Human Limits

A colleague who wants to lose some weight sent me an e-mail asking about the “Wheat Belly” diet which advocates cutting wheat based products and foods from your diet.  A book based on this concept is a best seller and among other things there is discussion in the book about how “addictive” wheat based products are and some potentially bad biological effects of high yield varieties that have emerged through selective breeding over the last 50-100 years.  From what I can tell, this is just the latest iteration of the “low carb” approach to weight loss and dieting that has had a number of incarnations over the last 50 or more years.  So, what did I tell my friend?

1)  Low Carb Diets Reduce Variety

There is pretty good evidence that just restricting food variety reduces the amount we eat.  Get rid of wheat based products and you restrict variety a lot.   Here is a link to an animal study that makes this point:

“Thus, the present results suggest that limiting dietary variety, regardless of palatability, may be a useful strategy for weight loss in overweight and obese individuals by reducing caloric intake within individual meals.”

2)  Carbohydrate Restriction & “Water Weight”

The pictures below are two photos taken a few days apart of Olympic 1500m swim champion Grant Hackett.  On the left is a shot when he was tapered and after he had carbo loaded for a 10k open water swim (the swimming equivalent of a 26 mile marathon).  The photo on the right is a few days later when he was back to his normal training.  Along similar lines, it has been known for years that low carb diets lead to rapid weight loss because water is stored along with carbohydrate in the body.  When the carbs are depleted the water goes with them.   A study from the 1990s tracked this carefully over a few days of a very low calorie diet and showed a 4.3 kg (9 lb) weight loss almost entirely from changes in body water.  A lot of the appeal of low-carb diets is this early and impressive weight loss.  Don’t be fooled into thinking it is fat loss.

3)  Feeling Full Helps

Dietary fat and protein probably make most people feel full for longer.  The biology is complex and relates to how fast food leaves various parts of your digestive tract and a whole bunch of hormonal signals related to what makes us hungry and what makes us feel full.   So, this is perhaps another reason that low carb diets seem to work.   However, there is concern that low carb but high fat and protein diets work but are not optimal to reduce or control things like cholesterol.  This too is a complex topic with a lot of individual variability.  But feeling full for longer is good if you want to lose weight.

4)  The Brain & Food Addiction

The way the brains of people who are obese or prone to overeat are stimulated by food or images of food is different.  Does this mean they have a food addiction?  Who knows, but the summary below does give us some hints about what the issues are and what might be done to address them.

“Prefrontal cortex areas linked to cognitive evaluation processes, such as evaluation of rewarding stimuli, as well as explicit memory regions, appear most consistently activated in response to images of food in those who are obese. Conversely, a reduced activation in brain regions associated with cognitive control and interoceptive awareness of sensations in the body might indicate a weakened control system, combined with hypo-sensitivity to satiety and discomfort signals after eating in those who are prone to overeat.”

Is this innate?  Or does it happen over time.  Is it biology or environment?  My guess is that is probably both and that the brain can be rewired over time and with some effort.  Self-control related to both diet and exercise seems to be the key for long term successful “losers”:

“These findings suggest that weight loss maintenance efforts can be improved by addressing challenges such as long-term self-monitoring and problem-solving skills, and that maintenance success might depend on how people think as much as what they do.”

What is interesting is that both the brain imaging studies and the behavioral studies both cite issues related to body perceptions and self-monitoring.  Perhaps it is more than just will power and there is a “skill” and focus element to weight loss like most other things that are difficult to do.

5)  Exercise & Physical Activity

Most of us don’t have the time, energy or motivation to train like an elite athlete and be a in a position to essentially eat all day long.   However, there is some evidence that if we exercise a lot we might sit around more during the rest of the day and lose some of both the energy expenditure benefits and health benefits of exercising.   So a key thing to remember is to both exercise and also build more low grade physical activity into your day.

Summary

Despite wave after wave of claims related to low carb diets, at some level if you have seen one you have seen them all.  They clearly “work” at generating rapid weight loss, reducing dietary choice and they probably help people feel a bit fuller.  However, the key to successful long term weight loss appears to be related to developing the skills and behavioral strategies needed to effect long term changes in diet, exercise and overall physical activity.   What is interesting about my colleague is that he is highly successful, self-disciplined, and focused in many areas of his life.  He is also seen as a problem solver by many co-workers.  So, he has the general skill set needed to be a successful “loser”, and my bet is that he will be once he consistently applies these skills to his exercise and weight loss goals.

