Focus on the Process, Not the Outcome

Imagine, if you dare, that you are Kansas City Chiefs Head Coach Andy Reid. Fresh off two Super Bowls (and almost a third), your team now sits at 3 wins and 4 losses after a blowout defeat in which you scored zero touchdowns. You could indulge in self-pity and just listen to radio talking heads conjecture on your anticipated win-loss record come Thanksgiving.

But if your Andy Reid cosplay is true to form, I’d bet dollars-to-donuts that, instead of focusing on that intermediate outcome, you’d spend the next practice working on the process to make a better outcome more likely: fundamental skills like making sure players line up in the proper formation, know their assignments, and use sound technique in blocking, tackling, throwing, and catching. I’d bet you would want to make sure your players take care of nagging injuries.

Let’s think about the ultimate goals of medical care through this process-oriented lens. As we’ve outlined before, every medical test or treatment should aim to accomplish at least one of the following goals:

1. It makes the patient feel better.

2. If it does not make the patient feel better, the test or treatment should make the patient live longer.

3. Finally, if a test or treatment makes no difference in how the patient feels and makes no difference in how long the patient lives, it should at the very least save money.

If a diagnostic or therapeutic strategy can’t be proven to cause #1, 2, or 3, it isn’t worth pursuing. In this framing, weight loss is a winner: it clearly meets criterion #1. Not only does weight loss increase one’s self-esteem come bikini season (at least according to literally every magazine cover I’ve ever seen in the checkout aisle of a supermarket), it reduces the risk of multiple potentially debilitating chronic diseases, and it eases joint pain. And, as has been repeatedly shown by programs such as the Diabetes Prevention Program, which we push hard at KBGH as part of our work with CDC and KDHE, weight loss saves money (criterion #3). But in terms of #2, life prolongation, weight loss has historically fallen short. And prolonging life is maybe the thing doctors are most proud of, given our 40-year extension of life expectancy in the developed world in the last century or so.

This is a paradox.

An excellent review published this week took on this paradox head-on and concluded that interventions for obesity would be more effective at preventing early death if they focused less on weight loss and more on increasing physical activity and improving fitness levels. That is, talk less about the outcome of a reduced body weight in six or twelve months, and talk more about the physical activity that will help the patient get there:

iScience

As you can see above, for any given weight, you’re less than half as likely to die of any cause if you’re cardiovascularly “fit” than if you’re not cardiovascularly fit (the word “unfit” seems a little pejorative here, but maybe that’s just me).

This isn’t necessarily new news. We’ve known for a long time that the things that happen in doctors’ offices that truly prolong life are surprisingly limited. But they’re powerful, and physical activity promotion is right there with cholesterol management, blood pressure control, and smoking cessation in terms of its potential to make people live longer. Physical activity reduces your risk of death from any cause by about 23% in a given period of time. Focusing on the process of being active daily achieves the outcome–the outcome we’re all ultimately most interested in–of a reduced risk of death, even without taking into account weight reduction.

Journal of the American Medical Association

This approach of process-over-outcomes and health at any size is provocative, but it is gaining steam. We’ll hear several speakers address the topic at the upcoming KBGH-sponsored Live Well with Diabetes Day of Discovery Event. Just as Andy Reid is surely telling his players to focus on their skills and decision making and not on their wins and losses, those speakers will likely tell us to start paying more attention to physical activity and food choices and less attention to the scale.

As the Medical Director of the Kansas Business Group on Health, I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Links for Wednesday, August 29, 2018: Dirty Kanza Promotions, Dangerous playground comeback, Dutch cycling politics

This Dirty Kanza video showed up in my email yesterday

And this cornball teared up a little watching it. I'll carry a torch for this race as long as I live. 

Playgrounds that are just a little bit dangerous are coming back, baby

When I visited my alma mater last spring, I was pretty bummed out that the old playground, made up largely of concrete pipe:

concretepipe.org

and buried tractor tires:

http://lapaceksorchard.blogspot.com/

had been completely replaced with the same safety-first playground equipment you can find anywhere:

Not Skyline's playground, but it might as well be. They all look alike. (playcreation.com)

The problem with this kind of playground isn't that it's ugly or unsafe. It's that it's boring. And kids don't want anything to do with a boring playground. It can't compete with omnipresent screens. Public playgrounds that allow for slightly riskier play (think swinging and teeter-tottering) on a variety of surfaces--nothing exotic, just sand, grass, gravel, and the like--see 53 percent more visitors than the ultra-safe playgrounds like the one above, and kids are 18 percent more physically active.

“The take-home message ... is: Stop setting your bar at the level of the most anxious parent. If you do that, you’re guaranteed to produce boring and dull playgrounds,” said Tim Gill ... “If you set your bar at the level of the average parent or maybe even at the level of the parents … who do want some more excitement and challenge in their kids’ lives, then, things start to look different.”

