The Doctor Weighs In

by Pat Salber

Here is a check list of health check-ups recommended to keep you healthy from youth to old age. I grabbed it from CNN.com. They, in turn, got it from the National Institutes of Health and the University of California, Berkeley.

There may be some differences of opinion about the details of some of these recommendations from preventive health experts, but by and large, this checklist offers good guidelines that you can discuss with your primary care physician.  Future posts will explore the scientific basis of these recommendations, but for now, regard these as a a reliable source of "general advice."

In your 20s:

• You should have two physical exams in your 20s. During the first exam, ask to have your cholesterol checked. Other blood tests are not needed in healthy people.

• Go to the dentist every year for an exam and cleaning

• If you have vision problems, have an eye exam every two years

• Have your blood pressure checked every year

• Men should perform a monthly self-exam to check for testicular cancer, the most common cause of cancer in males between the ages of 15 and 34

• Women should perform a monthly breast self-exam

• Women should have a yearly pelvic exam and Pap smear to check for cervical cancer. If your Pap smears are negative for three years in a row, the frequency may drop to every two or three years

• You should have a tetanus-diphtheria booster every 10 years.

In your 30s to 40s:

• Continue yearly visits to the dentist for cleaning

• Whether you’ve had vision problems or not, you should begin eye exams every two years. After the age of 45, start testing for glaucoma

• Continue keeping track of your blood pressure every year

• If your cholesterol remains normal, check it every five years

• Have a physical exam every one to five years

• Men should perform monthly testicular self-exams and women should perform monthly breast self-exams

• Women should have a yearly pelvic exam and Pap smear to check for cervical cancer. If your Pap smears are negative for three years in a row, the frequency may drop to every two or three years

• Women should have a yearly pelvic exam

• Women over the age of 40 should have a mammogram done every year to check for breast cancer. Earlier mammograms may be recommended for women at high risk for breast cancer

• Around age 45, everyone should be screened for diabetes every three years, or earlier if you are at high risk.

• You should have a tetanus-diphtheria booster every 10 years.

In your 50s:

• Continue yearly dental and blood pressure checkups as well as vision testing every two years

• If you cholesterol remains normal, check it every five years

• Have a physical exam every one to five years

• After age 50 men should have a yearly rectal exam to check for colorectal cancer and prostate cancer

• Have a stool guaiac test done every year and flexible sigmoidoscopy every three to five years to check for colorectal cancer. Periodic colonoscopies may be needed for those at high risk for colon cancer.

• You should receive a flu vaccine every year after the age of 50

• You should have a tetanus-diphtheria booster every 10 years • Men should perform a monthly testicular self-exam and women a monthly breast self-exam

• For women, a mammogram continues to be needed every year to check for breast cancer

• Continue to be screened for diabetes every three years

For 60s and above:

• Continue yearly dental and blood pressure checkups as well as vision testing every two years

• Have your hearing tested every year

• Check your cholesterol every three to five years, if it’s normal

• Begin yearly physical exams

• To check for cancer, every three to five years, everyone should have a sigmoidoscopy exam or every 10 years a colonoscopy

• Men should have a yearly rectal exam to check for colorectal cancer and prostate cancer

• Women should continue to perform monthly breast self-exams and have yearly mammograms, pelvic exams and Pap smears

• Men should perform a monthly testicular self-exam

• Get a flu shot every year

• After 65, get a pneumonia vaccine (good for 5 to 10 years).

• Get a tetanus diphtheria booster every 10 years

• Continue to be screened for diabetes every three years.

by Pat Salber, MD

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

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

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

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

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

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

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

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

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

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

Brian Klepper 

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 Brian Klepper

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

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

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

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

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

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

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

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

Percentage of Obese Americans - 2005

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

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

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

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

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

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

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

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

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

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

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

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

Thanks heavens, the Farm Bill is finally getting the attention of the healthcare community. In case you can’t make the link here are some equations:

Cheap corn = cheap high fructose corn syrup = fat = diabesity.

Pesticides + chemical fertilizers = toxic soil and toxic water

I could go on and on, but you get the point.