It has been a while since I did a post on big picture issues related to health care in the U.S. In the last couple of months several ideas or perhaps rescue fantasies have emerged or perhaps re-emerged and I want to go over them.

1)  Lack of Price Transparency

In the U.S. prices for various medical procedures are convoluted, idiosyncratic and extremely hard for even the experts to understand.   A recent NY Times article on the costs of having a baby in the U.S. highlights many of these issues.   Because there is no obvious rack rate and prices are not posted by most medical providers, some employers are essentially capping what they will pay for a given procedure or service.   Along these lines, my bet is that there is going to be a big price transparency movement, more so-called bundled payments, and that the regulators will play a role in this.   The important thing to remember is that what people and insurance plans actually pay typically has little relationship to what the list price is if you can find it.   The other point here is that even if prices are more transparent it might not do that much to lower overall medical care costs which are driven in large part by utilization of services.  I am all for more transparency, but it is not going to solve the cost problem.  It is also interesting to note the late physician turned science fiction writer Michael Crichton raised many of these issues in a long article in the Atlantic published in 1970!

2)  Rising Costs: a Problem Everywhere

The next point I want to make is that rising prices are a problem in almost all rich countries and a number of developing countries.   Many of these countries have strict price controls and essentially government run programs.  So thinking that there is some magical intervention “the government” can or should do to fix the problem is simplistic at best.  My bet is that Obamacare will struggle to contain costs.  The real drivers of rising costs are likely the aging population and advances in technology.

3)  The Recent Slowing of Health Care Spending Growth

The rate of growth of health care spending has slowed recently.   If this trend continues it has all sorts of implications for things like the U.S. Federal budget.  However, I would urge caution in assuming that this trend will last forever.   In past economic slowdowns there has also been a slowing of medical care spending growth followed by a rebound when the economy picked up.  As I pointed out above no government in the developed world has effectively dealt with this issue over the long run, the population is still aging, and technology marches on.

4)  Denial & Practice Variation

The current focus on price transparency and the recent slowing of spending growth are major distractions away from at least one major issue that might tend to reduce the rise in spending over time.  That issue is the tremendous regional variation in the use of health care services in the U.S. and the lack of relationship between a number of markers of utilization and outcomes.  Some argue that 30% of Medicare spending does not contribute to improved patient outcomes and is thus “wasted”.  The figure below is a bit dated but still relevant and generally accurate.  It shows a range of estimated savings for Medicare if all 50 States had utilization rates and practice patterns similar to the five most efficient States.  Numbers in these general ranges likely apply to health care spending as a whole.

There are a number of ideas out there about how to deal with this issue, but they are likely to be challenging to implement.

5)  Rent Seeking & Why This is Hard to Fix

Almost 18% percent of the GDP is spent on health care in the U.S.  Almost 50% of this spending comes from the government in terms of either programs like Medicare or Medicaid, the VA, or Indian Health Service.  Additional government spending is due to insurance provided to government workers at the Federal, State, and Local levels.   There are also significant government subsidies for health care spending via the tax code.  So, in one form or another “the government” probably covers 60-70% of medical costs in the U.S.  As a result there is a huge and diverse group of vested interests angling for either maintaining or expanding their piece of this economic pie via what might be characterized as ‘rent seeking’ behavior:

“…..rent-seeking is an attempt to obtain economic rent by manipulating the social or political environment in which economic activities occur……”

Summary

Dealing with the high cost of health care in the U.S. is going to take more than price transparency and don’t bet the farm that current moderation of rising costs is going to last forever.   The 800 pound Gorilla in the basement is utilization which, given the aging population, ever more technology, and economic incentives to over utilize, will be very difficult to contain. 

After the post on Alain Mimoun I got a nice note from publishing icon and fitness activist George Hirsch:

“Thanks for this. As a teenager, I attended the 1952 Helsinki Games and became a lifelong admirer of Mimoun, a true champion in every way.”

