COVID-19 May Be Worse in the Fall. The Time to Protect Yourself is Now.

The rate of new COVID-19 cases is finally headed downward again in Kansas:

Statnews.com

Statnews.com

We’re not through this yet.

With fall comes cooler weather and seasonal influenza stacked on top of the COVID-19 pandemic. This looming threat is causing foundational changes in our expectations of the season. Several college conferences have already cancelled sports. Theater releases of movies that cost hundreds of millions of dollars to produce have been delayed indefinitely, and others have gone straight to video on demand. The spookiness of the Halloween season is real, and getting realer every day.

So we and our employees should continue masking. Masking works (as long as the mask isn’t a fleece buff). We should continue socially distancing whenever possible, and we should obviously get vaccinated against seasonal influenza when we can. We should get the COVID-19 vaccine as soon as it is available. But what else can we do?

We can lose weight. Real disaster preparedness isn’t hoarding water or ammunition. It is largely the preparation of your body and your bank account for emergencies. A recent study in the Annals of Internal Medicine found that, especially in people younger than 65, obesity was one of the biggest risk factors for intubation and death with COVID-19. And the bigger patients were, the higher the risk. “Morbidly” obese COVID-19 patients–those with a body mass index, or BMI, of 40 kg/m2 or greater–were 60% more likely to die or require intubation, compared with people of normal weight:

Annals of Internal Medicine

Annals of Internal Medicine

And obesity may even decrease the effectiveness of a future SARS-CoV-2 vaccine.

So if you are one of the roughly 40% of Americans who are obese, then to protect yourself this fall, the time to start reducing risk is now. This isn’t about judgement or shaming. I’ve been very vocal in the past about my disdain for the opinion that obesity is some personal or moral failing. It is not. It is a product of genetics and environment, just like heart disease, cancer risk, and yes, risk for infections.

How can you, as an employer, help your employees reduce risk beyond vaccination?

Traditional worksite wellness programs are disappointing, unfortunately, although as we’ve blogged about in the past, some worksite strategies for weight loss have proven modestly effective around the holidays. And restricting one’s diet to “unprocessed” foods such as those in Group 1 of the NOVA Food Classification System appears to result in weight loss even without intentional dieting. If we take the problem seriously, though, we’re inevitably led to the question of coverage of weight loss programs like the Diabetes Prevention Program, coverage of weight loss medications, and coverage of bariatric surgery. [Disclaimer: KBGH is funded in part by two CDC grants that aim to identify obese or pre-diabetic people and refer them into programs like the Diabetes Prevention Program that help them lose weight and reduce their risk.]

If you’re not already covering these benefits, consider them the next time you update your employee benefits. And, as always, if KBGH can be any help in determining the potential benefits to your employees from these programs or treatments, please contact us!

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

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.

You can't use drugs to "prevent" diabetes

Big, big disclosure here: I am a paid consultant for a CDC grant that aims in part to increase use of the Diabetes Prevention Program. So there. Read on.

Good to see you again, Mrs. D. You mind if I call you Mrs. D? Thanks. Reminds me of "Mrs. C" on Happy Days. You know, she was the only one with the cojones to call the Fonz "Arthur." So you can see the resemblance.

I'm glad you asked about the recent study that showed a medicine called "liraglutide" (brand names Victoza or Saxenda) "prevented" diabetes. You're a smart person, so you read some of the fine print in the study, and you know that ~2200 patients, most of them obese, were randomly given a daily shot of placebo or a daily shot of liraglutide, a chemical that mimics a gut hormone to trick the pancreas into producing more insulin. Liraglutide has the side effect of making people feel fuller sooner after eating. Doctors call this "early satiety." The tricky vocabulary's how we make so much money.

All of the patients had elevated blood sugars, but not so elevated that they could be labeled "diabetic." They were "pre-diabetic" in the current nomenclature, just like you. It means the same thing as "impaired fasting glucose" or "impaired glucose tolerance." The study set out to prove that liraglutide could "prevent" the onset of diabetes. Now you're probably wondering: If I'm taking a diabetes drug, what's the point of having "prevented" diabetes?

And you're on to something, Mrs. D. This is an absurd question at face value, but it keeps getting tested, mostly by drug companies. Not surprisingly, in most cases people getting the diabetes drug were less likely than those getting a placebo pill or shot to have their blood sugars rise high enough to be diagnosed with diabetes.

I'm about to get really, really snarky, Mrs. D, but before I do, it's important that I make this point: the prevention of diabetes is actually a HUGE deal, and not only because diabetes remains the number one cause of blindness, kidney dialysis, and foot amputation in the United States. It is astonishingly expensive. Of the $3.2 trillion (!) that Americans spend on health care annually, diabetes directly accounts for $101.4 billion, making it officially the most expensive disease in America. If you can prevent people from advancing from the just-a-little-abnormal-sugars "pre-diabetes" to old-fashioned diabetes, you save about $12,000 per year in expenses. Now, that's insurance company money, but we all pay for it in premiums.

This is where your insurance premiums are going.

This is where your insurance premiums are going.