Michael Pollan, journalist and author of the best-selling book, "The Omnivore’s Dilemma," summed it up nicely in his April 22, 2007  NY Times opinion piece, "You Are What You Grow":

“Compared with a bunch of carrots, a package of Twinkies, to take one iconic processed foodlike substance as an example, is a highly complicated, high-tech piece of manufacture, involving no fewer than 39 ingredients, many themselves elaborately manufactured, as well as the packaging and a hefty marketing budget. So how can the supermarket possibly sell a pair of these synthetic cream-filled pseudocakes for less than a bunch of roots? For the answer, you need look no farther than the farm bill. This resolutely unglamorous and head-hurtingly complicated piece of legislation, which comes around roughly every five years and is about to do so again, sets the rules for the American food system — indeed, to a considerable extent, for the world’s food system. Among other things, it determines which crops will be subsidized and which will not, and in the case of the carrot and the Twinkie, the farm bill as currently written offers a lot more support to the cake than to the root. Like most processed foods, the Twinkie is basically a clever arrangement of carbohydrates and fats teased out of corn, soybeans and wheat — three of the five commodity crops that the farm bill supports, to the tune of some $25 billion a year. (Rice and cotton are the others.) For the last several decades — indeed, for about as long as the American waistline has been ballooning — U.S. agricultural policy has been designed in such a way as to promote the overproduction of these five commodities, especially corn and soy.”

Now, according to a press release from American Public Health Association and other organizations:

“Over 300 health professionals from around the country- physicians, nurses, dietitians and public health practitioners - sent Congressional leaders a letter today calling for the 2007 Farm Bill to be a "Healthy Food Bill," to better combat childhood obesity and other illnesses by making healthy food more affordable and accessible.

'The Farm Bill is fundamentally a public health bill,' said Dr. Benjamin of APHA. "Its long reach affects the food security of our nation and, in turn, our health." The letter, sent to Chairs and Ranking Minority Members on the House and Senate Agriculture Committees, targets policies in previous Farm Bills that have helped make the calorie-dense foods Americans already over-consume - namely cheap starches and highly processed foods made from added sweeteners and oils derived from corn and soybeans - some of the cheapest to buy.

Obesity and unhealthy eating constitutes a national crisis, with $117 billion per year in estimated treatment and indirect costs. The epidemic of childhood obesity promises that these children will have more heart
disease, diabetes, cancer and stroke, in some cases not long after they become adults.

'Our communities are flooded with cheap, unhealthy foods that ultimately are helping drive healthcare costs through the roof,' said Dr. David Wallinga, director of the Food and Health Program at the Institute for Agriculture and Trade Policy. 'None of us can afford the status quo. Our Farm Bill should support greater access to healthier foods for children, and support farmers growing healthier foods. It's an investment everyone will benefit from.'

From 1985 to 2000, the real consumer cost of fresh fruits and vegetables rose nearly 40 percent while that of sugars and fats actually dropped 7-14 percent. Soda pop prices dropped most of all, by 24 percent in real dollars. By encouraging the over-production of a few raw commodity grain crops, Farm Bill policies have worked at cross-purposes with healthy eating recommendations, such as those in the USDA's own Dietary Guidelines for Americans.

The letter also singles out the industrial-scale production of food animals raised on grain and routinely fed human antibiotics as growth promoters, which increases antibiotic resistance. Impacts on the health of consumers, communities and the planet from the intensive use of pesticides and fossil fuels in agriculture are highlighted as well.

The health professionals called for a new Farm Bill that will improve access to healthy foods (fresh fruits and vegetables, whole rather than refined grains, and better fats), help ensure better school access to healthy foods, and help to build the infrastructure to get healthy foods to low-income communities.

'This letter reflects our professions' understanding that the obesity crisis has links to a food system that is seriously out of balance,' said Dr. Robert Lawrence, Director of Johns Hopkins' Center for a Livable Future, and Professor of Environmental Health Sciences at the Johns Hopkins Bloomberg School of Public Health. 'The Farm Bill has to be part of the prescription for improving our health."

To read the full letter, go to: http://www.healthobservatory.org/
<http://www.healthobservatory.org/> , or
http://www.farmandfoodproject.org/
<http://www.farmandfoodproject.org/> "

Pat Salber, MD

The President has indicated that he will veto the bill on Monday when he returns to Washington, DC. Please tell the President to uphold his duty to the 70% of Americans who support embryonic stem cell research and not to veto S. 5....send a fax to the White House and ask President Bush not to veto hope!"

Here is how you can help:  Send a simple email to President Bush today at comments@whitehouse.gov or fax (202-456-1111).  Your message doesn't need to be long (he probably won't read it anyway) or complicated.  Just be clear about what you want. 

