The Doctor Weighs In

By Dov Michaeli MD, Ph.D

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

The physiology of acute stress

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

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

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

The other type of stress

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

Why do we prefer sweets and fats?

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

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

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

In summary

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

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

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

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

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

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

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

Epilogue

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

By Dov Michaeli MD, Ph.D

If you are a woman, you don’t have to read on. But if you are a man, I mean a real one, with a prostate, this is for you.

An Article in the Feb 15, 2007 issue of Cancer by Wright, Chang, Schatzkin, et al. has some disturbing news for obese men; They have a higher risk of dying from prostate cancer than men of normal weight. The study, called the NIH-AARP Diet and Health Study, found that men who reported weight gain after age 18 (!) were also found to be at increased risk of dying from prostate cancer. These findings did not change when age, family history of prostate cancer, race, or past screening history were accounted for. The most likely explanation underlying the observed association is that heavier men have hormonal alterations that adversely affect prostate cancer progression leading to death.

A total of 287,760 male study participants were included in this analysis. Men were between 50 and 71 years of age at the start of the study in 1995-1996, at which time they filled a questionnaire that asked about the height, weight, and other factors, as well as cancer screening practices. The authors of this study looked at body mass index (BMI), which was calculated from height and weight. They also examined weight change from age 18 years to baseline (1995-1996). Approximately 29% of men were classified as normal weight (BMI <25 kg/m²), 50% as overweight (BMI 25-29.9 kg/m²), and 21% as obese (BMI >30 kg/m²). During five years of follow-up, 9,986 cases of prostate cancer were identified. During six years of follow-up, 173 prostate deaths occurred.

Critique

This study had several strengths, including the large number of men with prostate cancer, a wide range of reported weights, and the ability to determine if any other factors affected the association between BMI and prostate cancer risk. This last statement is especially important, since studies of this sort are susceptible to what we call “confounding factors”, meaning that other factors, not the ones studied, may account for the results. Having participated in the study (as a subject), I can verify that the investigators left no stone unturned. I remember thinking, as I filled out the exhaustive, and exhausting, questionnaire that the only thing they left out was asking about the phase of the moon on the day I was born.

The study results add to the growing evidence that obesity increases the risk of fatal prostate cancer. What is alarming is that this prospective study identified increasing weight after age 18 as a risk factor for prostate cancer death.

What about women?

No, I am not talking about women with a prostate gland. Rather, about obese women’s susceptibility to cancer. Indeed, there is compelling evidence that these women are indeed at higher risk of dying of breast cancer. And this is not surprising at all. The adipose tissue in men can synthesize a close relative of testosterone, which can fuel the growth of cancerous prostate tissue. Likewise, adipose tissue in females can synthesize a close derivative of estradiol, a hormone stimulating the growth of breast cancer.

Why do we see younger adults with breast and prostate cancer?

At least for men, this study offers an explanation. We now know that weight gain after age 18 can affect a person’s risk of getting prostate cancer. We also know, from other studies, that chronic exposure to testosterone (or its adipose-synthesized derivative) is carcinogenic, and will accelerate the onset of the malignant process. That may explain why we see now men in their 30s and 40s with prostate cancer.

We also know that women with a long term exposure to estrogen have a higher risk of developing cancer of the breast. This is why women who have children at a later age are more susceptible to breast cancer than women who had children early and often. And early obesity may be the reason why we see now women in their 30s with breast cancer.

Should this finding be used in a public campaign to combat obesity among our teenagers? I think so.

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!

One of the attributes of a great image is its ability to convey vast amounts of information and meaning quickly and simply. Here's a terrific example.

In one of his typically astute comments, Barry Carol alerted us to a wonderfully clever graphic by Wellington Gray - the image needs more space to be viewed properly than this blog allows, so you'll have to click on the link - displaying the percentage of people older than 15 in different developed countries with a Body Mass Index greater than 30. In other words, the percentage of fat adults.

At 31% of our adult population, the US has the most obesity by far, fully 20-25 percent higher than our closest competitors in the race to lifestyle oblivion, Mexico and the UK. At the skinny end of the scale, France, Austria and Italy are at 9%, and Norway is at 8%. The ridiculously industrious Koreans and Japanese are hovering around 3%, or about 1/10th of our obesity problem.