And as I've pointed out before, a big chunk of that extra spending isn't insurance money at all; it's coming out of your pocket in the form of co-pays and whatnot. And it's not much better for the Medicare crowd, who we all pay for in taxes:

So let's perform a quick thought experiment. You came to see me because you weren't feeling your best, and I checked a blood sugar on a hunch, and it's slightly elevated at 106 mg/dl. That's in that pre-diabetic range I've been talking about.

Bummer.

Now, we've got some options here. But let's say I tell you that the best way to keep yourself from becoming diabetic is to inject yourself with 10 units of insulin every night before bed. That way, your blood sugars will go back to normal, and we can both wash our hands of the whole issue. Great, right? We've prevented a case of diabetes! Your blood sugars are normal, after all.

BUT YOU'RE ON A DIABETES DRUG NOW!

Of course we haven't prevented a case of diabetes! We've just put you on a diabetes drug that has (predictably) lowered your blood glucose levels. The entire assertion that we've prevented anything is as laughable as the assertion that we could "prevent" a diagnosis of hypertension by putting you on blood pressure medications.

To make the situation even more ridiculous with liraglutide, it costs a fortune: over $3,000 a month for the 3 mg dose! If you wanna know where that extra $12k a year is going, I think we're hot on the trail. Think what else we could do with that amount of money. And if you for some reason think the idea of "preventing" diabetes by taking a diabetes drug isn't patently absurd, it works only modestly better than metformin, a drug that can easily be obtained for $3-4 per month.

But the final insult, Mrs. D, is that liraglutide worked barely better in its study than a program called the "Diabetes Prevention Program," or "DPP." In the liraglutide study, roughly 2% of people receiving the drug went on to have blood sugars high enough to be diabetic in three years, versus 6% of people getting placebo, for what we call an 80% "relative risk reduction." (Drug companies love using relative risk because it makes the numbers sound so much more impressive) In the original version of the Diabetes Prevention Program, 4.8% of people getting counseling on diet and lifestyle by a coach went on to be diabetic, versus 11% getting placebo, for a 58% relative risk reduction. The numbers for both groups in the DPP were higher, which I blame on an older participant population.

The cost of the Diabetes Prevention Program? $429 per year. So you might not be surprised to know that in 2016, when CMS was debating whether to allow Medicare to cover the DPP, the Pharmaceutical Research and Manufacturers of America (PhRMA) fought against it, saying that twenty years of evidence was only "preliminary." They do. Not. Care. About your health or the seemingly inevitable transformation of America into a single, enormous insurance company that also happens to field a Navy. And we should all remember that back when insulin was discovered, the University of Toronto held the patent for insulin to keep any single company from exploiting the drug for unreasonable profit. How times have changed.

Okay. Deep, cleansing breaths. I'm calming down. Liraglutide is a good medicine for diabetes. It helps keep sugars down, it helps with weight loss, and it may even help prevent heart attacks. In diabetics, that is. But you're not diabetic, and you don't have to become diabetic, and all drugs come with a cost, financially and otherwise. I think we can agree that diabetes is expensive enough; we shouldn't use drugs to "prevent" it that are even more expensive than the disease itself.

So, Mrs. D. You'd be a great candidate for the DPP. But even if you weren't, do you know what the DPP asks of its participants? 150 minutes a week of physical activity and some dietary modifications to allow you to lose around 7% of your body weight. Let's think about what that might look like. The average bike commute in this country is around 19 minutes one-way. Do that five days a week, and you're at 190 minutes already! And that doesn't even count trips to the grocery store! And if you stop drinking insect bait and cut out the foods that aren't really foods:

If you cut those out from your diet and start eating most of your food from the produce aisle or from the canned fruits and vegetables aisle, don't you think that 7% weight loss sounds pretty modest? I bet you'd blow it out of the water. 

And besides, do you really want to cross that grim threshold from "person" to "patient?" Because the first time you put the needle of that Saxenda pen into your skin, that's what you'll have done. You'll have moved the wrong direction on the Double Arrow Metabolism Wellness Index. You'll have gone from a person with agency, someone who takes medicines to feel better or live longer, to someone who has yielded control to a chemical--a $30,000 a year chemical--to do something you could have done better yourself. You'll have succumbed to a philosophy of better living through chemistry.

Maybe Du Pont doesn't deserve this.

Maybe Du Pont doesn't deserve this.

Or do you want to be the person who SAVES thousands of dollars per year by ditching the fancy gas-powered wheelchair so you can propel yourself through space with your own legs and feet and by eating real foods you made with your own hands and eating them when you want, the way you want, and in the quantities you want? Do you want to live by a philosophy of self-determination, where you know that every healthy, happy day you live from now on was of your own making? 

If that life is what you want, then don't try to prevent diabetes with drugs. It can't be done. 

Link dump - March 3, 2017

People who cook real food and eat it at the table like human beings instead of eating processed garbage in front of a screen like drooling automatons have a lower risk of obesity. Good to know.

