Why You Should Arm Your Bullshit Alarm Before Reading Diet News.

In the fight over best diet for health and weight loss, it's protein lovers vs. vegetarian zealots. So far, a clear winner has not emerged. Only one loser: you, the victim of biased research. Here is an example of why you should keep your bullshit alarm on high alert when reading about weight loss diets.  

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Ellen M. Evans and colleagues wanted to know whether overweight men and women differ in their body composition responses to different weight loss diets [1]. So they enrolled 58 men and 72 women with a BMI greater than 26, and randomized them into two diet groups.

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Individualized Medicine, Ignorant Medics And An Invitation To Lose Weight.

In my previous post I promised to talk about your individualized way to achieving optimal health. If that made you think about personalized medicine, you were right. Almost. Because personalized medicine is still light-years away from us. That's the bad news. The good news, personalized prevention is an emerging reality. At least in my lab. Which is why I would like to invite you to become a part of it. No strings attached. But before we get to this let's first get on the same page about the personalization of medicine.

Two questions we need to ask ourselves: What is personalized medicine and why would we want it?

Professor Jeremy K Nicholson of the Imperial College, London, defined personalized medicine as "effective therapies that are tailored to the exact biology or biological state of an individual" [1]. Such tailoring of a treatment, say for your high blood pressure, would require your doctor to evaluate your biochemical and metabolic profile in order to prescribe you the most effective drug or treatment at the most effective dose, with the least possibility of side effects.

Now, why would we want this?

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The one way to make you slim, fit and healthy?

That your fattening lifestyle drives health insurance costs up is nothing but a fat lie. That much I have told you in the previous post. With Marlboro Man and Ronald McDonald doing better for your health insurer's balance sheet than Healthy Living, you might think that public health should look beyond economics as an argument for health.  In this post I will tell you why they shouldn't. 

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Am I shittin' you? Learn to be a skeptic!

Learn to be a skeptic!

Why you cannot believe what you read about medical studies.

In my last blog post I promised to tell you why you shouldn't trust any study results, particularly when you didn't read the study yourself. It has to do with the methods of biomedical research. To make my point, I'll take the gold standard research method, the double blinded randomized controlled trial, or RCT. 

Let's say we want to test a drug, which is supposed to lower blood pressure in those who suffer from hypertension. The researchers have decided to enroll, say, 100 "subjects". That's what we typically call the people who are kind enough to play guinea pig in our studies.   

The researchers will first do a randomization of subjects into one of two groups (very often it is more than one group, but to keep it simple we will assume just two groups). What we mean with randomization is that we randomly assign each subject to one of the two groups. One group - the intervention group - will receive the drug, the other group - the control group - won't. What they get instead is a sugar pill, a placebo. 

With the randomization we want to make sure that, at the start, or baseline, both groups are indistinguishable from each other with respect to their average vital parameters. For example, if we were to calculate the mean age, blood pressure and any other variable for each group, these mean values would be not different between groups. That's important, because we want to isolate the effect of the drug. We don't want to worry at the end whether the effect, or lack thereof, was maybe due to some significant difference between the groups at baseline. 

Once the randomization is done, we organize the trial in such a way that neither the "subjects" nor their physicians and nurses know whether they get the placebo or the active drug. Both sides are blind to what they get and give, which is why this set-up is called double-blinded. That's an important feature, because a researcher often goes into a study with a certain expectation of its outcome. Either that outcome supports his hypothesis, or it doesn't. To eliminate the risk of, more or less subconsciously, influencing the study towards a desired outcome, double-blinding is very effective tool.

Fast forward to the end of our trial. We have now all the data in hand to compare the two groups. After unblinding, the researchers will compare the two groups with each other. In our example, they will compare the average, or mean, of the blood pressure values of all the individuals for each group. If the intervention group's mean value is lower than that of the control group, then it is plausible to reject the null-hypothesis, that is to REJECT the idea that the drug is NOT as ineffective as the placebo (we are, of course, assuming here that the sugar pill didn't lower the blood pressure of the control group). 

There are statistical tools to determine whether the difference between the groups may just be a chance event, or whether chance is a very unlikely explanation. We can never rule out chance completely. Now, when we are confident that it is the drug and not pure chance, which has lowered the mean blood pressure in the intervention group, we write our paper to present it in one of the medical journals. 