Of course the subtext of this graphic is that we can see immediately who has an advantage or a disadvantage on cost, productivity and competitiveness in the increasingly global marketplace. The US' unbridled lust for poor food and inactivity, urged on by the industries that profit from those traits, will  translate to the biggest costs and the lowest productivity, and these influences will undermine our long term competitiveness. The Japanese and Koreans, who take the term "lean" seriously, will whip our fat asses.

The obesity problem, like the health care problem, is a matter of national will, policy and lobbying. As long as the agriculture and junk food, prepared food and fast food sectors lobby unimpeded for tax subsidies for low nutrition foods, open access for their advertising to our children and murky information about what's in the stuff we stuff down our gullets, they'll prosper and America will decline.

The rules that guide how businesses behave are decided in policy. Effecting change will require that our nation's non-agriculture and non-food business leaders, our most influential individuals, come together and collectively determine that change is necessary. They must decide that it is in their economic interests for American workers to be healthy so they can be productive, and so that productivity can translate to competitiveness.

As with health care reform, meaningful reform on behalf of America will require convergence with the expediencies of power. Under our current system, nothing else can accomplish the change we so desperately need.

Brian Klepper is a health care analyst based in Atlantic Beach, FL. 

by Pat Salber

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

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

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

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

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

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

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

Brian Klepper

Any lingering doubts that America's cavalier attitude toward lousy food and obesity is draining the nation's health and economic vitality should have been laid to rest last week. Two important studies were released that quantified just how much our inability to resist fast food is costing us.

 In Health Affairs, the premier journal of health care market dynamics, economics and policy, Professor Ken Thorpe and colleagues from Emory reported on a study comparing incidences of chronic disease in the US and in 10 European countries.  They found strong evidence that Americans have much higher levels of lifestyle-related chronic disease than do Europeans - in other words, we're sicker - that American medicine tends to identify and treat disease more aggressively than does European medicine, and that our more excessive lifestyles and aggressive treatment patterns undoubtedly contribute significantly to our much higher per capita health care spending, which can be twice what Europeans pay.

The second study, from the Milken Institute, is called An UnHealthy America: The Economic Burden of Chronic Disease, and it provides a calculation of the direct and indirect costs of seven of the most common and costly chronic diseases. The findings are staggering. America currently spends more than a trillion dollars - more than $200 billion for direct care and more than $900 million in lost productivity - on avoidable conditions. Unless we do something differently, that number is expected to rise to $6 trillion by the middle of the century, crippling the nation's health status and economy.

While Dr. Thorpe and his colleagues present compelling evidence that, at least in part, Americans pay so much more for our health care than Europeans because we take such poor care of ourselves. And once we get disease, we may not manage the care processes as well as Europeans do.

But those points aside, in a sense there  is little new in these studies. Instead, they confirm what we already all know, and in a damning way. As a people, we appear to be nearly unconscious of the impacts of our habits on our health or prosperity.

America's addiction to fast, prepared and junk foods is, of course, continually stoked by the propaganda machines of  the processed food industry, which spend huge sums on both marketing and lobbying. 

America's health care crisis has two enormous wings. On one side, a fee-for-service reimbursement system and a lack of transparency cultivate an opportunistic culture that generates excessive care and cost throughout the health care supply chain, the care delivery system and the financing sector. On the other, a food industry preys on our children without regard for the consequences to them or the welfare of the nation.

Neither of these problems can be resolved until the nation's most powerful individuals - the business leaders who run firms outside of health care and the food industries - unite to demand greater adherence to behaviors that work for, rather than against America's future.

Brian Klepper 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The American Diabetes Association recently published Proceedings of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus. The proceedings are published in a July 2007 supplement to Diabetes Care.

The experts participating in this conference have recommended the following screening strategy for Gestational Diabetes Mellitus (GDM):

Risk for gestational diabetes should be ascertained at the first prenatal visit.

Low risk:

• Member of an ethnic group with a low prevalence of GDM
• No known diabetes in first degree relatives
• Age < 25 years old
• Weight normal before pregnancy
• Weight normal at birth
• No history of abnormal glucose metabolism
• No history of poor obstetrical outcomes

If all of the following characteristics are present, low risk women are not required to have blood glucose tested routinely.