I like different. An abrasion, bruise, or even a broken bone here and there is the cost of doing business for raising interesting, innovative, resourceful kids.

The Dutch are known for their everyday, casual love of cycling. But their policies and infrastructure didn't come easily

"Rotterdam, for example, was completely obliterated during the Second World War and rebuilt in this post-war, modernist image — designing cities around the automobile, where people would live outside the city, commute by car into the city every day, and everyone would have more light and space and air. They’d be living happily in the suburbs.

It didn’t take long for Rotterdammers to realize this wasn’t the future they wanted. The spaces they were building were inhospitable to walking and cycling and public transit. Cycling rates were plummeting. There were more road fatalities.

So, not just in Rotterdam, but in cities across the Netherlands in the ’70s, there was a real rejection of this car-centric urban planning.

Some of them resisted better than others. In Rotterdam, they managed to reverse the tide and retrofit some of these spaces for other modes of transportation. But certainly a lot of Dutch cities made mistakes. In Utrecht, they paved over canals. In Amsterdam, they came just a single city council vote away from demolishing the Jewish quarter of their city to build a four-lane motorway."

But now cycling transcends politics:

Chris Bruntlett: ...We had conversations with politicians there and they made it perfectly clear: Even the right-wing in the Netherlands has to support more spending on cycling.

David Roberts: Because of public pressure, public opinion?

Chris Bruntlett: Exactly. It’s not a tenable or realistic position to win an election when probably 80 percent of the population cycles at least once a week.

Building on all that NZ pregnancy cycling momentum from last week. (Pic: Modacity/Vox)

I'm changing the way I talk about walking

I spend a lot of time trying to convince people to be more physically active. I spend time on top of that trying to convince people that we should change the built environment, parking policies, and traffic laws to allow people to be more physically active.

One of my old standby stories is of a person who's spent most of his life sitting on the couch watching TV. He goes in for a routine operation, has a catastrophic adverse event, and ends up paralyzed as a result. When he wakes up the surgeon and the anesthesiologist gather to tell him the bad news. The first question out of this man's mouth, a man who has not walked further than from the bed to the bathroom, the bathroom to the kitchen, the kitchen to the sofa, or the car to his office cubicle in years, is this: "When will I walk again?"

I've even posted the story here from time to time. 

My point with the story has always been to get people to approach the world from a perspective of abundance. Don't take for granted the gifts you have today. Our bodies were designed by millions of years of evolution to move bipedally. If we forsake that, we end up less healthy and less happy. 

But yesterday I listened to Enter the Exos, a new-ish episode in Rose Eveleth's always thoughtful series Flash Forward. 

In the episode, Rose spends a predictable amount of time talking about the possibility that robotic exoskeletons, or even powered clothing, will make us faster, stronger, and less prone to injury:

I'm talking about the one on the left.

But she spends an even greater amount of time talking with people with various disabilities about their perception of exoskeletons. This is the part that got me. William Peace, blogger of Bad Cripple, has this to say: 

Your typical bipedal person exposed to a barrage of misleading news stories is led to believe all paralyzed people share one goal in life--walking. Please cue the soaring inspirational music accompanied by the brave and noble young man or woman struggling to walk surrounded by health care professionals, computer scientists, and engineers who share the same ritualized ideal. 

There is so much to unpack there. I walk, and I like doing it, so I've always thought that other people without the ability would want it. And maybe they would, if the technology were developed that could be applied to people with all kinds of disabilities (cerebral palsy is a lot different than spinal cord injury is a lot different than post-polio, etc). But bipeds like me have a hard time imagining that someone wouldn't want to get closer to the way I move, just like people with normal hearing are mystified by deaf culture. When I put myself in the position of someone who is in a wheelchair or needs another assistive device, I can see and hear the condescension in my words.

So I'm changing my pitch. I'm going to lean more on the "move through space" message and delete the "walking" part. I plan to work harder on the infrastructure message, with curb cuts and tactile crosswalks and protected walking lanes and a hundred other easy fixes that make life better not only for differently abled people, but for people who can walk and bike without difficulty like me.

And I'm going back to my perspective of abundance: we don't have functioning exoskeletons or other sexy fixes for paralysis or weakness yet, but we're all cyborgs already. Most of us carry a device in our pocket that literally has the world's knowledge at our fingertips. We should harness that technology to find safer routes for human-powered transportation of all kinds. And people who can't walk have a 235 year history of constantly improving wheelchair technology whose potential could be unleashed with a little more attention paid to the way we design our environment and laws.

