Ho Ho How to Avoid Holiday Weight Gain (Encore)

You can already see it coming: the weight we all gain over the holidays is as predictable as the weight we try to take off for the summer. A few years ago researchers used WiFi-enabled “smart scales” whose buyers were aware that their weights would be used for research to track the weights of American, German, and Japanese subjects for one year. The scales are important: people frequently misreport their weight, or they change their diets when they know they’ll have to report somewhere to be weighed. By having the scale in their house and wirelessly communicating with the database, the investigators hoped to reduce this bias. For any given holiday the researchers compared the maximum weight at no more than 10 days after the start of the holiday to the weight that was measured 10 days before the holiday.

The results? In all three countries, the participants’ weight rose in the 10 days after Christmas Day, compared with the 10 days before Christmas (+0.4% in the U.S., +0.6% in Germany, and +0.5% in Japan). The raw amount of weight gained wasn’t large: only 1.3 pounds for an average American. But the researchers pointed out that since the population of this study—people who spent ~$150 on a scale—is probably wealthier and more motivated toward weight loss than average, the results of the study probably underestimate the effect on the general population. For example, the average worker gains 2-3 pounds per year (half of that between Halloween and New Year’s Day, naturally) and weights in this study had gone down to pre-holiday levels within six months or so.

So: what can we do to help our employees prevent this weight gain in the first place?

An interesting answer comes from two groups of researchers who elected to try a “weight prevention” approach rather than a traditional weight loss approach. First, investigators at the University of Georgia developed a program they called Holiday Survivor for state employees. Participants were divided into teams and were instructed by a worksite wellness professional on self-monitoring and regular weigh-ins from the end of October to mid-January. Efforts were put toward increased awareness of food intake and physical activity through self-monitoring, but the program was geared not toward teaching new knowledge, but instead to build social support for positive behaviors. Each team of four employees received points for participating in weekly program activities like a healthy potluck, a 5 km run/walk, or “lunch and learns,” and for completing weigh-ins. Individual participants also received points on two occasions for providing proof of food logs (not the logs themselves). In early January a prize ceremony was held to celebrate team and individual achievements.

In spite of the emphasis on weight maintenance, the employees lost an average of 4.4 pounds (from 196.7 in October to 192.3 pounds in January).

A second group of investigators in the U.K. randomized workers in a variety of jobs to either get a pamphlet on the dangers of holiday weight gain (without dietary advice) or to get instruction on recording their weight at least twice weekly (ideally daily), ten tips for weight management, and pictorial information about the physical activity calorie equivalent (PACE) of holiday foods and drinks (that is, information such as “13 minutes of running for a can of sugared soda”). The goal was for participants to gain no more than ~1 pound of their baseline weight.

Over the holiday season the group getting the pamphlet alone gained on average 0.8 pounds, while those weighing frequently, getting tips on weight management, and informed of the PACE of holiday foods lost 0.27 pounds.

The Kansas Business Group on Health generally takes a prosaic view of traditional worksite wellness practices. We tend to believe that true health is hard to define and harder to measure, and that improvements in health are rarely as simple as old-fashioned carrot-and-stick rewards or punishment. But this strategy of proactively engaging employees to manage a known occupational hazard (the holiday season) is novel and promising. If any members have had similar luck we’d love to hear about your strategies!

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.

Are Sugared-Beverage Bans an Effective Employer Wellness Strategy?

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:

Health impact of sugared beverages

Sugared beverages account for the majority of excess calories Americans take in. Accordingly, a person’s intake of sugared drinks tracks very neatly to his or her risk of diabetes and cardiovascular disease. Even artificially sweetened beverages are linked to early death, possibly through their effect on the bacteria, or “microbiome” growing in our intestines. But getting people to drink less of them is a vexing problem. Countries and cities including Mexico, Philadelphia, and Berkeley, California, among many others, have experimented with taxing sugared drinks, with mostly health-positive results. New York City under Mayor Michael Bloomberg attempted to limit the size of sugared drinks that could be sold to sixteen ounces or less, a move that was eventually blocked by the courts. And banning sugar-sweetened beverages in schools has not reduced consumption, at least in survey data.

Is banning the sale of sugared beverages effective?

Recently the we’ve seen the results of a sugared-drink sales ban implemented by the University of California at San Francisco (UCSF) in 2015 (students and employees were still able to bring drinks on-campus). Investigators followed the habits and health indicators of 202 volunteer subjects before and after the prohibition. Ten months after the ban, subjects’ consumption of sugared drinks was down by almost half: 48.5 percent. Even though the participants still drank a large quantity of sugared drinks after the ban—18 ounces a day, on average—they saw dramatic improvements in health. They lost almost an inch from their waists, and the fraction of the study population who decreased their drink intake the most saw improvements in insulin resistance, the phenomenon that leads to diabetes.