Wichita roads are friendlier to cyclists. I've experienced this myself, and I've meant to write a letter to the Eagle thanking the city and its drivers for not killing me, but now it's taken care of. *washes hands*

Obese people who "self stigmatize" may be at higher metabolic risk. This is an interesting hypothesis. Intuitively, I believe it; there's so much undeserved self-hatred out there among people who weigh more than they want to. But the sample size of this paper makes me suspicious. It has the smell of p-value hunting.

Aggressive treatment of subclinical hypothyroidism with levothyroxine in pregnancy probably doesn't result in smarter kids. This is disappointing.

Taxing sugared drinks makes people drink less insect bait. Go figure.

Have a good weekend

Have a good weekend

What the hell is water?

There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says, "Morning, boys. How's the water?" And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes, "What the hell is water?"

-David Foster Wallace

 

I don't know exactly what the late, great DFW meant by this. Tragically, he's not around to tell us. But what I think he meant is that the most important realities are often the ones that are the hardest to detect. And to continue to borrow DFW's analogy, most of us paddle forward as best we can without ever feeling the flow of water against us, pushing us back, keeping us from reaching our potential. That rush of water consists of a lot of things, but most of them are visible if you look closely.

I’m a physician, as you might have deduced by the initials after my name. And physicians by training are supposed to notice the things that others don't. But most of us don't, and I've been more guilty of this than anyone in the past. See, I'm an endocrinologist. That’s a specialist in metabolic and hormonal disorders (think disorders of the pituitary, thyroid, and adrenal glands; and osteoporosis and diabetes and whatnot). You’d think that an endocrinologist is a person particularly well-trained to help patients escape the vortex of fancy motorized wheelchairs, faux-food, time-sucking devices, and all the other things pulling us under.

But that’s not at all what I was trained to do. In fact, I found during my career as an academic endocrinologist that instead of getting people safely to shore, I was often quickening or deepening the vortex that my patients were swimming in. In 15-minute office visits, I’d prescribe drugs that cost thousands of dollars and have trite, brief (in case the 15-minute visit didn’t give it away) conversations about what they could do with their weight, or their fatigue, or their sadness. The visits cost me 15 minutes, that is. They cost my patients a lot more. A lot more.

I was doing my best, obsessing over the things I could measure or manipulate, like blood sugars, cholesterol, blood pressure, and weight. All those are important. Don’t let anything you read here convince you otherwise. But I was swimming in the vortex myself. I simply paddled forward in the water I was trained to swim in, comfortably moving myself from today into tomorrow, spending the loads of money I made on things that didn’t make me happy and working extra hours to pay them off. I drove like a maniac between two clinics and four hospitals, often putting almost 100 miles a day on my car. The vortex deepened. The extra hours ate into time that I should have spent doing things I loved, like chasing my kids or riding my bike, so I weighed thirty pounds more than I wanted to. The water sped up. And then my blood sugars--one of those things I prided myself on controlling--started going up. And then I started getting really unhappy and resentful at work. I was swimming as hard as I could, but spiraling. What I couldn’t detect was that I and my patients needed to become people again.

What’s that? My patients weren’t people? What am I, a veterinarian?

P. henrylawsoni can out-wrestle A. woodhousii any day of the week.

P. henrylawsoni can out-wrestle A. woodhousii any day of the week.

What I mean is, that once a person crosses that gauzy threshold from the waiting room to the exam room, he experiences a transition from personhood to patienthood. And patients are bad swimmers. Let me illustrate. Most of us, whether we’ve thought about it or not, exist somewhere on this spectrum:

  1. I feel great. I’m as healthy as I can be, and I’m intentionally doing things daily to improve my health.
  2. I’m healthy, but mostly by accident.
  3. I’m not sick, but I don’t feel good. I’m always stressed out.
  4. I have one or two health problems that I manage pretty well, but I’m broke.
  5. I have a few health problems that I struggle to manage, I’m broke, and I’m working a second job to pay medical expenses.
  6. I have been hospitalized one or more times in the last year for chronic health problems, and I can’t work.
  7. I’m in a nursing home or assisted living because I can’t take care of myself anymore.
  8. I am dying.

The thing about this spectrum is that the strategy for moving up on it depends on where you start, and it’s never a straight line. If you’re one of the unfortunates at #7 or #8 that our system most definitely calls patients, my thoughts are with you. If you are at #5 or #6, your strategy for moving up may involve a lot of pharmaceutical help. I have opinions, at least metabolically speaking, on what that help might look like. But if you’re at #4 or above, and you’re working on getting to #1, the path to get there may meander through the local pharmacy for a bit, but most of the path is outside in the sunshine and fresh air. The path most definitely does not intersect with your couch.

So by reading this blog, if you’ll bear with me, you’re going to learn to feel the water around you, and you're going to get the skills to map out your own path out of the evil vortex. I intend to be completely honest and transparent about what I know and what I’m not so sure about. There’ll be philosophical stuff, like what a good partner in health ought to offer. There may even be diversions into seemingly unrelated topics, like pop culture, the weather, or my favorite, cycling. If I haven’t scared you off yet, come back for the next post.