Seven Tips for Healthy 2012 Planning

As we welcome a new year it is an opportunity to re-evaluate, consider the coming year and make intentions for improving our health and sense of well being.  EverythingHealth sifts through the latest medical literature and evidence to offer these proven recommendations for staying on top of your game.

If you are 50 or older and haven't had a colonoscopy, schedule one in 2012.  It's time! 

Top EverythingHealth Books of 2011

We at EverythingHealth love end of the year lists and we love reading.  Here is our pick for the best read Health (and everything)  books in 2011.  (not in order...all are terrific)

The Immortal Life of Henrietta Lacks, by Rebecca Skloot
Cutting For Stone,  by Abraham Verghese
Outliers,  by Malcolm Gladwell
The Help,  by Katheryn Stockett
The Checklist Manifesto,  by Atul Gawande
Middlesex, 

Answer to Medical Challenge

The answer to the CT scan image medical challenge is #3, Intercostal Muscle Rupture.

The image shows subcutaneous emphysema and an intercostal muscle defect between the ribs.  the patient recovered after repair of the intercostal hernia.  Subcutaneous emphysema is air under the surface of the skin. 



It is not unusual for these muscles between the ribcage to be strained or even get small

Medical Challenge

For my non medical readers, this is an abnormal CT scan.  The CT scan takes a transverse image sliced through, so you are looking at the patient sliced in half transversely.  This is the chest area. I will orient you:

The whitish circle and v-shaped part is the vertebral column.  So you know that is the back.   Bone shows up whiter than organs.  The small whitish lines in a circle are the

High Ratings for Personal Physicians

It's time for some good news!   A study that looked at online patient ratings  about their physicians from 2004 through 2010 showed that the average physician rating was 9.3 out of 10.  That is amazingly high and shows that patients (at least the ones who posted on Dr.Score) are very content with the care they receive from their doctor.  Even though some patients will post a nasty comment

Holiday Dinner from the Boss

Marney is bossy.  Click to read her instructions for the Thanksgiving Potluck and be glad you aren't invited.

EverythingHealth tip:  Stay out of the stores today.  Rest, play games with the kids, Take a long walk in nature with the entire family and the dog and then drink the rest of the Christmas wine.

Happy Holidays EverythingHealth

I get a lot of pleasure out of being a health blogger and it is only possible because of you, the reader.  Thank you for visiting EverythingHealth and allowing me to keep my mind sharp by researching articles and healthy living for you to read and enjoy.



Merry Christmas, Happy Hanukkah, Happy Holidays, and may we all have a wonderful 2012, no matter where we live on Earth. 

Kwashiorkor in Northern California Means Fraud

Kwashiorkor in Niger

Is it plausible that one small hospital in rural Northern California treated 1,030 cases of Kwashiorkor within a two year period?

Before you answer that, let me explain what Kwashiorkor is.  It is a severe form of protein malnutrition...starving to death actually.  It is the type of starvation you see in African children.  It is so severe that the patient needs

Strange Compulsion

Pica is a medical term that refers to people who eat substances that are not nutritious like clay, dirt, paper or starch.  Lithophagia is the eating of rocks or pebbles.  The Xray above is from a 48 year old homeless man who came to the emergency department with abdominal pain, constipation and intermittent blood in his stool for 2 weeks.  The abdominal Xray showed small radio-opaque pebbles

A Sign of the Times

Every now and then, I venture out to go shopping at mainstream chain clothing stores.  Although I find it onerous, there are certain things I can't get at thrift stores.  For example, I can never find nice jeans.

The last time I set foot in these stores was about two years ago.  It was tough to find pants my size at that time-- many stores simply didn't sell pants with a 30 inch waist.  This year, it was even harder, since some of the stores that formerly carried 30W pants no longer did.  I managed to find my usual 30W 30L size in two stores, but I had a bizarre experience in both cases.   I put them on, and they were falling off my waist.  Since my waist size hasn't changed in two years, and my old 30W 30L pants of the same brand still fit the same as they did when I bought them two years ago, I have to conclude that both stores have changed their definition of "30 inches".  My new size is 28W 30L, which is tough to find these days.
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Osteoarthritis

Severe osteoarthritis of the hands
One of my patients came to see me today with severe right knee pain.  This is not a new problem, and in fact, we have been dealing with flare ups of  her osteoarthritis for years.  It mainly affects her knees and hands and today her right knee was swollen and felt like the "bone was rubbing together" with each step. She could hardly walk because of the pain.

Affordable Health Care Act Provides Senior Benefits

While the courts and politicians wrangle about the Affordable Care Act (ACA, "Obamacare"), some of the benefits have kicked in for Medicare beneficiaries.  The Act empowered the Center for Medicare and Medicaid Services (CMS) to eliminate co-payments for a number of preventative services and to cover services that were not included before.  Patients on Medicare now receive:
Bone mass measurements

Women Don't Need As Many Pap Tests

Women have been told they should have screening for cervical cancer with a pap test every year.  The visit to the gynecologist or internal medicine physician has been a right of passage for most young women and most are very compliant with that annual visit throughout their lives.

Well, the times they are a-changin' because new guidelines issued by the US Preventative Services Task Force and the

60 Minutes Report on the Flavorist Industry

A reader sent me a link to a recent CBS documentary titled "Tweaking Tastes and Creating Cravings", reported by Morley Safer.

Safer describes the "flavorist" industry, entirely dedicated to crafting irresistible odors for the purpose of selling processed and restaurant food.  They focused on the company Givaudin.  Dr. David Kessler, author of The End of Overeating, makes an appearance near the end.

Here are a few notable quotes:

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Fingernails

Let's see how much you know about fingernails?  The arrow points to what part of the fingernail?
1.  Lunula
2.  Eponychium
3.  Cuticle
4.  Nail groove
5.  Proximal nailfold

If you answered #1, you would be correct.  The lunula is most noticeable on the thumb.



Did you know that nails on your dominant hand grow faster than nails on the nondominant hand?  As you age, nails are usually thicker

Unhealthy Food at Childrens Hospitals

A study published in the journal Academic Pediatrics reveals that 93% of California children's hospitals offered unhealthy food to outpatients, visitors and staff in the cafeteria and snack bars.  Said another way, only 7% offered healthy food.  What did these foods consist of to be called "unhealthy"?  Try fried food, sweetened beverages, burgers and lots of sugary sweets.

The study found that

Don Berwick Says Medicare is Wasteful

I was thrilled when Dr. Don Berwick took over as head of the Center for Medicare and Medicaid Services (CMS).  It was a politically charged appointment and the GOP wasn't standing for his type of medicine.  He would have never been confirmed and now he is saying goodbye to Washington.  Dr. Berwick admits Government is more complex than he realized and said "Government decisions result from the

New Review Papers on Food Reward

As research on the role of reward/palatability in obesity continues to accelerate, interesting new papers are appearing weekly.  Here is a roundup of review papers I've encountered in the last three months.  These range from somewhat technical to very technical, but I think they should be mostly accessible to people with a background in the biological sciences. 

Food and Drug Reward: Overlapping Circuits in Human Obesity and Addiction
Written by Dr. Nora D. Volkow and colleagues.  This paper describes the similarities between the mechanisms of obesity and addiction, with a focus on human brain imaging studies.  Most researchers don't think obesity is an addiction per se, but the mechanisms (e.g., brain areas important for reward) do seem to overlap considerably.  This paper is well composed and got a lot of media attention.  Dr. Volkow is the director of the National Institute on Drug Abuse, a branch of the National Institutes of Health.  The NIH is the main source of biomedical research funding in the US, and also conducts its own research.

Here's a quote from the paper:

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Another Simple Food Weight Loss Experience

Whole Health Source reader Sarah Pugh recently went on a six-week simple food (low reward) diet to test its effectiveness as a weight loss strategy, and she was kind enough to describe her experience for me, and provide a link to her blog where she discussed it in more detail (1). 

Consistent with the scientific literature and a number of previous reader anecdotes (2), Sarah experienced a reduction in appetite on the simple food diet, losing 15 pounds in 6 weeks without hunger.  In contrast to her prior experiences with typical calorie restriction, her energy level and mood remained high over this period.  Here's a quote from her blog:

Well, it looks like the theory that in the absence of nice palatable food, the body will turn quite readily to fat stores and start munching them up, is holding up. At the moment, the majority of the energy I use is coming from my insides, and my body is using it without such quibbles as the increased hunger, low energy, crappy thermo-regulation or bitchiness normally associated with severe calorie restriction.