Here is some sample language:

"President Bush,

Don't veto hope.  Americans want sensible, sensitive stem cell research.  S-5 provides for that.  This legislation is life-affirming.  Let it stand.

Sincerely,"

Please help.

Pat Salber, MD

Given the drawbacks of the current commonly used diabetes screening methodology – fasting blood glucose – and the fact that more than 20 million people are thought to have undiagnosed diabetes in the US alone, an easier and more convenient screening test would be a very welcome addition to the diabetes testing armamentarium.

Fasting Plasma Glucose

The limitations of using fasting plasma glucose (FPG) as a screening test for diabetes include the following factors:

• You have to fast overnight before having the test – that means you have to get yourself to a clinic or laboratory in the morning before going to work. Hmmm. Not such an easy thing to do when you have to get the kids to school and yourself to work. So, if you are like me you keep putting it off and putting it off – it doesn’t mean you are ignoring the need to have the test – it is just a fact that today’s crowded lives don’t mesh well with yesterday’s screening technologies.

• You need to have blood drawn. Again, no big deal for some people, but a dreaded experience for others. I have seen great big guys faint on the spot when they see their blood sucked up into that little tube. So, again, it can be one more reason to put “diabetes screening” on the bottom of the “to do” list.

• The test misses quite a few cases of diabetes. It only detects elevated glucose when a person is fasting. It does not detect abnormal elevations of glucose after a meal. An even more inconvenient Oral Glucose Tolerance Test (OGTT) is needed for that. This test involves having blood drawn, drinking a standardized glucose-containing solution and then having blood drawn again 30, 60 and 120 and, sometimes, 180 minutes later.

So, you may be thinking, what’s the big deal if you put off screening for diabetes. It is because diabetes complications mount up as diabetes remains undiagnosed year after year. That is the reason that many diabetic patients will have one or more irreversible complications at the time they are diagnosed (Harris MI, Diabetes Metab Res Rev 16:230-236, 2001).

Enter SAGE

SAGE is a new diabetes screening technology. It is short for “Spectroscopic measurement of dermal AGEs.” AGEs are “advanced glycation end products” that form when glucose levels, over time, are elevated. AGEs serve as biomarkers for diabetes.  Their levels correlate with existing complications of diabetes and have been shown to predict future complications, such as diabetic kidney or eye disease

Like A1C (a blood test that measures glycosylation of hemoglobin), but unlike a spot glucose blood test, AGEs are not affected by acute increases in glucose. Therefore, a test that measures skin AGE levels can be performed regardless of whether the individual has fasted or just eaten. This fact, combined with the fact that there is no need to draw blood, makes this technology highly attractive.

AGEs are measured using a spectroscope that measures skin fluorescence. AGE accumulation impacts flourescense. Since skin naturally accumulates AGEs over a person’s lifetime, it is necessary to apply an algorithm to correct for age.

How does SAGE compare with FPG and A1C testing?

Maynard and his New Mexico colleagues, as reported in Diabetes Care May 2007,  performed a head-to-head comparison of SAGE with both FPG and A1C testing. 351 people were tested with the SAGE technology in the fasting and fed states. They also underwent FPG , A1C and OGTT testing. The idea was to see how many of the people who had abnormal OGTT tests (the most sensitive of the diabetes diagnostic tests) also had abnormalities in the other tests. Here is what they found:

• The SAGE test identified almost 29% more individuals who were OGTT “positive” compared to FPG and 17% more than A1C testing

If these results hold up and if the testing equipment can be made to be both easily transportable and affordable, then this technology could make highly sensitive diabetes screening tests accessible to the millions of individuals who cannot or will not avail themselves of FPG testing. Early diagnosis of opens up opportunities for early intervention and prevention of diabetes complications.  This is really exciting.

As always, you must be aware that there is a caveat about this study. The lead author, John D. Maynard, MS works for VeraLight, a for-profit company that is manufacturing the SAGE instruments. Catriona Nguyen, another author on the paper is affiliated with InLight Solutions, a related company. Although VeraLight’s mission is to

“help stem the tide of the worldwide diabetes epidemic by driving early diabetes detection, thus enabling initiation of therapies that can prevent diabetes or reduce its complications”

we, nevertheless, need to be cautious about placing too much hope on technology "proven effective" by industry funded and/or affiliated publications…..we have been burned before.

Pat Salber, MD

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

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

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

Why?

