Archive for the ‘Research and Health’ Category
Yesterday I was fortunate enough to land a featured op-ed in the New York Times about precision medicine in specific and the general topic of moonshots in medicine like the war on cancer. For those interested in learning more about these topics here is link to a classic paper by Comroe and Dripps on medical innovation and goal directed progress via “big science” vs. blind luck and marginal gains leading to progress. On a related note Bill Gates recently reviewed the 10 year results of his billion dollars of spending to improve health in the developing world. His conclusion was that not much had changed……
The graphic below is about the hype cycle. The question is always when and how long does it take to hit the plateau of productivity and just how high is it compared to the original expectations.
Over the Holidays I bumped into a colleague who told me about her 95 year old father (a retired pharmacist) who is still physically active and living independently. He walks two miles per day, and plays golf (he shot his age at 91, but is now “only” doing 9 holes). He is also active in his church and community. The other interesting thing is that “Dad” had a hard time retiring and for many years pinch hit in pharmacies in the upper Midwest that were short staffed. My colleague also mentioned in follow-up e-mails that her Dad lost his mother in childbirth, was a WW2 veteran who got off the farm and into the pharmacy via the GI Bill, and he also quit smoking back in the 1960s.
Did He “Know” Lester Breslow?
The graphic below is one I use in talks on healthy aging and “who makes it to 90”. It highlights the key principles on this topic that were discovered by the pioneering epidemiologist Lester Breslow. When I heard the story of my colleague’s father what Breslow discovered certainly seems to ring true for “Dad”.
Circumstances & How You Respond
The other thing that hit me about “Dad” in specific and that also seems to apply to many healthy agers is how resolute and resilient they have been over the years. Somehow they all seem to understand — or maybe have learned — that you can’t always control the circumstances you find yourself in but you can control how you respond. At some level this may be a learnable life skill and the Holocaust survivor and famed psychiatrist Viktor Frankl felt that resilience can be learned. He noted:
“Forces beyond your control can take away everything you possess except one thing, your freedom to choose how you will respond to the situation.”
Please Share Your Story
I personally find stories like the one above to be incredibly interesting and inspiring. If you have one, please share it in the comments section and in a future post I will highlight the key messages and insights.
Thanks and remember the words of John Wooden:
“Do not permit what you cannot do interfere with what you can do.”
Who can think about New Year’s without thinking about drinking. The chart below is about 15 years old but still considered accurate and shows the relationship between drinking and the risk of cardiovascular disease. It shows that moderate alcohol consumption (essentially 1-2 standard drinks per day) is generally protective.
While moderate drinking is generally good for you, it is important to remember that binge drinking (4 drinks for women 5 for men) is bad news, and it is common.
The highlights of the bad news according to the CDC include:
- Motor vehicle crashes. Every day, 32 people in the United States die in motor vehicle crashes that involve an alcohol-impaired driver.
- Intimate partner violence. About 2 of 3 incidents of intimate partner violence are associated with alcohol.
- Risky sexual behaviors. Excessive drinking increases risky sexual behaviors, including unprotected sex and sex with multiple partners, which can result in HIV infection, other sexually transmitted diseases, and unplanned pregnancy.
- Fetal alcohol spectrum disorders. Any alcohol use by a pregnant woman can cause harm to a developing fetus, resulting in physical, behavioral, and learning problems later in life.
- Chronic conditions. Over time, excessive drinking can lead to alcohol dependence, liver disease, high blood pressure, heart attack, stroke, and certain kinds of cancer.
The data above and resources in the links speak for themselves. Enjoy New Year’s and every other social occasion that includes alcohol but remember that alcohol is perhaps the most dangerous drug and needs to be used judiciously.
A couple of weeks ago I floated the idea that for many problems facing the world a sort of collective grieving process is going on. In this post I want to pick up on that theme again as it applies to obesity. In general, for obesity I believe we have mostly moved beyond denial and are now “bargaining” about what to do about obesity both as individuals and society as a whole.
