The Doctor Weighs In

Disruptive innovations are new technologies, processes, or business models that blow status quo products out of the water and, eventually, replace them entirely. Here are some examples:

• Automobiles replaced horses

• Semiconductors replaced vacuum tubes

• Digital cameras are in the process of replacing film cameras

Lord knows we could use a big dose of disruptive innovation in health care. Most of us are still getting care in a delivery model that is more than 50 years old. And many of us would say it no longer works well.

"Minute Clinics" are often cited as an example of a disruptive innovation in health care, although these retail-based, nurse practitioner run urgent care clinics still have a long way to go before they replace the more traditional office visit, urgent care center, or emergency department as the place to get minor ailments treated.  Nevertheless, their rapid uptake are an indication that health care is ripe for change.

More and more people are unhappy with, unable to access, or can’t afford medical care as usual. That is why I was delighted to learn about a competition being sponsored by the Robert Wood Johnson Foundation and Changemakers.net, an initiative of Ashoka, an organization that describes itself as “Innovators for the Public.”

The competition is titled "Disruptive Innovations in Health and Health Care: Solutions People Want." It is  seeking “new products, technologies, services, delivery systems, business models -- or some combination thereof -- that help consumers to better manage their health and health care.” By better they mean, in ways that are more affordable, accessible, simple and convenient – all issues that sorely need addressing in the current health care “system.”

The application process, like the competition itself, is innovative. You go to a section called “Mosaic of Solutions” to determine what types of barriers to care and innovative strategies are likely to lead to disruption. The suggested barriers in the Mosaic for health care are the following:

• Health care is not consumer friendly (you can say that again!)

• Patients are not empowered • Medicine is complex and expensive

• There are monopolies of knowledge (although the internet revolution is starting to change this)

The healthcare Mosaic lists the following innovative strategies or insights:

• Democratize access

• Simplify through technologies

• Center the consumer in the business model

• Work down the chain of command (for example, help mothers of kids with cerebral palsy get licensed as in-home providers)

The application is filled out and posted online. Readers, including your competition, can then comment on and make suggestions to improve your application. After about 11 weeks, three judges will select 12 finalists. Over the ensuing 2 weeks, the Changemakers community will vote for 3 winners.

Each winner will receive $5,000 -- not much in the Trillion Dollar world of health care, but the winners will also be eligible for additional funding from Robert Wood Johnson. The Foundation has pledged to provide up to $5 million to fund disruptive innovations in health and health care in the United States that show potential to grow and make a large scale impact.

So if you have a great little idea and want to make it a great big product, think about entering this competition. If you are discouraged by the status quo in health care and  just want some inspiration, then bookmark this website and check in periodically to learn what the innovators are up to.

This competition promises to be informative and fun.

Pat Salber, MD

There is a great story in the SF Chronicle about a woman named Barbara Hillary. The headline in the print version of the Chronicle proclaims “Black woman reaches goal – North Pole.” But to me the real story here is that Hillary is a 75 year old lung cancer survivor who hired a personal trainer and learned to ski so that she could go to the North Pole.

When I was a kid I thought being 65 meant getting a Barcalounger and watching the soaps. Now, grammas and grampas are engaging in adventures previously thought to be the purview of the young and crazy.

Hillary, the article says, grew up in Harlem. She was a nurse and a community activist. After retirement, she battled lung cancer. By age 72, she was dog sledding in Quebec and photographing polar bears in Manitoba.

When she learned that no black woman had yet reached the North Pole, she set her sights on that goal. She contacted a travel company, Eagles Cry Adventures, Inc. They get people to the North Pole in all sorts of way, including being dropped off by helicopter.

But that would be too easy for Barbara Hillary. She wanted to ski in. But she didn’t know how. “Skiing wasn’t a popular sport in Harlem,” she points out. So she signed up for cross-country skiing lessons and hired a personal trainer who helped her get fit for the trip.

Hillary faced another challenge in getting to the North Pole. The trip cost $21,000. Not one to let anything get in the way of her dream, she solicited donors and scraped together the money.

She arrived in the base camp, via Norway, and, together with her fellow travelers, pitched a tent (I don’t think my grandmother was ever in a tent, let alone pitched one). On April 23, Hillary set off on skis with two trained guides. She reached her goal:

“Standing at the top of the world, she could have cared less. The enormous expanse of ice and sky left Hillary, for once in her long life, speechless.”

Way to go, Barbara Hillary. Way to go! I can’t wait to read about your next adventure.

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.

There are a bunch of little things I have wanted to share…but they are all pretty brief, really not enough to justify a “whole post.” So, I am now inaugurating a new, occasional TDWI post (you get to do that when you are “in charge”). This post will give me a chance to capture some great, but brief, unrelated ditties, for your reading pleasure. Many of these postlets have been sent to TDWI by readers who will be credited for enriching our collective reading experience.

These posts will be called “This and That” or T&T, for short.