Obstacles to overcome

So the science of limiting sugared drinks at the worksite seems sound, at least in terms of reducing the risk of employee illness. But major obstacles threaten such policies: first, the happiness of workers is likely to be affected, at least in the short-term. Employees may rebel against a workplace culture they perceive as too paternalistic. This viewpoint was exploited by tobacco companies during the implementation of smoking bans in the recent past. This is where an honest outreach program to employees would be worthwhile: we know that excess sugar intake is linked to depression, and that improved dietary habits can profoundly improve mood in depressed people. Sharing these stories with employees in an engaging way that shows light at the end of the sugared-drink tunnel may help. After all, a decade after widespread smoking bans, norms have shifted to the point that a re-introduction of smoking in worksites and restaurants would be met with fierce opposition.

Second, your company may have a contractual arrangement with beverage vendors. This is particularly true of institutions of higher learning. However, possibly sensing the movement of the tide away from sugared drinks, beverage companies are frantically working to offer healthier alternatives and the National Automatic Merchandising Association, the trade organization for vending companies themselves, has pledged to make at least a third of its offered products meet the standards of at least two of the healthy food standards set by Partnership for a Healthier America, the Center for Science in the Public Interest, the American Heart Association, Centers for Disease Control and Prevention, or the USDA’s Smart Snacks. So leaving vending on-site but reducing or eliminating sugared drinks is a potential compromise.

Has your worksite attempted to change the availability of certain snack foods or sugared drinks? The Kansas Business Group on Health would love to hear about your experience.

Ho Ho How to Avoid Holiday Weight Gain

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:

You can already see it coming: the weight we all gain over the holidays is as predictable as the weight we try to take off for the summer. A few years ago researchers used WiFi-enabled “smart scales” whose buyers were aware that their weights would be used for research to track the weights of American, German, and Japanese subjects for one year. The scales are important: people frequently misreport their weight, or they change their diets when they know they’ll have to report somewhere to be weighed. By having the scale in their house and wirelessly communicating with the database, the investigators hoped to reduce this bias. For any given holiday the researchers compared the maximum weight at no more than 10 days after the start of the holiday to the weight that was measured 10 days before the holiday.

The results? In all three countries, the participants’ weight rose in the 10 days after Christmas Day, compared with the 10 days before Christmas (+0.4% in the U.S., +0.6% in Germany, and +0.5% in Japan). The raw amount of weight gained wasn’t large: only 1.3 pounds for an average American. But the researchers pointed out that since the population of this study—people who spent ~$150 on a scale—is probably wealthier and more motivated toward weight loss than average, the results of the study probably underestimate the effect on the general population. For example, the average worker gains 2-3 pounds per year (half of that between Halloween and New Year’s Day, naturally) and weights in this study had gone down to pre-holiday levels within six months or so.

So: what can we do to help our employees prevent this weight gain in the first place?

An interesting answer comes from two groups of researchers who elected to try a “weight prevention” approach rather than a traditional weight loss approach. First, investigators at the University of Georgia developed a program they called Holiday Survivor for state employees. Participants were divided into teams and were instructed by a worksite wellness professional on self-monitoring and regular weigh-ins from the end of October to mid-January. Efforts were put toward increased awareness of food intake and physical activity through self-monitoring, but the program was geared not toward teaching new knowledge, but instead to build social support for positive behaviors. Each team of four employees received points for participating in weekly program activities like a healthy potluck, a 5 km run/walk, or “lunch and learns,” and for completing weigh-ins. Individual participants also received points on two occasions for providing proof of food logs (not the logs themselves). In early January a prize ceremony was held to celebrate team and individual achievements.

In spite of the emphasis on weight maintenance, the employees lost an average of 4.4 pounds (from 196.7 in October to 192.3 pounds in January).

A second group of investigators in the U.K. randomized workers in a variety of jobs to either get a pamphlet on the dangers of holiday weight gain (without dietary advice) or to get instruction on recording their weight at least twice weekly (ideally daily), ten tips for weight management, and pictorial information about the physical activity calorie equivalent (PACE) of holiday foods and drinks (that is, information such as “13 minutes of running for a can of sugared soda”). The goal was for participants to gain no more than ~1 pound of their baseline weight.

Over the holiday season the group getting the pamphlet alone gained on average 0.8 pounds, while those weighing frequently, getting tips on weight management, and informed of the PACE of holiday foods lost 0.27 pounds.

The Kansas Business Group on Health generally takes a prosaic view of traditional worksite wellness practices. We tend to believe that true health is hard to define and harder to measure, and that improvements in health are rarely as simple as old-fashioned carrot-and-stick rewards or punishment. But this strategy of proactively engaging employees to manage a known occupational hazard (the holiday season) is novel and promising. If any members have had similar luck we’d love to hear about your strategies!

My comments from the Envision Adult Support Group

I had the pleasure of speaking at Envision this morning about diabetes awareness. Here are my comments:

Thank you for having me. This is not my first time speaking at Envision. It’s always a pleasure to be here. There’s an old joke that the moment a speaker steps to the lectern the crowd wonders: will this be a short, informative talk, or are we stepping into a low-key hostage situation? I promise this is not a hostage situation.