Costs of Obesity
Last week the big consulting firm McKinsey released a report on the global costs and consequences of obesity and what to do about it. Incredibly the report put the global costs of obesity at about 2 trillion dollars per year. This is about equal to the global costs of smoking and also the global costs of “armed violence, war and terrorism”. The report concluded that no single action is likely to solve the problem but that a range of policy options might work. The chart below is an example of what various anti-obesity interventions might do to obesity related years of life lost in Britain. My guess is that similar calculations would also apply to the U.S. and most countries where obesity is a serious problem. Of note I see at least three things missing from this chart:
- Taxes on high calorie foods or sugar sweetened beverages
- Higher insurance premiums for obese individuals
- Re-engineering the built environment
Denial Not Gone
At the same time the McKinsey report was coming out, the U.S. CDC was being pressured to take down a website called “lean works” that included an obesity “cost calculator”. The concern was that such a tool might lead to workplace discrimination against obese individuals. So, perhaps denial that obesity is a problem and that something needs to be done about it is not totally gone.
Who Stays Lean?
Last month I was giving a talk in Denmark about what to do about physical inactivity and obesity. The talk was to a group of health care professionals who were uniformly lean and fit. Being Danes, many ride their bikes to work. So, at some level I was preaching to the converted. What occurred to me as well during the talk was that I was also talking to a group of highly educated people who all had a suite of behavioral characteristics that let them control their current behavior to prevent a future undesired outcome. In other words these people all had a sense of delayed gratification and conscientiousness. These traits likely permitted them to adopt and adhere to “healthy” lifestyles and remain lean in an obesogenic world. From what I can tell only a modest fraction of the population has a high level of these behavioral traits and skills. So what do we do in a world where so many people have so much trouble with what might be described as “self-control” and personal responsibility?
Beyond Personal Responsibility?
This brings me to the built environment and other big picture interventions to address the obesity and inactivity problem. The next chart shows how the battle against infectious disease was largely “won”. A lot of this had to do with things like sewers and clean water supplies. In other words, basic sanitation and civil engineering vs. medical care or medical interventions made a big difference.
When big, dirty and disease ridden cities were being re-engineered and rebuilt in the 1800s and early 1900s, no one was telling the general public that clean water was their “personal responsibility”. Instead slums were cleared and sewers and water works were built and things like cholera epidemics stopped. That having been said, I wonder how many people in today’s world would consistently boil their own water over days, months, and years in the absence of reliable clean water supplies. My guess is that over time only the most conscientious people would do it. At some level our current world is just as toxic and maybe larger scale interventions are needed.
Going Far Enough?
I applaud the McKinsey report, but does it go far enough? My guess is that many of the food policy recommendations will likely work if they can ever be implemented in a comprehensive way. However, I also have serious doubts about whether that can be done. I also believe (as cigarette taxes have shown) that humans are price sensitive and that economic tools have to be part of the solution to the obesity problem. There also probably needs to be a serious discussion about how car “unfriendly” the world needs to be if we really want to make a dent in the inactivity element of the obesity epidemic. It is hard to imagine that our physical world might be redesigned in a way similar to what happened in cities 150 years ago, but perhaps it will happen. There are innovative proposals on the table in London to promote more bikes and fewer cars.
None of this will be easy, but the partial success of the anti-smoking movement in some countries shows that over time it is possible to change bad societal habits, but it takes more than simple personal responsibility. So let the bargaining begin!
A few weeks ago I did a post that included 8 charts on how the U.S. got so obese.
Below is a chart I missed from a paper published in early July. This study argues that less physical activity and not more calories is the primary cause of the obesity epidemic in the U.S. The black lines show the number of people who self-reported no leisure time physical activity in 2009-2010. The blue lines are the historical data from about 20 years ago. Twenty years ago about 19 percent of women and 11 percent of men got no leisure time physical activity. The more recent data shows that about 51% or women and about 44% of men get no leisure time physical activity. In essentially every demographic group there has been a 2-4 fold increase in inactivity over the last 20 years.