I can't promise that everyone will experience results like this, but this is basically what the food reward hypothesis suggests should be possible, and it seems to work this way for many people.  That's one of the reasons why this idea interests me so much.

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Scientists and Tattoos

Prof Datta's  Love Tattoo
A surprising number of scientists have tattoos hidden under their lab coats and these tattoos are examples of their cool geekiness.   Prof Sandeep Robert Datta has a tattoo of a twisting ladder of DNA.  The DNA message spells out the initials of his wife, Eliza Emond Edelsberg.  True love manifested through amino acids that are the building blocks of protein!!!  

A Brief Response to Taubes's Food Reward Critique, and a Little Something Extra

It appears Gary Taubes has completed his series critiquing the food reward hypothesis of obesity (1).  I have to hand it to him, it takes some cojones to critique an entire field of research, particularly when you have no scientific background in it.

The food reward hypothesis of obesity states that the reward and palatability value of food influence body fatness, and excess reward/palatability can promote body fat accumulation.  If we want to test the hypothesis, the most direct way is to find experiments in which 1) the nutritional qualities of the experimental diet groups are kept the same or at least very similar, 2) some aspect of diet reward/palatability differs, and 3) changes in body fat/weight are measured (for example, 2, 3, 4, 5, 6, 7, 8, 9).  In these experiments the hypothesis has both arms and one leg tied behind its back, because the most potent reward factors (energy density, sugar, fat) have nutritional value and therefore experiments that modify these cannot be tightly controlled for nutritional differences.  Yet even with this severe disadvantage, the hypothesis is consistently supported by the scientific evidence.  Taubes repeatedly stated in his series that controlled studies like these have not been conducted, apparently basing this belief on a 22-year-old review paper by Dr. Israel Ramirez and colleagues that does not contain the word 'reward' (10).

Another way to test the hypothesis is to see if people with higher food reward sensitivity (due to genetics or other factors) tend to gain more fat over time (for example, 11, 12, 13, 14, 15, 16).  In addition, studies that have examined the effect of palatability/reward on food intake in a controlled manner are relevant (17, 18, 19, 20, 21, 22), as are studies that have identified some of the mechanisms by which these effects occur (reviewed in 23).  Even if not all of the studies are perfect, at some point, one has to acknowledge that there are a lot of mutually buttressing lines of evidence here.  It is notable that virtually none of these studies appeared in Taubes's posts, and he appeared largely unaware of them. 
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Thanksgiving Idea

Happy Thanksgiving to EverythingHealth readers.

Thanks to KM for this way to appreciate Thanksgiving.  I did it and it only took about 7 minutes.  Here's the concept:

Get a piece of paper or a word doc on your computer.  Write one thing you are grateful for for each year of your age.  If you are older, you have lots of reasons to give thanks.  Don't over think it or try to put it in order of "

Two Recent Papers by Matt Metzgar

This is just a quick post to highlight two recent papers by the economist and fellow health writer Matt Metzgar.

The first paper is titled "The Feasibility of a Paleolithic Diet for Low-income Consumers", and is co-authored by Dr. Todd C. Rideout, Maelan Fontes-Villalba, and Dr. Remko S. Kuipers (1).  They found that a Paleolithic-type diet that meets all micronutrient requirements except calcium (which probably has an unnecessarily high RDA) costs slightly more money than a non-Paleolithic diet that fulfills the same requirements, but both are possible on a tight budget. 

The second paper is titled "Externalities From Grain Consumption: a Survey", with Matt Metzgar as the sole author (2).  He reviews certain positive and negative externalities due to the effects of grain consumption on health.  The take-home message is that refined grains are unhealthy and therefore costly to society, whole grains are better, but grains in general have certain healthcare-related economic costs that are difficult to deny, such as celiac disease.

There are a lot of ideas floating around on the blogosphere, some good and others questionable.  Composing a manuscript and submitting it to a reputable scientific journal is a good way to demonstrate that your idea holds water, and it's also a good way to communicate it to the scientific community.  The peer review process isn't perfect but it does encourage scientific rigor.  I think Metzgar is a good example of someone who has successfully put his ideas through this process.  Pedro Bastos, who also spoke at the Ancestral Health Symposium, is another example (3).

Smoking is still a Huge Problem in the U.S.

I live on the West Coast and where is rare to see a smoker.  Because it is not socially accepted,  smokers are not out in the open.  They lurk behind buildings to take a smoke break at work and I don't even own an ashtray for friends because none of my friends smoke.  But San Francisco isn't the rest of America.   In 2010 there were 45.5 million Americans who smoke, with men smoking more than

Amazing Spider Animation

This is one of the most accurate and beautiful pieces of animation I've ever seen. And I love the title: "Loom" (Warning: if you are arachnophobic you may wish to avoid but if you want to see nature at her best, the detail is amazing.)

Hat tip to Micro Voyage and the creators at Polynoid

Yoga for Back Pain

Low back pain is one of the most common conditions to affect humans.  More than 80% of Americans experience low back pain at some time in their lives and "chronic" pain is on the rise as people live longer and get heavier.  Numerous studies have shown that doctors and patients underutilized exercise as a treatment for chronic back and neck pain even though it has been shown to be effective.  A

Answer to Medical Challenge-Yellow Nail Syndrome

Yesterday's Medical Challenge answer was clear to some readers and a mystery to others.  The answer was:
#4  Yellow Nail Syndrome.  Although nails can become discolored from nail polish, the medical Yellow Nail Syndrome is a sign of a serious disorder and not well understood.  It is believed to be associated with  restrictive lung disease or  (rarely) problems with lymphatic drainage channels.

Medical Challenge

This weeks medical challenge from the New England Journal of Medicine is a hard one.  Patients come all the time with nail problems and most are easy to diagnose.  Full disclosure to my readers...I missed this one.   A couple of hints...all of the nails are obviously affected.  Click on the image to enlarge and make your diagnosis in the comments section.   I will post the answer tomorrow so be

Ode to Andy Rooney

Andy Rooney, the broadcaster with a wry look at life, has died at age 92.  He worked up to the end after delivering his 1,097th commentary on life.  Andy Rooney had a knack of picking a topic that no-one had thought about, comment on it and listeners would say "Oh yea, that is so true".  He touched a nerve in modern American society.  Here are my Andy Rooneyisms:
Why do we have foods like "

Follow Up on 1991 Gulf War Veterans

Remember the 1991 Gulf War between the United States and Iraq (aka: "Operation Desert Storm")?  A new study has been published in the American Journal of Epidemiology that assessed the health status of 5,469 deployed Gulf War veterans compared to 3,353 non deployed veterans.  At 10 year follow up, the deployed veterans were more likely to report persistent poor health.  The measures were

Does High Circulating Insulin Drive Body Fat Accumulation? Answers from Genetically Modified Mice

The house mouse Mus musculus is an incredible research tool in the biomedical sciences, due to its ease of care and its ability to be genetically manipulated.  Although mice aren't humans, they resemble us closely in many ways, including how insulin signaling works.  Genetic manipulation of mice allows researchers to identify biological mechanisms and cause-effect relationships in a very precise manner.  One way of doing this is to create "knockout" mice that lack a specific gene, in an attempt to determine that gene's importance in a particular process.  Another way is to create transgenic mice that express a gene of interest, often modified in some way.  A third method is to use an extraordinary (but now common) tool called "Cre-lox" recombination (1), which allows us to delete or add a single gene in a specific tissue or cell type. 

Studying the relationship between obesity and insulin resistance is challenging, because the two typically travel together, confounding efforts to determine which is the cause and which is the effect of the other (or neither).  Some have proposed the hypothesis that high levels of circulating insulin promote body fat accumulation*.  To truly address this question, we need to consider targeted experiments that increase circulating insulin over long periods of time without altering a number of other factors throughout the body.  This is where mice come in.  Scientists are able to perform precise genetic interventions in mice that increase circulating insulin over a long period of time.  These mice should gain fat mass if the hypothesis is correct. 

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The Brain Controls Insulin Action

Insulin regulates blood glucose primarily by two mechanisms:

1. Suppressing glucose production by the liver
2. Enhancing glucose uptake by other tissues, particularly muscle and liver

Since the cells contained in liver, muscle and other tissues respond directly to insulin stimulation, most people don't think about the role of the brain in this process.  An interesting paper just published in Diabetes reminds us of the central role of the brain in glucose metabolism as well as body fat regulation (1).  Investigators showed that by inhibiting insulin signaling in the brains of mice, they could diminish insulin's ability to suppress liver glucose production by 20%, and its ability to promote glucose uptake by muscle tissue by 59%.  In other words, the majority of insulin's ability to cause muscle to take up glucose is mediated by its effect on the brain. 