This is the story of Victoria. When we tell biographies, one of our first instincts is to say when and where someone was born. “Robert Goddard was born October 5, 1882 in Worcester, Massachusetts.” You know what I’m saying. But here’s the thing: Victoria hasn’t been born yet. Yet we already know some things about her, assuming she’ll be born in the United States. We know she’ll have a lifetime risk of developing diabetes of around 50%. A coin toss. We know she’ll have a lifetime risk of being overweight or obese of at least 70%. Way worse than a coin toss. We know that these risks will be less related to any specific decision Victoria makes than to the environment in which she is conceived, gestated, born, raised, and in which she ultimately works.

But before we get to that, you deserve to know how I make my money. I have a strange career. I’m an endocrinologist by training. That’s a doctor who specializes in metabolism and hormonal disorders. I’m still board-certified, and I still see patients at Guadalupe Clinic. But the much bigger fraction of my career is spent trying to change the way care is delivered. That sounds too simple. You know the frustration of calling for a doctor visit, waiting on hold, getting an appointment months from now, then waiting in the waiting room for a half an hour while you do paperwork, then waiting in the exam room in a paper gown for another twenty minutes, and then never even getting a copy of your labs once you’re done? That’s what I mean. That’s what we’re trying to change. More care can be delivered by non-doctors in non-offices and at the convenience of you, the patient. 

One of the organizations that pays me to try to affect this change is the Centers for Disease Control, the CDC. Specifically, they along with the Kansas Department of Health and Environment pay me to try to encourage more doctors to offer care like the Diabetes Prevention Program or Diabetes Self-Management Education, or the Diabetes Self Management Program, all of which we’re going to talk about today. So be a cautious consumer. As I talk, ask yourself if you think I really believe the things I’m saying, or if I’m just a government stooge repeating words put into my mouth by my benign overlords.

I originally called this talk, “Should I go to diabetes education?” But I’ll talk about more than that.

Let’s get back to Victoria, our future, not-yet-even-a-twinkle-in-her-mom’s-eye. When Victoria grows into adulthood she’ll be told by her doctor that she needs to take in fewer calories and burn more calories in the form of physical activity or exercise. Good advice. We call these the “Big Two”: diet and exercise. And historically we’ve blamed the obesity and diabetes epidemics on decreased physical activity and increased caloric intake. The physics of it just make sense: you can’t make fat out of air. But there’s a big problem with limiting our explanation of her risk to this simple “calories in, calories out” model: the math doesn’t add up. 

Intentional leisure time physical activity--that’s the kind that takes equipment, like shorts or special shoes or a bicycle or a pool--has gone up (way up) since the 1980s. Yet as a nation we’re fatter than ever. Investigators writing on the findings of a 2016 study in Obesity Research & Clinical Practice noted, “A given person, in 2006, eating the same amount of calories, taking in the same quantities of macronutrients like protein and fat, and exercising the same amount as a person of the same age did in 1988 would have a BMI that was about 2.3 points higher…about 10 percent heavier, even if they follow the exact same diet and exercise plans.”

Why is this? Why are we punished for having habits that are objectively better than those of our parents?

Well, it is no one thing. Anyone who tells you that they know the exact problem and have the precise solution is lying or excessively optimistic or both. It’s the combination of a lot of things, and like Victoria’s, our risk is teetering one way or the other long before we’re conceived, let alone born. Let’s go back to pregestational Victoria. 

If Victoria’s mom is anything like most of us, we know a couple things. First, she probably carries a few extra pounds. And we know that those extra pounds carry just the slightest advantage in reproduction. That is, Victoria’s mom is ever so slightly more likely to get pregnant and carry a baby than a woman who is of a normal body weight or who is too thin. So Victoria is simply more likely to be born than someone with a very thin, non-diabetic mom would be.

The second thing we know about Victoria’s mom is that she has probably had some chronic, low-grade lead exposure, especially if she has lived her life in an urban center where dense car traffic spewed leaded exhaust into the air for decades and let it settle into the soil. The higher the lead level in Victoria’s mom’s blood, the higher Victoria’s risk for obesity, even if mom never had enough lead in her blood to be considered “lead poisoned,” and even if Victoria herself never had enough lead in her own blood to be considered dangerous by current standards. 

And birds of a feather, well, you know…flock together. Victoria’s mom is likely to choose a mate whose body in some way matches hers. Or he chooses Victoria’s mom. Either way, since we know that something like two-thirds of body weight is heritable (that is, two-thirds of your risk of being thin or being heavy), having both a mom and a dad who carry extra weight puts even more pressure on Victoria’s future weight.

Since Victoria’s mom and dad have bills to pay, there’s a big chance they put off having a family. That’s the new American way. Not only the American way; the western way. The age at first birth in the United States has gone from 22 to 26 since the 1960s. And every five years parents wait to have a child, the risk of obesity in the child may go up fourteen percent. 