High risk:

• Severe obesity
• Strong family history of type 2 diabetes
• Previous history of GDM, impaired glucose metabolism (e.g., insulin resistance, metabolic syndrome, or type 2 diabetes), or glucosuria (glucose in the urine)

Perform blood glucose testing as soon as feasible if one or more of the high risk factors are present. If GDM is not diagnosed, blood glucose testing should be repeated at 24-28 weeks or at any time a patient has symptoms or signs that are suggestive of hyperglycemia.

Average risk (everyone who is not low or high risk):

Perform blood glucose testing at 24-28 week on all average risk women

New to the screening guidelines this year is the inclusion of “normal weight at birth” to the list of requirements to be considered low risk. This was added because of evidence that women who were at the extremes of birth weight have altered insulin action and/or insulin secretory capacity that may predispose them to the development of GDM as adults.

There is an increasing prevalence of GDM in the US that appears tied to the increase in obesity and type 2 diabetes incidence. Because impact of GDM on both the mother and the fetus can be ameliorated with aggressive treatment, it is imperative that all pregnant women seek early prenatal care, have their risk for GDM assessed, and have glucose tolerance testing as outlined above.

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

By Dov Michaeli MD, Ph.D

An article in the New England Journal of Medicine, July 21 issue (The spread of obesity in a large social network over 32 years, N.A. Christakis and J.H. Fowler, pp. 370-379, 2007) dropped like a bombshell into the medical community, exploding many long-held assumptions and beliefs.

What was the question this research attempted to answer?

To quote the authors: “ The prevalence of obesity has increased substantially over the past 30 years. We performed a quantitative analysis of the nature and extent of the person-to-person spread of obesity as a possible factor contributing to the obesity epidemic.” The italics are mine, to emphasize the fact that the authors set out to explore a quite revolutionary concept: obesity, like any infection, spreads by person to person contact.

How the study was done

The authors took advantage of a famous study run by the Federal Government in Framingham , Mass. Basically, the study consisted of medical researchers taking exhaustive medical history, blood tests, physical examination and x-rays on a massive scale; most of the townspeople volunteered for the study, and since its inception in 1970 to date the original subjects, their children and grandchildren, have been subjected to repeated periodic examinations. The main objective of the Framingham Heart Study was, as the name implies, to identify all the factors that contribute to heart disease. But because of the extensive data base, including data that could be important in other diseases, such as smoking and lung cancer, this study became a rich trove of information for medical researchers in many diverse fields.

For this study an evaluation was made of a densely interconnected social network of 12,067 people assessed repeatedly from 1971 to 2003. The BMI (body mass index) was available for all subjects. Obesity was defined as BMI ≥ 30. The authors used statistical models that had been developed to analyze other network systems (for instance, person-to person spread of the influenza virus, or effect of peer influence on alcoholism in schools) to examine whether weight gain in one person was associated with weight gain in his or her friends, siblings, spouse, and neighbors. Before we go to results, here are a couple of definitions used in network studies:

Ego: The person whose behavior is being analyzed.

Alter: A person connected to the ego who may influence the behavior of the ego.

And the results were…

Surprising would be an understatement. Here is a summary:

· If an ego stated that an alter was his or her friend, the ego’s chances of becoming obese increased by 57% if the alter became obese. The type of friendship appears to be important. Between mutual friends (both ego and alter state that they are friends), the ego’s risk of obesity increased by 171% (!) if an alter became obese. In other words, if your friend becomes obese you might as well just give up and start gorging. In contrast, there was no statistically meaningful relationship when the friendship was perceived by the alter but not by the ego.

· How can we talk about any subject without invoking sex? So here it is: When the sample was restricted to same-sex friendship the probability of obesity in the ego increased by 71% if the alter became obese. But that’s not all: a male-male friendship increased the ego’s chances of becoming obese by 100% if the alter became obese, whereas the female-to-female spread of obesity was not significant.

· What is the “reach” of this relationship of friendship and obesity? When an ego becomes obese, his/her friend (or alter) has a 45% higher chance of becoming obese (as compared to a random network). A friend of the friend (2 degrees of separation from the ego) has a 20% increased probability of becoming obese, and a friend of a friend of a friend of the ego (3 degrees of separation from the ego) has a 10% increased probability of becoming obese. At four degrees of separation from the ego there is no increase in probability of becoming obese (thank God!)

· Geographic distance made no difference: a distant alter had just as strong an influence on the ego as the friend next door. Reminiscent of chaos theory predicting that a butterfly in California may cause a hurricane in Alabama .

· Neighbors, on the other hand, had no influence on the ego’s obesity.