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Carpal Tunnel Syndrome

Immediately Post-op Carpal Tunnel release
Carpal Tunnel Syndrome (CTS) is common and is the result of the median nerve becoming squeezed or "entrapped" as it passes through the wrist down into the palm of the hand.  Because this is a sensory nerve, the compression causes tingling, burning and itching numbness in the palm of the hand and fingers. A different nerve goes to the little finger and

Teens and Soda and Junk Science

The headlines of a number of newspapers say "Soda Boosts Violence Among Teenagers."  A new study out of Harvard's Public Health Division analyzed data from 1878 14 to 18 year olds and found those who drank over 5 cans of non-diet soda a week consumed more alcohol and smoked more cigarettes.  Additionally those teens were more likely to carry a knife and exhibit violence toward family and peers.

Harvard Food Law Society "Forum on Food Policy" TEDx Conference

Last Friday, it was my pleasure to attended and present at the Harvard Food Law Society's TEDx conference, Forum on Food Policy.  I had never been to Cambridge or Boston before, and I was struck by how European they feel compared to Seattle.  The conference was a great success, thanks to the dedicated efforts of the Food Law Society's presidents Nate Rosenberg, Krista DeBoer, and many other volunteers. 

Dr. Robert Lustig gave a keynote address on Thursday evening, which I unfortunately wasn't able to attend due to my flight schedule.  From what I heard, he focused on practical solutions for reducing national sugar consumption, such as instituting a sugar tax.  Dr. Lustig was a major presence at the conference, and perhaps partially due to his efforts, sugar was a central focus throughout the day.  Nearly everyone agrees that added sugar is harmful to the nation's health at current intakes, so the question kept coming up "how long is it going to take us to do something about it?"  As Dr. David Ludwig said, "...the obesity epidemic can be viewed as a disease of technology with a simple, but politically difficult solution".

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Robots Bring Care to Remote Places

Both in the United States and around the globe there is a mismatch between needed medical care and the doctors who can provide it.  Most physicians are located in urban areas where there are hospitals, teaching schools, lab and Xray and specialists to deal with most every medical condition.  Rural areas in the United States lack these resources and patients either do without,  or must travel far

Kid's Allergies and Asthma

There never seems to be enough time for parents to ask all of the questions they want of their kid's pediatrician.  And parents whose children have allergies or asthma have lots of questions and new concerns that pop up all of the time.  The American Academy of Pediatrics has published an updated guide called "Allergies and Asthma - What Every Parent Needs to Know."   This paperback should go a

Ovarian Cancer Screening of No Value

If you want to create an outcry of indignation,  just inform people that certain screening tests are of no value and do not increase time on this earth.  People love the idea that if they do all the right things and get all the medical tests at the right time, they can prevent disease ( ....uh...no, tests don't prevent anything) or catch cancer early and cure it.

The furor over the lack of

Losing Fat With Simple Food-- Two Reader Anecdotes

Each week, I'm receiving more e-mails and comments from people who are successfully losing fat by eating simple (low reward) food, similar to what I described here.  In some cases, people are breaking through fat loss plateaus that they had reached on conventional low-carbohydrate, low-fat or paleo diets.  This concept can be applied to any type of diet, and I believe it is an important characteristic of ancestral food patterns.

At the Ancestral Health Symposium, I met two Whole Health Source readers, Aravind Balasubramanian and Kamal Patel, who were interested in trying a simple diet to lose fat and improve their health.  In addition, they wanted to break free of certain other high-reward activities in their lives that they felt were not constructive.  They recently embarked on an 8-week low-reward diet and lifestyle to test the effectiveness of the concepts.  Both of them had previously achieved a stable (in Aravind's case, reduced) weight on a paleo-ish diet prior to this experiment, but they still carried more fat than they wanted to.  They offered to write about their experience for WHS, and I thought other readers might find it informative.  Their story is below, followed by a few of my comments.

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Male Circumcision

Male circumcision has been practiced for cultural and religious reasons since ancient times and it is estimated that about 1/4 of the world's men are circumcised.  It is a controversial topic and the debate about medical benefits of circumcision has not been fully resolved.   The Journal of the American Medical Association (JAMA) has recently published three randomized trials from Africa that

Doctors Charging Add On Fees

 My telecom bill is pretty high when you take the basic rate and then add on "additional bundled services ($4.99)", "Internet Services ($7.00)", "Additional Voice Service ($25.72)", Taxes, surcharges and fees ($10.47), "911 fee ($.24)" and "other charges and credits ($2.99).  One way doctors could deal with their declining incomes (down 7%-25% adjusted for inflation depending upon the specialty)

Calming

All is Well

Answer to Medical Challenge

The answer to the Medical Challenge this week is #3 - Graves' disease.

The skin changes seen on the lower legs are typical of Graves' dermopathy.  The skin has a leathery texture, thickening and fissuring.

Graves' disease, named after the Irish doctor Robert James Graves, who first described it in 1835 is caused by an overactive thyroid gland.  Thyroid auto-antibodies stimulate thyroid hormone

The Case for the Food Reward Hypothesis of Obesity, Part II

In this post, I'll explore whether or not the scientific evidence is consistent with the predictions of the food reward hypothesis, as outlined in the last post.

Before diving in, I'd like to address the critique that the food reward concept is a tautology or relies on circular reasoning (or is not testable/falsifiable).  This critique has no logical basis.  The reward and palatability value of a food is not defined by its effect on energy intake or body fatness.  In the research setting, food reward is measured by the ability of food or food-related stimuli to reinforce or motivate behavior (e.g., 1).  In humans, palatability is measured by having a person taste a food and rate its pleasantness in a standardized, quantifiable manner, or sometimes by looking at brain activity by fMRI or related techniques (2).  In rodents, it is measured by observing stereotyped facial responses to palatable and unpalatable foods, which are similar to those seen in human infants.  It is not a tautology or circular reasoning to say that the reinforcing value or pleasantness of food influences food intake and body fatness. These are quantifiable concepts and as I will explain, their relationship with food intake and body fatness can be, and already has been, tested in a controlled manner. 

1.   Increasing the reward/palatability value of the diet should cause fat gain in animals and humans

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Michael Jackson's Doctor

The 2nd degree manslaughter trial of Dr. Conrad Murray, the doctor who attended Michael Jackson at the time of his death June 25, 2009,  is now underway in LA.  The testimony that is taking place is certainly revealing of the last day of Mr. Jackson's life.  Michael Jackson died of an acute Propofol overdose and the toxicology report also revealed Valium, Lorezepam, Versed, Lidocaine  and

This Weeks Medical Challenge

Avert your eyes if you can't stand this weeks Medical Challenge  from the New England Journal of Medicine.  Click on the image for a better view.

This Patient is being treated for an endocrine disease.  What is it?
1.  Acromegaly ("giantism")
2.  Cushing's disease (excess cortisol)
3.  Graves' Disease (hyperthyroidism)
4.  Hashimoto's thyroiditis (a thyroid disorder)
5.  Type 1 diabetes

  The

scintillating scotoma

image from myaspiebrain
Nothing like experiencing a medical condition first-hand to really help a doctor understand it from the patient's point of view.  After all these years, I had my first (and hopefully last) scintillating scotoma while sitting on the couch playing "words with friends" on my ipad and watching TV.  A scotoma is a partial loss of vision in a normal visual field.  Scintillate

Bedside Manners Worth $42 Million

A Chicago couple believes doctors should have good bedside manners and they have ponied up $42 million dollars to teach it.  Matthew and Carolyn Bucksbaum have donated to the Bucksbaum Institute for Clinical Excellence at the University of Chicago.  They made the donation for their own personal physician to lead it and say he's the kind of doctor students should emulate.  They were motivated to

The Case for the Food Reward Hypothesis of Obesity, Part I

Introduction

When you want to investigate something using the scientific method, first you create a model that you hope describes a natural phenomenon-- this is called a hypothesis.  Then you go about testing that model against reality, under controlled conditions, to see if it has any predictive power.  There is rarely a single experiment, or single study, that can demonstrate that a hypothesis is correct.  Most important hypotheses require many mutually buttressing lines of evidence from multiple research groups before they're widely accepted.  Although it's not necessary, understanding the mechanism by which an effect occurs, and having that mechanism be consistent with the hypothesis, adds substantially to the case.