For several reasons:

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

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

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

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

Dov Michaeli MD, Ph.D

Photo from USA Today, by Jeff Mitchell, Getty ImagesAccording to a front page story in USA Today, there has been a “mind-boggling” increase in the number of people who are severely obese (aka morbid obesity). A study, published in the journal Public Health, by RAND Corporation researcher Roland Sturm, documents that there are 2.6 million more people with a body mass index of 40 or higher than there were just five years ago. Overall almost 25% of people are now considered obese, up from 20% in 2000. A staggering 66% of people in the US are either overweight or obese.

To help us visualize what this means, USA Today published a chart to accompany the article. Here is what it takes to be obese or severely obese:

Height                    Obese                    Severely Obese

5 foot 4                             174                                             232

5 foot 10                          209                                              278

George Blackburn, associate director of nutrition at Harvard Medical School is quoted as saying the increase in the percent of severely obese people is a catastrophe.

All this fat is not going to melt away without effort — effort on the part of individuals, communities, and society as a whole. For Americans to lose all that weight and get physically fit will require both personal and collective responsibility.

We need more bike paths; attractive, easy to use stairwells; safe neighborhoods; availability of inexpensive healthy foods; PE in schools; exercise breaks at work; and, in general, an American lifestyle that makes it easier to do the right thing for our health and well-being, than the wrong.

Failure to make significant changes in our work and family lives will indeed lead to a health catastrophe – more and more childhood and adult obesity, epidemics of diabetes, heart disease, high blood pressure and abnormal lipids and other obesity-linked diseases.

So, let’s get on with it…let’s work together to get the lifestyles we want and need.  I really hope I am not writing about severe obesity levels of 30% in 2012.

Pat Salber

We all know the devastating statistics:

· 13.5 million people in the US suffer from coronary artery disease

· 8 million people have diabetes type 2.

· 95,000 people are diagnosed every year with colon cancer, and a sedentary lifestyle increases the likelihood of getting this disease by 40%.

· People who don’t exercise have about a 60% increase in osteoporosis; 250,000 suffer from hip fracture every year.

· 50 million suffer from hypertension.

· More than 60 million people in the US are overweight.

You might conclude from the last bullet that obesity is the culprit. You’d be only partly right. Lack of physical fitness is the other culprit, regardless of percentage of body fat. Even if we take people with a high % of body fat (more than 25%), the relative risk of death from all causes in the fit person is half that of the unfit.

Exercise and the body.

The effects of exercise on the body are well known:

· Exercise increases HDL, the good cholesterol, by an average of 4.6%. This, in turn, results in a decreased risk of coronary artery disease.

· Exercise increases insulin sensitivity, reducing the risk of metabolic syndrome and diabetes type 2.

· Exercise strengthens the heart muscle, improving its function.

· Exercise increases bone size and density, reducing bone loss due to aging and osteoporosis.

· Exercise increases muscle strength, coordination and reaction time. Result: improved balance and stability; reduction in falls and bone fractures.

What about mind?

This is a truly fascinating story, and you can read about it in more detail in an article in Newsweek, March 26, 2007 , by Michael Craig Miller, MD, from Harvard Medical School . Here are the salient points:

· Exercise has been known for many years to give, during and after exercise an “endorphin high”. This is the feeling of satisfaction, well being, and increased self-esteem that many people experience. This effect is short term, on the order 1-2 days in duration.

· Aerobic exercise increases blood supply to the brain, thus increasing oxygen and nutrient supply to the neurons, and removing metabolic waste materials from the brain.

· Aerobic exercise increases the production of neurotrophic factors in the hippocampus.

What are neurotrophic factors?

When the nerve cells are getting organized to form the organ that we call ‘brain’ (a process that doesn’t end at birth, it actually continues until about age 20), they do it under the direction and control of peptides and proteins that are secreted by the nerve cells themselves. But the job of these factors doesn’t end there: they continue to shape, modify, and re-shape several areas of the brain. They are essential for the formation of new neurons from stem cells—a process called neurogenesis. They also are important in the formation of new connections between existing neurons—a process called neuroplasticity. These two processes are important because they are the basis for learning and memory; everything we know and remember is stored in neuronal circuits. Furthermore, the thicker the connections between the neurons the faster the flow of information in the circuits—very much like the broadband required for fast transmission of electronic signals. The brain factors cause this thickening as well.