If the subject is a little more sexy, than just lowering blood pressure, there will sure be some journalists who pick it up and report to their readers that, say, eating chocolate makes you slimmer. I'm not kidding. This headline very conveniently went through the media shortly before Easter this year [1]. Good for Hershey who are running it of course on their webpage. And in the media it reads like it did in the Irish Times: "Good news for chocoholics this Easter. Medical Matters: No need for guilt over all those Easter eggs."    

I'm not going to comment on the media geniuses, because it's their job to put an angle on every story, so that YOU find it interesting and read their stuff. But since I'm sure you'll follow these links, just let me warn you: the chocolate study was an observational study, not an RCT. And one thing we MUST NOT do with the results of observational studies is to confuse association with causation. Only when we conduct an RCT, where the intervention group eats chocolate and the control group doesn't, might we be able to determine whether there is a causal link. And for obvious reasons we can't blind the subjects, to whether they eat chocolate or not. But I'm digressing.

Back to our blood pressure study. When we compare the group averages, everything looks very convincing. And sure enough, as researchers we are happy with the results, and we are perfectly correct, when we conclude, that this medicine does its job. 

But will it do it for you? When you are hypertensive? You might be wrong if you say "Yes". And you will be wrong more often than we, as researchers, or your doctors care to admit. For one simple reason: The variability of effect within the group. You give 50 people the same drug, and I bet with you, and I'm not the betting type, that you'll have 50 different results. 

The mean value of the entire group glosses over these inter-individual differences. Let me give you an example from a study performed on 35 overweight men, who were studied in a supervised and carefully calculated 12-weeks exercise program, with the intention of reducing body weight. The mean weight loss was 3.7 kg. That was almost exactly the amount of weight loss which the researchers had expected from the additional energy expenditure of the exercise program. But when they looked at each individual, it became clear that the group mean doesn't tell you anything about how YOU would fare in that program. 

First of all, the standard deviation was 3.6 kg. Now, a standard deviation of 3.6 kg simply tells you that approximately two thirds of the participants experienced a weight loss anywhere between 3,7 kg (the mean) minus 3.6 kg and 3.7kg + 3.6 kg, that is between 0.1 kg and 7.3 kg! That's a lot of kilos. And what about the remaining one third of those participants? They are even further from these values. In this case the greatest loser went down by 14 kg, and the biggest "winner" gained almost 2 kg. A spread of 16 kilos!

Here is the graph which shows you the change on body weight and fat for each individual participant. Which one would you be?

This effect is what you do not see when you don't read the studies. And in most studies, it isn't made obvious either. 

Which is why, you shouldn't be surprised to learn that most major drugs are effective only in 25-60% of their users [2]. The same goes for weight loss drugs and interventions, for almost everything we study in biomedicine. 

That's not a problem for us in public health. Because a drug, which works in 60% of the patients, helps us reduce the burden of disease in our population. Public health is not interested whether you are one of the 60% or not. But you are. And that's why I believe not only medicine, but also prevention must be individualized.

 Which is why the GPS to chronic health, which I currently develop, is all about helping you find your individual path to your health objectives.

Why not have a look at it, and maybe even try it out? 

References

1.           Golomb, B.A., S. Koperski, and H.L. White, Association Between More Frequent Chocolate Consumption and Lower Body Mass Index. Archives of Internal Medicine, 2012. 172(6): p. 519-521.

2.           Wilkinson, G.R., Drug Metabolism and Variability among Patients in Drug Response. N Engl J Med, 2005. 352(21): p. 2211-2221.

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Are fat people just lazy?

Are fat people just lazy? Or is it in their genes?

Let's look at an unlikely place for the answer: an AA meeting. If you get up and say "My name is Jane, and I'm not really an alcoholic, I don't drink that much..." they throw you out. They welcome you back, once you say "My name is Jane and I'm an alcoholic". The same should be true for fat people. And I'm using this politically incorrect term deliberately. Because unless you wake up to the reality, you won't be able to change that reality.