So do we have an obesity epidemic or an inactivity epidemic?
You hear a lot of yapping about how the USA got so fat as a nation. All sorts of people want some simple reason for rise in obesity. That having been said, in the next eight charts I want to tell you a little bit about “what we know for sure” and see if I can paint a more complete picture of how this happened.
1. Obesity takes off in the late 70s.
The light grey bottom band on this chart from the NIH shows that the fraction of overweight American adults has been pretty constant at about 35% for years. The darker middle band shows that starting in the late 1970s the number of people who are obese has gone from about 10% to about 30%. The top band is the number of people with extreme obesity and it has gone from about 1% to about 6%!
2. Sugar consumption takes off in the early 1980s.
Chart 2 shows that sugar consumption per person has increased from just over 80 pounds per year in 1980 to about 100 pounds per year or more over the last 20 years. Where we get this sugar from has changed too. Sucrose (table sugar) consumption has gone down and High Fructose Corn Sweetener (HFCS) has gone from essentially zero in 1970 to more than 40 pounds per year. This has led some people to label HFCS as the bogyman responsible for “all of this obesity”. A far bigger problem is probably just total sugar consumption.
3. Cheese consumption has also skyrocketed.
Total cheese consumption as shown in chart 3 has also gone way up over the last 40 years. I am not sure what this means but just like sugar it is possible to construct a scenario where cheese is the culprit and “cause” of the obesity epidemic. A more plausible explanation is that the sugar and cheese consumption trends show what happens when agriculture policy is designed to generate a lot of tasty high calorie commodities that can then be turned into highly processed and convenient and low cost things to eat.
4. Cheap Food?
Chart 4 shows that the average person only spends about 10% of their disposable income on food. That is way down since 1930. The world does not get fat overnight or in just a year or two and the fact that spending on food went down so much in the 1950s and 60s might have set us up for the explosion of obesity that started in the late 70s. As I pointed out in the explanation of chart 3, this is another example of agriculture and food policy contributing to the problem.
5. Eating Out?
Perhaps another result of “cheap food” ag policy and other changes in society like more mom’s working, people staying single longer, smaller families, and relentless marketing is that we eat far fewer meals at home than we used to as shown in chart 5. The people who sell us this food know how to pack the calories in and pack them in a way that keeps us coming back for more. The average person also typically underestimates the calorie content of the fast food they eat which amplifies the cheap food problem.
6. Screen time.
Chart 6 speaks for itself and is emblematic of the massive increase in screen time that we have all experienced since about 1980. Sitting in front of a screen can’t be good for your waistline.
7. Occupational physical activity is way down.
Many people used to work at jobs that required either some or a lot of manual labor. Almost no one doses now, even the mailmen drive. Chart 7 shows that occupational physical activity is down by more than 100 calories per day for both men and women. This coupled with the fact that a lot of people get minimal or no recreational physical activity or exercise is another major problem. Some people have argued that the decline in occupational physical activity might explain most or the entire obesity epidemic.
8. Smoking is down.
Smoking has also declined over the last 40 years and smokers tend to weigh less than non-smokers. So, one unintended consequence of the welcome reduction in smoking rates might be more obesity. This is a trade that most public health experts would gladly make except perhaps from people with extreme obesity. Just like sugar and/or cheese consumption, occupational physical activity, and screen time you can argue that less smoking “is responsible” for the obesity epidemic. But as I have tried to emphasize throughout this post, the cause is likely a combination of what we eat and less physical activity and not any “one thing”.
The eight charts above are a sample of the many things that have likely contributed to the obesity epidemic. Thus, it is unlely there is any one explanation for the obesity epidemic and be suspicious of anyone who says there is. The charts also show that a multipronged approach will be required to turn the problem around. Changing food and agriculture policy and what we put in our collective mouths will be one part of any solution. Figuring out ways to get more of the population to build more physcial activity into their day will be the second part.
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