That led to a longer exchange about George’s role as a leader of the NY Marathon in bringing Mimoun’s great competitive partner Emil Zatopek to New York in 1979.  The picture below is of Bill Rogers, George and Zatopek out for a run in Central Park.

As e-mail conversations sometimes do, things drifted to Zatopek’s support for greater political freedom as part of the Prague Spring in 1968.  With the suppression of the Prague Spring, Zatopek lost his official status and was apparently given a series of menial jobs.  At some level he was probably protected from even more harsh treatment by his international status and George Hirsch indicated that it did not take a major diplomatic effort to get him to New York in 1979.  In 1990 he was politically “rehabilitated” as communism crumbled in the former Czechoslovakia.   So, like Mimoun, Zatopek was a man of great personal resilience.

How Does This Relate to Nelson Mandela?

All of this discussion about resilience got me thinking about Nelson Mandela whose health and perhaps life is slipping away at age 94.  The details of Mandela’s life are well known, but perhaps less well known is that he was devoted to a program of calisthenics and running in place during his nearly three decades as a political prisoner.   In his 70s he then had the physical stamina to emerge from prison, lead his country and focus on reconciliation vs. revenge.  He also continued an exercise program well into his 80s.  I can’t help but think that his physical endurance contributed to his mental endurance and the resilience it took to just keep pushing forward against long odds.  From a scientific perspective surely the exercise helped him deal with the stresses of resistance and leadership and kept him cognitively sharp for a long time.

The 4^th of July is a time when we should all spend a few minutes reflecting about the ongoing struggle for human freedom.  Thinking about how Nelson Mandela pressed on over so many years is a good place to start, and so is following his example and getting some exercise before the festivities and fireworks start.  At some level resilience is a skill that can be learned and physical activity can surely contribute to it.

The great French/Algerian runner Alain Mimoun, who won the marathon at the 1956 Olympics, died last week at the age of 92.  Mimoun is best known for his many silver medal finishes to the incomparable Emil Zatopek who is arguably the greatest distance runner of all time.  Less well appreciated is that Mimoun is in many ways a herald of all that came after him:

• He was born in Algeria when it was still a French Colony.  This is what we now might call the developing world and his excellence anticipated by more than a decade what other North African Arabs and runners from Ethiopia and Kenya have achieved starting with Abebe Bikila in 1960.
• He competed well for a very long time in an era when careers at the highest level typically lasted for only a few years.  In 1960 he competed in his fourth Olympics and placed 34^th in the marathon with a time of 2:31:20 at age 39.
• He won the French national title in 1966 at age 45 and in his early 50s he broke 2:35.
• He remained fit and active into his 90s.

I knew about his races with Zatopek and his victory in 1956 from the Bud Greenspan documentary “The Persistent Ones”, but I had no idea that he was one of the first great master athletes as well and a model for successful aging.  The video below shows Mimoun running in the forest at about age 90.  He was clearly a man ahead of his time and an example for us all.

click here for video

Brazil is slated to host the 2014 World Cup Soccer tournament and the 2016 Summer Olympics.  Currently the FIFA Confederations Cup soccer tournament is being held there as a sort of dry run for these big events and the festivities have been marked by massive public protests over “spending on stadiums” vs. basic public service.  The video below has gone viral and was posted a few weeks before the protests started.

click here for video

Mexico City 1968 and Denver 1976

The circumstances were different but there were large public protests including a massacre of about 40 protesters in early October of 1968 before the Mexico City Olympics.  Here is a link to BBC reporting from that time and also a more recent review of what happened in Mexico City.  In the early 1970s the people of Denver rejected public funding for the 1976 Winter Olympics, and the games were moved to Innsbruck, Austria. So, this is not the first time people have questioned the priorities associated with massive public spending on global sports extravaganzas.

Let Them Eat Stadiums?

Here is a link to an NYT op-ed piece entitled “Let Them Eat Soccer” with more on the situation in Brazil.  I have been to Brazil a couple of times.  It is a spectacular place poised to become a world power with world class people and capabilities in many areas.  However, it is marked by all sorts of problems related to corruption, extremely high levels of social inequality, and just plain growing pains.  In this context, is spending lavishly on stadiums a good idea?  Similar questions have been raised in the US about public subsidies for professional sports stadiums which seem a bit crazy since the owners of the big sports franchises are typically “billionaires”.  With people taking to the streets in Brazil and the ability of protests to go viral, I wonder what the long term effects will be on the ability of governments all over the world to subsidize stadiums.  The recent US Open Golf Tournament at Merion also shows that extravagant purpose built venues are not essential to great competition.  So, maybe there is a middle way.