Five years after they marry, Victoria’s mom and dad decide to get pregnant, and they have good luck. But during Victoria’s gestation, her dad encourages her mom to “eat for two.” We now know that increased fat and sugar in mom’s diet can cause “epigenetic effects” in the fetus. Remember the way DNA is put together, with A and T and C and G all writing a code that turns amino acids into proteins? Epigenetic effects aren’t changes in the A-T-C-G order of base pairs in the DNA itself; these are modifications of those base pairs, like sticking an extra branch onto the side of the “A” to keep it from coding quite as efficiently as it should. And we know one of the possible effects of these epigenetic effects may be to make Victoria more prone to weight gain and diabetes.

Finally, Victoria is born. Her mom breastfeeds her, like most moms do now, and which may have some protective effect. But after that Victoria eats what her folks buy for her: a largely government-subsidized diet that is >50% highly processed, has little fiber, and contains >2x the meat needed. We now know that this highly processed food dramatically increases our risk for weight gain and diabetes.

Investigators at the NIH recently paid twenty volunteers (ten men, ten women) to live in a research hospital for a month. They were randomly assigned to eat either an “ultra-processed” diet (think packaged meat, gravy, and potatoes) or an unprocessed diet (like fresh broccoli, cooked rice, and frozen beef) for two weeks. The diets were identical in the number of calories and amount of nutrients like fat, sugar, protein, and fiber. The volunteers were observed closely for food intake, and frequent testing was done to determine how many calories they were burning. After two weeks each person in the study was “crossed over” to the  opposite diet from what they’d started on. That is, the processed diet folks started eating the unprocessed diet, and vice-versa.

What the investigators found was dramatic. In spite of having equal  numbers of calories available to them at every meal and snack, the people eating the processed diet ate about 500 calories per day more  than the people eating the unprocessed diet. This showed up in their weight: the processed dieters weighed, on average, 2 pounds more at the  end of two weeks than they did at the start of the diet. All their extra weight was in the form of fat. And this may not have even done the effect justice: since the processed food had so little fiber, investigators had to sneak fiber into the processed food just to bring the level up to the unprocessed diet’s fiber. Without that, the results probably would have been even more dramatic. 

When young Victoria turns twelve her parents decide to reward her for her good grades with new cell phone. To keep up with the social scene at school she starts sleeping with it, checking social media when she wakes up at night. As a result of this she ends up sleeping less than seven hours per night. This disrupted sleep has a measurable, clinical effect on her appetite, probably because of changes in hormone levels like ghrelin (from the stomach) and leptin (from fat). 

In addition to the effect of abnormal hormones, Victoria is exposed to a lifetime of endocrine disrupting chemicals like those in air pollution, pesticides, flame retardants, and food packaging. Endocrine disruptors are chemicals that mimic or block the effects of naturally occurring hormones. Investigators in 2017 measured the amount of bisphenol A, a chemical you’ve heard of as “BPA,” in the urine of volunteers. They noted that people in the top quartile of BPA excretion, that is, the people who had more BPA in their urine than 75% of their peers, had a mean body mass index (BMI) a full point higher than people with the lowest BPA level. And BPA is one of thousands of potential chemicals we are exposed to now that were not in our environment even a few decades ago. 

While Victoria eats her processed diet and takes in a strange brew of endocrine-disrupting chemicals, she lives and works in a strictly air-conditioned, heated car, office, and home that block any exposure she would normally have to hourly or seasonal temperature excursions. She’s almost never hot and almost never so cold that a cardigan can’t fix it. The effect of this may be to increase hunger. Researchers in the journal Physiology and Behavior noted that people in an office experimentally heated to 81 degrees reported decreased hunger, decreased desire to eat, feeling fuller longer. Not surprisingly, they were thirstier than their cooler peers. 

Because she lives in a cul-de-sacced suburb that is poorly designed for walkability, Victoria does not have the opportunity to walk anywhere. Not to the store, not to work. Her only opportunities for meaningful physical activity come from going to the gym. She cannot spontaneously exercise. The effect of this can be dramatic. In 2014, engineers reported in the Journal of Transportation and Health that going from an intersection density of 81 per square mile to 324 per square mile dropped was associated with a reduction in obesity from 25% to less than 5%. Similarly, going from a community design that made walking difficult to a grid-like walkable layout cut the obesity rate by a third. 

Perhaps in part because of her poor sleep, processed diet, lack of exercise, Victoria becomes depressed and is put on an SSRI medication by her doctor. These medications and many others have the effect of a small but predictable amount of weight gain.

Depressed yet? Don’t be. There’s not a thing on that list that we couldn’t fix if we wanted to. But I’m not here to talk politics or policy. I’m here to talk about things you can do personally to change your risk of weight gain, diabetes, and complications of diabetes. And anyone in the room with type 1 diabetes, which is less affected by weight, don’t go away. A lot of this applies to you, too. 

