The Doctor Weighs In

By Dov Michaeli MD, Ph.D

The April 14 online edition of the Proceedings of the National Academy of Sciences carried an intriguing article titled “ Endogenous steroids and financial risk taking on a London trading floor”. Both authors, J.M. Coates and J. Herbert are from the Dept. of Physiology, Development and Neuroscience at Cambridge University . But J.M.C. is also from the School of business at Cambridge , and his main research interests are summarized by him thusly: “ I have been sampling endogenous steroids from traders on a trading floor in the City to determine the role of both testosterone and cortisol in their decision making and in their performance. I compliment this field work with behavioral experiments set in the lab and in artificial asset markets”

Raging hormones and bubbles

The rationale for this field of research is both compelling and fascinating. As stated by J.M.C  “ the waves of irrational exuberance and pessimism that destabilize the financial markets ,may be driven by naturally produced steroid hormones. With receptors in almost every nucleated cell in the body, steroids such as testosterone and cortisol affect the moods we experience, the memories we store and recall, and the behavior we display in competitive and risk-taking situations”.

This is absolutely fascinating because for the first time we find a serious attempt to explain economic phenomena on the basis of human physiology.

What they found

The investigators took saliva samples from 17 male traders on a London stock trading floor twice daily over the course of eight days. They monitored the traders' levels of testosterone, the hormone most often associated with aggression and sexual behavior, and cortisol, the so-called stress hormone.

They tracked those levels against the amount of money that a trader made or lost, and against the variation in the market. What they found was that when the traders made more money, they had elevated levels of testosterone. When the markets were particularly variable, they had elevated levels of cortisol.

Aha, you might aver; how do you know what is cause and what is effect? Isn’t it just as possible that traders had their testosterone levels go up as a consequence of making money?

Good thought, but…

A further analysis showed that traders who started their days with elevated testosterone made more money than those who didn't. One trader went on a six-day winning streak, making twice as much money each day as the previous one. Over that period, his testosterone levels rose steadily, some 74 per cent! This guy must have been a raging bull by the end of the week. Just think of the rollicking weekend he must have had.

So should stock traders join the ranks of sports figures and take testosterone as a performance enhancer?

Not quite. There is a point of diminishing returns; too much testosterone leads to too much aggression and reckless decision making. In some it may even lead to criminal behavior.

Cortisol, anxiety and risk management

Cortisol is one of the stress hormones. It rises when stress levels are up, which is stating the obvious. But what is less apparent is its role in limiting risk. Let’s go back to the savannah for a minute. You spot a lion striding toward you. Being the testosterone macho that you are you’d be perfectly willing to take the beast on. One guy, Samson, actually did it and lived to tell the tale, so why can’t you? Fortunately, your eyes send the brain another message: don’t kid yourself, this is dangerous! The order goes out to the adrenal glands and a flood of cortisol is released into the circulation, raising your anxiety level and making you have some second thoughts: after all, this is a tale from the bible, and you know how believable those are; besides, this guy Samson- did anybody see him kill the lion? Maybe he was just using it as a line to get Delilah to do what Philistine girls do better than the Israelite ones do? So you hedge your bets and climb up the closest tree. In other words, cortisol made you manage your risks more rationally.

Indeed, when the markets stopped going in one direction and started fluctuating, as markets always do, cortisol levels went up and trading became more restrained.

Of course there is a downside to cortisol as well, especially when exposure to it is chronic.