 AA have long ago realized that fact. And they have a 50% long-term success rate. That is, half the alcoholics who join AA stay dry for the rest of their lives. That's way more than what public health, clinical and commercial weight loss programs achieve with obese participants. We are happy if 10% of those who enter these programs achieve a 10% weight loss AND keep it for more than 2 years. It's that bad. Is it because of the genes? A study published recently in Nature Genetics, might supply another excuse to some overweight people. But before we look at this study, let's look at some other facts first.

One thing we all know for sure: if you are overweight, you obviously have taken in more calories than you have expended. Over quite some time, because it takes a while to accumulate all those energy reserves on your waist and hips. Boils down to one of the tenets of a universal law of physics that says: Energy can neither be destroyed nor miraculously created. Not even on your hips.

Now I know all the objections raised by so many overweight people, like "But, I hardly eat anything. How can I be fat? Even my friends say, from what you eat nobody can get fat." Believe me, I've heard them all.  And my heart sinks, when I do, because I know there goes the hopeless case. The Jane who goes to AA and tells them she is different. The study published in Nature Genetics might just deliver her the next excuse. Not because the researchers tell her so, but because some media genius might just read it the wrong way. As they often do. So, let's look a what the researchers say.

The researchers conducted a meta-analysis of some 14 genome wide association studies involving altogether 14,000 children, one third of which were obese. They found 7 genetic markers which correlated with obesity and which also turned out to correlate with obesity in adults. The beauty of looking at genetics in kids is, that they haven't been exposed to decades of lifestyles which may obscure such links. 

So, the results clearly point into the direction of some genetic signature predisposing a person to become obese. But having this signature doesn't mean you'll inevitably become obese. Because most kids who have the signature are not obese. It's only that this signature shows up a little more often in the obese kids than in their non-obese peers.  And there is one more thing, you need to keep in mind. Over the past 20 years the human genetic make-up hasn't changed at all. But the obesity rate in US kids has. In fact it has tripled during that period. And health behavior has changed, too. And so did our environment.

What makes me always frustrated in all this debate about genes vs. environment vs. behavior is my scientist colleagues' and the media's inability to educate their audience about the complete picture. Genes make up the blueprint to your organism. True. But they don't make that organism. Genes make proteins, but whether they make them or whether they are silenced into not making them, that depends on epigenetics, on the interaction with your environment, and on your behavior, which again is influenced by all the others. It is a very complex relationship, and I'm afraid, genetics will not help us, to solve the obesity epidemic. But neither will the stigmatization of the obese. 

What we need, is a way to help those who recognize their fatness as a resolvable reality, resolve it. That's why I'm working on the GPS tochronic health, because I know that once the health behaviors put you on track to chronic health and longevity, your overweight problem will resolve automatically. As a side effect. But only if the obese person works with us. 

So did that answer the question? You decide for yourself.    PrintPDF

How to get to chronic health. With three steps into the age of chronic health and longevity.

Into the age of chronic health.

My yesterday's post was all about what's holding us back from achieving chronic health for everybody. Today I want to look at the three important steps we can do right now to enter the age of chronic health and longevity. 

Incentivize health! 

Earlier this year Standard & Poor's told the G20 economies:  Get prevention to work or we will downgrade your triple A rating by latest 2018. Because your economies won't be able to deal with the costs for treating your sick, demented and frail population. Of course Standard & Poor's phrased it more politely but the message was all the same.  Why is that so important? Because it's the first step to making everybody realize that your chronic health is not just this often proclaimed "higher good", it is an economic asset. It makes you more productive for your employer, and less costly for your health and life insurer. Once your health shows up in the shareholder value universe, employers have an incentive to invest into it. And they have an incentive to share with you in the form of a health dividend. The keyword here is incentive. The lack of it is what ails our current health care strategies. Because until now we have failed to incentivize people's prevention efforts. Think about it: Whether it's status or money or anything else that turns your neighbors green with envy, the driving force behind all human endeavors is the prospect of incentives. It's hardwired into our brains. It's why everybody's efforts to achieve chronic health needs incentives, too. As we have seen, the prospect of being healthy in a distant future can't beat the siren call of a humble tiramisu, or of the drag on a cigarette, or of staying on the sofa instead of jogging through the Park. So, if the phenomenon of hyperbolic discounting has taught us anything, it is the need for incentives with which to beat those that lure us into unhealthy behaviors.