There are several known neurotrophic factors that have been shown to increase in concentration due to a sustained, long term exercise regimen:

· BDNF (Brain-Derived Neurotrophic Factor).

· NPY (Neurpeptide Y).

· VEGF (Vascular Endothelial Growth Factor).

The fact that we can identify specific brain peptides that increase neurogenesis and neuroplasticity is interesting enough. But what makes it even more fascinating is where in the brain this increase happens.

Enter the Sea Horse.

In the temporal lobe of the brain there is an area, called the hippocampus, because it is shaped like a sea horse. This area regulates emotions and stores memories. In fact, it has been known that in aging brains and in depression, two situations in which neurogenesis and neuroplasticity are reduced, the hippocampus gets smaller. Furthermore, electroshock therapy and antidepressants caused an increase in the size of the hippocampus, apparently due to increase in neurogenesis and neuroplasticity.

It was especially gratifying to read in the latest Proceedings of the National Academy of Sciences (PNAS, vol. 104, p. 4647, 2007) the report by Warner-Schmidt and Duman. The unequivocally demonstrated that the antidepressant drug fluoxetine (Prozac) and the pain-control drug desipramine (Norpramine, Pertofran), cause a large increase in VEGF in a specific area of the hippocampus (The subgranular zone). Interestingly, desipramine’s action is inhibition of pain signals ascending through the spinal cord to the brain; in other words, it inhibits the perception of pain.

Not surprisingly, aerobic exercise does the same thing. We even know how this happens on the molecular level—through the action of the very same brain factors: BDNF, NPY, and VEGF.

The take home lessons

· We now know beyond the shadow of a doubt that aerobic exercise increases the feeling of well being, increases learning capacity and improves memory.

· Aerobic exercise ameliorates depression and is becoming an additional tool in the treatment of this disease.

· Aerobic exercise reverses the effects of aging on the brain.

· Aerobic exercise may reduce the perception of pain—an important implication for people suffering from chronic pain, such as arthritis.

One final note: to all you Yoga practitioners, iron pumpers, and assorted other exercise enthusiasts—these effects on the brain were demonstrated only with aerobic exercise. Sorry.

Dov Michaeli, MD, Ph.D

Yes, I know. We’ve all read these articles ad nauseam. And we all are in agreement, so what’s more to say? As Chris Matthews would say: tell me something I don’t know. Try this, Chris. Today on NPR was this news item:

· If current trends continue, over 50% of the population (that’s everybody, adults and children) would be obese or morbidly obese by the middle of the century.

· Babies as young as 2 years old are now being seen in hospitals and clinics with severe obesity and diabetes type 2.

· An 880 lbs (that’s not a typo) man had to be taken to the hospital. It required 16 men (and I don’t mean girlie-men) to move him, a part of the house had to be demolished, and a specially constructed vehicle/ambulance had to be used.

Question: where in the world can something like that happen? The answer is posted at the bottom of this column.

The battle between profit and portions .

In today’s New York Times Sunday Business section (NYT, Sunday, March 25, 2007 ) there is a new look at the obesity problem—from the business perspective (“Will diners still swallow this?” by Andrew Martin). There is actually a profit incentive for restaurants to stuff us with ever bigger portions. How could that be? Simple, the cost of food is only about 30% of the total; the rest is fixed expenses: labor, rent, utilities, taxes, etc. This is from research soon to be published by Marion Nestle, professor of Nutrition, and Lisa R. Young, a dietician and adjunct professor, both at NYU. So now the calculus is quite straightforward; Starbuck’s, a uniquely American phenomenon of marketing genius, offers a 12-ounce “tall” for $1.70, while the 16-ounce “grande” (how did they come up with those names?) will set you back by $1.89. Now consider that the extra 2 ounces costs Starbuck’s about 5 cents. Labor and other fixed costs are, well, fixed. Multiply the 14 cents extra profit per cup by the millions of cups sold every day, and enormously grande profits can fill you with a new appreciation of the power of large portions.

The same math applies to Super Size hamburgers (McDonald’s), Colossal hamburgers (Ruby Tuesday), Thickburgers (Hardee’s), Megabreakfast (Denny’s), to name a few. Ruby Tuesday’s actually tried to reduce the portion size and charge less for the smaller portions, but customers voted with their feet. They soon had to re-join the portion-size arms race.