Here is the first TDWI T&T post (enjoy):

· Email from Skip McGinty: Why Ellen DeGeneris says she can’t quite get around to exercise:

“I gotta work out. I keep saying it all the time. I keep saying I gotta start working out. It's been about two months since I've worked out. And I just don't have the time. Which uh..is odd. Because I have the time to go out to dinner. And uh..and watch tv. And get a bone density test. And uh.. try to figure out what my phone number spells in words.” Ellen DeGeneres

· Snack tips from Fitness magazine (my plane reading Houston to SF):

Cracker snacks, how do they stack up:

Ritz crackers Serving size = 5 crackers Calories/serving = 80

Wheatables Serving size = 17 crackers Calories/serving = 140

Multi-grain Wheat Thins Serving size = 17 crackers Calories/serving = 130

Triscuits (I love ‘em) Serving size =6 crackers Calories/serving =120*

Kavli Thin Crispbread Serving size =3 “sheets” Calories/serving= 60

Wasa Fiber Rye Crispbread Serving size = 1 sheet Calories/serving = 30**

*120 calories and I only get to eat six small Triscuit crackers…this is why I don’t eat them anymore

**Wasa Fiber Rye crackers are the perfect snack food. You can eat two (comparatively gigantic crackers) and only ingest 60 calories. Try dipping them in Haig’s hummous. Now there is a snack that is satisfying, filling, and modest in term of calorie contribution

· Are you a runner or walker? Got lots of old running shoes lying around?

Of course you do. If you are never going to use them again, here’s how you can put them to good use. Box them up and send them to Ana Weir at www.oneworldrunning.com. She will wash them, spiff them up, and then send them to folks in the developing world so that they can run, hike,or just plain get around in shoes. Thanks, Ana.

· Finally, Barry Messersmith sent this to TDWI to help readers recognize and respond to stroke-in-progress (Thanks, Barry!):

“A stroke victim may suffer severe brain damage when people nearby fail to recognize the symptoms of a stroke. This test is recommended by physicians. Ask the person these 4 things:
1. Ask the individual to SMILE.
2. Ask the person to SPEAK A SIMPLE SENTENCE
(Coherently, i.e. . . It is sunny out today)
3. Ask him or her to RAISE BOTH ARMS.
4. Ask the person to 'STICK' OUT THEIR TONGUE.
If the tongue is 'crooked', if it goes to one side or the other,
this is another sign of a stroke.
If he or she has trouble with ANY ONE of these tasks, call 911 immediately and describe the symptoms to the dispatcher.”

OK, a bit of a disjointed post, but fun, huh? Let me know if you like this new feature. If so, T&T will be a keeper…if not, this could be the first and last This and That.

If you like the idea of sharing short, but substantiated, health tips, email them to me @ psalber@comcast.net. You could find your name in the bright lights of TDWI, cool huh?

Pat Salber, MD

I am a big fan of the Family Violence Prevention Fund.  They have been on the cutting edge of every issue related to family violence  for years now.  These issues range from helping the criminal justice system respond better to victims to improving the health care system response to family violence.  If there is a way to try to reduce the tragedy of family violence, the Fund is there trying to figure out the best way to do it.

Now, they have a marvelous extension of their efforts -- that is a focus on helping boys learn to respect the women in their lives and to actively disavow activities and attitudes that are at the core of violence against women.  Innovative, yes.  But listen to this.  They have a program that targets coaches, that's right, sports coaches, to engage them as role models to help boys grow into nurturing, supportive boyfriends, husbands, sons, nephews, and friends of girls and women.  What a great idea!

Violence against women is not and never has been simply a "women's' issue."  It is an issue that affects men, women, children, and indeed everyone directly and indirectly related to the victim and the abuser.  Thank heavens an organization like the Family Violence Prevention Fund has taken a broader view of the problem and has begun to address the family violence as an issue that impacts just about everyone.

To learn more about Coaching Boys into Men, check out this site:  CBIM

To help support the Fund as it engages men in their programs, do what I do every year, give the best Father's Day Gift possible, a donation on behalf of your guy to the Founding Fathers program of the Family Violence Prevention Fund.  It is much better than just giving a "thing".  Just ask the men in my life -- Dov, Jason, Kevin, Gili, wouldn't you rather be gifted a Founding Father membership than get one more tie or another pair of socks.  This gift is not just for you -- it is also for your daughters, your wives, your sisters, your mothers and grandmothers and your girlfriends.

Thank you, Family Violence Prevention Fund, you are doing life-changing work.  And for that I say:  Amen.

Pat Salber, MD, MBA

This may seem off-topic, but let me remind you that financial independence is good for your health.  There is ample evidence that being poor anywhere in the world is associated with poorer health outcomes.  So, it isn't such a leap to say that helping people acquire the capital they need to start or grow a business is good public health. 

So I refer you to Nicholas Kristof's op-ed on micro-loans in the March 27, 2007 NY Times.  He writes about how easy it is to make small loans to individuals in need of capital to grow their businesses.  We are not talking thousands of dollars, we are talking loans of $25, $30, $40. 

We have known about the benefits of small loans made directly to individuals, particularly impoverished women to help them get a sustainable business up and running.  In fact, Muhammad Yunus won last year's Nobel Peace Price for his work on microfinancing in Bangladesh. 