If you’ve heard me talk before you might be aware of Justin’s Rubric for Quality Health Care. Any potential medical test or treatment should meet one of three standards. Either:

  1. It should make the patient feel better. This includes hundreds of treatments, like using medications and physical therapy for pain, prescribing inhalers for asthma, giving antidepressants and therapy for depression, and replacing knees. It does not, unfortunately, include much of diabetes care. Any person in the room who takes multiple doses of insulin per day and checks her blood sugar even more often than that can attest to this. Or:

  2. If it does not make the patient feel better, the test or treatment should make the patient live longer. This applies to everyday things like checking and treating high blood pressure and high cholesterol (neither one of which make most patients feel any better or worse today) to surgery and chemotherapy for cancers (most of which make patients feel much, much worse at least in the short-term, but prolongs many lives). Or finally:

  3. If a 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. The best example of this may be diabetes screening. As far as we can tell, screening for diabetes does not prolong life, at least not in the two or three trials that have specifically addressed the question. But diabetes screening linked to preventive measures like the Diabetes Prevention Program clearly saves money.

Diabetes was once a syndromic diagnosis, usually diagnosed when someone presented with epic amounts of urine, extreme thirst, unintentional weight loss, and sometimes strange infections. The very words we use to describe this condition give the crudeness of the diagnosis away: diabetes is from a Greek word meaning siphon, “to pass through.” Mellitus is from a Latin root word meaning honeyed or sweet. Because once upon a time, the diagnosis was confirmed by your doctor tasting your urine for sweetness.

But as our ability to test became more sophisticated, we began finding asymptomatic people with elevated blood sugars, and we had to decide who was normal and who was abnormal. It’s a tougher question than you may think, and we may still not know the answer.

So when should Victoria be screened? Or should she be screened at all? Like many questions in medicine, it depends on who you ask. Every test has risks and benefits. In the case of diabetes screening, the risks are small. There is the issue of the needlestick, but beyond that you mainly risk having an abnormal lab value on your chart. The primary benefit is financial. If Victoria is diagnosed with diabetes she can expect to spend $8,000-12,000 dollars more on medical care than the average non-diabetic person, with 12 percent of that coming out of her own pocket. Unfortunately people who are screened for diabetes and catch it early don’t seem to live longer than those who are caught according to symptoms, but they may feel better in the long run. And if we’re lucky enough to catch Victoria’s blood sugars before they rise into the frank diabetes range, we have things we can offer her.

With this in mind The United States Preventive Services Task Force (USPSTF) says that anyone between the ages of 40 and 75 should be screened at least every third year. The American Diabetes Association says that screening should begin at age 45 but expands this to say that anyone as young as age 10 with certain risk factors like family history; Native American, African American, Latino, Asian American, or Pacific Islander heritage; or certain signs of insulin resistance in the skin or reproductive organs should be screened. They’ve developed a tool alongside the American Medical Assocation and the Centers for Disease Control called the Diabetes Risk Test--you can take it yourself at preventdiabeteswichita.com--that asks a few questions (some demographics, your family history, your physical activity, your height and weight) and tells you whether they think you ought to be screened.

Screening generally means a check of Victoria’s first-morning blood sugar after fasting overnight. It can’t be done with a fingerstick, so Victoria has to resist the urge to borrow a machine from her mom. It needs to be done in the lab with blood drawn from a vein.The cutoffs that we set for pre-diabetes and diabetes are, naturally, semi-arbitrary, but they’re ultimately based on the eye. If Victoria’s result is a blood sugar of 126 or above repeatedly, it means she’s diabetic. If you think 126 is kind of a strange number, you’re right. That number is set at the point where she’s more likely to develop diabetic eye disease. So it’s the eyes that make all the difference in how we define diabetes.

If her blood sugar is below 100, she’s normal. But again, if she’s over 40, most people think she should get it repeated at least every third year.

If Victoria’s blood sugar falls into that range of 100 to 125, between “normal” and “diabetic,” her best bet is to seek out the Diabetes Prevention Program, a one-year program designed to help people decrease their risk of going on to develop diabetes. The DPP, as it’s called, is sixteen weekly one hour visits with a health educator followed by eight monthly visits. In those visits you learn problem solving strategies around food choices and physical activity with the support of your coach and a team of other patients. The program has been shown to reduce the risk of going on to develop diabetes by almost sixty percent, roughly twice as effective as metformin, a common diabetes medication. In addition to simply making your numbers look better, the DPP has been shown to improve cholesterol levels, to reduce absenteeism from work, and to increase patients’ sense of well-being. For anyone insured by Medicare, the program is a covered benefit. 

But what about the unlucky folks who go on to have diabetes?

We have a great program available here in town called the diabetes self-management program, or DSMP. It was developed by researchers at Stanford who were interested in making people with chronic diseases feel more in control of their lives and their destinies. It is 2.5 hours a week for six weeks, and it is taught not by a nurse or a doctor, but by a person who has diabetes herself. Investigators have determined that going through a self-management program like this reduces days in the hospital by almost two per year, probably cuts ER visits, cuts the risk of depression, and reduces low blood sugars. Best of all, it is free! If you’re interested, either ask your doctor or go to selfmanageks.org.