The downside of cortisol

A few days ago we reported on a Kaiser Permanente study that showed increased risk of dementia in males over 40 who had an increased central obesity, or abdominal girth that is 35 inches in women and 40 inches in men. Even men with a normal BMI had a 2 fold increase in risk if their abdominal fat was excessive. Now, if you think that you are in great shape because your BMI is within the normal limits, and you proudly display your six-pack abs to anybody who would care to look, think again . Experts now think that subcutaneous fat -- the flabby variety under the skin in areas like the buttocks, legs and arms -- while unfashionable, is fairly benign. Researchers at the Washington University School of Medicine in St. Louis demonstrated that when they removed an average of 22 pounds of subcutaneous fat via liposuction from 15 overweight women, they found no change in the women's cholesterol levels, triglycerides, insulin sensitivity or other health risks. We are talking here about visceral fat, or fat that underlines your awsome abs, lining your intestines and other internal organs. This fat in excess can be deadly. It is associated with the diseases of metabolic syndrome, but also with gall bladder disease, sleep apnea, numerous cancers, and dementia. So even if you are not flabby (you cannot pinch your skin and subcutaneous fat), but your belly is sticking out – you probably have excess visceral fat.

A major factor in determining this deadly distribution of fat is cortisol. This is probably why people under chronic stress are more prone to all the diseases we just mentioned.

But wait, there is more. Cortisol also causes increased risk of arthritis. It also leads to shrinkage of the prefrontal cortex and hippocampus, brain regions associated with decision making and factual memory, meanwhile it contributes to growth in the amygdala, a region associated with emotional memory and anxiety. Not good stuff.

The good news

Cortisol levels can be controlled by reducing stress levels. And visceral fat is the first to go when someone loses weight in general. Aerobic exercise, like walking or running, is particularly effective. Doing sit-ups, abdominal crunches and pilates can strengthen your abdominal muscles, and help hold your stomach in, but they won't target visceral fat specifically.

Some final thoughts on stock trading

Here are some questions that beg for a study.

· Are women better traders because they are less prone to wild speculation?

· Are stock traders more prone to heart disease and diabetes? Or more critically for their clients, are they likelier to become demented?

· Should clients insist on a broker’s full disclosure of his health record?

Or may be the answer is a lot simpler: get a woman broker.

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

Who hasn’t complained about loss of memory? With increasing frequency, I forget where I left my glasses, what’s her name? Where did I meet him? And for the hundredth time, what’s the name of this bird?

No, it is not incipient Alzheimer’s. I still write blogs, although that’s no proof of a sound mind. I manage a large drug development project, read the newspapers daily and am up on the latest political twist. So what’s going on?

Beware received wisdom

When I went to medical school (UCSF) I was struck by a paper I read claiming that 50% of what we were taught would be either obsolete, or plain wrong, within 5 years; amazing, but true, and not very reassuring to both physician and patient. One of the things I was taught with great certitude was that with age we progressively lose neurons, which make up the gray matter in the brain. True enough even today. It was then a no brainer to conclude that this loss of neurons is responsible for the creeping loss of cognitive function in the elderly. This tidbit of “information” turns out to be part of the 50% that is obsolete, and maybe even wrong.

The nerve cell

A neuron, like any other cell, has a “body”, enclosed by a membrane. It contains a nucleus, where DNA resides, mitochondria, the power plants that provide energy for the functions a neuron performs, and cytoplasm, where proteins are shuttled about and enzymes perform what they are supposed to. But then there is something unique to neurons: they have long projections, some of them inches long (which is enormous in the context of microscopically small cells). These long projections, called axons, serve two purposes: they serve as conduits for a traffic of neurotransmitters and other substances on their way out of the neuron. And, through tiny projections coming off their surface, called dendrites (small branches, in Latin), they make contact with other neurons around them. This is how information, in the form of electrical impulses, is passed around the brain along precisely demarcated circuits and over very long distances. The neuronal cell bodies, where the nucleus and the DNA reside, are the “brain” of the cell; they have a gray hue under the microscope—hence “gray matter”. The axons, on the other hand, are considered conduits only, very much like water or sewer pipes—no “brain” at all. They have a white hue, and are called the “white matter”.

Organization of the brain

The human brain can be divided into major functional regions, each responsible for different kinds of “applications,” such as memory, sensory input and processing, executive function or even one's own internal musing. The functional regions of the brain are linked by a network of white matter conduits. These communication channels help the brain coordinate and share information from the brain's different regions. White matter is the tissue through which messages pass from different regions of the brain.

Scientists have known that white matter degrades with age, but they did not understand how that decline contributes to the degradation of the large-scale systems that govern cognition.