How to break up with your phone, Double Arrow Metabolism edition: Days Six and Seven

Saturday's (Come back to [real] life) assignment: Get back in touch with what makes me happy in my offscreen life. I'm asked to complete an exercise:

• I've always loved to...ride my bike
• I've always wanted to...publish something non-academic
• When I was a kid, I was fascinated by...reptiles
• If I had more time, I would like to...write more
• Some activities that I know put me into flow are...none. Ever. Don't get me started.
• People I would like to spend more time with include...friends from college

I'm supposed to make a list of specific fun, off-phone things to do in the next few days. Here goes:

1. Visit the Monet to Matisse exhibit at the Wichita Art Museum
2. Volunteer for Bike Walk Wichita
3. Meal plan for the week
4. Ride my bike every day
5. Visit the herpetarium at the Sedgwick County Zoo

Sunday's (Get physical) assignment: Make some time to get back in touch with your body by doing something physical and enjoyable. I plan to commute by bike to my volunteer activity with Bike Walk Wichita today. Two birds, one stone.

The second assignment is to buy an alarm clock so as to more effectively banish my smartphone from my bedroom. I've been thinking about doing this for a while. My trusty, rusty old clock radio from college has been commandeered by my daughter, so now when I wake up in the night I can't tell what time it is without looking at my phone. My beloved George Nelson clock is hard enough to read during the day:

I'm not super-pumped about the style of the normally reliable Wirecutter's top pick, so I'll add "shop in-person for a clock radio" to my list of non-phone activities for the weekend. 

Just minutes a day

Remember the proliferation of exercise gadgets in the 1990s? You had the knee squeezer:

The sit-up machine: 

I don't see how this is better than a sit-up.

The aluminum pretzel:

I'm sensing a theme here...

And many, many others. What they all had in common (in addition to being highly inefficient ways to part you from your money) was their promise to turn you from "before" to "after" in some small period of time daily, usually under 30 minutes. 

Newsflash: doing anything--anything--physical for 30 minutes a day is going to help you out. It doesn't have to be a gymnastics routine. Hell, try doing push-ups, planks, and crunches for 30 minutes a day. It's a lot of work.

Both pictures are "after." Where can I buy those shorts? Rowrrr.

But that's all an aside. Here's the thing I'm really thinking of today: I’m not sure how may times I’ve had a parent or grandparent of young kids tell me how much physical activity he or she gets as a result of “chasing around a two-year old.” I’ve always been suspicious of the claim. Don’t get me wrong--parenting, especially at the toddler phase--is exhausting. But it tends to be exhausting in the way a stakeout is exhausting, mostly from monotony and sleep deprivation. It’s emotionally taxing because of the lingering self-doubt about the quality of your parenting and the everyday small decisions you fear will lead to some real harm if made improperly. Physically, it never seemed demanding at all with my two kids. There was some lifting, sure. But most of the parents I see in public with their kids are sitting somewhere gazing into their smartphones. It’s the kids who are doing all the physical activity. The parents are unlikely to take twenty steps in an hour, it seems. [note: none of this cynicism applies to daycare workers, most of whom really hustle]

Obviously I’m a little jaded. As I write this, I’m sitting in a fairly spectacular local park, taking part in a fundraiser. I can see eleven parents from my perch at a picnic table (at least I think they’re parents. They’re sitting adjacent to the playground with small children zipping between them. Oh, and there are 12 if you count me). Of the 12, twelve are either writing (that’s me), texting, or eating. Zero are interacting with children in any physical way. In an unusual turn of events, I’m actually primed for some moral superiority, since the kids and I got here by bicycle, in the #familypeleton, so I have the ~3.5 miles to the park and the 3.5 miles home on my side. That's enough self-congratulation for the day. My point is, being with your kids might bring you joy most of the time, but it won't bring you physical activity unless you do it self-consciously, just like any other activity. 

What got me thinking of this is the fact that I’ve had innumerable conversations with people about physical activity over the last decade in which one or both of us advocated for “Simple strategies to add physical activity to your routine!” These discussions were often irrationally enthusiastic about the awesomeness of parking at the far end of the parking lot, or substituting a rake for a leaf-blower, or using a whisk instead of an electric mixer. You get my drift, I hope. Here’s the problem: it’s almost all bunk. Desperate, depressing bunk. And I say this as the person who has on many occasions been on the giving end of this advice. Now, before Blue Zones fans come at me with pitchforks and torches (both good ways to “Add physical activity to your routine!”, by the way), let’s perform a little thought experiment.

Let’s imagine that you wake up from a routine surgical procedure to find a doctor solemnly standing over your bed.

“Justin, I have some bad news,” she says as she pulls up a chair. Your name is Justin in this dream, by the way.