The celebrity “Southern” cook Paula Deen was essentially fired by the Food Network for bad behavior including use of the N word.  In reading about this incident I ran across the picture below of loyal fans lined up outside her restaurant in Savannah, Georgia waiting to eat.  The N word aside, this photo is a perfect example of the obesity epidemic in America, and raises the question of how and why we celebrate people who promulgate too much of a good tasting thing.  Are there celebrity smoking and drinking advocates?  Are there celebrity drive too fast advocates?  Are there celebrity unsafe sex advocates?  Do these folks, if they exist, get their own TV shows?

Southern Cooking & The “Stroke Belt”

Diet matters and Southern Cooking and other unhealthy behaviors (smoking, inactivity, and obesity) have been implicated as causes of the so-called stroke belt which is shown in the first map below.  It shows a region of the country where strokes are an especially big problem and other markers of public health are typically low.  Obesity is also associated with about a 40% increase in health care costs that we all share one way of the other through health insurance premiums, taxes for programs like Medicare and Medicaid, or government disability payments.  The second map shows the impact of these behaviors on life expectancy.  The life expectancy data are confounded by things like poverty, race and education that seem to interact with all sorts of behavioral risk factors and determine who gets what disease and dies when.  Paradoxically the data in the second map also shows that there are areas of the country with life expectancy values that rival those seen in places like Scandinavia and even Japan.

Summary

I am not sure we need to become a country of food puritans, but I do think we need recognize that these problems are not going to go away unless we do something, and cleaning up the countries diet, especially in the stroke belt might be a good start.  The other interesting thing about the stroke belt is that it is a region of the country devoted to the rhetoric of “small government” and “individual responsibility”, but the data suggests that these philosophies are difficult for people to practice and that maybe Mayor Bloomberg is right.  Denial is typically not a good policy and it is never a smart policy.

The recent and controversial AMA decision to categorize obesity as a disease has a raised a number of questions and discussion points.  I thought I would cover a few here to help readers sort through the issue on their own.

Definition of Disease

Below is an extended quote from the wiki definition of disease.  It is similar to other definitions I found and if you link to the site there is a pretty comprehensive discussion of the concept of disease and related things like “disorder” or syndrome.  Based on the blurb below obesity certainly seems to fit many of the definitions of a disease.  One interesting recent observation is that if you track obesity in social groups it moves through them with a pattern that looks a lot like the way infectious disease moves through a population.

“A disease is an abnormal condition that affects the body of an organism. It is often construed as a medical condition associated with specific symptoms and signs.[1] It may be caused by factors originally from an external source, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune diseases. In humans, “disease” is often used more broadly to refer to any condition that causes pain, dysfunction, distress, social problems, or death to the person afflicted, or similar problems for those in contact with the person. In this broader sense, it sometimes includes injuries, disabilities, disorders, syndromes, infections, isolated symptoms, deviant behaviors, and atypical variations of structure and function, while in other contexts and for other purposes these may be considered distinguishable categories. Diseases usually affect people not only physically, but also emotionally, as contracting and living with many diseases can alter one’s perspective on life, and their personality.”

Defining Obesity

BMI or body mass index has emerged as a favored definition of obesity.  This definition is probably OK when thinking about groups or populations of people but does not always tell you much about an individual.  There can be “normal weight” people with a lot body fat and health problems, and there can be heavy people with lots of muscle mass and very little body fat.   Then there is the problem of distribution of fat.  Visceral fat or “belly fat” is worse for your health than fat in your lower extremities. When I started medical school in the early 80s fat was seen mostly as a tissue that simply stored excess energy, but in the last 20 or so years it turns out that some fat cells secrete all sorts of biologically active substances that wreak havoc on the blood vessels, heart, liver, pancreas, skeletal muscle and brain.  One critical thing to note is the physically active “fat people” are largely protected from some or most of these problems

What Does Disease “Status” Do?