But did you know you (that's right you, and me) can become microlenders with just a click of your mouse.  www.kiva.org is a website that helps link entrepreneurs in poor countries with willing microlenders around the world.  Kiva was founded by a young American couple, Matthew and Jessica Flannery "after they worked in Africa and realized that people remained in poverty because of the unavailability of credit at any reasonable cost.

Kiva partners with local lenders.  In Afghanistan, the financial partner is Ariana Financial Services, run by Storai Sadat.  Ms. Sadat was in her second year of medical school when the Taliban came into power and put an end to her dreams of becoming a doctor.  It is one of those stories where something bad (having to quit medical school) became something extraordinary (leader of a company facilitating microloans).  Ms. Sadat says that "being a finance person is better than being a doctor.  You can cure the whole family, not just one person.  And it's good medicine -- you can see them get better day by day."  Isn't that what public health at its best aims to do?

Imagine being able to do what Nicholas Kristof did.  He has loaned $25 to a baker in Kabul, Afghanistan.  The baker received other microloans to the total of $425 (the cost of a nice dinner for four in San Francisc0).  The baker, Abdul Satar, used the money to open a second bakery.  He has hired four employees.  He now has an economy of scale when he buys flour and firewood for his oven that allows him to improve his profitability.  And he has hope.  When Mr. Kristoff looked him up on a recent trip to Kabul, Satar said:  If you come back in 10 years, maybe I will have six more bakeries." 

Thanks, Nicholas Kristoff for telling all of us about www.kiva.org.  Thanks to you I am now a lender to three entrepreneurs in different parts of the world:

• Erkin Yakubov is a father of three in Tursun-Sade, Tajikistan.  He is raising money to purchase some hogs to build out his livestock family-run business
• Lamo Sow is the lead for a group of 8 women in Ker Gu Mag, Senegal.  These women need capital to buy farm products when prices are low and sell them in biweekly produce markets when prices are high (buy low, sell high -- isn't that what we all want to do?). 
• Pepe Figota lives in Faleapuna, Samoa.  She sells food products at a local open air market.  She need money to buy mats and fine board for printing.

I can log into kiva.org and periodically read about the progress these entrepreneurs are making toward their goals.  I can also learn the status of my payback.   I love to travel, so of course, like Nicholas Kristoff, I hope I get the chance to visit these borrowers in person one day in order to see first hand their businesses, made possible in part by my microloan and in large part by the creativity of two young Americans who made kiva.org possible.

Check it out.  www.kiva.org

Pat Salber, MD

I have been thinking about aging recently. I am not getting any younger, my loved ones are not young either; for heaven's sake--my little kids are in their forties (well, very very early forties). So where do you turn for sage advice? my favorites are the ten commandments. No, not THE Ten Commandments. I am talking about George Carlin's infinite empathy and wisdom-cum- smile. So here they are:

HOW TO STAY YOUNG

by George Carlin

1. Throw out nonessential numbers. This includes age, weight and height. Let the doctor worry about them. That is why you pay him/her.

2. Keep only cheerful friends. The grouches pull you down.

3. Keep learning. Learn more about the computer, crafts, gardening, whatever. Never let the brain idle. " An idle mind is the devil's workshop." And the devil's name is Alzheimer's.

4. Enjoy the simple things.

5. Laugh often, long and loud. Laugh until you gasp for breath.

6. The tears happen. Endure, grieve, and move on. The only person who is with us our entire life, is ourselves. Be ALIVE while you are alive.

7. Surround yourself with what you love, whether it's family, pets, keepsakes, music, plants, hobbies, whatever. Your home is your refuge.

8. Cherish your health: If it is good, preserve it. If it is unstable, improve it. If it is beyond what you can improve, get help.

9. Don't take guilt trips. Take a trip to the mall, to the next county, to a foreign country, but NOT to where the guilt is.

10. Tell the people you love that you love them, at every opportunity.

AND ALWAYS REMEMBER:

Life is not measured by the number of breaths we take, but by the moments that take our breath away.


Woopdeedo, who cares ..

nobody couldn't have said it better.

Thanks, George; I already feel younger.

Dov Michaeli

Super Bowl Sunday (SBS) presents a huge challenge to dieters.  It is hard enough to stay on track on ordinary days, but add house parties, giant bowls of potato chips, free-flowing beer and the best food advertisements America has to offer and you can almost hear your will-power cracking. 

What's a dieter to do?  Here are a few tips that may keep you from completely blowing it:

• Get your workout in before the partying starts.  Add an extra 15 minutes of something tougher than usual (faster walk, higher level on the stationary bike, pushups on your toes instead of your knees).  Be careful not to let this make you feel so self-righteous that you add an extra 1500 calories to your SBS food intake.
• Have some low calorie snacks around...you know, the usual fresh veggies with low calorie dip.  Eat them first.  And then, chug down a large glass of water.  This will go a long way towards filling you up before you start automatically reaching for the chicken wings.
• Stick to lite beer or wine diluted with water, or diet soda. 
• Everytime your team scores, jump up, cheer, and then run around the sofa, pumping your arms in the air (Rocky style).  Burns calories and, well, it is just plain fun. 
• Skip dinner.  You probably ate enough during the game to keep you from starving.  If you doubt this, write down what you ate, being careful to include every chip and dip from the beginning of the day.  Now do a quick count of the calories.  You may find it enlightening.
• At the end of the day, renew your resolve to lose weight and get healthy.  Tomorrow is another day.   Get right back on track with your diet, exercise and daily food and exercise logging.