With that in mind, this post will go into greater detail on the evidence supporting food reward and palatability as major factors in the regulation of food intake and body fatness.  There is a large amount of supportive evidence at this point, which is rapidly expanding due to the efforts of many brilliant researchers, however for the sake of clarity and brevity, so far I've only given a "tip of the iceberg" view of it.  But there are two types of people who want more detail: (1) the skeptics, and (2) scientifically inclined people who want mechanism.  This post is for them.  It will get technical at times, as there is no other way to convey the material effectively.

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Plastic Surgeons Behaving Badly

What is it about "Patient Privacy" that some doctors don't understand?  A St. Louis, Mo. plastic surgeon is being sued by 5 patients after she posted "before" and "after" photos of their bare breasts and torsos on her website to show the benefits of their breast implants.  To make it worse, she also posted their full names with the photos and several of the women are prominent in their

What is Listeria?

If you have watched any news over the past week you know there is a listeria outbreak from contaminated cantaloupes that has been traced to Jensen Farms in Colorado. The CDC has confirmed 72 illnesses, including 13 deaths linked to the melons and three other deaths may be involved.  By now most of the cantaloupes should be gone as they usually last only a couple of weeks.  The recalled

Humans on a Cafeteria Diet

In the 1970s, as the modern obesity epidemic was just getting started, investigators were searching for new animal models of diet-induced obesity.  They tried all sorts of things, from sugar to various types of fats, but none of them caused obesity as rapidly and reproducibly as desired*.  1976, Anthony Sclafani tried something new, and disarmingly simple, which he called the "supermarket diet": he gave his rats access to a variety of palatable human foods, in addition to standard rodent chow.  They immediately ignored the chow, instead gorging on the palatable food and rapidly becoming obese (1).  Later renamed the "cafeteria diet", it remains the most rapid and effective way of producing dietary obesity and metabolic syndrome in rodents using solid food (2).

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Land Mines Around the World

We must not turn a blind eye to the shocking facts about land mines and the damage they cause to civilians and our own troops.  The fact that modern warfare involves buried explosives that are completely untargeted  should shock the conscience of the world.  The number of severe wounds that affect our servicemen is on the rise and the Army's Landstuhl Regional Medical Center in Germany is filled

Primal Docs

Chris Armstrong, creator of the website Celiac Handbook, has designed a new non-commercial website called Primal Docs to help people connect with ancestral health-oriented physicians.  It's currently fairly small, but as more physicians join, it will become more useful.  If you are a patient looking for such a physician in your area, or an ancestral health-oriented physician looking for more exposure, it's worth having a look at his site:

Primal Docs

Update 9/22: apparently there is already another website that serves a similar purpose and has many more physicians enrolled: Paleo Physicians Network.

Chocolate May Benefit the Heart and Reduce Stroke

In case you missed it, I'm happy to report something that should please most everyone.  A study published in the British Medical Journal showed that consumption of chocolate (candies, candy bars, chocolate drinks, cookies and deserts) lowered the rates of stroke, coronary heart disease and blood pressure.  It seems that chocolate is good for you!

The study (which did NOT receive funding from the

Cocaine Smuggler Swallowed Drugs

This CT scan reveals reddish capsules that are intertwined through out this man's intestines.  The 72 capsules are filled with almost a kilogram of cocaine.  The man was arrested in Sao Paolo, Brazil, as he was getting ready to board a flight to Brussels.  He was an Irish guy and he was taken to the hospital for removal of the baggies.  We don't know how they were removed but usually they are

Doctors Improving Quality

I spent the day today with 60 physicians and nurses at a symposium focused on quality improvement and reducing mortality from sepsis.  Sepsis (overwhelming infection) is the number 1 cause of hospital deaths and the mortality rate can be as high as 60% if the patient goes into shock from infection.  Survival depends upon thousands of independent pieces coming together in an organized way.  A

Fat Tissue Insulin Sensitivity and Obesity

In this post, I'll discuss a few more facts pertaining to the idea that elevated insulin promotes the accumulation of fat mass.  

Insulin Action on Fat Cells Over the Course of Fat Gain

The idea that insulin acts on fat cells to promote obesity requires that insulin suppress fat release in people with more fat (or people who are gaining fat) to a greater extent than in lean people.  As I have written before, this is not the case, and in fact the reverse is true.  The fat tissue of obese people fails to normally suppress fatty acid release in response to an increase in insulin caused by a meal or an insulin injection, indicating that insulin's ability to suppress fat release is impaired in obesity (1, 2, 3).  The reason for that is simple: the fat tissue of obese people is insulin resistant.

There has been some question around the blogosphere about when insulin resistance in fat tissue occurs.  Is it only observed in obese people, or does it occur to a lesser extent in people who carry less excess fat mass and are perhaps on a trajectory of fat gain?  To answer this question, let's turn the clocks back to 1968, a year before Neil Armstrong first set foot on the moon. 

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Medicine Prices in 1900

Click on image for a better view
This looks like a pretty good deal.  Physicians in attendance, large, well ventilated rooms and food.  Medicine and nursing by caring nuns included.  All for $7-$10.00 a week.  If that is too expensive you can opt for a ward for $4-$6.00/week.

Of course, you will likely be prescribed arsenic and be bled via a slice in your arm vein.  Enemas and purgatives are

Remember 9-11-01

We Remember

Sjogrens Syndrome Slows Venus Williams

U.S. Open 2010
I was lucky enough to see Venus Williams play her first professional tennis match when she was a teenager.  It was obvious she was something special and her coach-father said "If you think she's good, wait until you see her little sister." (Serena Williams).

Venus and her sister, Serena have dominated women's tennis over the past decade but she is currently sidelined with a

NSAIDS May Increase Risk of Miscarriage

A new study of more than 52,000 pregnant women in Canada shows that miscarriage rates were more than twice as high for women who took a nonsteroidal anti-inflammatory drug (NSAID) compared to women who did not.  The study, published in the Canadian Medical Association Journal reported that women who used prescription NSAIDS for just 4 days during early pregnancy had an increased risk for

Hyperinsulinemia: Cause or Effect of Obesity?

Is Elevated Insulin the Cause or Effect of Obesity?

The carbohydrate hypothesis, in its most popular current incarnation, states that elevated insulin acts on fat cells to cause fat storage, leading to obesity.  This is due to its ability to increase the activity of lipoprotein lipase and decrease the activity of hormone-sensitive lipase, thus creating a net flux of fat into fat cells.  I'm still not sure why this would be the case, considering that fat tissue becomes more insulin resistant as body fat accumulates, therefore insulin action on it is not necessarily increased.  Total fat release from fat tissue increases with total fat mass (1), demonstrating that insulin is not able to do its job of suppressing fat release as effectively in people who carry excess fat.  But let's put that problem aside for the moment and keep trucking.

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Foods that Lower Cholesterol

All physicians recommend dietary (lifestyle) changes for patients with high cholesterol (aka: hyperlipidemia).  But this dietary advice which focuses on low fat intake is often confusing for patients and physicians can be pessimistic that it will even work.  Many rush into prescribing statins because we know they will "get the numbers down".  New evidence published in the Journal of the American

Catered Paleo Dinner with Yours Truly

Gil Butler, organizer of the Western Washington Paleo Enthusiasts group, has organized a catered "paleo" dinner on Sunday, October 9th.  He will be screening the first episode of "Primal Chef", Featuring Robb Wolf and others.  He invited me to give a short (20 minute) presentation, which I accepted.  There are still roughly 30 spots remaining [update 9/21-- the event is full].

The event will be in the Ballard neighborhood of Seattle and the price is $15.76 per person.  I will not be paid for this talk, it's just an opportunity to share ideas and meet people. 

Click here to register.

Summer Fresh Tomato Pasta

The farmers market in my area is bursting with fresh tomatoes now.  If you are lucky, you have tomato plants that are producing fruit.  Here is a healthy way to use tomatoes that your family will love.

Summer Fresh Tomato Pasta

Serves 4-6
Ingredients:
6-8 tomatoes chopped
5 tbs extra virgin olive oil
Juice of 1/2 fresh lemon
1 chopped clove garlic
1/2 cup chopped fresh basil
Salt and pepper

Book Review: The End of Overeating

The End of Overeating was written based on the personal journey of Dr. David A. Kessler (MD) to understand the obesity epidemic, and treat his own obesity in the process.  Kessler was the FDA commissioner under presidents George HW Bush and Bill Clinton.  He is known for his efforts to regulate cigarettes, and his involvement in modernizing Nutrition Facts labels on packaged food.  He was also the dean of Yale medical school for six years-- a very accomplished person. 