What holds our companies and insurers back from incentivizing health big time? Certainly it is not unwillingness, and rarely is it uncertainty about the size of the returns on investment. It is rather the lack of a tool with which to direct incentives to where they are deserved and to withhold them from where they are not. A tool which helps you to express, in objectively measurable terms, not only your health but also your efforts and achievements of preserving it. We are currently testing the first prototype of such a tool. We started to develop it with this and two more goals in mind. The first is to help you to...  

Outfox your brain!

As you have learned above, the evolutionary ape in us is well protected against any interference of free will and reason, the two things that make us human. But whether human or ape, we all have the ability to develop a 6th sense for mastering any skill which improves our chance of survival, makes our life easier or more enjoyable. In your case, think swimming, think cycling, think keeping your in-laws out of your hair. So we thought, how about a 6th sense for your daily calorie balance? We thought, if you knew it intuitively, at any moment, and before it shows on your bathroom scale, you would effectively know your metabolic state. With that knowledge you will be able to correct and to keep that balance always in line with your weight targets. This intuitive knowledge does not eliminate the craving for the tiramisu. But it enables you to recognize the need for taking some compensatory measure and to select the appropriate size of that measure.  This idea was borne out of the results of a new web-assisted intervention which we developed and tested in Germany with the aim to institute lasting behavior change in adults at elevated risk for chronic disease. Once the participants of our clinical trial showed signs of mastering this 6th sense, they also started to drop their dress sizes. And they still keep those dress sizes down.

Now, I can hear your question: Even if, say, my employer pays me a monthly or quarterly health dividend, in the form of money or annual leave or whatever floats my boat, how can you be so sure that my new lifestyle of eating right and exercising right will bring me chronic health and longevity? Which brings me to the last point. 

Take Biomedicine's most powerful tools!

Let's just look at how your chances play out. If, at age 45, you are free of any risk factors, you stand a 97% chance of making it through to your 80th birthday in good health. If, however, you already have 2 risk factors, such as hypertension and elevated blood sugar, for example, those chances shrink to a mere fifty-fifty. And even if you are among the lucky half, who will see those 80 candles on their cakes, chances are that you won't blow them out under your own steam. Because one of those nasty chronic diseases will have taken that last piece of strength and dignity away from you. The good news is that simple health behaviors - physical activity, dietary and smoking behaviors - determine which version of the party, if any, will apply to you. In fact, biomedicine currently knows no intervention which prevents disease and promotes longevity better than physical activity and dietary behaviors. There is one caveat, though: these simple behaviors need to be tailored to your individual health profile, which also means to your genotype AND your phenotype. 

Which is why my colleagues and I are building an intervention matching feature into the tool I mentioned earlier. It will give you the means to match your individual health and risk profile with the physical activity and dietary strategies most suitable for your profile. We call this tool the GPS to chronic health and longevity. It takes its coordinates on the landscape of health from your vital functions and keeps you right on track towards your health goals.

It is the engine which we hope will give you the power of mapping and following your personal path into the age of chronic health and longevity. After all, nobody deserves the indignity of a stroke or a heart attack and the disabilities that come as a consequence. 

I firmly believe we are only a tiny step away from the age of chronic health and longevity. To that tiny step you can contribute.  Just visit me at indiegogo until 31st of May. 

I'm looking forward to meeting you there. 

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The three hidden barriers to chronic health, weight loss and weight maintenance.

Into The Age of Chronic Health

The most amazing thing about modern health care systems is that they let most of us die from chronic diseases which we know how to prevent. So why don't we?

As a public health scientist I have devoted the past 15 years of my life to answering this question. Many of my colleagues outdo each other with doom and gloom predictions of aging societies buckling under the economic burden of aging related diseases. I believe that the age of chronic health and longevity is about to begin. With you. And with a radically new approach to make the prevention of heart attacks, strokes diabetes and cancers finally work.     

Because, until now, it doesn't. But don't just take my word for it, let's look at some of the facts first:

You have probably heard that obesity is the new smoking. In fact for every American who stopped smoking in 2011 another one became obese.   

Today, for the first time in human history there are more overfed than malnourished people walking this planet. And their lifestyles of too much food and too little exercise have become the number one risk factor for the number one chronic disease and killer: cardiovascular disease with its most well-known end points - heart attack, stroke and heart failure. With nasty other diseases on the side: diabetes, kidney failure and certain cancers.