· How about family relationships? Surprisingly weaker than friendships. Obese husband effect on wife—44% increase in probability; Obese wife effect on husband—37% increased likelihood of obesity. Siblings of the same sex—55%; Siblings of the opposite sex—27%. But caution: before you blame your same sex sibling for your obesity, the difference between the 55% and 27% increase in likelihood of obesity was not statistically significant.

So what does it all mean?

I must admit, I am baffled. The obvious conclusion is that obesity can spread just like any other infectious disease. Amazing, if true.

When I read claims that are in apparent clash with reality as I know it, or that stretch my credulity, I approach such claims with an increased index of suspicion. Space does not permit an in-depth analysis of the work, but here is one objection: The social relationship (ego-alter) was determined on the basis of 0.7 relationships per ego. Does this truly reflect the social milieu of an individual? Would, say 3 or 4 social relationships per person (much more realistic) completely negate this finding? In other words, despite the enormous number of people participating, the sample of total relationships is just too small. That could lead to spurious results. For example: if you had a sample of 2 and you added another 1, that addition can have a large influence on the result. If you had a sample of 100 and added another 1, the likely influence is quite small. Here the sample size is 0.7! adding 1 or more relationships could upend the analysis and its conclusions.

So am I skeptical of the study? Yes and no. And the reason I hope I am wrong will be the subject of another posting.

by Pat Salber, MD

A small story in the business section of USA Today is good news (I hope). It says eleven major food companies, including giants Coca-Cola, Pepsi, and McDonalds will announce changes in how they advertise their products to kids. The Council of Better Business Bureaus (CBBB), in an effort to respond to the epidemic of childhood obesity, has organized the Childrens Food and Beverage Advertising Initiative to get food companies to “pledge” to stop advertising unhealthy products to children. These voluntary measures are supposed to go into effect by the end of 2008.

Evidently each company is making its own pledge. McDonalds, the article notes, will only promote meals with “no more than 600 calories, no more than 35% of calories from fat, 10% of calories from saturated fat and 35% total sugar by weight.” Is that dinner they are talking about? Or a mid-afternoon snack. When it comes to healthy eating, the devil is always in the details.  Products in Kraft Foods' Sensible Solutions line, which has less fat and calories than their other foods, will be the only types of products advertised to kids.

Although, the USA article was pretty positive about the Initiative, it did close with a quote from Kelly Brownell, director of the Rudd Center for Food Policy and Obesity at Yale University. Brownell says that the food companies’ voluntary guidelines for advertising to kids “are a good move in the right direction, the risk is that it stops here.” We’ve all seen that happen before, right? It is the rare industry that voluntarily reigns in bad practices that are highly profitable.

Digging Deeper

This article motivated me to dig a bit deeper. According to a press release found on the CBBB’s website, the eleven companies* participating in its Childrens Food and Beverage Advertising Initiative, have

“pledged to focus essentially all of their advertising primarily directed to children under 12 on products meeting better-for-you standards or refrain from advertising to that age group.” (Better-for you, compared to what?? … the high sugar, high fat they were advertising to kids before?). Steven J Cole, President and CEO of the CBBB goes on to day, “These expansive commitments significantly exceed the Initiative’s baseline requirements.”

The Pledges

Here are some of the pledges:

McDonalds:

All advertising primarily directed to children under 12 will be for meals that meet “specified calorie, fat, saturated fat, and sugar limitations consistent with the Dietary Guidelines for Americans 2005 and other government standards. They will restrict their advertising to the “Advertised Meal” that must provide no more than 600 calories; and no more than 35% of calories from fat, 10% of calories from saturated fat, and 35% total sugar by weight

The “Advertised Meal” will either be a 4 piece Chicken McNuggets® Happy Meal with low fat white milk and apple dippers with low-fat caramel dip or a Hamburger Happy Meal with low fat white milk and apple dippers with low-fat caramel dip. Scroll down to Appendix A of the pledge to see the details of what’s actually in the “Advertised Meals”

Kraft Foods

Kraft has pledged to only advertise products to children that meet its Sensible Solution nutrition criteria. Cool Whip Lite, Honey Maid Bees, Oscar Mayer Fat Free Wieners, and Lunchables Pizza are some of Kraft’s Sensible Solution products.  (Want to see the rest?  Here's the link to Krafts' Sensible Solutions products.)