So what’s new?

New research, published December 6, 2007, in the journal Neuron, begins to reveal how simply growing old can affect the higher-level brain systems that govern cognition. The research was conducted by Randy buckner’s group at the Harvard Medical School and the Howard Hughes Medical Institute. As Jessica Andrews-Hanna, a graduate student in Buckner's lab and the lead author of the study stated:
“The crosstalk between the different parts of the brain is like a conference call; we were eavesdropping on this crosstalk and we looked at how activity in one region of the brain correlates with another.”
Buckner, Andrews-Hanna, and their colleagues looked at crosstalk in the brains of 93 people aged 18 to 93, divided roughly into a young adult group (18-34 years old) and an old adult group (60-93 years old). The older participants were given a battery of tests to measure their cognitive abilities—including memory, executive function and processing speed. Each person was studied using functional magnetic resonance imaging (fMRI) exams to measure activity in different parts of the brain. fMRI can precisely map enhanced blood flow in specific regions of the brain. Increased blood flow reflects greater activity in regions of the brain that are utilized during mental tasks.
For the task used in the Neuron study, subjects were presented words and were asked to decide whether each word represented a living (e.g., dog) or nonliving (e.g., house) object. Such a task requires the participants to meaningfully process the words.
Buckner's group explored whether aging in the older group caused a loss of correlation between the regions of the brain that — at least in young adults — engage in robust neural crosstalk.
They focused on the links within two critical networks, one responsible for processing information from the outside world and one, known as the default network, which is more internal and kicks in when we muse to ourselves. For example, the default network is presumed to depend on two regions of the brain linked by long-range white matter pathways. The new study revealed a dramatic difference in these regions between young and old subjects. “We found that in young adults, the front of the brain was pretty well in sync with the back of the brain,” said Andrews-Hanna. “In older adults this was not the case. The regions became out of sync and they were less correlated with each other.” Interestingly, the older adults with normal, high correlations performed better on cognitive tests.
According to the authors, it is inferred that in a young, healthy brain, signals are readily transmitted by white-matter conduits. As we age, those conduits are compromised. Depending on the networks at play, the result may be impaired memory, reasoning or other important cognitive functions. Buckner and Andrews-Hanna emphasized that other changes in the aging brain may contribute to cognitive decline. For example, cells' ability to express chemical neurotransmitters may also be compromised.

My take

1. Extremely important work. The dogma that “dropped neurons” is solely responsible for the cognitive deficits of normal aging simply did not make sense. First, the billions of neurons in the brain have plenty of capacity to make up for losses; we have a tremendous reserve. Second, the brain has the capacity to reroute specific information through alternative circuits if the original ones are compromised in any way. This is what underlies the phenomenon called “brain plasticity”, which is the basis for rehabilitation of stroke victims, or the educational strategies for dyslectic children.

2. This finding, like any in science, raises new questions. What is the nature of the disruption in the default network? Is it reduced number of axons due to neuronal death? Is it a functional defect in the conductive properties of the axons? Is the dysfunction generalized or restricted to specific pathways? What is the root cause of the changes? How can they be avoided?

What can we do about it now?

No doubt you have encountered claims of “brain rejuvenation”. Just work on your daily crossword puzzle, learn a new language, solve sudoku puzzles, stand on your head. The trouble with all these is that they work—but very specifically. If you do your daily crossword puzzles or sudoku you’d be good at them, but you will still forget names and misplace your car keys.

So far, the most convincing global change in the aging brain is reduced blood supply. Blood vessels either get occluded (atherosclerosis) or degenerate because of death of tissue they had supplied. Not surprisingly, the only strategy that proved effective in maintaining the overall integrity of cognitive function is, you guessed it, increase blood supply through aerobic exercise.

So throw away your sudoku puzzle or crossword puzzle and go out for a brisk walk or run. And don’t forget the keys to the house.