Kessler's book focuses on 1) the ability of food with a high palatability/reward value to cause overeating and obesity, 2) the systematic efforts of the food industry to maximize food palatability/reward to increase sales in a competitive market, and 3) what to do about it.  He has not only done a lot of reading on the subject, but has also participated directly in food reward research himself, so he has real credibility.  The End of Overeating is not the usual diet book baloney. 
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Research in Guatemala Lacked Medical Ethics

The shocking details of  U.S. medical experiments done in the 1940's in Guatemala are just now coming to light.  A Presidential Commission for the Study of Bioethical Issues has been looking at medical "research" that was done from 1946-48 by the U.S. Public Health Service and the Pan American Sanitary Bureau.  This research in Guatemala was paid for by the U.S. Government and it involved

Readmission After Hospital Discharge is Not an Indication of Poor Care

Hospitals across the country are working on quality initiatives to reduce re-admissions to hospitals.  There are consultants, conferences, forums, meetings, physicians, nurses and administrators who are spending hours upon hours (and lots of $$$) to find ways to keep patients who have been discharged from being readmitted within 30 days.  Why all of this activity?  It is one of the quality

A Roadmap to Obesity

In this post, I'll explain my current understanding of the factors that promote obesity in humans.  

Heritability

To a large degree, obesity is a heritable condition.  Various studies indicate that roughly two-thirds of the differences in body fatness between individuals is explained by heredity*, although estimates vary greatly (1).  However, we also know that obesity is not genetically determined, because in the US, the obesity rate has more than doubled in the last 30 years, consistent with what has happened to many other cultures (2).  How do we reconcile these two facts?  By understanding that genetic variability determines the degree of susceptibility to obesity-promoting factors.  In other words, in a natural environment with a natural diet, nearly everyone would be relatively lean, but when obesity-promoting factors are introduced, genetic makeup determines how resistant each person will be to fat gain.  As with the diseases of civilization, obesity is caused by a mismatch between our genetic heritage and our current environment.  This idea received experimental support from an interesting recent study (3).

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Ten Things to Do Before Summer Ends

I can't believe August is almost over.  Here are 10 things to do before summer ends:

1.  Buy luscious fruit at a local farmer's market.  The tomatoes, corn,  peaches, nectarines and plums are in full bloom.  Buy local and enjoy tastes that need no extra sugar or seasoning. (I just ate the best cantaloupe I have ever tasted from our local market.  I didn't even know I liked cantaloupe)

2. Put on

Price List for Medical Tests

I am smacking myself on the forehead and saying, "Why didn't I think of this?"  Dr. Richard Parker, Medical Director at Beth Israel Deaconess Medical Center,  has sent out a list to his physician colleagues of 56 common medical tests and procedures.  What is revolutionary is that there are prices next to each item.  You non physicians may be surprised to know that we doctors have no idea what the

Too Hot for Ya? Cool off Like an Orangutan

EMBED-Orangutan Cools Himself Off Like A Human - Watch more free videos

Patients and Doctors Need Skin in the Game for Appropriate Care

Dr. Victor Fuchs, Ph.D. wrote an op-ed in the New England Journal of Medicine about "The Doctor's Dilemma - Delivering Appropriate Care".  Physicians are trained to deal with each patient one at a time and to make decisions based on that patient alone.  Now we are in an era when the high cost of treatment can actually bankrupt the system.  Rising health care costs are everyone's problem. 

Seed Oils and Body Fatness-- A Problematic Revisit

Anthony Colpo recently posted a discussion of one of my older posts on seed oils and body fat gain (1), which reminded me that I need to revisit the idea.  As my knowledge of obesity and metabolism has expanded, I feel the evidence behind the hypothesis that seed oils (corn, soybean, etc.) promote obesity due to their linoleic acid (omega-6 fat) content has largely collapsed.

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Answer to Medical Challenge

The answer to yesterday's Medical Challenge is #3 - mucocele.

These lesions are nontender, smooth and usually translucent.  They are commonly found on the cheek or lip and can be the result of repetitive cheek or lip biting.  They usually disappear without any treatment.  Any new growth or lesion in the mouth should be checked out by a physician.

Thanks for playing.

Research Drug Might Extend Life for Obese

I usually choose not to write about the "new new scientific thing" that gets picked up by the press,  because early research is usually not reproducible and good science takes a long time to validate as true.  But since we know that mice and rats that are kept on low-calorie diets live 30% longer (and healthier) than their fat cohorts, I was interested in a new research compound, SRT-1720,  that

Image Challenge

Here we go again where you get to be the diagnostician.  This young boy presented with a non-tender mouth lesion that developed with no known trauma or cause.  Can you guess the right answer?
Click on the image for a better view and then make your choice in the comment section.  Return tomorrow for the answer and bragging rights if you get it right.
1. Dermoid Cyst
2. Hemangioma
3. Mucocele
4.

Food Palatability and Body Fatness: Clues from Alliesthesia

Part I: Is there a Ponderostat?

Some of the most important experiments for understanding the role of food palatability/reward in body fatness were performed by Dr. Michel Cabanac and collaborators in the 1970s (hat tip to Dr. Seth Roberts for the references).  In my recent food reward series (1), I referenced but did not discuss Dr. Cabanac's work because I felt it would have taken too long to describe.  However, I included two of his studies in my Ancestral Health Symposium talk, and I think they're worth discussing in more detail here.

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I Got Boinged, and Other News

The reaction to my post "The Carbohydrate Hypothesis of Obesity: a Critical Examination" has been overwhelmingly positive, particularly among the scientists I've heard from. 

On Saturday, the inimitable maker and writer Mark Frauenfelder posted a link to my post on the variety blog BoingBoing.  BoingBoing has been on my sidebar for three years, and it's the place I go when I need a break.  It's a fun assortment of science, news, technology and entertainment.  BoingBoing was originally a zine started by Frauenfelder and his wife in 1988, and it has been on the web since 1995.  Today, it has multiple contributing authors and it draws several hundred thousand hits per day.  I'm thrilled that Frauenfelder posted my article there.  Apparently he likes my blog.  Thanks!

I added a new section (IIB) to my original post.  It discusses what human genetics can teach us about the mechanisms of common obesity.  It is consistent with the rest of the evidence suggesting that body fatness is primarily regulated by the brain, not by fat tissue, and that leptin signaling plays a dominant role in this process. 

What Pregnant Women Eat Influences Baby

Attention, pregnant women!  The foods you eat now might influence your babies' palates after they are born.  New research published in the journal Pediatrics, shows that the fetus actually drinks amniotic fluid in the womb.  The amniotic fluid is flavored by the foods the mother has recently eaten and flavors can be transmitted to the amniotic fluid and mother's milk.

It makes sense that as the

Physicians and Pharmacists Scheme to Steal from Medicare

A large group of physicians and pharmacists were indicted today in U.S. district court of Michigan for healthcare fraud by billing Medicare, Medicaid and private insurers for illegally prescribed drugs.  Four physicians, 1 psychologist and 12 pharmacists used 26 pharmacies across Michigan to bill Medicare for Xanax, Vicodin and Oxycodone to the tune of at least $37.7 million.  They billed $20.8

Answer -Scrotal Calcinosis

Readers of EverythingHealth have great diagnostic skill .  The correct answer to yesterday's Medical Challenge is #5- scrotal calcinosis.  These yellowish scrotal nodules are benign and have nothing to do with calcium or phosphate metabolism.  The cause is unknown.  It was first described in 1883.  Here is another photo of scrotal calcinosis.  

This Weeks Medical Challenge

I know this will gross some of you out, but, hey folks, this is the wondrous human body!  (click on the image for a better view)

 Here is a hint:  These lesions are not tender and variations of this photo are quite common on men's scrotums.

Take your best shot at the diagnosis and make a comment.  The answer will be posted tomorrow so check back.  (Sign up on the right side of the blog as a

The Carbohydrate Hypothesis of Obesity: a Critical Examination

Introduction

I'd like to begin by emphasizing that carbohydrate restriction has helped many people lose body fat and improve their metabolic health.  Although it doesn't work for everyone, there is no doubt that carbohydrate restriction causes fat loss in many, perhaps even most obese people.  For a subset of people, the results can be very impressive.  I consider that to be a fact at this point, but that's not what I'll be discussing here. 