Here's rooting for you...

Pat Salber, MD, MBA

A friend put me in touch with Maureen Whitehouse, a former model and now author of a new book, Soul-Full Eating. Maureen sent me a copy of her book to review. Now, it is a pretty book with a serenely beautiful cover photo – it’s a lettuce leaf (I think) and something that looks like a animal bone stuck in something that could be some sort of fruit. It is all a little blurry and abstract. But it does remind me of the décor of some of the nicer high-end spas I have frequented.

The subtitle of the book is “A (Delicious!) Path to Higher Conscious.” Oh, oh, I’m thinking … this may be a little too zen for me. I practice yoga because it is a great exercise and my main stretching activity. But I have never really been the meditating sort. I avoid the silent dinners at my annual visit at Rancho La Puerta … not being able to imagine how someone could pass up the chance to blab with the terrifically interesting people who attend that spa.

So, you can imagine my mind set when I started reading Soul-Full Eating. Each chapter starts with a quote. “Eat with love what’s grown with love, prepared with love, and served with love” is the basic principle of Soul-Full Eating. Hmmm.

Each chapter also has exercises to perform to help you understand the ideas presented in that chapter. The first chapter’s exercise was “Just for one day, do only what you genuinely love to do.” Yeah, right…but what about all of work I have to do. Who is going to write the post for The Doctor Weighs In?

Things aren’t going well for me and this book until I hit page 24. There, the author described a “mind-fullness” exercise that she uses in her True Beauty workshops. She describes how she walks into the workshop, and without saying a word, hands the participants three raisins.

Then she asks them to examine the raisins as though they had never seen a raisin before. They are to experience the raisin with what Zen Buddhists call “a beginner’s mind.” She tells the readers to get three raisins and do the exercise while reading this section.

So, I go to the kitchen and open the package of raisins that has been sitting, untouched, in my cupboard for several months (no, really several years, I think). I pick out three raisins and sit to read the section.

First, she tells us, examine one of the raisins carefully. Look at it closely and roll it in the palm of your hand. Lo and behold, the raisin I have picked out is actually two raisins stuck together. Had I just popped it in my mouth, I never would have known that. Next you lick the raisin. It is softer than it felt in my hand. At last, she tells you to put it in your mouth, but not chew it or swallow it, rather let your tongue explore it. Amazing, as I explore the raisin, it starts to get soft and feels like it is plumping up. It likes being in my mouth.

Now, she tells us, to slowly chew , but still not swallow. You are to chew that little raisin until it liquefies. That takes a long time. Meanwhile, you start to really taste the raisin. Ordinarily, if I eat raisins, I just pop a handful of those little sugar bombs in my mouth and swallow. I am not sure I ever really thought about the taste before.

The raisin tastes pretty darn good…earthy and sweet, but not too sweet. It is nice. I swallow the juice. It took about 3 minutes from touch to swallow…considerably longer than my usual “grab and swallow” raisin eating approach.

The author instructs us to repeat this exercise two more times. Each time consciously exploring the raisin and trying to find something new about it that you didn’t notice before. By the time I swallowed the third raisin, I realized how good it was to roll a raisin in your mouth with your tongue. And, how much flavor it has when allowed to slowly disintegrate and dissolve with during the long slow chewing process.

I must say, this exercise did get me in touch with my feelings about raisins in a way I have never experienced before. This, according to Maureen Whitehouse, is mind-full eating. I think I like it! I think I like this book. I think I’ll read the rest and will try to do what Maureen says --  that is to really be there when I eat.  Soul-Full Eating…a pretty good idea.

I must confess, I use Google to complete the NY Times Sunday crossword puzzle (please don't tell Will Shorz). And I regularly use Google instead of the phone book. I plan my vacations, do research for my blogs, and try to locate old friends using Google search. In fact, I use Google for just about everything, but I haven't been using Google to diagnose disease. Turns out, it is not too bad. Some of you may have heard about a doctor who astonished her colleagues by diagnosisng a rare condition

Click to read more ...

Dr. Dov Michaeli writes about rewarding good behavior.  He tells us there is a neurologic explanation for why rewards work when it comes to changing behavior in drug addiction .  He says they should also work when it comes to losing weight.

Don’t demonize, incentivize: lessons for weight control from drug abuse treatment programs

by Dov Michaeli, MD, PhD

An article published in the November issue of the American Journal of Psychiatry and cited by the NIH News on November 6 describes an interesting study of incentive-based therapy for methamphetamine abusers.

No, you haven’t stumbled into the wrong blog. This study is of great significance for people struggling to lose or maintain body weight, and to community and medical groups involved in issues of obesity and metabolic syndrome.

The lead scientist, Dr. John Roll of Washington State University, and his colleagues observed that participants who received Contingency Management (CM- -also known as Motivational Incentives) along with psychosocial therapy did better than participants who only received psychosocial therapy.