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

By Dov Michaeli MD, Ph.D

Every Sunday morning we have a family ritual: 8-9 in the morning it’s “Meet the Press”, 9-9:30—the Chris Matthews Show. And while the TV is blaring and we OD on politics, we walk on the treadmill or step on the elliptical, do abdominals and pushups, do Yoga and lift weights—in short: we indulge our political and fitness addictions simultaneously, and feel self-righteous and quite superior to the flabby unwashed masses.

I love to watch Chris at his best: benignly opinionated, urging his guests to express their opinion on a political subject before pronouncing the Matthews ‘truth’ (“Tell me something I don’t know… here is what I think”), full of lively energy; the man is manifestly enjoying exposing hypocrisy, mendacity, stupidity and other ills of our political leading lights.

So guess how surprised I was when I found out that Chris Matthews makes stupid mistakes, like any one of us. As I sorted through today’s mail my eyes fell on the cover of the latest issue of Diabetes Forecast. There he is on the cover, smiling his heart-melting Irish smile, over the title: “Chris Matthews: the Hardball host goes head-to-head with type 2”. I guess for the readership of this magazine there is only one sort of “type 2”— diabetes. Chris was interviewed by Dan Gilgoff, the politics editor of Beliefnet.com and author of The Jesus Machine: How James Dobson, Focus on the Family, and Evangelical America are Winning the Culture War. (I can’t resist a digression here. Dan, don’t fret: Dobson, Focus on the Family, and Evangelical America are losing the cultural war!).

The interview was an eye-opener for me. I have to admit, I used to attribute much of the American people’s lack of sophistication in health matters to poor education. No more; here is a highly educated individual, possessing an uncanny capacity to ferret out ignorance, stupidity, and dishonesty who betrays an incredible degree of ignorance when it comes to his own health.

Here are some excerpts from the interview, along with some gratutitous comments.

Q. You knew for years that you had diabetes but did very little about it.

A. … I had malaria after coming back from a trip to South Africa in 2001, but what I kept [hearing about] from my doctor was my high blood sugar levels. And I said, “What does that have to do with anything?”

Comment: Chris, with your sharp ear to nuance and encrypted messages—what did you think your doctor was trying to tell you? And you, doctor, were you too pressed for time to press your point home? By the way, going to South Africa without taking the Malaria pills? Did you think you were beyond the reach of lowly creatures such as mosquitoes?

Q. But you more or less ignored your diabetes until even more recently, right?

A… I also wasn’t doing any kind of dieting. I was aware of a general need to skip some things. The toughest habit is going to an airport in the morning when you haven’t had breakfast and seeing the pastries there. Hunger is the best chef—you see a couple pastries and have that and a cup of coffee for breakfast. There was a time when I’d have a hamburger and French fries for lunch with a beer or white wine, and I’d have cheesecake for dessert. It was pretty outrageous.

Comment: I agree. Many a time did I find myself struggling to walk past the Peet’s and Starbuck’s Coffee stands at the SF airport, without succumbing to the temptation of the pastries. But where was your doctor? How come you weren’t warned about pastries, hamburgers, French fries, beer or white wine for lunch? This is inexcusable.

Q. Did you consider reforming your diet after learning about your high blood sugar levels?

A…. I didn’t say, “Wait a minute, this is something I can reasonably deal with.” I didn’t understand the importance of it or the doability of it—that I could solve this problem, that it would be over, and I would be just like everybody else….

Comment: That he didn’t understand the importance of it is in part his doctor’s fault, and in part Matthews’ own dismissive attitude when confronted with inconvenient facts.

Q. You stayed in the hospital a few days. How scary was it?

A. When you have three doses of morphine and it still hurts, you begin to worry.

Comment: And I am sure you went back to your TV show, blasting any and all comers for their lack of clear solutions to our health care problem. Chris, it is people like you who are part of the problem.

Q. You’ve certainly lost a good bit of weight in the past year.

A. On my scale at home I’ve gone from around 235 to about 205, and I think I can lose some more if I do a little more exercise. I really haven’t done any exercise to lose all this weight, just changing what I eat.