What I want to discuss is a hypothesis.  It's the idea, championed by Gary Taubes, that carbohydrate (particularly refined carbohydrate) causes obesity by elevating insulin, thereby causing increased fat storage in fat cells.  To demonstrate that I'm representing this hypothesis accurately, here is a quote from his book Good Calories, Bad Calories:

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Family Diets

I'm just back from a safari in Tanzania and experiencing the culture, the animals and the beauty of that Country was a thrill.  Seeing how some of the traditional Massai and other African natives live reminded me of a fascinating comparison of how families around the world eat.  Check out Time Magazine's comparison photos from the book "Hungry Planet".  


One week diet for the Revis family of

Ancestral Health Symposium

Last weekend I attended the Ancestral Health Symposium at the University of California, Los Angeles, organized by Aaron Blaisdell, Brent Pottenger and Seth Roberts with help from many others.  It was a really great experience and I'm grateful to have been invited.  I was finally able to meet many of the people who I respect and admire, but knew only through the internet.  I'm not going to make a list because it would be too long, but if you take a look at the symposium schedule, I think you'll understand where I'm coming from.  I was also able to connect with a number of Whole Health Source readers, which was great.  I recognized some of them from the comments section.  Now I know it wasn't just my mom with 57 Google accounts.

The symposium was the first of its kind, and represented many facets of the ancestral health community, including "Paleolithic" diet and exercise patterns, low-carbohydrate diets, Weston Price-style diets, traditional health-nutrition researchers as well as other camps.  For the most part they coexisted peacefully and perhaps even learned a thing or two from one another. 

I was very impressed by the appearance of the attendees.  Young men and women were fit with glowing skin, and older attendees were energetic and aging gracefully.  It would be hard to come up with a better advertisement for ancestrally-oriented diets and lifestyles.  I saw a lot of people taking the stairs rather than the elevator.  I like to say I'll take the elevator/escalator when I'm dead.  I think integrating exercise into everyday life is healthy and efficient.  Escalators and elevators of course make sense for people with physical disabilities or heavy suitcases.

The first talk was by Dr. Boyd Eaton, considered by many to be the grandfather of the paleolithic diet concept.  I was very impressed by his composure, humility and compassionate attitude.  Half his talk was dedicated to environmental and social problems.  Dr. Staffan Lindeberg gave a talk titled "Food and Western Disease", which covered his paleolithic diet clinical trials as well as other evidence supporting ancestral diets.  I like Dr. Lindeberg's humble and skeptical style of reasoning.  I had the great pleasure of having dinner with Dr. Lindeberg and his wife, Dr. Eaton, Pedro Bastos, Dr. Lynda Frassetto, Dr. Guy-Andre Pelouze and his son Alexandre.  Pedro gave a very nice talk on the complexities of traditional and modern dairy.  The following night, I was able to connect with other writers I enjoy, including Chris Masterjohn, Melissa McEwen, John Durant, and Denise Minger. 

Dr. Pelouze is a french cardiovascular surgeon who strongly supports the food reward/palatability concept of obesity.  We had a conversation the evening before the conference, during which he basically made the same points I was going to make in my talk.  He is particularly familiar with the research of Dr. Michel Cabanac, who is central to the food reward idea.  He eats an interesting diet: mostly raw, omnivorous, and extremely simple.  If I understood correctly, he mostly eats raw meat, fish, fruit and vegetables with little or no preparation.  He sometimes cooks food if he wants to, but most of it is raw.  He believes simple, raw food allows the body's satiety systems to work more effectively.  He has been eating this way for more than twenty years, and his son was raised this way and is now about my age (if I recall correctly, Alexandre has a masters and is studying for an MD, and ultimately wants to become an MD/PhD).  Both of them look very good, are full of energy and have a remarkably positive mental state.  Alexandre told me that he never felt deprived growing up around other children who ate pastries, candy et cetera.  They woke up early and ran six miles before the conference began at 8 am. 

I gave my talk on Friday.  Giving a talk is not like writing a blog post-- it has to be much more cohesive and visually compelling.  I put a lot of work into it and it went really well.  Besides the heat I got from from Gary Taubes in the question and answer session, the response was very positive.  The talk, including the questions, will be freely available on the internet soon, as well as other talks from the symposium.  Some of it will be familiar to people who have read my body fat setpoint and food reward series, but it's a concise summary of the ideas and parts of it are new, so it will definitely be worthwhile to watch it.  

We have entered a new era of media communication.  Every time someone sneezed, it was live tweeted.  There are some good aspects to it-- it democratizes information by making it more accessible.  On the other hand, it's sometimes low quality information that contains inaccurate accounts and quotes that are subsequently recirculated. 

It was a great conference and I hope it was the first of many.

Dietary Guidelines for Americans, My Way

I just saw this on BoingBoing.  Simple but true. 

This image was created by Adam Fields. 

The people who design government dietary guidelines are gagged by the fact that politics and business are so tightly intertwined in this country.  Their advice will never directly target the primary source of obesity and metabolic dysfunction-- industrially processed food-- because that would hurt corporate profits in one of the country's biggest economic sectors.  You can only squeeze so much profit out of a carrot, so food engineers design "value-added" ultrapalatable/rewarding foods with a larger profit margin.

We don't even have the political will to regulate food advertisements directed at defenseless children, which are systematically training them from an early age to prefer foods that are fattening and unhealthy.  This is supposedly out of a "free market" spirit, but that justification is hollow because processed food manufacturers benefit from tax loopholes and major government subsidies, including programs supporting grain production and the employment of disadvantaged citizens (see Fast Food Nation).

Interview on Super Human Radio

Today, I did an audio interview with Carl Lanore of Super Human Radio.  Carl seems like a sharp guy who focuses on physical fitness, nutrition, health and aging.  We talked mostly about food reward and body fatness-- I think it went well.  Carl went from obese to fit, and his fat loss experience lines up well with the food reward concept.  As he was losing fat rapidly, he told friends that he had "divorced from flavor", eating plain chicken, sweet potatoes and oatmeal, yet he grew to enjoy simple food over time.

The interview is here.  It also includes an interview of Dr. Matthew Andry about Dr. Loren Cordain's position on dairy; my interview starts at about 57 minutes.  Just to warn you, the website and podcast are both full of ads.

Weight Gain and Weight Loss in a Traditional African Society

The Massas is an ethnic group in Northern Cameroon that subsists mostly on plain sorghum loaves and porridge, along with a small amount of milk, fish and vegetables (1, 2).  They have a peculiar tradition called Guru Walla that is only undertaken by men (2, 1):
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The Wildebeast

We are off to see the wildebeast cross the river as the great migration is taking place right now in Tanzania.  EverythingHealth will be on vacation for the next few weeks.  Scan the right side of the page for the best of health blogs and happy reading.

Cholera in Haiti

Water for the Hospital Emergency Room

 Is anyone paying attention to the plight of Haiti anymore?  Unfortunately the rebuild (after the earthquake on Jan 12, 2010)  never really happened and Haiti seems as poor and troubled as ever.  Over 800,000 people still live in makeshift tent encampments. Now they are plagued with a cholera epidemic that just won't stop.  It is nearly impossible to

Italians Not Following The Mediterranian Diet

For years I have touted the health benefits of the "Mediterranean Diet" and encouraged patients to eat like the Europeans.   Fresh farm vegetables, olive oil, fish and red wine have been linked with longevity and good health.  I just read in NPR news that young Italians are forgoing the eating patterns of their elders and are imitating the "U.S. diet".  The result is soaring obesity, just like in

Simple Food: Thoughts on Practicality

Some people have reacted negatively to the idea of a reduced-reward diet because it strikes them as difficult or unsustainable.  In this post, I'll discuss my thoughts on the practicality and sustainability of this way of eating.  I've also thrown in a few philosophical points about reward and the modern world.
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Answer to Yesterdays Medical Challenge

The answer to yesterdays medical challenge is #5-medial nail dystrophy due to trauma.  Here is another photo that is from chronic picking of the cuticle and pushing back the cuticle.

The other answers were good guesses but none of them cause the median (middle of nail) changes.  Traumatic dystrophy from nervous picking is actually quite common.  Other traumas to the nail bed can cause the nail

This Weeks Medical Challenge

This weeks challenge is from Consultant Live.  This 56 year old man was noted to have these thumbnails at his physical exam.  The remainder of his nails were normal.  He denied trauma and worked as a banker.  What is the diagnosis?