You probably also heard about major studies, like the U.S. government funded Diabetes Prevention Program, and the Look AHEAD trial, which proudly, and correctly, report weight loss and major reductions in cardiovascular risk factors among participants in the lifestyle arms of these trials. What you don't hear so often, is that within 3-4 years after enrollment, most participants will have regained not only most of their weight but also all their risk factors.

Ok then, lifestyle change prevents disease. But what prevents lifestyle change?

Why is it that over the last 30 years of public health efforts we have not seen a demonstration of any program that results in a clinically meaningful weight loss that can be maintained for more than 2-3 years in the majority of participants and at low cost?  That's the question which Dr. Richard Khan threw at an assembly of public health advocates, who had gathered earlier this year under the event's message "Prevention works!".  Dr. Khan, who teaches medicine at the University of North Carolina, was the chief scientific officer of the American Diabetes Association for 25 years. The man certainly knows what he is talking about. 

Now think about the implication. If you chose a lifestyle of which you know might increase risk of disease and premature death, then you make that choice either willingly or it is not your free will which makes that choice.

My money is on the latter. Because how else could we explain that an obese child maintains her fattening habits despite experiencing the same psychological agony as a child with cancer? How else could we explain that obese adults maintain their bulk when it significantly reduces their chances of getting an academic education, a job and a mate? How else could we explain that over the past 20 years the obesity rate in the US went up by 60% when, during the same period, Americans doubled their spending on weight loss products to US$ 60 billion annually? They WANT to lose weight, but they don't. The explanations are called addiction, hormones and hyperbole.  

Food addiction

The neurohormonal architecture which drives an addict to crave and consume his drug, despite knowing and hating the consequences, is exactly the same architecture that keeps us going for the sweet, fatty and salty stuff in restaurants, hawker centers and vending machines. Does that explain, why the food industry adds sugars to so many foods in which you least expect it? You bet. In fact we shouldn't be afraid of calling ourselves food addicts, because this is what Mother Nature intended us to be all along. With this addiction she drove our ancestors for millions of years to what is naturally sweet in the natural human habitat: fruits. They deliver not only the carbohydrates for which we have very little storage capacity in our bodies and without which our brain can't function. Fruits also pack a punch of essential micronutrients. Unlike the cokes and cakes and cookies which deliver more sugar than we need and no other nutrients with it.  

Hormones

Once you have changed your figure into the shape of a beached whale, you will also have changed the way the hormones of your gut and of your fat tissue work. It's a rather complicated picture unfolding in the labs of biomedicine, but one emerging theme is a colossal malfunction of the satiety and appetite signaling pathways. Instead of feeling full, you are now ready to add a tiramisu to a lunch that would have satiated a family of four in rural Bangladesh.

Hyperbole

Actually it's called hyperbolic discounting, and it's a simple mathematical formula, which behavioral scientists have found to neatly describe why we will still grab that tiramisu tomorrow even though we swear today that we won't. It has to do with how we more steeply discount the relatively larger but more distant reward of staying healthy against the relatively smaller but immediate reward of enjoying the tiramisu. It doesn't operate only in humans. The behaviors of rats, pigeons and apes, for example, follow the same formula. Which means, Mother Nature must have found out early during evolution that this principle is a recipe for survival in her species. We simply inherited this survival tool.   

With all these issues stacked in favor of an ever expanding population of chronically ill people, why do I believe that we might be close to the age of chronic health and longevity? For three reasons: Because Wall Street is getting into the act, because we can outfox our brain, and because biomedical science has got the tools ready.

How we will enter the age of chronic health is the subject of the next episode, so stay tuned!