It is not only consumers who force the restaurants into this dance macabre; Wall Street, with its quarterly profit obsession, will crush the shares of restaurants who even try to reverse course--next quarter same store sales and profit margins will not look good. It took a privately held company, T.G.I. Friday’s, and a gutsy CEO with a well-developed sense of morality (and Super Size prefrontal and frontal cortexes?) to announce a Right Size policy, and reduced prices to match.

What’s to be done?

It’s tough. Consumers were brainwashed that they get better value with large portions. A typical argument of the‘free-choice, market-forces’ crowd is that if we consumers didn’t want to eat those gigantic portions- we would simply leave some on the plate. Right…In reality, most people will eat whatever quantity is put in front of them. This is well documented in the literature. I, for one, have to clean up my plate; my mother used to say, in Yiddish, that it was a sin to leave food on the plate. And if I didn’t ask for seconds, it was a sign that I didn’t like her cooking…Restaurant chains LOVE such mothers.

Professor Rolls of Penn State U., who did research on the behavior of consumers when offered large portions, suggested that restaurants may start a small, almost surreptitious, downsizing of food portions. I suspect that in our competitive, no prisoner taken economy, competitors will quickly spread the word.

I favor a sustained, widespread education campaign, not much different from the anti tobacco campaign. I believe that in the last analysis an educated citizenry will force a return to sanity and sanité.

So what country was it?

AUSTRALIA ! I couldn’t believe it. My icon of outdoorsmen, frontiers people, the epitome of healthy lifestyle. Say it isn’t true mate, please.

Dov Michaeli MD, Ph.D.

We know that diet and exercise can prevent the onset of type 2 diabetes in people with impaired glucose tolerance. We also know that healthy lifestyle measures are more effective than even the most effective drugs. That being said, we also know that in the real world with Mickey Ds and Starbucks on every corner, long work hours, longer hours in front of the computer, and way too few hours exercising our body parts, that medications will be a part of the treatment armamentarium utilized to prevent type 2 diabetes.

So the question before us today is which drug should be used. An editorial in the March 20, 2007 issue of the Annals of Internal Medicine takes a stab at answering that question.

David Nathan, MD from the Massachusetts General Hospital Diabetes Unit and Michael Berkwits, MD, Deputy Editor of the Annals review the results of the DREAM trial (AKA, the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication trial --- seems like you can’t have an important trial nowadays without a cute acronym).

The DREAM trial randomly assigned more than 5,000 patients with impaired fasting glucose (>110 mg/dL, but less than 126 mg/dL) or impaired glucose tolerance (a glucose level 2 hours after an oral glucose load between 140 mg/dL and 199 mg/dL) into one of four groups. One group received ramipril (an ACE inhibitor), one received rosiglitazone (an insulin sensitizer), one group received both drugs, and one group received a placebo.

The participants were evaluated after 2, 6, and 12 months and annually thereafter to determine if they had either developed diabetes or died. They were also evaluated to see if their glucose levels improved during those time frames. The participants were middle-aged and they were obese (mean BMI 31 kg/m2).

Here is what the study showed:

• Participants taking the drugs had a significant reduction in the progression to type 2 diabetes
• The reduction was entirely attributable to taking rosiglitazone.
• More patients taking rosiglitazone regressed to normal blood glucose levels (almost 39% in the rosi group compared to 20% in the placebo group.
• Although both medications were generally safe, rosiglitazone was associated with a higher prevalence of peripheral edema (swollen ankles) and a ~ 2.2 kg weight gain. In addition, there was an increased frequency of heart failure in a small number of patients (0.5% in the rosi group compared to 0.1% in the placebo group)

The authors talk about what clinicians (and patients) should do in light of this new information. First of all, they point out that rosiglitazone is expensive and has some uncommon but serious side effects. There are, they remind us, other medications that have been shown to prevent progression from impaired glucose tolerance to type 2 diabetes.

Metformin is available as an inexpensive generic formulation. At least in people with BMIs of 35 or higher, the percent reduction in progression to diabetes is only slightly lower than that described with rosiglitazone (53% vs. 60%). In addition, it is well tolerated except for some minor gastrointestinal symptoms, and it is much cheaper. The other effective drug, acarbose, is poorly tolerated because of adverse GI side effects.

So what’s a clinician to do?

• Continue to counsel and support patients with impaired glucose tolerance or impaired fasting glucose to adhere to a healthy lifestyle (you know, diet and exercise).
• For patients unable to unwilling to make these changes, they recommend considering metformin, as opposed to rosiglitazone, as a medication to prevent type 2 diabetes.