The AMA decision does not do anything right away other than make a statement and raise a bunch of questions:

• Will disease status increase public awareness of obesity as a medical problem?  My guess is that most people are probably already aware that obesity is a problem.
• Will disease change medical practice and encourage more Drs. to discuss the issue with patients?  Should things like exercise and physical activity be a vital sign?
• Will disease status influence the way insurance covers certain treatments like gastric bypass?  Some plans do, some don’t and here is link to a nice opinion piece on that topic.  What happens if the insurance plans that political leaders get cover it but not the plans the rest of us have?
• Will disease status limit the use of sin taxes and incentive plans linked to weight loss by governments and insurance companies?
• Will disease status encourage people to take more or less responsibility for their own behavior?  Obesity is a lot more than a few bad genes “making us fat”.  In fact genetics likely plays a minor role for most people and the big increase in average body in the US over the last couple of generations has occurred faster than any genetic changes that might explain it.  For the vast majority of us it is all about the environment and our behavior.

Our Obesogenic World!

We live in a high calorie low physical activity world primed to make us all fat.  At some level it is amazing that anyone remains normal weight.  The lessons from improved traffic safety and smoking rates over the last 50 plus years tell us that these big public health problems require structural changes in society as well as changes in individual behavior and so-called “choice”.    Where to start with the obesity problem: Sugar and fat taxes or other policies designed to reduce calorie consumption and increase healthy food choices?  Walking and biking friendly urban planning?  Safe streets to encourage getting outside in all neighborhoods?  More PE and better nutrition at school?  Financial incentives via health insurance plans?  Limiting our own screen time and that of our kids?  Drs. and nurses communicating more about the problem with patients with easier referrals to diet and exercise programs?  The short answer is all of the above.

With the Tour de France set to start at the end of June, Major League Baseball in mid-season and international track and field winding up it, seems like a good time to review a few developments in the world of doping.  Where to start?

Baseball

The big doping news in baseball center around reports (starting last winter) that a Miami “clinic” was providing performance enhancing drugs to a number of high profile players.   Major League Baseball has obtained the records from the clinic and is considering action including the suspension of a large number of players.  The take home messages from this story include:

• Drug testing, both the tests and the way they are administered, remain beatable.
• High profile cases are frequently more about paper and financial trails than testing.
• Baseball seems to be taking this more seriously than in the past.

Track & Field

In April there were reports that some high profile distance runners were being treated with thyroid hormone “replacement” therapy.  Here is a link to a thoughtful analysis by the Science of Sport blog.  It raises a number of questions about therapeutic exemptions for athletes with real medical conditions.  The other big issue here is that if heavy training and competition alters key hormone levels should the athletes be permitted to use supplemental doses to get their levels back to “normal”.   This is a slippery slope and could lead to a situation where upper limits of normal for hormone levels and hematocrit are established and “doping” up to that level is allowed.  Perhaps the biological playing field would be level but what about individual variation and the challenge of working with what you have?  At some level this might already be happening with the use of low dose doping programs designed to fly under the testing radar.  For those of you wanting a deeper dive on this topic the links above are excellent and cover a lot of ground.

Cycling

A colleague sent me a link to a Velo News (the bible of Cycling) article on a new analysis of power outputs on iconic Tour de France mountain climbs.  The data come from a number of top cyclists over the last ~30 years and provides a color coded index of suspicion related to who might have been doping on what climb when.   The idea is that if you know a rider’s power output in watts/kg you can make reasonable estimates of oxygen consumption and that some of these power outputs would require people to be working at VO₂max for prolonged periods of time, at altitude, at the end of long rides with multiple climbs.  This is a collection of circumstances that seems physiologically unlikely at best.   The article is an interesting read and here is a link to the full analysis being published as a one time magazine and also a podcast interview with the author.

Summary

At one level the news is depressing and it appears that doping goes on more or less unchecked with ever more sophisticated “work arounds” to beat the testing.  At another level perhaps the testing, analysis and detective work are getting good enough to keep the lid on things to some extent.  This has been likened to having enough speed limit enforcement on the highways to keep most drivers close to the speed limit.  Perhaps this is the best we can hope for given the money and fame at stake in professional sports.