Comment: Chris, I watch you every Sunday on TV. You need to lose a minimum of 20 more lbs. You may rid yourself of the daily insulin injections, and as a bonus, you’ll wow the beautiful female political commentators on your show if you lost 40 lbs, and exercised!

Q. Why your aversion to exercise?

A. Don’t have any time. When am I going to do it?

Comment: What a lame excuse. There are people who run multi-billion dollar enterprises who find time to exercise. You make time, Chris. Get up one hour before you normally do, and just do it. It is going to grow on you, it will energize you to go after the bad guys, and you’ll feel sick on days that you skip—I guarantee it.

Q. As a public figure, do you feel obligated to send a message about diabetes?

A. What people ought to be told about diabetes is that if they have it in the family or sense that they’re on the road to it, they should go to their doctor and ask him what he thinks and actually listen to the doctor like they would use [their] financial advisor.

Maybe it’s an Irish thing—we like to think we can talk our way out of things or that we can avoid them. But I’ve come to respect doctors a whole lot through this whole thing because they know what they’re talking about and they’re telling you to do something for your own good.

Comment: You are right, Chris; people ought to listen, even more than to their financial advisor. It is a matter of their health and life—pretty existential stuff.

But you are wrong about it being an “Irish thing”. I have had Russian patients come in with a list of medications and treatments they had decided they needed, and all attempts at telling them otherwise were a waste of time. My own father would go to the doctor only to tear up the prescriptions he was given and treat himself with his grandmother’s nostrums. And my Rabbi told me that when your Celtic forefathers had no idea that the emerald island even existed, the Jews of Ireland already suffered from diabetes. And why did they have diabetes? Because they didn’t listen to their (Jewish) doctors.

See you next Sunday on TV.

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 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.

by Pat Salber, MD

The cabbie who drove me from the airport to the hotel on my last business trip probably weighed 400 pounds.  We made small talk during the trip.  He told me he was hoping to leave Nevada soon and move to Oregon.  But, he said, it was tough getting the time and resources to make the move.

He works 12 hours days, six days a week.  The cab company deducts chunks of his pay  for their share of his revenues and to cover his health insurance premium and a tax on his tips.  His take home pay is $500 every two week pay period.

As we started talking about his health insurance, the conversation naturally drifted to health.  He is prediabetic, he told me, and his brother is a type 2 diabetic who has already had some toes amputated.  He knows he is facing the same future if he doesn't lose weight, but how can he do it?

When you drive a cab 12 hours a day, you often eat on the run.  That means fast food, high fat, and lots of calories.  Also, how do you fit in exercise?  Should he try to walk before the 12 hour shift or, perhaps, go out in the middle of the night when his shift is over? 

I found myself wondering what I would do if I were his doctor.  Of course, I would recommend he lose weight, alot of it.  And, I would tell him to get moderate to vigorous exercise 30 to 60 minutes a day.  I would prescribe any needed medications.  And, I would tell him to join WeightWatchers, or better yet an on-line weight loss support program, like PEERtrainer (www.peertrainer.com).

Chances are, in my 15 minute office visit, I wouldn't have learned about the challenges presented by his daily schedule.  I wouldn't understand that my recommendations were unlikely to be followed -- not because he wouldn't, but rather because he couldn't.

If something doesn't change, his prediabetes will most likely become diabetes.  He will probably have a heart attack or stroke or maybe, like his brother, he will end up with toes or feet amputated -- all potentially preventable if he could change his lifestyle.

At the end of the ride, all I could think of to say was that he needed to get a new job -- one that is less stressful and would allow him to exercise and eat better.  But I knew this too would be a daunting task given the long hours he already works and the meagerness of his financial resources.

I keep mulling over his story and wondering, how could you help this man?  I haven't come up with an answer.  Can you?

This is an oldie, but goodie, first published on TDWI September 15, 2006

Brian Klepper

OK, I'll admit it. I love reading the obituaries. They recount the marvelous achievements as well as, occasionally, the equally glaring flaws, of people we knew or, more often, didn't know.  I can't help being astonished, shocked, delighted, repulsed. Who knew all that was lurking under there?