“Your appendectomy went fine. You’re going to heal right up. But you had a rare complication of the anesthesia, and it appears you’re now paralyzed from the neck down. The good news [doctors always try to segue into the good news as quickly as possible, amiright?] is that you’re still able to breathe on your own, so you shouldn’t have any trouble talking, and you won’t need a ventilator.” As you try to shake off the last remains of the sleeping medicine, and as your spouse softly weeps at your side, the doctor goes on. “But you won’t be able to do any intentional physical activity beyond breathing, talking, smiling, and blinking.” She then explains that the condition is likely permanent, at least as permanent as you are.

As you let this news settle over you, what will you miss? Will you miss your thighmaster or ab cruncher or aluminum pretzel time? I hope not. But if so, that's cool. Will you miss mowing the lawn? Maybe, if you’re one of the guys Lowe’s advertises to in the springtime. Will you miss using a whisk? Well, I guess, insofar as you’ll miss cooking in general. (note: Julia Child has a great old clip in which she talks about how normal cooking should lead to the cook getting sweaty. It’s awesome. You should look for it. I'd link it, but I can't find it, and I'm in a hurry.) But I’m willing to wager that the walk across a shimmering, sweaty, oil-stained parking lot upon which you’ve intentionally parked your automobile far, far from the entrance to the big box store is something that approximately zero percent of us would miss. Zero percent of responders to this scenario would miss running a vacuum cleaner, or washing their tile floor by hand, or any of the 1,000 other “strategies” I’ve heard in this regard.

What would you miss? Dancing with family at weddings, maybe. The spray of water on your face as you waterski. I’d desperately, achingly, miss my morning cycling route that takes me through the sunrise in summertime and through a crystal wonderland in the winter. I know this because I've been sick lately, and I fear the cold air would make me sicker. I’d miss the bike ride to school with my kids. I’d miss the competent, reassuring thud of a frisbee into my outstretched hand. I’d miss the brace of cool water against my face the first time I dive into a pool in the springtime. I’d miss...nothing at all related to parking.

Here’s my point: Movement isn’t just a utilitarian product of 85 million years of evolution. It isn’t just a means of getting from point A to point B. It is a source of joy. So, sure, park at the edge of the Target parking lot. But even better, leave your car at home and find joy in the 30-minute bike ride or hour walk to the store because it brings you joy, is good for the planet, and it saves you money. Instead of burying your face in your smartphone while your kids play, take pleasure in helping your kids hunt fireflies or throw snowballs or walk around the neighborhood for 30 minutes in the evening. Take a big step, not a small one. Move because it makes you feel good, not because it adds steps to your FitBit.

Links for Tuesday, November 21, 2017: more on the new HTN guideline, Gymnastics coaches throwing robot shade, the last iron lungs, Germany bans smartwatches, and Raymond Chandler hated US healthcare

Thoughtful post on the new HTN guideline by Dr. Allen Brett

Representative quote: "Consider, for example, a healthy white 65-year-old male nonsmoker with a BP of 130/80 mm Hg, total cholesterol level of 160 mg/dL, HDL cholesterol of 60 mg/dL, LDL cholesterol of 80 mg/dL, and fasting blood glucose of 80 mg/dL — all favorable numbers. The calculator estimates his 10-year CV risk to be 10.1%, making him eligible for BP-lowering medication under the new guideline. To my knowledge, no compelling evidence exists to support drug therapy for this person."

A gymnastics coach says the Boston Dynamics robot flip was a 3.5/5.0

'In a back salto, says Mazloum, “you want to be able to go as high as you can, and you want to be able to land as close to where you take off as possible.” To do that, the gymnast has to squat, throw her arms up by her ears so her body is a straight line (in gymnast-speak, opening the shoulder angle and the hip), then contract into a “closed” position again. By these standards, Atlas’ trick is “not the cleanest flip,” explains Mazloum.

Here’s Mazloum’s critique: Atlas didn’t quite get to that open position, “so it didn’t really get the full vertical that we look for. That’s why it went backwards a little bit.”'

The last of the iron lungs

Get your kids vaccinated for polio, folks.

Germany has banned smartwatches for kids

If I understand this correctly, it is not because smartwatches cause kids to be distracted monsters (although I don't doubt that that statement is at least a little bit true). The decision stems from the capability of bad guys to hack in and monitor the location of little Dick and Jane:

You have to wonder who thought attaching a low-cost, internet-enabled microphone and a GPS tracker to a kid would be a good idea in the first place. Almost none of the companies offering these “toys” implement reasonable security standards, nor do they typically promise that the data they collect—from your children—won’t be used be used for marketing purposes. If there ever was a time to actually sit down and read the terms and conditions, this was it.

Get your shit together, parents.

Asking parents to destroy them might be a bit of an overreaction, though.

Raymond Chandler paints a dark picture of American healthcare in a newly-discovered story

The title, "It’s All Right – He Only Died," sounds like the title of a video residencies would show interns to convince them that quality improvement and patient safety are part of their job.