What is CM?

CM is a program that applies rules and consequences to help people change their behavior. In this study, for example, participants in the CM-based drug abuse program were told they have to produce drug-free urine samples on a regular basis. When they were successful at doing this, they received plastic chips that could be exchanged for a variety of prizes.

Matrix model psychosocial therapy

The psychosocial therapy in this study consisted mostly of the Matrix Model; this is a comprehensive treatment approach including the following:

• individual counseling
• cognitive behavioral treatment (a mode of treatment that seeks to identify distorted thinking that influences mood and behavior and to replace it with more rational, adaptive thoughts and actions)
• family education, and
• self-help programs

Study results

Participants of the study that received psychosocial therapy plus CM were drug-free for a period 60% longer than those who received psychosocial treatment alone.

This is a well designed clinical trial:

§ The study was controlled (the psychosocial without CM participant group served as the comparison or control group)

§ It was randomized (participants were randomly assigned to the treatment group or the control group) and,

§ The end-point was an objective measure (drug-free urine).

I believe that the results of this study are significant beyond the treatment of methamphetamine addiction, and may, in fact, have relevance specifically to weight control.

Incentivize, don’t demonize

A few days ago (october 29, 2006) the New York Times  published a front page article by Gina Kolata decrying the fact that there is an increasing tendency to demonize obese people. A few days later the New England Journal of Medicine published a study that demonstrated that indeed demonization does not work as a motivational force. Fair enough!

Kolata makes the point that obesity is in large measure controlled by our genes. This too is correct, but to a scientist this statement is not helpful. What genes? What functions are controlled by those genes? How much leeway is there for environmental/behavioral factors to modify the genetic influence?

We hear a lot about obese people having a more efficient metabolism, namely that they store more energy (calories) as fat, whereas the inefficient metabolizers have a more “leaky” energy metabolism, a lot of calories are “blown off” as heat. But even this is not a satisfactory answer; a scientist would demand a mechanism to explain this “leakiness”, and data to back it up.

There is however another way to approach this problem. From studies of the brain of addicted animals and humans we know that addiction to alcohol, for instance, is genetically determined. And we have a pretty good idea how it works. The brain has centers that are specialized for coupling our actions to reward.

What purpose do these reward responses have? We know from imaging studies of the brain that reward/pleasure centers are located deep in the mid-brain, which means that they are quite ancient in evolutionary time scale. Even  mice have them, so they must be hard wired in the brain, and must have some function basic to survival.

Indeed, let’s consider a basic drive like hunger. If finding food was not coupled to the sensation of pleasure (think of the term ‘comfort food’) we, or the mice, probably wouldn’t be seeking it so actively under conditions of scarcity. In other words-it is an adaptive response that gives its owner a survival advantage.

But what happens when environmental conditions change abruptly? Again, let’s consider food supply. Food became more abundant when humans started domesticating plant and animals and gradually became farmers rather than hunters gatherers. This happened about 10,000 years ago. But the real explosive increase in food supply happened only about 100 years ago- a mere nanosecond on the evolutionary clock. No gene could mutate and adapt to the new situation in this time period. So here we are blessed with an abundance of food as well as with multiple systems, some metabolic, some neurological, all designed to maximize the hunger drive. Hence overeating and obesity.

Let’s go back to our addiction model. When a person takes a drug, be it a narcotic administered in the hospital to treat pain or a kid experimenting with a street drug for recreational purposes, the sensation is that of pleasure. What happens on the cellular level is that the drug will bind to a receptor on the membrane of a neuron (nerve cell) in the reward center. That receptor then transmits a message to the inside of the cell through a process called ‘signal transduction’. This particular neuron will then fire off a signal to an adjacent neuron in the same reward center, and very quickly thousands of neurons get activated-resulting in the sensation of pleasure.

What happens when this stimulus (the drug) is repeated chronically, over a prolonged period of time? The cellular response becomes attenuated and accordingly-the reward response is unfulfilled. To keep the reward/pleasure response the cell increases the number of receptors on its surface, the signal becomes ‘loud’ again and the ‘hunger’ for reward is satisfied again. This process repeats itself again and again and the result is-addictive behavior.

The experiment described in the Journal of Psychiatry showed in a rigorous scientific way what we all knew intuitively: reward works. It doesn’t matter how trivial the reward looks to us-what is important is what it means to the recipient.  ( I still remember how I worked myself to exhaustion in elementary school doing my homework so that I would win a ridiculous paper gold star; I can still taste the pleasure of this reward). But from a neurobiological perspective, this experiment is quite instructive. What it may tell us is that we can set up an alternative reward pathway, to compete with original ‘addictive’ one.

But will it work in weight loss? Can we counteract the pleasure pathway of feeling ‘full’ and contented? I think that if we couple psychosocial treatment with a reward, we could more effectively counteract the urge to overeat. What kind of reward? Here is one. The simple pleasure of standing on the scale and realizing that you are making progress, pound by painful pound, is a self-reinforcing reward. Hence the recommendation of frequent weighing; the immediate feedback allows self-correction before things get out of hand. And the pleasure of seeing progress is reinforcing and strengthening the resolve to continue.