There's a good one in Saturday's New York Times that's relevant to this blog.  Epidemiologist Ralph S. Paffenbarger Jr., MD, DrPH, ScD died at 84, ironically of heart failure. Dr. Paffenbarger became nationally influential for his work describing the relationship between exercise and longevity and for promoting vigorous activity to prevent heart disease. He was a professor at both Harvard and Stanford, and in 1987 he became President of the American Epidemiological Society. He helped write the exercise recommendations for the US Surgeon General's Report on Physical Activity and Health, published in 1996.

It's clear from the article as well as the Wikipedia entry that he had an active, inquiring, engaged mind. One simple but important insight early in his career was that the sedentary drivers on London's double-decker buses had higher coronary risks than the more active conductors. Later, during the 1960's, he established a  study - it's still running - that looked at the effects of exercise on 17,000 male Harvard graduates, ages 30 to 70. Here's a paragraph from the obit:

By the 1970s, the study’s preliminary findings suggested that men burning 2,000 or more calories a week faced a substantially lower risk of death from heart disease than their more sedentary peers. Indeed, in 1984, Dr. Paffenbarger concluded that, among 640 men in the study who had died of cardiovascular disease, the death rate for the most sedentary was nearly twice that for the most active. By the ’90s, the study refined that figure, finding that regular exercise reduced coronary death rates by 25 percent to 33 percent.

Maybe most interestingly, Dr. Paffenbarger actively translated his work's meaning into his own life. A sedentary 45 year old, he started running and was hooked by the second week. He said, “I found it invigorating. I could consider my thoughts and conflicts, I could prepare letters, ponder problems, prepare talks.” It eventually became a 50 mile a week habit. He became a marathoner, competing in 151 marathons, as well as ultra-marathons like the grueling 100 mile mountainous Western States Endurance run.

But most importantly, he nailed down for the rest of us incontrovertible evidence of a simple life truth. Nothing's certain, but if we're active, we improve our chances to live better longer.

Here's to you and a well-lived life, Dr. Paffenbarger!

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

It has been well-documented that women could reduce their risk of being diagnosed with breast cancer by eating vegetables and fruits, exercising and keeping a non-obese BMI (>25). But the pervasive feeling among physicians (yours truly included) was that once cancer is diagnosed, changes in life style are too little too late. But a recent study (Journal of Clinical Oncology, vol. 25, pp. 2345-2351, 2007) looked at this issue, and the results were totally unexpected.

How the study was done

A prospective study was performed of 1,490 women diagnosed and treated for early-stage breast cancer between 1991 and 2000. Enrollment was an average of 2 years postdiagnosis. An analysis of the effect of interaction between different factors on survival (called multivariate analysis) found that a combination of exercise, equivalent to a 30 minute walk six times a week, and a diet rich in vegetable and fruits (five or more daily servings) had the biggest effect on survival. There was no effect of obesity per se on survival; as long as the woman exercised and ate well her chances of survival were significantly increased.

How big was the effect?

Very big! Women who adhered to the diet and exercise regimen had a 50% reduced risk of dying, compared to women who did not.

Mind you, these were women with end stage disease. To keep things in perspective, when we get say, a 20% increased survival with a new chemotherapy drug, this is grounds for accelerated approval by the FDA. Here is a completely natural and healthy way of prolonging survival, with the only ‘side effect’ being… feeling much better. Not bad.

The usual caveats

The study was prospective, which is the gold standard for good clinical trials. It was also multi-institutional (UCSD, Stanford, Kaiser Permanente, Arizona Cancer Center in Tucson , and the M.D. Anderson Cancer Center in Houston , TX ), which avoids the possibility of institution-specific confounding factors. The patients were all end-stage, which avoids the ‘contamination’ of the sample with early stage, curable cancer.

On the downside, the study was relatively small (1,490 patients), although the results were statistically significant, because the effect was so big. If the effect was smaller, a much larger sample would have been necessary. Still, the authors rightly conclude that further study is needed.