Last year investigators looked for randomized trials--that is, studies where patients are randomly assigned one treatment or another--of diabetes education. They included only trials that compared diabetes education with usual care, and they included only trials that lasted at least a year. Ultimately they found 42 trials that met these criteria, enrolling just over 13,000 patients and lasting an average of a year and a half. What they found was striking: diabetes self-management education significantly cut the risk of dying of any cause in type 2 diabetes patients by 26 percent. That is, a patient in the diabetes education arm of one of these studies was 26% less likely to die, by car wreck, chocolate poisoning, diabetic ketoacidosis, or any other cause, than a person receiving usual care.

In spite of this evidence, the utilization of diabetes education is disappointingly low. Only about one in five patients with diabetes ever attend. 

So let’s review, very briefly. Our risk--and Victoria’s--for being overweight or obese or having diabetes begins to accrue long before we’re even conceived and is constantly modified by our environment as we age. But many of the things that affect that risk--the cleanliness of our air, the foods available for us to eat, the design of our streets, and others--are modifiable. If in spite of optimizing all those things you still find yourself with an elevated blood sugar, you have several options.

So if you think you might be at risk for diabetes, get tested. If you’re pre-diabetic, ask for a referral to the diabetes prevention program. If you’re like Victoria, if your diabetes is out of control--if your hemoglobin A1c level is higher than what your doctor would like it to be, or if you have low blood sugars--ask your doctor about getting into a diabetes education program. If your diabetes is well-controlled numbers-wise but you feel out of control, also consider going to the  diabetes self-management program. The risk of the program is vanishingly low, and the potential benefit is large.

What are processed foods, and are they bad for us?

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:

Are Processed Foods Bad for Us?

We hear a lot about eating “real” foods and avoiding overly processed foods. Food writer Michael Pollan famously said his rules for the ideal diet were to 1) eat food, 2) not too much, and 3) mostly plants. He went so far as to say that any food with more than five ingredients, or an ingredient you can’t pronounce, is probably bad for you. But what’s the evidence that this is right?

Thanks to the work of investigators at the NIH, we have new evidence that processed foods should not make up the bulk of our diets. Researchers paid twenty volunteers to live in a research hospital for a month. Ten of them were men, and ten were women. The volunteers were randomly assigned to eat either an “ultra-processed” diet or an unprocessed diet for two weeks. The diets were identical in the number of calories and amount of nutrients like fat, sugar, protein, and fiber. The volunteers were observed closely for food intake, and frequent testing was done to determine how many calories they were burning.

An example “ultra-processed” meal was:

  • steak (Tyson)

  • gravy (McCormick)

  • mashed potatoes (Basic American Foods)

  • margarine (Glenview Farms)

  • corn (canned, Giant)

  • diet lemonade (Crystal Light) with NutriSource fiber (researchers had to add fiber to the drinks in the processed diet to match the fiber of the unprocessed diet)

  • low fat chocolate milk (Nesquik) with NutriSource fiber.

In contrast, the unprocessed meal on the same day was:

  • beef tender roast (Tyson)

  • rice pilaf (basmati rice (Roland) with garlic, onions, sweet peppers and olive oil)

  • steamed broccoli

  • side salad (green leaf lettuce, tomatoes, cucumbers) with balsamic vinaigrette (balsamic vinegar (Nature’s Promise)

  • orange slices

  • pecans (Monarch)

  • salt and pepper (Monarch)

In spite of having equal numbers of calories available to them at every meal and snack, the people eating the processed diet ate about 500 calories per day more than the people eating the unprocessed diet.

After two weeks each person in the study was “crossed over” to the opposite diet from what they’d started on. That is, the processed diet folks started eating the unprocessed diet, and vice-versa.

What the investigators found was dramatic. In spite of having equal numbers of calories available to them at every meal and snack, the people eating the processed diet ate about 500 calories per day more than the people eating the unprocessed diet. This showed up in their weight: the processed dieters weighed, on average, 2 pounds more at the end of two weeks than they did at the start of the diet. All their extra weight was in the form of fat.

This finding could have a real impact on your employees’ health. When you are thinking of food for a large function, or thinking of how to contract food in an on-site cafeteria, it may be worth looking at the NOVA food classification system and working to increase the availability of Group 1 foods, those that are “unaltered following their removal from nature.”

Examples of these would be:

  • vegetables

  • fruits

  • potatoes (fresh, packaged, cut, chilled, or frozen)

  • whole-grain wheat, oats and other cereals

  • eggs

  • fresh, chilled or frozen meat, poultry, fish and seafood

  • pasta, couscous, and polenta

  • milk or yogurt without added sugar

Bon appetit.