Everyone who has tried to lose weight knows that daily weighing is important, but the pleasure from the reward may not be enough to sustain weight loss or weight loss maintenance over the long run. It would be great to see CM applied to weight loss in a variety of ways and be rigorously studied to determine its effectiveness. It would be one more tool in the toolbox that could help people achieve a healthy weight.

For most of my career in medicine, the emphasis has been on treating disease. New drugs, new diagnostic tests, and new surgical approaches have improved life, delayed death, and created a culture of “if it’s broke, just fix it.” Prevention has not been a very popular nor lucrative way to practice medicine. Until recently, Medicare did not cover many preventive services. And, commercial insurers limited prevention coverage, often at the urging of their employer customers who were footing the bill. Now that our country and, in fact, the entire world is awash in chronic preventable diseases—such as obesity and type 2 diabetes -- health care professionals, policy wonks and politicians are rediscovering the joys of prevention. Better yet, they are realizing we will not be able to turn the tide on these chronic illnesses by health care alone. We need a strong and effective public health approach. Cigarette smoking is a good example. Although we have known about the link between tobacco and many different diseases, such as lung cancer and heart disease, for many years, we learned relatively late that counseling and/or cajoling of smokers by health professionals is not been nearly as effective as passing laws that restrict where smokers can smoke.

Click to read more ...

Rick Botelho is a family doc who really cares about health promotion and disease prevention. He understands that many people have a strong desire to help family members improve their health habits. But all too often good intentions are perceived by the recipient as nagging or worse, a criticism of who they are as human beings. Rick has written a guidebook, Motivate Healthy Habits: Stepping Stones to Lasting change to help families make lasting improvements in their health habits. Here is a summary: Improving Your Family’s Health Habits: Change Yourself before Helping Others By Rick Botelho www.motivatehealthyhabits.com Does giving information and advice to family members help them to change their unhealthy habits work? Then, you’re the lucky one. Despite knowing what to do, most family members do not change their behavior. Giving information and advice addresses only surface change. Knowledge alone seldom changes behavior. For most people, behavior change is a challenge.

Click to read more ...

I am an active participant in the Gather community.  Gather (www.gather.com) is considered a "social networking" website.  The focus is on bringing together people who like to write and people who like to take pictures.   With the permission of the author, I have reproduced an amazing story by Wendy Hanawalt about what it was like for her to be really, really fat.  She has since had gastric bypass surgery.  She has given her permission to share that story as well and I will, on another day. 

Memoirs of a Fat Broad by Wendy Hanawalt

"When you're really, really fat -- and by that I mean what doctors refer to as "morbidly obese," there is one thing that is screamingly clear: people who are not really, really fat have no idea what it's like. As a formerly really, really fat person who's now just fat, I have to say that we have no one to blame for that misunderstanding but ourselves. Our modus operandi is to hide: hide our feelings, even from ourselves, hide who we really are, hide our shame, hide our disabilities. And so, as part of my "coming out" as a person with reorganized intestines (having had gastric bypass surgery), I'm going to "tell on myself," write about what it's like in vivid detail, so that some of you (those who are not RRF) will have a new understanding of the experience and -- at least I hope -- those of you who are RRF will hear someone singing your song.

The day I went in for my surgery, I weighed 290 pounds, just a wee bit short of the dreaded 300 mark. Twenty pounds were gained during the months prior to the surgery. I was supposed to be losing weight. Indeed, one of the conditions for having the surgery was that I lose 25 pounds, so that the doctors would have an easier time rummaging around in my internal organs without fighting so much fat. But I was taking four shots of insulin a day for my diabetes, without ever managing to get it down to a reasonable level. (When you have diabetes, you quite literally live and die by the numbers on your meter.) One of the jobs of insulin is to hold on to fat. In a healthy body, this is a good thing, preventing you from death in times of starvation. But when you've got Type 2 diabetes, you've got more insulin than anyone would ever need, except that your body can no longer use it, so it keeps cranking out more, which holds on to the fat and, as an unfortunate side effect, gives you a voracious appetite. As one diabetes educator said to me, "It's one of the sad ironies of this disease that the most effective tool we have for keeping it under control also helps to make it worse." I lost touch with the surgical team at my medical center, because I figured well, I hadn't lost the weight, so they wouldn't touch me. Finally, the program coordinator called me and said, "So where are you about this?" I told her, and she replied, "Let me call the surgeon and get back to you." When she did, she said, "He says get in here." When I did, he said, "Let's operate on you before you gain more weight." Bless his soul.

People who have gastric bypass surgery tend to relate to their surgeons as saviors and saints. A little nutty, I thought, when I was on the outside looking in. But now, having lost 100 pounds and having gotten my life back, I can say unequivocally, my surgeon saved my life.

