagnosed.

That’s why I am recommending if you have diabetes or if you know someone who has diabetes, get your hands on a great little book, "Know your Numbers, Outlive your Diabetes.” It is written by Richard Jackson, MD, a doc at the world famous Joslin Diabetes Center and Amy Tenderich, a professional journalist who also happens to have diabetes (check out her website: www.DiabetesMine.com).

Five Numbers to Know

This book points out that there are five essential tests everyone with diabetes should have:

• Hemoglobin A1c (often just called A1c). This is a measure of the average blood glucose levels over the previous two to three months
• Blood pressure
• A full lipid profile – not just a total cholesterol, but a full panel that determines LDL, HDL (often called good cholesterol), and triglycerides (blood fats that go up after we eat)
• Microalbumin: a test of whether diabetes has cause kidney damage
• A Retinal Eye Exam to asses whether there is any evidence of eye damage

The authors explain what these tests mean and how often you should get them. What I particularly like is that they stress that you need to be the owner of these numbers:

“These numbers belong to you, and knowing them is your right, as well as critical to your health – just like the numbers in your bank account.”

They even give you advice on how to get your hands on these numbers:

“It is your right to request them, so don’t feel intimidated about speaking up….A call to the office should suffice…” but they recommend, “make the call at a time when you have some other paperwork to do, and use a speakerphone so that you don’t get too frustrated trying to get through or waiting on the line.”  It seems like they may have had some first hand experience calling doctors' offices.

Don’t feel like you have to do everything at once

There is a chart in the book that the authors titled “Your Diabetes Health Account.” Using it, you can compare your numbers to the certain targets in order to determine how well you are doing. For example, if all of your numbers are at optimal targets, you can see that you have five “bags of money” in your diabetes account. These are your health assets. If your tests are past due or way out of whack, then you have health debts which should be paid off as soon as you can. By taking a close look at your diabetes health account, you can pinpoint your focus of what you need to do to get your health account back in balance.

They counsel, “Rather than depressing you, knowing your priorities should boost your confidence; you have learned exactly which health factors are most important for you right now and which may not need attention on an everyday basis."

Take Action

Once you learned your numbers and assessed your diabetes health account, it is time to take action. The book provides strategies for how to improve every one of the five essential factors. The tips provided are practical, but detailed enough to help even a novice diabetes-self-manager get started.

The first part of the book lays out the strategies for improvement and the second part dives deeper into the diabetes toolkit they are helping your prepare. Advice on diet and exercise are clear and easy to follow. For example, one strategy for portion control, an important element of a weight loss diet, is to share a meal. Pretty simple, huh? Or you can divide your food before you start to eat and have it put into a “doggie bag” before it automatically goes into your mouth to end up around your middle. Avoid buffets. We all know we eat too much at buffets…it is simply too easy to pile it on the plate.

Other good information

There are chapters on diabetes drugs and diabetes devices as well as information about low and high blood sugar. The chapters are well laid out with important information placed in boxes.

Sprinkled through the book are stories of real people living with diabetes, like Loretta, a kindly grandmother with type 2 diabetes who lost weight and brought her hemoglobin A1c into control or Marci, a “high-powered New York City account executive" who enlisted her husband to help her deal with “diabetes frustration.”

Empowerment

Yeah, I know, some of you hate the “empowerment” word. But that is what this book sets out to do. It arms you with information. It helps you understand your particular needs and challenges. And it provides guidance on how to go, one step at a time, from where you are now to where you want to be in terms of diabetes health.

So, there you go. If you have diabetes, if someone you care about has diabetes, or if you are a health professional working with people with diabetes, then buy (and read) this book. You will be glad you did.

Pat Salber, MD

Here is the translation for calories on food packaging:

Calorie free:   Fewer than 5 calories per serving

Low calorie:  40 calories or less per serving.  If a serving is 30 grams or less or 2 tablespoons or less, it signifies 40 calories per 50 g of the food

Reduced or fewer calories:  At least 25 percent fewer calories per serving than the reference food

That means you can say something is "reduced in calories" if there are 25% fewer calories, but the food can still be very high calories.  75% of a big amount is still a big amount

Here is food for thought for the profit-oriented among us (yours truly included). Can you make money off of Obese America?

Here are some facts:

• Sixty-six percent of Americans are obese or overweight
• Seven million are more than 100 pounds overweight.
• $33 billion in services are spent each year on health care for the obese.

So, it should not be surprising that a widely followed web site that tracks the stock portfolio of Wall Street mavens (Warren Buffett) and not so mavens, and some outright…well, you get the point, has created, (I am not making this up) an "Obesity Index”.

I thought it would be educational and, yes, profitable to take a look at it:

The Obesity Index

                                                   Approx.  Price       Actual Price

Name stock (symbol)             Oct.12 ’06          April 12 ’07       % gain

Nutrisystem (NTRI)                         67                    54.64             -18.4 %

Life Time Fitness (LTM)                 48                     50.51                 5.2 %

Town Sports Center (CLUB)          15                     23.24              54.9 %

Nautilus Inc. (NLS)                            14                     14.30                0.0 %

Herbalife LTD. (HLF)                       37                     39.50                 8.7 %

Weight watchers (WTW)               46.5                  47.3                 2 1.8 %

And for an enlightening comparison:

McDonald’s (MCD)      &n