In the meantime, visit my crowd funding campaign, watch the videos, recommend the campaign to your friends and, if you like what you see, participate in our chronic health project: www.indiegogo.com/adiphea

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How to admire obese people? The Token Fat Girl

Yesterday, on a whim, I started searching the web for sites where obese people present themselves and how they deal with obesity. My expectation was:  I won't find much. Boy was I wrong. In fact I was so wrong, that I decided to discuss some of the outstanding people whose sites I have seen. Before I get to The Token Fat Girl, let me explain why I didn't expect to find what I found:

There is a stigma attached to being overweight. Interpersonal and work related discrimination against overweight people pervades our society [1]. Whether it's finding a sex partner or a salary, if you are female and have a BMI north of 30, your weight alone reduces your chances compared with a peer of normal weight. And don't think for a moment that my colleagues from the health and medical sciences are free from such bias. One in 4 nurses reports being repulsed by obese patients [2], and exercise science students show a strong bias against obese people, equating obesity with laziness [3]. The frequently used before-after portraits of successful weight reducers have been found to reinforce the belief that weight loss is a matter of volition, which in turn reinforces the stigmatization of the overweight [4]. This bias has become so pervasive in our society that even obese people themselves now endorse the fat=lazy equation [5]. Uncharacteristically for my otherwise more colloquial blog I include here the references to my statements. For one simple reason: To take the wind out of the sails of those who would otherwise eloquently try to summarily refute my statements.  

Now, what's my point? With this type of agony load, wouldn't we rightly expect the obese person to simply change her lifestyle if this change was really up to her free will - her volition - to make? Yes we would. The fact that most obese people really WANT to be slim but never seem to get there should, however, make us question the power of free will over our health behaviors, particularly the dietary and exercise behaviors. Let me illustrate that point a little more.

If the volition-behavior assumption was true, children would change their fattening behaviors once the agony load from being obese crosses a threshold at which they would be motivated to actively pursue weight loss. This agony load is indeed high for the obese child. In fact it has been found to be equal to that of child cancer patients receiving chemo therapy [6]. Yet the percentage of obese children and adolescents has more than tripled over the past 40 years.

So my question to the stigmatizers, to those who believe in the fat=lazy equation, is: if obesity was a result of behavior, and if health behavior is a matter of choice, then why do children and adults choose to be ostracized, stigmatized and victimized?

Obviously our health behaviors are driven by something more powerful than volition alone. I will address this issue in a separate blog entry.

What I want to highlight here is the extraordinary guts of people like The Token Fat Girl, who proudly present themselves and address their weight openly and publicly. Not only is her courage admirable, but so is the frankness with which she approaches her life. I quote from her site: " I've struggled with being overweight or obese my entire life and while I don't agree that I can be obese and healthy, I do believe that it shouldn't stop me from living a pretty decent life." Here is a girl with an admirable sense of reality. A girl with that attitude would certainly solve her weight issues if those were solvable by volition only. 

This issue is at the core of my work. I have a pretty clear model about what drives our health behaviors. That model was part of my dissertation work. I also believe that our strategy of helping people to train a 6th sense for their daily calorie balance is a promising alternative to diets and weight loss fads. I would love to enroll people like the Token Fat Girl into our chronic health project. So if you know somebody who fits this description, give them my contact.  

   

1.           Carr, D. and M.A. Friedman, Is obesity stigmatizing? Body weight, perceived discrimination, and psychological well-being in the United States. J Health Soc Behav, 2005. 46(3): p. 244-59.

2.           Puhl, R. and K.D. Brownell, Bias, Discrimination, and Obesity. Obesity Res, 2001. 9(12): p. 788-805.

3.           Chambliss, H.O., C.E. Finley, and S.N. Blair, Attitudes toward obese individuals among exercise science students. Med Sci Sports Exerc, 2004. 36(3): p. 468-74.

4.           Geier, A.B., M.B. Schwartz, and K.D. Brownell, "Before and after" diet advertisements escalate weight stigma. Eat Weight Disord, 2003. 8(4): p. 282-8.

5.           Wang, S.S., K.D. Brownell, and T.A. Wadden, The influence of the stigma of obesity on overweight individuals. Int J Obes Relat Metab Disord, 2004. 28(10): p. 1333-7.

6.           Schwimmer, J.B., T.M. Burwinkle, and J.W. Varni, Health-Related Quality of Life of Severely Obese Children and Adolescents. JAMA, 2003. 289(14): p. 1813-1819.

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What weight loss?
You have probably heard one or the other diet guru claiming that manipulating the nutrient composition of your diet will make you lose weight. Well, for those of you, who stubbornly cling to the notion that excess weight is simply a matter of too many calories-in vs. too few calories-out, here is the good news: You are right, after all. It really doesn't matter.
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