Life getting up to 300 pounds is, perversely enough, also a descent, a descent into a special kind of hell. I had bad knees: I couldn't walk up stairs without spending minutes per stair, pulling myself laboriously up by the hand railing as I went. The stairs at my job became impossible. I blessed my employers when they put in an elevator: one less ordeal to face, first thing in the morning. I could not stand, move, walk, without crippling back pain. My son would ask me to take him to the mall, but I could walk no more than a couple of feet before I needed to sit down, sweating profusely. "You go ahead in the store; I'll wait for you here." If I did go into the store with him, my only thought was to find myself someplace to sit, or at least something I could lean against. I prayed for him to get done so we could leave. After a while, I gave up and purchased a cane. I noticed that people started staring at me when I had a cane, and I knew what they were thinking, but it didn't matter, because I couldn't move otherwise. I knew, as surely as I knew anything, that one day I would be one of those women on the motorized scooters, terrorizing the children as she criss-crossed the supermarket.

There was the trip to Universal in Florida. It was a special event for my son and nephew, because they were going to visit all the fabulous haunted houses in this extravaganza of fantasy. I stood in one line for a half hour and nearly died. Eventually my sister and I paid the extra thirty dollars per person -- sixty dollars! -- so that we could cut to the front of the lines, and still I was in too much pain to walk. I had to stop, and my sister and the kids spent a good half hour looking for a wheelchair which I had been too proud to take at the beginning of our journey. I kept saying, "Go on without me," I was so humiliated at having ruined their experience. But they would not.

The flight to Florida had held its own horrors. For the first time in my life, I had to ask for a belt extension. One attendant was very nice about it; the other was clearly irritated. I had ordered an aisle seat so that I could lean far into the aisle and away from any person sitting beside me. But it probably was not enough, and I could see the smoldering anger in the eyes of the person beside me, and I did not blame them, not one bit. I vowed then to never fly again, unless I could afford two seats. So I spent a couple of hours leaning against the armrest, holding my breath, willing myself smaller.

The diabetes had been with me for fifteen years, starting at the time I started to gain weight. I swear that nothing in my lifestyle had changed, and yet I had gained 80 pounds. Doctor after doctor insisted that I had been eating more, doing less, that I had brought it on myself. It didn't match my experience, and yet I thought they must be right, and so I went into a spiral of shame, first ignoring the diabetes completely for a number of years and then, when it was no longer possible to do so, enduring the endless journey from doctor to doctor to doctor: the foot doctor, the eye doctor, the cardiologist, the endocrinologist. (I was almost fifteen years into my diabetes before I met a Type 2 expert at the renowned Joslin Center who told me that my experience was not in my imagination, that over and over again, he met people who gained weight inexplicably and then developed diabetes. Something about the spiral of insulin resistance.) During that time I developed a whole host of medical problems, some of them related to the diabetes and some of them not, but always in the back of my mind was the thought, I've done this to myself. I'm bad and stupid and lazy and I deserve this. I deserve to die. At my highest weight, I was taking ten different prescriptions. My co-pays, even with good insurance, added up to over $200 a month. I took Actos and glucophage for diabetes, plus two different types of insulin (which required prescription syringes), a diuretic for my blood pressure, verapamil and coumadin for a heart arrhythmia, synthroid for a thyroid deficiency caused by having to have my thyroid surgically removed, a diet pill and an antidepressant. Half the pills caused weight gain, the other half strove mightily to lower the blood sugar levels elevated by the weight gain. Eventually the diabetes took its toll, and I developed neuropathy in my feet, intense burning pain, especially at night. I developed hammer toes as my feet began to curl in on themselves, a result (my foot doctor told me) of the nerves dying in my foot and leg muscles, causing them to atrophy and pull in. I could no longer wear normal shoes, resorting to sandals and sneakers to avoid the pain.

Personal hygiene became a special horror. I invested in a hand-held shower to reach the places I could no longer reach on my own. My husband complained about the hand-held, hated the fact that it cut down on the water pressure. It was entirely too humiliating; I begged him not to make me explain to him why I needed it. Despite all my efforts of constant showering and drying and powdering and medicating, I developed open sores, the result of skin touching skin without exposure to air. Similarly, rashes and other infections left me screaming in agony. No ointments or powders or pills would stop the bleeding and weeping from sores all over my body. (Sorry to be so graphic, but it was my life.)

My life was spent on the couch, because there wasn't much of any place else I could go, except to get into my car to drive to work, where I sat at a computer every day. I could barely walk my dogs down to the end of the driveway for their daily pee breaks, never mind take off on a cardio-friendly walk. My back was in such pain that even sitting on the couch proved too painful, and the only way I could get comfortable was to lay across an ottoman. The diabetes was causing a particularly fast-growing cataract in my one good eye (I had lost the sight in the other), so I was quickly becoming blind and could not read, could barely see the television. (Thankfully, it grew so fast that surgery was ordered quickly, and now I can see brilliant, beautiful color, quite clearly, a big change from the gray my life had become.) What was there to do, except to eat?