I agree. A larger population size may have canceled out confounding factors that have not been considered. For instance: The women were entered into the study 2 years post diagnosis, and after receiving chemotherapy. If the diet/exercise regimen did not make any difference in mortality, then it would not have made any difference in the outcome. But if we assumed that it did, then during the 2 years preceding enrollment the women who did not follow the regimen got sicker and entered the trial in poorer shape, increasing their chances of dying earlier. The net effect would have been to exaggerate the magnitude of the effect, not necessarily negate it.

Having said that, I think this study is of tremendous importance because it showed the role of lifestyle not only in the prevention of cancer, but also in therapy. This is novel, encouraging, and requires a major research effort in order to incorporate it in the treatment of breast and other cancers (for instance colon cancer) that have shown a relationship to diet, exercise and obesity.

Yesterday’s New York Times ( May 8, 2007 ) carried a front page article by one of the paper’s premier science reporters, Gina Kolata. The article, titled “genes take charge, and diets fall by the wayside”, is an excerpt of her newly published book “Rethinking thin: the new science of weight loss- and the myths and realities of weight loss”. In the article she reviews the succession of studies started in the late 1950’s by Dr Jules Hirsch at Rockefeller University , which culminated in recent studies demonstrating conclusively that the tendency to weight gain and obesity is genetically determined. Ms. Kolata describes the heartbreak of dieting, a constant struggle of losing weight, trying to maintain, gaining, dieting again, and so on and so on. Psychological testing showed the toll this struggle can take; people are perpetually unhappy, many are chronically depressed, some are suicidal.

One of the major conclusions Kolata cites is that each body has a metabolic “comfort zone”, and dieting to go below this zone is painful, metabolically unsound, and essentially futile.

I admit I haven’t read the book yet, but if the excerpt reflects the message of the book, I strongly disagree.

Why?

For several reasons:

· Yes, a metabolic range specific to each body makes a lot of intuitive sense. But to accept it we need to see the genetic/molecular/physiological mechanisms. The evidence is still not in. Having been around the block a few times, I never cease to marvel at nature outsmarting us, and upending our ‘no brainers’ and ‘slam dunks’.

· The fact that genes control our metabolism does not mean that they are the sole players. Genes interact with the environment, and the outcome of this interaction is all important. The old debate of nature vs. nurture set up a false choice; nature and nurture operate together in biology. The best example is diabetes type 2. An individual may have the genes that predispose to this disease. But it will be expressed clinically only if that individual overeats and exceeds a certain BMI.

· The most obvious evidence that genes are not the final word in weight regulation is the recent obesity epidemic. If  "obesity genes",which undoubtedly have been with us for eons, were such an all-controlling factor, why is it that only in the last few years did this epidemic break out? The answer is well-known: we take in a lot more calories, and we exercise a lot less. Yes, the genes were there all along, but they were not expressed.

I believe that research into the genetic basis of obesity and diabetes is absolutely essential. But it should not become an excuse for the fatalistic attitude of “it’s beyond my control”. Counteracting and ovecoming the genetic dictate may be unpleasant, tough, exasperating—but it beats the alternative.

Dov Michaeli MD, Ph.D

This is from the Wall Street Journal and is too perfect to change a word.  Thanks, Kevin Helliker.  This is a real motivator.

Benefits of a Canine Running Mate

By KEVIN HELLIKER  (April 17, 2007)

Hearing the shriek of a fierce wind outside, I tried sleeping late the other morning. But my 80-pound Labrador came beside the bed and bumped her cold nose against my ankle. In her view, an April snowstorm is no excuse for canceling our predawn run. So moments later we were jogging down the dark shoreline, assaulted by pellets of ice, watching the sky brighten over Lake Michigan. It was exhilarating.

After decades of jogging with friends, colleagues and loved ones, I've come to see that the ideal running mate is a dog. She is not competitive. Your fastest speed is nothing next to hers, so you will never run too fast for her. But neither will she whine about, let alone ridicule, your slowness. The only time she will complain is when you don't run at all, and that type of push is what personal trainers charge money for.