The doctor who turned away the patient, Chandler writes, had “disgrace[d] himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long-acquired skill might help or save”.

Links for September 18, 2017: American sperm, movement is life, neighborhoods and vascular disease risk, and Taiwanese fruit ghosts

Canada needs our sperm. America!

Background: It is illegal to pay for sperm donations in America's hat. 

"What Canada should do is legalize compensation for renewable bodily fluids in our own country. It would be the morally right thing to do. It would help make and save more lives, without harming anybody.

Until we realize our mistake, we need you Americans to keep rolling up your sleeves and unzipping your pants not just for the sake of lucre, but also for the sake of the thousands of current and future Canadians whose lives depend on you."

The more you move, the longer you live.

Bottom line up front (BLUF): Over 4.0 years of accelerometer use, total sedentary time was associated with an increased risk of dying. Not only that, but the longer the usual sedentary bout, the higher the risk of dying (roughly double for the highest quartile). This study is encouraging, in a way: you don't have to move that much to really affect your risk, you just have to move often. But this doesn't apply to you, dear reader, since you ride your bike to the grocery store and forsake social media. Don't you?

If you live in a disadvantaged neighborhood, the usual risk factors for heart disease probably underestimate your risk.

BLUF: In a group of patients from the Cleveland Clinic, the Pooled Cohort Equations Risk Model, or PCERM of the American College of Cardiology and American Heart Association underpredicted vascular disease risk in patients from disadvantaged communities (those with a high "Neighborhood Disadvantage Index," or NDI). For a patient from a disadvantaged community, the model only achieved a "concordance index," a measure of how well it predicts vascular disease, of 0.70. In Affluent communities, on the other hand, the concordance index was 0.80. That doesn't sound like a huge difference, but the NDI was much more powerful at predicting variation between census tracts than was the PCERM tool itself.

Fruit names do not invite ghosts, says Taiwanese government

"The seventh month of the lunar calendar is called Ghost Month, when the gate of the underworld is said to open and people prepare offerings for the dead.

People have refrained from offering bananas, plums, pears and pineapples, because the fruits’ names sound like they are inviting ghosts in Hoklo (also known as Taiwanese), the market’s Fu-te Temple (福德宮) chairman Lin Lai-fa (林來發) said.

In Hoklo pronunciation, banana sounds like “inviting” (tsio), plum like “you” (li), pear like “come” (lai) and pineapple like “prosperity” or “more” (ong), the combination of which sounds like an invitation for ghosts to stay in someone’s home."

Whatever, Taiwanese Agricultural and Food Agency. I've seen a Dragon Fruit. That thing's bound to attract demons.

Links for Thursday, August 3, 2017: Robot Soccer, Weight Watchers can't pivot its message, Overuse of back surgery in professional athletes, and non-lecture based medical school

First things first: for any of you subscribing to the RSS feed of this blog, I've reduced the frequency of emails. Look for them on Thursdays at 10 am now. Moving on...

Humanoid robots are hilariously terrible at soccer (for now)

Weight Watchers is having a hard time adjusting its message to a more wellness-oriented and less weight-oriented world

The fact that we talk more about "wellness" and less about weight now isn't completely by accident:

In late 2015, Women’s Health, a holdout, announced in its own pages that it was doing away with the cover phrases ‘‘drop two sizes’’ and ‘‘bikini body.’’ The word ‘‘wellness’’ came to prominence. People were now fasting and eating clean and cleansing and making lifestyle changes, which, by all available evidence, is exactly like dieting.

I was the Medical Director of a large weight-loss clinic for several years earlier in my career. The quotes from people at Obesity Week in this article are heartbreaking:

I am 41, I would say. I am 41 and accomplished and a beloved wife and a good mother and a hard worker and a contributor to society and I am learning how to eat a goddamned raisin. How did this all go so wrong for me?

I'd much rather talk to people about being "well" and "happy" and "strong." Any day.

Are professional athletes the canary in the coal mine of excessive back surgery?

Should the experience of Tiger Woods and Steve Kerr help others make decisions about surgery? We imagine that they both received care from the most highly esteemed professionals, that cost was not an obstacle, and that their care was attentive. Presumably, their results did not meet expectations discussed with their providers. Steve Kerr has sought to share his experience with others and advised during an April 23 press conference, “I can tell you if you’re listening out there, if you have a back problem, stay away from surgery. I can say that from the bottom of my heart. Rehab, rehab, rehab. Don’t let anybody get in there.” Recent media reports indicate that Tiger Woods not only continues to experience back pain that is impeding his play, but additional consequences include side effects associated with opiate pain relievers.