That statement is the very definition of insanity. Why would you want to do the one thing that had brought you to this disastrous state of affairs? Well, simply because it was all I knew how to do. From the time I was six years old, eating was how I learned to handle all the painful, nasty, inexplicable feelings threatening to bubble up inside me and overwhelm me. I needed to quiet those feelings, numb them at the very least, and food was very effective for that. The sensory experience of eating the food was wonderful and then, after I had eaten way too much, the dull ache, the exhaustion, was a welcome protection from the pain. I lived the first two-thirds of my life in a state of calorically induced numbness, having absolutely no clue what I was feeling from one moment to the next. I remember that I went for whole years without shedding a tear. I became adept at putting on the cheery façade in front of strangers, so that no one suspected what was going on underneath, except that, to some people, I did not seem completely "real." Indeed, they saw me as manipulative, because they sensed I was giving them only what I thought they wanted. They were right.

With my family, the façade came down. I was generally grumpy, often short-tempered, to the point that I would scream at the children for the stupidest things. I was an exposed nerve, it seemed, and everything was hitting that nerve. Life was a toothache. The anti-depressants helped to soothe that pain somewhat, although they came with their own list of problems.

And that was my life. And it was only getting worse. I seriously contemplated suicide, because there just didn?t seem to be much point in continuing on in this fashion. The thing that stopped me was knowing what it would do to my children. But as for me? I was done.

And then I met someone who had had the gastric bypass surgery and had lost 75 pounds. I had always stayed far away from the idea of that surgery, considered it dangerous, too life altering, but also it seemed to me that there was something humiliating about admitting that life had gotten so bad, that I was so out of control, that I needed surgery to get headed in the right direction. But I was curious, and I asked this woman what had made her decide on the surgery. She stopped for a minute to think, and then looked at me and said, "You know what? I just decided I was tired of trying to do it 'the right way.'"

Bells went off inside me. That simple statement was what sent me in the direction of the most profound life-altering decision of my life."

This blog was originally publsihed on the PEERtrainer website (www.peertrainer.com) on July 20, 2006.

In some communities, like Hunter's Point in San Francisco, it is easier to get cigarettes and liquor than it is to get a crunchy apple or a juicy pear. A study, conducted by Literacy for Environmental Justice (LEJ), a Bayview-Hunter's Point nonprofit, looked at food availability in Hunter's Point and nearby Bayview, found that fruits and vegetables accounted for less than five percent of what was sold in those neighborhoods. People who live Bayview-Hunter's Point had to leave their neighborhoods, often travelling for miles on public transportation, in order to buy healthy foods for their families. But that is going to change, according to a story in today's San Francisco Chronicle, thanks to Robert Pinkard, a jovial fellow who has owned Surfside Liquors, a community gathering place, for 32 years. Encouraged and helped by LEJ, he is going to sell fresh produce in his liquor store. And, he has been named a Community Hero because of his committment to improving the health of his customers. There is a personal story here. Robert Pinkard used to weigh 499 pounds and wore a size 62 suit.

Click to read more ...

Rick Botelho is a family doc who really cares about health promotion and disease prevention. Unlike a lot of doctors who glibly tell patients “loses weight” or “stop drinking,” Dr. Botelho really understands how hard it is to make lifestyle changes. He has written a guidebook, “My Healthy Habits” and a companion workbook, “My Healthy Habits Journal, to help individuals find the motivation to change. He advocates moving beyond “health information, advice and self-management supports,” to “motivational approaches to behavior change.” The book takes you through a step-by-step approach that is designed to move you from an unmotivated state to being ready to make the changes and then actually making the changes. The book uses check lists and journaling to help you understand your current readiness to change and to explore barriers to change, including emotional barriers. In his chapter on “Understanding Change,” Dr. Botelho describes the “Force for Change” model. The model is based on the idea that both internal and external factors are involved in determining whether we will make changes in our health habits. The internal factors include understanding where you are at on a scale of “readiness to change.” Readiness to change stages are as follows:

Click to read more ...

There is a wonderful story in the San Francisco Chronicle today about a boxing coach who whipped a bunch of Middle School kids into shape. Kermit Bayless, PE director of Frick Middle School in Oakland, California uses a bullhorn and boot camp techniques to get the teens moving, really moving. They do jumping jacks, push-ups, stretching and jogging, while counting in unison. Bayless paces in front of the group, shouting directions and quizzing them on the names of the muscles being targeted. "What does PE do?" shouts Bayless. "It sets the tone for the whole school," the students shout back. He is right. Frick Middle school is one of the SF Bay Area's highest-achieving middle schools on the state fitness test. 68% of Frick 7th graders achieved high marks on the fitness test last year, compared with just 16% of all Oakland 7th graders. Across the state, only 29% of 7th graders passed the fitness test. Frick Principal Calvin Criddle believes the strict fitness program has done more

Click to read more ...

A Wall Street Journal Online/Harris Interactive health-care poll of more than 2200 adults, about half men and half women, showed that 48% of Americans have made at least one health-related New Year's resolution for 2006. This is up slightly from the 41% reported in a similar poll in 2005. "This year, I will do it" is a familiar promise many of us have made this time of year...only to fizzle out by the end of the month...or at best the end of the next month. But are the results of New Year's resolutions really that bleak? A look at the success of 2005 New Year's resolutions in this poll documented that almost half of those who vowed to eat healthier last year, say they succeeded. More than a third who made a resolution to lose weight say they were successful. More than 40% of those who promised to exercise more

Click to read more ...