General Mills

General Mills will no longer advertise to children foods with more than 12 grams per serving. (Be careful with this one, serving sizes are usually a fraction of what actually gets poured into the bowl or put on the plate). They also pledge to advertise only Healthy Dietary Choices to children under 12.

In fact, according to information on the CBBB website, General Mills has partnered with Nickelodeon (scroll down to page 4 of the pledge) to bring the popular Nickelodeon characters SpongeBob SquarePants, Dora the Explorer and Diego to frozen and canned vegetables. The goal is to make eating vegetables fun for kids. Each package of frozen vegetables will also include stickers featuring the characters that parents can use to reward children for eating their vegetables.

Note, these are frozen and canned vegetables – not the fresh kind that you can get for a fraction of the cost in the veggie section of your local market. And, it is of interest, that the brands touted in the pledge are frozen beans and frozen broccoli with butter sauce!

Never good enough.

I could go on and on, but you are probably thinking. What a crab…nothing is ever good enough. Well, in the midst of an obesity epidemic that threatens the world’s children with early onset chronic diseases and a shortened lifespan, then, heck yeah, promoting frozen buttered broccoli instead of the fresh kind and “apple dippers with low-fat caramel dip” instead of real low fat, fresh apples is not really good enough.

Let’s keep on pushing and pushing until the industry really gets it right. But, we have to do more than blab about it. We have to buy better, cook better, eat better and, in this way, fundamentally change the market for food.

Big job? You bet? But it can be done. Just the fact that these eleven companies are now trying to figure out how to market healthier foods indicates that they will respond to consumer demand (and regulatory threats). When more and more of us choose to shop in the outer perimeters of supermarkets (where the fresh foods are) or in local farmers’ markets, you can bet that industry will be watching.

Pat Salber, MD

Brian Klepper 

California always seems to be ahead on things that matter. A CNN story this week highlights that state's terrific anti-obesity TV campaign. The ads have cute kids sweetly asking "Dad, could you buy me some diabetes?" and "Can I drink another cup of sugar?" The goal is to shock adults into appreciating that the cheap, tasty foods they shovel down their children's gullets will have real impact. In one of the CNN clips, Adam Sandler says the ads work so well that he and his little girl suddenly dropped their cheeseburgers. I passed along the link to folks in Florida's government, and asked, "Why aren't we doing something like this?"

It's a fair question, but as I tried to point out in my post the other day on food companies' lobbying influence, these ads, powerful as they are, are hardly a match for the food industry's virtually unlimited resources and unrestrained marketing power. A well-intentioned state agency may place a few high profile ads, but the food companies can run theirs unrelentingly and in many different media. They're all over kids’ TV programming, in children’s books, and at schools. They have product placements in the movies, and are on Internet gaming sites. It's difficult to go head-to-head and expect to win against such sophisticated techniques and on so many fronts.

We’re utterly losing the war on obesity. The disease and cost numbers make that abundantly clear. The other day, Bob Laszewski at The Health Care Policy and Marketplace Review reminded us of an important 2005 Emory University study on the topic. The team, led by prominent health services researcher Kenneth Thorpe PhD, analyzed the 20 medical conditions that accounted for most of the growth in health insurance spending between 1987 and 2002.

The conditions, in order of their influence, included:

1. Newborn and Maternity Care
2. Cancer
3. Pulmonary Conditions
4. Arthritis
5. Mental Disorders
6. Hyperlipidemia
7. Hypertension
8. Lupus
9. Back Problems
10. Upper Gasterintestinal
11. Diabetes
12. Kidney Problems
13. Infectious Disease
14. Heart Disease
15. Skin Disorders
16. Bronchitis
17. Endocrine Disorders
18. Other Gasterointestinal Diseases
19. Bone Disorders
20. Cerebrovascular Disease

During that 15-year period, the cost of treating obesity-related conditions rose tenfold, growing to two-thirds of our total health care spending. The number of people who became obese, the percentage of obese people with serious medical conditions, and the cost to treat each obese patient all skyrocketed.

The study’s authors had a simple summary statement:

"If insurers and employers are serious about reigning in health care spending, then obesity prevention should be at the top of their agenda."

There's no mystery here. Long term, the magnitude of the obesity crisis threatens our national health and economic welfare. The roots of obesity-related diseases and their costs lie in the marketing methods of the fast, prepared and junk food industries. Look for the source, and you’ll find the food industry's boardrooms and their DC lobbying offices.