Medical schools are moving away from the "Sage on the Stage" method of teaching

My medical school experience was very analog. We “learned” almost everything we learned via notes on those lectures. Most of the lectures were bad. Think “Bueller?” but with thyroid tumors. So, like this article notes, a small minority of students actually attended them. Maybe forty people (out of 175 in the class) sat and took in all they could in an hour of truly uninspired public speaking. So most of us acted on the judgement that our time was simply better spent elsewhere studying. We hired one another via a "note service" to take notes at lectures and distribute them by hand. Piles of photocopied notes filled the atrium outside the lecture hall daily. It was depressing.

I'm still volunteer faculty at the University of Kansas School of Medicine-Wichita. I teach a "problem-based learning" session about every other week. KUSM-W is in the process of moving to a curriculum that is almost completely problem-based. I enjoy the sessions as an instructor, but I wonder if they would have caused me some anxiety as a student; they're much more free-flowing than a set of notes to plow through. But the literature seems to indicate that they increase retention and more importantly, increase the likelihood of team-based practice in the future. 

Diabetes testing is for the [puppies and hoglets and billies]?

The Ad Council (with pro bono help by the ad agency Ogilvy) has released an admittedly adorable set of ads to encourage people to get tested for prediabetes. I agree with them in principle: testing for prediabetes is cost-effective in the long-term as long as it's paired with a lifestyle program that reduces the risk of advancing to full-blown diabetes:

 (mandatory conflict of interest disclosure here: I'm a consultant on a CDC 1422 grant that aims in part to increase screening, detection, and referral of pre-diabetic patients into the Diabetes Prevention Program)

Baby hedgehogs are called hoglets.

But unfortunately, the "testing" offered in these ads is probably far too sensitive. That is, it picks up too many possible pre-diabetes cases and over-diagnoses people.

The evidence for my contrarian stance is here:

Investigators publishing in JAMA Internal Medicine found that, according to a test very similar to the one in the commercials, almost 60% of patients over age 40 would qualify as "at risk" for pre-diabetes, and 81% (!) of those over age 60 would qualify. These numbers are clearly too high; the total population of pre-diabetic persons in the United States is about 86 million:

That's less than 30% of the population. Yet the puppies-and-hoglets-and-goats test says that almost twice that number is at risk. The United States Preventive Services Task Force, on the other hand, says that testing should be done based on only two factors: age (between 40 and 75) and Body Mass Index (25.0 or above). This is a more reasonable strategy based on risk of heart disease, but it unfortunately misses almost half of cases. Investigators publishing in PLoS Medicine found that, by looking at 1.6 years of electronic health record data from 2008-2010, only 45% of patients ultimately diagnosed with diabetes or prediabetes would have been screened under the USPSTF criteria. 78% of the missed cases would have been missed because they were under age 40, and 29% would have been missed because they were too thin, with a BMI under 25.0.

So what's the answer? The answer is to keep yourself from ever transitioning from "person" to "patient" in the first place. If you think you're at risk, based on the puppies-and-hoglets-and-goats test, a hunch, a past blood test, or a soothsayer, make a change. Jump into a new life and reduce your risk. It'll be cost-effective in its own right: Ride your bike to work. Pledge to eat only food that comes from the produce section without packaging for a month. Go to bed earlier at night. Give up bug juice for good. Make a change. And then, only after you've adopted the life you want and deserve, think about whether or not you want to get tested on your own terms.

Super four-pack of links July 11, 2017: the five percent and healthcare money, video game addiction, exercise to prevent diabetes, activity inequality, and evil coconut oil

Super-user sounds great, right? Who doesn't want to be super at something? Only this video (in Memphis-style) refers to the 5% of Americans that account for ~50% of health care spending in a year.

To paraphrase the end of the video: "There's almost nothing insurance companies won't charge, and Americans won't pay." How do you keep yourself from becoming a super-user? Everything medical is a matter of risk, so don't believe anyone who tells you there's a rock-solid simple way to keep from falling into that 5%, at least temporarily. But overwhelmingly, if you can keep a steady job you don't hate, if you can abstain from smoking, if you can get even a small amount of daily exercise (more is better, obviously), if you can keep your alcohol intake to a minimum, if you can abstain from recreational drugs (this includes marijuana, obviously), and if you can choose to eat mostly plant-based foods in semi-sane quantities, you're gonna stay out of The Five Percent.

Dara Lind and Dylan Matthews join Ezra to talk about the updated travel ban, how Trumpism has translated into policy, and the impact that increasingly awesome video games have had on young men's work habits.

Links!

White Paper: Leisure Luxuries and the Labor Supply of Young Men

Peter Suderman's piece about young men playing video games instead of getting jobs

What does excess immersion into video games mean for young men?