1. Psoriasis
2. Vitamin K Deficiency
3.  Lichen Planus
4.  Onchomycosis (fungus)
5. Median nail dystrophy due to trauma

The answer will be posted tomorrow.  Click on

Sixteen Pound Baby Born in Texas

A woman in Texas gave birth to a baby boy who weighed in at a whopping 16lbs, 1oz.   The average size of a newborn is about 7 lbs so this one was considered huge.  This was the 4th child for the mom who had gestational diabetes during pregnancy.  Between 2 and 10% of pregnant women develop this condition.  Women who have a body mass index (BMI) over 30 or who have a strong family history of

How Does Gastric Bypass Surgery Cause Fat Loss?

Gastric bypass surgery is an operation that causes food to bypass part of the digestive tract.  In the most common surgery, Roux-en-Y bypass, stomach size is reduced and a portion of the upper small intestine is bypassed.  This means that food skips most of the stomach and the duodenum (upper small intestine), passing from the tiny stomach directly into the jejunum (a lower part of the upper small intestine)*.  It looks something like this:
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Massage Therapy Relieves Chronic Back Pain

The Group Health Research Institute of Seattle, Washington has published a study in Annals of Internal Medicine that showed massage therapy may effectively reduce or relieve chronic back pain.  I am a big believer and supporter of massage therapy and have wondered why it is not a covered benefit for treating back and neck pain.  Even medical benefits savings plans offered by employers (where you

Uterine Environment and Autism

Two news events got people talking today.  One was that Casey was deemed not guilty of killing little daughter Caylee ( "O.J. all over again", I heard repeatedly).  I must admit I was rather surprised....

The second was the results of two new studies that were published in the Archives of General Psychiatry.  One of them stated that environmental factors during pregnancy might contribute as much

Liposuction and Fat Regain

If body fat really is actively regulated by the body, rather than just being a passive result of voluntary food intake and exercise behaviors, then liposuction shouldn't be very effective at reducing total fat mass in the long run.  People should return to their body fat "setpoint" rather than remaining at a lower fat mass. 

Teri L. Hernandez and colleagues recently performed the first ever randomized liposuction study to answer this question (1).  Participants were randomly selected to either receive liposuction, or not.  They were all instructed not to make any lifestyle changes for the duration of the study, and body fatness was measured at 6 weeks, 6 months and one year by DXA. 

At 6 weeks, the liposuction group was significantly leaner than the control group.  At 6 months, the difference between the two groups had decreased.  At one year, it had decreased further and the difference between the groups was no longer statistically significant.  Furthermore, the liposuction group regained fat disproportionately in the abdominal area (belly), which is more dangerous than where it was before. The investigators stated:

We conclude that [body fat] is not only restored to baseline levels in nonobese women after small-volume liposuction, but is redistributed abdominally.

This is consistent with animal studies showing that when you surgically remove fat, total fat mass "catches up" to animals that had no fat removed (2).  Fat mass is too important to be left up to chance.  That's why the body regulates it, and that's why any satisfying resolution of obesity must address that regulatory mechanism.

Food Reward: a Dominant Factor in Obesity, Part VIII

Further reading

I didn't come up with the idea that excessive food reward increases calorie intake and can lead to obesity, far from it.  The idea has been floating around the scientific literature for decades.  In 1976, after conducting an interesting diet study in humans, Dr. Michel Cabanac stated that the "palatability of the diet influences the set point of the ponderostat [system that regulates body fatness]" (1).  

Currently there is a growing consensus that food reward/palatability is a major contributor to obesity. This is reflected by the proliferation of review articles appearing in high-profile journals.  For the scientists in the audience who want more detail than I provide on my blog, here are some of the reviews I've read and enjoyed.  These were written by some of the leading scientists in the study of food reward and hedonics:

Palatability of food and the ponderostat.  Michel Cabanac, 1989.
Food reward, hyperphagia and obesity.  Hans-Rudolf Berthoud et al., 2011.
Reward mechanisms in obesity: new insights and future directions.  Paul J. Kenny, 2011.
Relation of obesity to consummatory and anticipatory food reward.  Eric Stice, 2009.
Hedonic and incentive signals for body weight control.  Emil Egecioglu et al., 2011.
Homeostatic and hedonic signals interact in the control of food intake.  Michael Lutter and Eric J. Nestler, 2009.
Opioids as agents of reward-related feeding: a consideration of the evidence.  Allen S. Levine and Charles J. Billington, 2004.
Central opioids and consumption of sweet tastants: when reward outweighs homeostasis.  Pawel K. Olszewski and Allen S. Levine, 2007.
Oral and postoral determinants of food reward.  Anthony Sclafani, 2004.
Reduced dopaminergic tone in hypothalamic neural circuits: expression of a "thrifty" genotype underlying the metabolic syndrome?  Hanno Pijl, 2003.

If you can read all these papers and still not believe in the food reward hypothesis... you deserve some kind of award.

Doctors Adapting and Trying to Survive

Close your eyes and think of a doctor.  Do you see a Marcus Welby type? A middle aged, smiling and friendly gentleman who makes house calls?   Is his cozy office staffed by a long time nurse and receptionist who knows you well and handles everything for you?  If that is what you envision, either you haven't been to the doctor lately or you are in a concierge practice where you pay a large upfront

Food Reward: a Dominant Factor in Obesity, Part VII

Now that I've explained the importance of food reward to obesity, and you're tired of reading about it, it's time to share my ideas on how to prevent and perhaps reverse fat gain.  First, I want to point out that although food reward is important, it's not the only factor.  Heritable factors (genetics and epigenetics), developmental factors (uterine environment, childhood diet), lifestyle factors (exercise, sleep, stress) and dietary factors besides reward also play a role.  That's why I called this series "a dominant factor in obesity", rather than "the dominant factor in obesity".
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Tennis at San Quentin

Many people can't understand why a law abiding citizen like me would go to San Quentin Prison and play tennis with the inmates.  I've written on this before and it is a fascinating look at life we don't usually get to witness.  Today was another San Quentin tennis day where I got to play some good, friendly tennis as well as hear some stories of redemption.

I spent a good deal of time talking

Drug Cessation and Weight Gain

Commenter "mem", who has been practicing healthcare for 30+ years, made an interesting remark that I think is relevant to this discussion:

Recovering substance dependent people often put on lots of weight and it is not uncommon for them to become obese or morbidly obese.

This relates to the question that commenter "Gunther Gatherer" and I have been pondering in the comments: can stimulating reward pathways through non-food stimuli influence body fatness?  

It's clear that smoking cigarettes, taking cocaine and certain other pleasure drugs suppress appetite and can prevent weight gain.  These drugs all activate dopamine-dependent reward centers, which is why they're addictive.  Cocaine in particular directly inhibits dopamine clearance from the synapse (neuron-neuron junction), increasing its availability for signaling.
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Rob a Bank to Get Health Care

Just when you think things can't get any nuttier with American health care, here comes the strange and sad case of James Richard Verone.  Mr. Verone, age 59, was laid off from his job of 17 years as a Coca Cola deliveryman.  He went through his savings and  took a part-time position as a convenience store clerk but he had no health insurance.   He had a back ache from lifting and bending and pain

Pterygium

 
This 45 year old man came to his doctor about a triangular shape growth in the inside corner of both eyes.  It had been present for a long time but seemed to be increasing.  There was no pain, no discharge and no visual problem.  The internal eye exam was normal.  What is the diagnosis?
These common conjunctival growths are called a pterygium (pronounced "teryjium").  We don't know what causes

Stop Unnecessary Medicare Tests

We are in a time when  Medicare is bankrupt and the GOP wants to privatize it and make seniors go to the open market to get insurance. Even the idea that we would dismantle this important social benefit is shocking yet everyone knows we have to bring costs under control.  So now we find that hundreds of hospitals (and radiologists)  in the United States are performing unnecessary CT scans on both

Food Reward: a Dominant Factor in Obesity, Part VI

Reward Centers can Modify the Body Fat Setpoint

Dopamine is a neurotransmitter (chemical that signals between neurons) that is a central mediator of reward and motivation in the brain.  It has been known for decades that dopamine injections into the brain suppress food intake, and that this is due primarily to its action in the hypothalamus, which is the main region that regulates body fatness (1).  Dopamine-producing neurons from reward centers contact neurons in the hypothalamus that regulate body fatness (2).  I recently came across a paper by a researcher named Dr. Hanno Pijl, from Leiden University in the Netherlands (3).  The paper is a nice overview of the evidence linking dopamine signaling with body fatness via its effects on the hypothalamus, and I recommend it to any scientists out there who want to read more about the concept.
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No Advantage for Screening Ovarian Cancer

There were 21,880 new cases of ovarian cancer diagnosed in the United States in 2010 and it is the 5th leading cause of cancer death among women.   Women are understandably afraid of ovarian cancer because there are usually no early warning symptoms and when discovered,  the disease is often advanced, difficult to treat and highly lethal. A large and well run study, reported at the American

Sunburned Feet

As a follow up to my last blog, check out these sunburned feet from a friend vacationing in Southern California.  Ouch.  Feet are especially sensitive because men wear socks all the time and they never get sun exposure.  Another worrisome area is the head, especially with a bald spot.  Don't let a sunburn ruin your vacation.  Prevention is the key.