California has taken the first step on this issue. We’ll soon see whether Washington takes it as seriously. On Wednesday, Dr. James Holsinger, the White House' Surgeon General nominee said that, if he gets the job, he will focus on childhood obesity. It’s one right issue for our time, but talk is cheap. The real question is what he or someone like him would be willing to do. If he carries the torch for nutrition guidelines and curbs on food company marketing, then he’ll stand with our children and America’s future. But if he refuses to actively confront how foods are sold or what the obesity data say, then he’ll be standing with the food companies and their lobbying dollars.

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

By William Bestermann MD

Half of health care's $2 trillion dollars is spent on five chronic conditions. Three of those conditions - vascular diabetes, coronary disease and congestive heart failure - are interrelated in their causation. If we simply applied what we have already learned, we could eliminate enormous suffering and significantly reduce the cost of these conditions.

Many professionals in positions of leadership today were educated in the 60s, opposed the Vietnam War, and viewed military intelligence as an oxymoron. But my oldest son, a West Point graduate, has taught me lessons that have changed my life and are relevant to the major conundrum facing medical practice today.

West Point places a primary stress on technical adaptation.  These young cadets are taught “Tactics Lag Technology.”  That is to say if the officer applies tactics appropriate to the last war in the face of more deadly weaponry in the current war, he will likely be responsible for the deaths of hundreds if not thousands of his personal friends, team mates, and countrymen.  Military officers, in their movement upward in rank and responsibility, learn of our own new technical capabilities, those of potential enemies, and how to integrate these into best military practices to minimize casualties while increasing the likelihood of success of the mission.  This is a central focus in military culture.

First, a bit of military history

These cultural attributes of the modern American military officer did not just drop out of the sky.  West Point cadets study the American Civil War in some detail.  That conflict saw the beginning of dramatic technical change including railroads, rifles in large number, and trenches that transformed warfare forever.  Prior to the War Between the States, for thousands of years, generals managed the attacking force in the same way.  The defenders would line up over a broad front, in ranks perhaps two or three deep, over a couple of miles depending on the size of the force. The attacking force would assemble in front of them in full uniform with color guards and regimental bands playing marching music.  Then the attackers would march to within effective range of their weapons.  As the Civil War began, most units were armed with muskets and the effective range was 40 yards.   So the Union and Confederate units would march to within 40 yards, fire one volley or perhaps several followed by a bayonet charge.  The carnage was not terrible and the loser was the one who lost his nerve and abandoned the field.  

As the war progressed, both sides replaced muskets with rifles and the defenders dug trenches.  As the Confederates prepared for Pickett’s charge at Gettysburg, the Union troops were behind a stone wall defense and armed with rifles.  Nearly a mile of open field lay between the opposing forces.  The Southern Commander Robert E Lee had ordered the charge, but Corps Commander Longstreet objected, simply knowing by observing the situation that the mission was impossible.  General Lee ordered him to charge the Union force in spite of the objection and Pickett’s Division was cut to pieces in a matter of minutes.

The following spring, US Grant had assumed command of all Union armies.  He was determined to end the war by capturing Richmond and crossed the Rapahannock River to begin what became the Overland Campaign.  In battle after battle, the Union forces charged entrenched confederates, with the same resulting horror the Confederates suffered at Gettysburg.  General Grant suffered 60,000 casualties in the month of May 1864 alone.  The puzzle of the rifle and the trench never was solved in the Civil War.

Amazingly, when WWI started 50 years later, tactics had still changed very little, though the technology of war had changed dramatically.  The forces involved had tanks, airplanes, machine guns, repeating rifles, mortars, breech loading artillery, trenches, and barbed wire at their disposal.  The method of attack had not changed.  The frontal assault was still the order of the day.  The British suffered 60,000 casualties on the first day of the Somme offensive.  The generals still did not get the message and over the new few months 500,000 promising young men were shot down in that single campaign.  WWI ended and the puzzle of the repeating rifle, trench and machine gun was still not solved.

The wrath of the status quo

The terrible carnage of WWI broke the spirit of Europe and there are still residual cultural effects on that continent.  In the aftermath, the promising young American officers Dwight Eisenhower and George Patton wrote infantry journal articles describing a new kind of attack that would later be called “blitzkrieg” or lightning war.  In this assault, all of the heavy weapons of the attacking force would be combined in units actually making the assault.  All of the tanks, artillery, bombers, machine guns, mortars and mechanized infantry would be thrown at the weakest point in the enemy line. They would break through, and turn left and right to “roll up” the force in the trench.  History has shown this to be a brilliant disruptive innovation in warfare and frontal assaults no longer occur.