I've tried to set the Weeds audio above to play at about the 46 minute mark. But if that doesn't work, fast forward to the 46 minute mark. Not because the discussion of what "Trumpism" is isn't interesting (it is), but because the discussion that follows helped me think more deeply about the problem of excess immersion into video games that young people, especially young men, are experiencing. I've blogged about this before, and I talked about it at a recent speaking engagement. We seem to be creating a generation of youths who are increasingly isolated in very immersive video games, and then they're growing up into increasingly isolated and lonely people, particularly after age 40. As Ezra Klein says in the piece: if this were a problem of drug abuse, I think we would be acting collectively to do something about it. That's an apt comparison, since game addiction and drug addiction seem to have some physiology in common. But since the solution to technological problems currently seems to be "more technology," we are kinda-sorta just plowing ahead and hoping that video games fix themselves. I'm not optimistic. I think we need to start introducing programs to help kids moderate their exposure to video games and increase their exposure to the world at a young age. Dylan Matthews, who generally defends the idea of video games as a pacifying technology for people who can't or won't work, ends with this quote: "When we're in our eighties, we're all gonna be doing, like, flight simulator stuff. That's, like, how we'll spend--or, VR stuff, at least--that's what retirement's going to look like." Yuck. No. No. No. 

A new meta-analysis shows that African-Americans who exercise may not derive the same protective benefit from type 2 diabetes as other races

(brief Healio write-up here)

 I'm not ready to sign on to this point; race is a very blunt instrument when it comes to genetics. As the cost of gene sequencing falls, I think we'll not only be able to tease out drug effects in people with specific genetic features; we'll be able to more precisely target interventions like physical activity. Maybe certain people in this collection of studies would have benefited more from strength training, while others needed more endurance-oriented activities. Maybe some would have benefited from a specific combination of drug and activity. We don't know the answers to these things now, but we will soon. 

Smartphone data shows that countries with the highest "activity inequality" are more likely to have large obese populations: 

More differences in activity within the population equals more obese people. 

So it isn't a surprise that the same investigators found that the higher the walkability of a city, the lower the "activity inequality":

Texas is not a place with a great deal of walkability. 

The cynical take on this study is something like, "Of course people who are inactive weigh more!" Fair enough. But the obvious policy implication of the study is that, to affect the activity level of the inhabitants of a city, the built environment must give opportunities for activity.

ADDENDUM (make it a five-pack): How coconut oil got a reputation for being healthy in the first place. I don't love coconut oil, but even if I did, I'd think of it like I think of butter: an ingredient to be used sparingly, mostly for flavor. 

June 13, 2017 links to confirm my pre-existing biases: No insulin, no BG checks and the cancer risk of physical inactivity and diet

If you're a diabetic person NOT on insulin, you probably don't need to be checking your blood sugar at home.

I like this paper for a couple reasons: first, it confirms what I already thought, which makes it my (and everyone else's, whether they admit it or not) favorite kind of paper. Second, it's by my old boss at UNC-Chapel Hill, John Buse (seen in that picture rocking a Willie Nelson-esque beard). Finally, it's a very practical look at what glucose monitoring is. If you're on insulin and can change your dose meal-to-meal and day-to-day, it makes sense to monitor glucose levels for safety and efficacy reasons. If you're on fixed doses of non-insulin medications, the act of glucose checking becomes much less practical, and just as big a pain in the ass as it always is. My screed against SMBG in this case, though, is called into question by the study. The investigators measured "health-related quality of life" at 1 year, and it didn't differ between the groups. So the people poking themselves didn't feel much worse than those who got off the hook. But I'm sticking to my guns: when it comes to self-monitored blood glucose levels in type 2 diabetics NOT on insulin, the juice (that's your blood) literally isn't worth the squeeze.

Some folks say that diet, physical inactivity, and the resultant obesity could overtake smoking in terms of cancer risk.

I say "no shit."

RIP Warner Blackburn: sadness at the Dirty Kanza

I finished the Dirty Kanza 200 yesterday, and I plan to write about the experience in detail. But for now, I want to mention Warner Blackburn, a man who died during the 50-mile race. He was given CPR on the course by a friend of mine and taken to the hospital, where he died of an apparent heart attack.

I suppose the most cyclist-y thing to say is that "Warner died doing what he loved" or some such crap. But I don't know that. I don't know that Warner even liked cycling. He left almost no trace on the internet. Maybe he was doing the DK 50 on a bet, or maybe he was trying to support a family member. My wife makes fun of me because I automatically assume that people in cycling and other outdoorsy pursuits are nice, even though I'm not the warmest cuddliest type around. So I'll say this: whether Warner liked cycling, or whether he was trying to support someone else, or whether he was trying to support a cool event for the local community, he went out on a high note. 

FWIW, for anyone thinking of starting exercising after a long period of physical inactivity, please take the Physical Activity Readiness Questionnaire first. It's a little too sensitive, meaning it may flag a few people who aren't that high risk, but if you have a "yes" anywhere on the form, it's worth talking to your doctor about before you go out and hit it too hard.