COMMENT:Runner David Hill, with two clients, Angie & Wombat.

There is growing appreciation of the value of having a workout companion, reflected in the popularity of Web sites such as exercisefriends.com, which matches partners in athletics. Running doesn't require a partner. But "The Loneliness of the Long Distance Runner" is more than just a great book: Over the course of hours on the running path, solitude starts to feel like isolation.

Unlike humans, of course, dogs can't talk. But any runner who has had a long-winded partner knows that silence isn't the worst quality. And unlike humans, dogs don't show up late, cancel or argue about which course to take.

A canine jogging companion can confer health benefits beyond the lift to your workout regimen. A body of scientific evidence shows that pet ownership can protect health. A pet can decrease blood pressure, reduce cholesterol and improve mood, among other benefits, says the Web site of the federal Centers for Disease Control and Prevention.

Yet these benefits accrue only if owner and pet manage to make it work. The most popular pet in America, dogs are also the most problematic, in large part because a growing number of them live in houses or tightly confined yards. Of the nearly 45 million American homes with dogs, a large percentage represent the second or third owners for those canines, pet advocates say. Owners often get frustrated by out-of-control chewing, barking, biting, whining or accidents on the rug.

Demand for help is so great that an entire industry -- replete with antidepressants, canine psychologists and shock collars -- is developing around canine control. But often the answer is as simple as exercise. In fact, canine expert Cesar Millan, star of the television show "Dog Whisperer," ranks exercise first -- ahead of discipline and affection -- as the key to a well-behaved dog. There are even treadmills for dogs to get them exercise.

A border collie mix named Flynn exhausted the patience of the first two families that adopted him from -- then returned him to -- a Chicago shelter. Then a marathoner whose running partner had moved away visited the shelter seeking a four-legged replacement. The marathoner, David Hill, found that several fast-paced miles a day relieved Flynn's anxiety and hyperactivity. "The running totally calms him down," says Mr. Hill, who now is a professional dog-runner, giving others' pets a workout.

The sheer pleasure that dogs take in running can remind performance-obsessed humans what's really important. After an ankle injury sidelined a competitive Boston runner named Jill Hourihan, depleting her conditioning, she was reluctant to start training again. Enter Alex, her run-happy dog. "He'd stand at the door with the leash in his mouth, and that would get me going," she says.

Security is another benefit. A head-in-the-clouds runner, I can count on my dog to see, hear and smell every creature nearby, including an array of Chicago wildlife from squirrels to the occasional coyote.

Dogs, especially large breeds, can run farther than humans. But like humans, they must build distance gradually. Small dogs can run farther and faster than most owners might think. But dogs of any size shouldn't be run seriously, especially on pavement, until they are nearly full-grown, some veterinarians say. English bulldogs may be one breed not built for running.

Cold is rarely a problem, but heat stroke can kill dogs, so run at dawn, dusk or night during summer. When a normally energetic dog seems sluggish, don't push him. He may be sick or overheated.

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)                           41.8                  47.64               14.8 %

Take away?

Despite the widespread news of our obesity epidemic, the barrage of advice to eat less, the women’s magazines featuring all kinds of diets that “will burn fat away in 1 week”—there is no money to be made in companies that peddle diet foods. Why? Because people simply can’t stay on those cardboard-tasting offerings for too long. On the other hand, McDonald’s is raking it in, and damn the coronaries.

What about Herbalife, doesn't everyone buy supplements?

Herbalife is a different story: Here is a summary of information obtained from Google.

· Herbalife Founder/Chairman Mark Hughes Found Dead at Age 44 (revised 12/17/04)

· Reports to the Securities and Exchange Commission

· Herbalife's "Work at Home" Promotions (link to another site)

· Canadian Herbalife Marketers Fined $150,000 for Operating Illegal Pyramid Scheme (posted 12/13/04)

· The Dubious Promotion of Herbalife's Niteworks™ (revised 12/11/04)

·