How did the senior army leadership respond?  The Chief of Infantry called Eisenhower in and told him that his articles did not represent sound infantry doctrine and that if he wrote any more articles of that nature he would be court-martialed.  Billy Mitchell actually was court-martialed for advocating similar valid innovative disruptions in the army air corps.  Thank goodness the innovations advocated by Eisenhower, Patton, and Mitchell were adopted and played a critical role in WWII.

The change from frontal attacks to the attack of supreme violence aimed at a point is a very dramatic example of paradigm change.  The whole dynamic of combat changed from a defense that could not be overcome to an attack that could not be resisted.  The officers directing the blitzkrieg assault were not more diligent, more industrious, smarter, brighter or more dedicated than their predecessors.  No, they were not superior in any way-they had simply used a new system, a new application that was more effective.

So what does all of this have to do with medicine?  

You might think “How could these people be so blind? We would never do such a thing.”

Think again!  The science around medical practice in the treatment of atherosclerotic vascular disease has utterly changed.  The evidence that demands a change in paradigm has become irrefutable.  The technology of vascular medicine has progressed at a pace fully equal to that seen in the military.  The old attack on vascular lesions in stable patients aimed at fixed narrowings – bypasses and stents – are as thoroughly discredited as frontal assaults in the face of machine fire. (More on this in another post.)

The Institute of Medicine is the medical arm of the National Academy of Sciences.  The IOM membership is composed of 1,400 of the best minds in medicine.  In its 2001 report, “Crossing the Quality Chasm,” the IOM summarized what was needed to treat chronic conditions:

“The current systems cannot do the job. Trying harder will not work.  Changing systems of care will.”

This document is the medical equivalent of the infantry journal articles written by Patton and Eisenhower.  It is a call to action and change, yet little in practice has changed since it was published in 2001.  Why?  The Chief of Infantry is alive and well.  Paradigm change has dramatic consequences and, for the leaders of the old order, the changes are negative.

The consequences of the utter failure of leadership in this case are exactly the same as a frontal assault: thousands of dead and disabled as a monument to our inaction.  Heart attack and stroke accounted for roughly 800,000 deaths in 2003. Many of these deaths were premature and avoidable. The bodies may not lie in heaps before a trench-line, but they mean the same thing: a failure to bring the full benefit of new technology to those we have promised to protect. 

There is a very real price to be paid for our failure to translate our new scientific knowledge about vascular disease into practice.  The Steno II trial compared optimal medical care (that is, drug therapy) in type 2 diabetes to usual care, and reduced the number of vascular events by half.  Only a small percentage of the study's patients had to be treated more aggressively to prevent a heart attack or a stroke.

The type 2 diabetic has a lifetime risk of dying from a vascular event of 65-80%.   Each risk factor - glucose, pressure, and cholesterol - treated to goal using the right medication reduces the risk of a vascular event by half.  Only 7% of type 2 diabetics have all three risk factors simultaneously to goal. 

Our failure to provide more aggressive risk factor management in these patients obviously is very damaging to their health.  The economic cost is equally painful.  Half of health care's $2 trillion dollars is spent on five chronic conditions. Three of those conditions - vascular diabetes, coronary disease and congestive heart failure - are interrelated in their causation. If we simply applied what we have already learned, we could eliminate enormous suffering and significantly reduce the cost of these conditions. In stable angina patients, optimal medical therapy was just as good in preventing a heart attack in a stable angina patient as optimal medical therapy plus a stent—for one third of the cost.

If current trends are any indication, medicine, the insurance industry and government will be slow to lead on transformation.  Patients and businesses that pay the bills must demand better or continue to receive medical care that is not what it could be.

Dr. Bestermann is medical director of the Vascular Medicine Center at the Holston Medical Group in Kingsport, Tennessee.

by Brian Klepper

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

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

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

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

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

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

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

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

Percentage of Obese Americans - 2005

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

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

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

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

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

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

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

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

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

It's absolutely in the national interest to turn this problem around. But unless we have dramatic change from elsewhere – chemical concoctions that make junk food tas