Summer sausage link-fest May 25, 2018

If you're overweight, combining aerobic exercise with strength training has the biggest effect on frailty. This is a small, but exceptionally well-conducted trial that is getting press because 1) it got into the New England Journal of Medicine, easily the most influential medical journal in the world, and 2) it addresses a functional outcome, not just weight. It seems to go under-recognized that obesity leads not only to inferior cosmesis and an increase in heart disease, sleep apnea, arthritis, and what not, but that it actually makes people frail. In my time running a medical/surgical weight loss clinic, we routinely asked incoming patients if they were able to get themselves off the floor in case of a fall. The patients were almost always surprised by the question, but many of them, after some thought, said that no, they would not be able to get themselves up after a fall. They were that frail. 

Speaking of exercise, your watch or other wearable sucks at telling how many calories you've burned. This isn't a surprise, given the disparate results I've seen from my old, broken Nike Fuel Band, my Garmin GPS, and apps like MyFitnessPal. And even though I've never heard of the Journal of Personalized Medicine before ten minutes ago, the methodology of the paper is solid. But the results were best, strangely, with cycling. This gives ammo to the old argument that people who like data (speed, weight, power, HR, etc) are naturally drawn to cycling.

Spring link 5-pack April 26, 2017

What are Americans dying of? Spoiler alert: obesity. Second spoiler alert: complications of diabetes.

Artificial sweeteners may be associated with stroke and dementia risk. I've mostly given up artificial sweeteners, but not because of this paper. I'm making a bit of a Pascal's wager on artificial sweeteners: they're surely not good for us, even though they may not be as bad as sugar itself. So I take steps to avoid them, just like I take steps to avoid sugar itself. The fact that this paper didn't show any risk associated with sugar-sweetened beverages makes me a little suspicious of its results. Maybe the editorialists' note that people sometimes switch to diet soft drinks after they are flagged as "high risk" by their doctors is right. They're on their way to a stroke one way or the other, and they just happen to have switched to a diet drink beforehand.

Garden City, Kansas voted to raise the legal age for the purchase of tobacco or e-cigarettes to 21 years. The decision "grew from a request made by a group of Garden City High School students earlier this year." Garden City is the fifteenth (!) city in Kansas to make such a decision.

Exercise may help cognition (that's the thinking part) in the elderly. Seemingly if you work moderately hard for at least 45 minutes. What is moderate? According the ACSM guideline they used, it is hard enough to use "40%-60% heart rate reserve." That means halfway between your normal resting heart rate and your maximum heart rate, which is usually calculated by subtracting your age from 220. So if your normal heart rate is 70 and you're 50 years old, you have a maximum heart rate of ~170, so using 50% of your heart rate reserve would mean getting your heart rate to ~120. Confused? Well, "moderate" intensity is also about a 5 or 6 out of 10 in perceived exertion. There. 

The FDA is warning (again) about bogus internet cancer treatments. A couple observations here: 1) I can't believe it's only 65 products. That must barely scratch the surface. 2) I don't know if the fact that so many of the products are co-marketed for cats and dogs is a good sign or a bad sign. 3) Even a casual observer must be astonished that we know so much about how to prevent cancer, and it's not complicated, and it's generally cheap or even money-positive (don't smoke, get a little exercise, eat fruits and vegetables, wear sunscreen)

But yet we as a society are so much more interested in giving our money to snake-oil salesmen for untested bunk.

My March WAMPO presentations

I was thrilled to get to speak to the Wichita Area Metropolitan Planning Organization about health effects of active transportation infrastructure. It was a great, receptive crowd. They gave me reason to hope for the future of a transportation system in which cars are a peripheral accessory and not the primary feature. 

Aaaaand I look a little like a wild-haired madman in the video, which I like. 

Things you can control right now

There are a lot of things you can't control: the weather, the stock market, your neighbor's loud music. But many, many things are under your control, as pointed out by Lori Deschene. And how well you do at seizing control makes a huge difference in your health and happiness:

Right now, you can control:

1. How many times you smile today.

7. When you pull out your wallet for luxuries.

11. How often you notice and appreciate small acts of kindness.

17. The type of food you eat.

21. How much exercise you get.

22. How many times you swear in traffic. [I'd amend this to say that you can control how often you're in traffic at all. If you're swearing at traffic, chances are you are the traffic.]

27. The attention you give to your loved ones when you see them.

28. How much you enjoy the things you have right now.

41. Whether you formulate a new plan or act on your existing one. [this is my favorite]

44. Whether you smoke or drink. [unless you’re an alcoholic, in which case you are in control of whether or not you seek help from a qualified practitioner]

50. How much rest you get at night.