My remarks from the Wichita Business Coalition on Health Care's Obesity Forum this morning

Thanks for inviting me to kick off this very important event. Let’s start with a healthy dose of intellectual honesty. Obesity is a disease. It has arguably been so since the beginning of time, but it was made official in this country in 1985 when the National Institutes of Health issued a statement following its Consensus Development Conference on Obesity. This was followed by the report of the World Health Organization’s Consultation on Obesity and then the report of a committee of the Institute of Medicine, now known as the Health and Medicine Division of the National Academy of Sciences. Finally, the American Medical Association in 2013. Obesity is a disease because it is a “definite, morbid process with characteristic symptoms which affects the entire body; and has a known pathology and prognosis.” Obesity shouldn’t need this label in order to be taken seriously. Whether we--our institutions and organizations--pay for obesity treatment should ultimately depend more on what outcomes we value and the cost of achieving those outcomes. That is, the material inputs and outputs of the process, not our opinions of the people or behaviors that lead to them. A materialist versus spiritualist argument. I recently spoke at the Chronic Disease Alliance of Kansas meeting. Some of you were there. I made the argument that even if you are a spiritualist by nature, if you’re interested in medicine or public health, you must invest in a materialist point of view. That means you have to provide evidence for your assertions. How does this little philosophical cul-de-sac apply to obesity? Because I would argue that in spite of ample evidence and the label of disease applied by the NIH, the National Academy of Sciences, the AMA, and others, we don’t treat obesity in this country as a disease.

Think of what happens if you have, say, osteoarthritis of the knee. If you go to the doctor complaining of knee pain that fits the pattern of knee osteoarthritis, within some small confidence interval, you’ll get the same treatment regardless of what doctor you visit: x-rays to confirm the diagnosis, then some initial combination of anti-inflammatory drugs plus or minus strength training or physical therapy; then possibly an injection of hyaluronate or another agent; then a surgical procedure. All backed by some degree of clinical evidence as to their efficacy, with a set of professional guidelines that dictate the order and intensity in which they’re used.

And treatment for the disease--osteoarthritis still--is not limited to the clinical environment. We live under a robust set of laws, regulations, and expectations surrounding the humane treatment of people with osteoarthritis: handicapped parking stalls, construction standards around accessibility (curb cuts and whatnot). Furthermore, an enormous industry exists which caters to osteoarthritic people’s needs: handrails, higher toilets, special bathtubs, purpose-designed kitchen utensils, and others. For all its imperfections, this set of guidelines and expectations has the hallmarks of science: organization of knowledge, adaptability, the ability and willingness to change as evidence evolves.

But what happens if a patient goes to see his or her doctor for obesity? Even if the patient is lucky enough to encounter a doctor that considers obesity a disease and not a personal character failing, no such predictability exists. Doctor one may prescribes meal replacements, a la Nutrisystem, Weight Watchers, or dozens of competitors. Doctor two recommends avoiding “carbs.” (once called Atkins, now called paleo or ketogenic diet; it never goes away, we just change the name every ten years or so to convince people to avoid whole grains, the single most protective dietary component against diabetes) Doctor three prescribes phentermine, or if the patient is lucky, one of the drugs actually approved by the FDA for weight loss, all of which are exorbitantly expensive and modestly effective. Doctor four recommends the Diabetes Prevention Program. Doctor five recommends bariatric surgery. Doctor six recommends probiotics or another microbiome-directed treatment.

When the patient leaves the doctors office, she enters a built environment designed to be maximally obesogenic. Four-lane arterial roads replacing walkable, bikeable streets, even though we know beyond certainty that trips taken by car, rather than by bike, foot, or public transportation, are perfectly, directly related to the obesity rate in any community. And the amount of money any community spends on car-related transportation is perfectly aligned with obesity rates. Our patient pays sales taxes on obesogenic foods (red meat, refined carbohydrates, sugared beverages, and fats) at exactly the same rate as protective, high-fiber, unprocessed fruits, vegetables, and whole grains, in spite of evidence that Pigovian taxation, in which unhealthy foods are taxed at a rate equal to their the social cost and healthy foods are subsidized, has a powerful effect. Similarly, crop insurance and subsidy programs--in whatever form they take--favor meat and dairy production over fruits and vegetables.

When a peer gets cancer, we offer words of encouragement and give her rides to the doctor. We judge those with obesity and say they’re getting what they deserve for their weakness and sloth. We consider people who are competent, functioning members of society to be somehow constitutionally flawed and subject them to various levels of social discrimination. Obesity, along with intelligence, seems to be one of the final acceptable targets of discrimination; we casually make jokes about fat people and stupid people with none of the anxiety that accompanies insensitive remarks about race or sexual orientation. This is surely short-lived; over 80 million people in the U.S. have an I.Q. less than 90, and over 100 million are obese by body mass index criteria. These are groups large enough to fight back.