It is noteworthy, that Dr. Nathan lists GlaxoSmithKline, makers of Avandia, the brand name for rosiglitazone, as a potential financial conflict of interest. His recommendation to not go with rosi as a first line diabetes prevention drug must surely have caused some heartburn in GSK marketing circles.

Pat Salber, MD

Check out DiabetesPHD on the American Diabetes Association website. It is a risk assessment tool that uses Archimedes, a sophisticated computerized health modeling program to determine your risk of developing heart disease, stroke, and/or diabetes and its complications (kidney failure, eye problems, foot problems) over the next thirty years.

The best thing about this program is it gives you a chance to see what happens to your risk if you lose weight, reduce your blood pressure or improve your cholesterol levels. You can also model the impact of taking certain medications or having better health habits (not smoking, taking an aspirin a day if you are over 40). It is pretty cool to watch the graphs of your risk improve in front of your eyes when you lop off 40 pounds or lower your cholesterol by 40 points.

The advice DiabetesPHD provides is specific to you since you entered your numbers which were then run through the Archimedes model (which is based on published scientific studies of health risks). The advice contains hyperlinks so that you can easily access more information on topics relevant to your risk profile.

Here’s how it works. You go to the data entry page of the tool and type in relevant information about yourself, including the names of any medications you are taking for diabetes, high blood pressure, or abnormal lipids -- so be sure to have you medication list when you sit down to use the program. You will also be asked to enter your latest blood pressure, blood glucose, as well as total cholesterol, LDL and HDL levels. It can calculate risk without these numbers, but is more accurate if you can provide them. You are also asked to answer a series of yes/no questions about your health history.

Once all of the information is entered you are given the choice of getting your results now or receiving them by email. It can take a number of minutes for the program to calculate your results because your information is being run against a very complicated health modeling program. So put aside about 15 – 20 minutes to use the tool, including entering the data and waiting for the results.

It is well worth the effort. The combination of a clear visual display of your health risks now and over the next 30 years and being able to see the impact of improvements in risk factors is powerful. These pictures are definitely worth a thousand words.

Pat Salber, MD, MBA

An article in the NY Times declares that one in eight adults in NY City has diabetes. That is 12.5% of the population or 700,000 people. Lest you feel relieved that you don’t live there, let me remind you that the rest of the country is not all that far behind. Overall, about 10.3% of Americans have diabetes and about a quarter of them don’t know it (yet). 

An additional 24% of adults in NY (and in the rest of the country) have abnormally high blood sugars that have not yet reached diabetic levels.  This condition is known as pre-diabetes.

Not too many years ago, the diabetes rate was 6%--half of the current NY rate. But our self-indulgent ways have caught up with us. Too little exercise, too many calories plus too much stress adds up to an epidemic of obesity, particularly abdominal obesity.  Abdominal obesity, especially visceral obesity, is linked to the development of Type 2 diabetes in genetically predisposed individuals.

It’s just a “touch of sugar.” Why all the concern? Because diabetes and it precursor, pre-diabetes, are the most familiar manifestations of a constellation of metabolic changes, known as cardiometabolic syndrome. Other manifestations of this syndrome are high blood pressure, dyslipidemia ((high triglycerides and low HDL (“good”) cholesterol)), clotting abnormalities, and problems with inflammation. People with cardiometabolic syndrome, even if they haven’t yet developed full-blown diabetes, have an increased risk of heart attacks and strokes.

Cardiovascular disease, strokes, and peripheral vascular disease are all very expensive conditions to treat in our technologically sophisticated health care system. These conditions already occupy some of the top slots when it comes to where our health care dollar are spent. So imagine what is going to happen now that the rates of diabetes have doubled (with no end in sight).

So, this epidemic of diabetes and pre-diabetes is not just a health care issue that burdens individuals and their families living with the disease. It is a looming societal problem that threatens to bankrupt our already fragile health care system. It could cause health care insurance premiums to escalate even further, impacting not only employers who provide coverage, but also public payors, like Medicaid and Medicare.

It is time to get deadly serious about doing something about prevention. We need to rapidly move to institutionalize regular exercise programs in school and at work. And we need affordable, easily accessible healthy eating options. That means we must be willing to regulate, legislate, and maybe even implement taxes (oh, oh, the tax word!) that can get us to where we need to be. Failure to do something