Viewed by an outsider, this set of circumstances does not resemble science. This is not the end result of a materialist view of the world. It resembles religion: a cultural system of competing behaviors, world views, and ethics that relate humanity’s problems not to the laws of the universe, but to supernatural elements. This elevation of the spiritual realm above the material realm is perfectly fine on Sunday mornings. I’m not here to make an anti-religion argument. Religion and spiritualism are vital in mobilizing public passion and opinion. NIH director Francis Collins, who discovered the gene mutation responsible for cystic fibrosis and later directed the Human Genome Project, is an evangelical Christian who advocates that religious belief can not only be reconciled with acceptance of scientific evidence, but that spirituality is vital to the responsible advancement of science. But spiritual thought in the absence of material evidence is unacceptable in the pursuit of a public health solution.

So how should we handle obesity as a health problem? As Kansans, we’re lucky to have perhaps the best model in our collective memories. We have Samuel Crumbine, early 20th century Dodge City physician who revolutionized the treatment of tuberculosis and other infectious diseases. At the outset of Dr. Crumbine’s career, infections were the leading cause of death by far and were dealt with in a quasi-spiritual manner. The consumption of tuberculosis was seen as God’s wrath. But Dr. Crumbine applied common sense strategies to limit the spread of the disease. He helped established sanitaria for tuberculosis patients, to isolate them from the public until they were no longer contagious. He spearheaded laws against spitting on the sidewalk (remember the bricks?), against shared drinking cups (you have him, indirectly, to thank for the modern bubbler-style drinking fountain), and against shared towels in public bathrooms. He advocated for fly-swatting campaigns. And all the while, he still promoted medical interventions for people already infected. Better antibiotics were developed. The entire specialty of cardiothoracic surgery grew not out of a need for coronary artery bypass grafting, but out of the need to drain tuberculous abscesses from the chests of infected patients.

When applied to obesity, I’m aware that lines blur. Calling something a disease moves individuals across a gauzy barrier between personhood and patienthood. You’re a person up until you’re labeled with a disease, then you’re a patient. The label inherently causes the patient to adopt a role in which he or she is excused from responsibility for his/her condition. This is healthy and appropriate; we know that the vast majority of lung cancers are caused by cigarette smoking, but we do not argue that smokers should be denied treatment. And the label creates an obligation for treatment that many obese people may not want. Roxane Gay and others have argued eloquently against the over-medicalization of body weight. And if this process (labeling of a disease, applying that label to people) entails an obligation for treatment, who will consent to pay the costs for that treatment? This social negotiation is just as big a part of what we need to address as any specific decision on the appropriateness or order of interventions.

I’m no Samuel Crumbine. I don’t even have a mustache. But if I channel Dr. Crumbine, I can see continued progress starting today. I can see the further development of a bike and pedestrian infrastructure, sensible parking policies, and street design that encourages higher density development with widely available green spaces. This can be partnered with local laws and regulations, a more sensible crop subsidy program, and a food tax system that encourages the production and consumption of quality foods over obesogenic foods. For patients who choose to seek help from their doctor, I can see a set of community-wide standards that promote a practical, stepwise approach to treatment that incorporates dietary and behavioral interventions alongside policies that make proven drug and surgical interventions more affordable. I can advocate for the development of a unified, science-based approach to obesity, motivated by spirituality but guided by material evidence.

Disclaimer: Health ICT was also a presenter, and the Forum was supported through a grant offered by the National Alliance of Healthcare Purchaser Coalitions and Novo Nordisk.

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. 

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. 

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. 

Link dump - March 8, 2017

Fewer and fewer Americans report trying to lose weight. We may be settling into our role as the one of the fattest countries on earth (we're coming for you, Tonga...). I can't help but think this is because of the many, many, many shitty options that people have had pushed on them that didn't work. Now they've given up. *sigh*

The search for the perfect artificial sweetener continues: 

"Let us pause here to acknowledge the sugar-frosted codependent embrace of Big Food and the American consumer. You could rightly fault consumers for their insistence on an oxymoronic product. But who has been indulging their fantasies for decades now, promising sweet, satisfying taste and no calories? Big Food, of course. Now customers are upping the stakes—and it’s not at all clear that companies can pass the test."

In what seems like a just reversal of a law that had the unintended consequence of highlighting the law of unintended consequences, after 60 years, street hockey will once again be legal in Hamilton, Ontario, under the following conditions:

  • The roadway has a speed limit of 40 km/h or less and is a local road.
  • Play happens in a place that is "safe and suitable."
  • People play no earlier than 9 a.m. and no later than 8 p.m.
  • No one plays during periods of limited visibility from fog, snow or rain.
  • Play is stopped for any vehicles. ("Car!")

Having robot minions control the lights for them may be turning kids into a bunch of lazy, entitled monsters.

No one can get you to take your medicines but you. Three reminder devices to take your medications were no better than no notification or device in a randomized controlled trial. 

Go. To. Bed. People who get out of bed in the morning tend to eat better and earlier in the day than night owls. Original paper here.

"We found that night owls had postponed timing of food intake, and less favorable eating patterns with higher intakes of sucrose, fat and saturated fat in the evening hours than early birds," said Maukonen, a doctoral candidate in the department of public health solutions.