Sunburn

Summer is here and this is the time for sunburn because people are so happy to be on vacation or out in the sun, they underestimate how much sun their sensitive skin can tolerate.  Sunburn is caused by UV radiation actually burning and damaging the cells of the skin.  While fair skin is more likely to burn, even people with darker skin can be easily sunburned if they are getting sun during the

Vitamin D Improves COPD

I am frequently extolling the health benefits of Vitamin D because almost weekly there is a new study that correlates high vitamin D levels with reducing some disease.  The latest is from the American Journal of Respiratory and Critical Care Medicine and research shows that high doses of vitamin D supplementation improved respiratory muscle strength in patients with Chronic Obstructive Pulmonary

Octomom's Doctor is Placed on Probation

Remember the media blitz over Nadya Suleman, the Southern California mother who underwent IVF and gave birth to eight babies?   The unemployed, single mother of 6 was only the second ever to give birth to a full set of octuplets.   Now, two years after the sensational births, the California State Medical Board has revoked the license of Beverly Hills fertility doctor, Michael Kamrava.  However

The Placebo Effect is Strong Medicine

Thanks to Kevin MD , (via Lukas Zinnagl, MD) for pointing me to this fascinating video on the Placebo Effect.  What is amazing is that placebos work even when the patient knows it is a placebo!  That is the power of the mind.  Check it out an be amazed!

Should Doctors Wear White Coats?

The Doctor's white coat has been a symbol of the profession for decades.  In the 1800's and up through the early 20th Century, doctors wore street clothes while performing surgery...rolling up their sleeves and plunging dirty hands into patient's bodies.  They often were dressed in formal black, like the clergy to reflect the solemn nature of their role.  (And seeing a doctor was solemn indeed as

Heart Disease and Heart Attacks

This amazing site called Kahn Academy is just filled with information on every subject!  This video explains atherosclerosis, heart attack and heart failure.  Watch and learn.

Why You Need a Colonoscopy

One of my pet peeves as a Physician is when people talk about screening tests "Preventing Cancer".  Mammograms, pap tests, prostate tests (PSA), X-rays, blood tests, ultrasounds do not prevent cancer.  The best they can do is detect an abnormality early and allow for treatment.  None of those tests prevent a malignancy.  There is one screening test, however, that CAN prevent cancer and that is a

Food Reward: a Dominant Factor in Obesity, Part V

Non-industrial diets from a food reward perspective

In 21st century affluent nations, we have unprecedented control over what food crosses our lips.  We can buy nearly any fruit or vegetable in any season, and a massive processed food industry has sprung up to satisfy (or manufacture) our every craving.  Most people can afford exotic spices and herbs from around the world-- consider that only a hundred years ago, black pepper was a luxury item.  But our degree of control goes even deeper: over the last century, kitchen technology such as electric/gas stoves, refrigerators, microwaves and a variety of other now-indispensable devices have changed the way we prepare food at home (Megan J. Elias.  Food in the United States, 1890-1945). 

To help calibrate our thinking about the role of food reward (and food palatability) in human evolutionary history, I offer a few brief descriptions of contemporary hunter-gatherer and non-industrial agriculturalist diets.  What did they eat, and how did they prepare it? 
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Facial Cellulitis

This 39 yer old woman had a small sore inside her nostril.  It worsened  and her nose started getting red so she was put on ciprofloxacin antibiotic.  The redness improved but 5 days into treatment two pustules developed and the erythema worsened.  A culture of one of the pustules grew out methicillin-resistant Staphylococcus aureus (MRSA).  She was treated with intravenous antibiotics and her

Time for Medicare to Quit Ignoring Primary Care

An article by Brian Klepper and Paul Fischer at Health Affairs has me all fired up.  Finally these two health experts are calling it like it is.  The Wall Street Journal, New York Times and EverythingHealth have written before about the way primary care is undervalued and underpayed in this country and how it is harming the health and economics of the United States.  A secretive,

Divorce rates higher in couples with long commutes

Researchers at Umea University in  Sweden found that divorce rates are 40% higher in people who have commutes greater than 45 minutes.  The study looked at 2 million households and found that long commutes were even more difficult for women.  The risk for divorce was highest during the first few years of commuting. 

We have been a commuting culture for decades...especially in large urban areas

Food Reward: a Dominant Factor in Obesity, Part IV

What is Food Reward?

After reading comments on my recent posts, I realized I need to do a better job of defining the term "food reward".  I'm going to take a moment to do that here.  Reward is a psychology term with a specific definition: "a process that reinforces behavior" (1).  Rewarding food is not the same thing as food that tastes good, although they often occur together. 

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Why Health Care Costs So Much

It is my job at EverythingHealth to steer the reader to great information.  For this reason I am providing you with a Link to The New England Journal of Medicine article titled "The $650 Billion Dollar question - why does cost effective care diffuse so slowly?"  I have retitled it "Why Health Care Costs So Much".

The United States spends much more on health care than other industrialized nations

Healthy Skeptic Podcast

Chris Kresser has just posted our recent interview/discussion on his blog The Healthy Skeptic.  You can listen to it on Chris's blog here.  The discussion mostly centered around body fat and food reward.  I also answered a few reader questions.  Here are some highlights:

• How does the food reward system work? Why did it evolve?
• Why do certain flavors we don’t initially like become appealing over time?
• How does industrially processed food affect the food reward system?
• What’s the most effective diet used to make rats obese in a research setting? What does this tell us about human diet and weight regulation?
• Do we know why highly rewarding food increases the set point in some people but not in others?
• How does the food reward theory explain the effectiveness of popular fat loss diets?
• Does the food reward theory tell us anything about why traditional cultures are generally lean?
• What does cooking temperature have to do with health?
• Reader question: How does one lose fat?
• Reader question: What do I (Stephan) eat?
• Reader question: Why do many people gain fat with age, especially postmenopausal women?

The podcast is a sneak preview of some of the things I'll be discussing in the near future.  Enjoy!

Top Ten Greatest Public Health Achievements of this Century

The Center for Disease Control published the top ten public health achievements from 2001-2010, the first decade of the 21st century.  In no order they are:

Vaccine-preventable Diseases - new vaccines for herpes zoster, pneumonia, HPV and rotavirus have saved thousands of lives  When you add in the older vaccines for diptheria, pertussus, tetanus and measles/mumps millions of lives have been

Fast Food, Weight Gain and Insulin Resistance

CarbSane just posted an interesting new study that fits in nicely with what we're discussing here.  It's part of the US Coronary Artery Risk Development in Young Adults (CARDIA) study, which is a long-term observational study that is publishing many interesting findings.  The new study is titled "Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis" (1).  The results speak for themselves, loud and clear (I've edited some numbers out of the quote for clarity):
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Answer to Medical Challenge

This is a really good one and several of you got it right.  The answer is #1. Endometrioma.  (scroll to post on 5/19/2011 for the image)

The woman's medical history was significant for dysmenorrhea (painful periods) and two recent laparoscopic resections of endometriomas. Histologic examination after resection of the nodule revealed the presence of endometrial glands and stroma. Endometriosis of

California will release expensive medical prisoners

I wrote previously about the Governor from Mississippi who released two sisters from prison because the cost of providing dialysis was more than the prison system could bear.  This seems to be a nationwide trend.  Under a state law signed by Gov. Arnold Schwarzenegger in September, prisoners who are in a highly incapacitated state and deemed to pose no threat to society can be released if the

This Weeks Medical Challenge

It's time again to test your diagnostic skill with the New England Journal of Medicine image challenge. (click on the image to see up close)   The nodule formed in this young woman in the umbilical (naval) area and bled intermittently.  What is the diagnosis?

1.  Endometrioma
2.  Metastatic adenocarcinoma
3.  Omphalith
4.  Umbilical hernia
5.  Urachal cyst

Give me your best answer as a comment

Food Reward: a Dominant Factor in Obesity, Part III

Low-Fat Diets

In 2000, the International Journal of Obesity published a nice review article of low-fat diet trials.  It included data from 16 controlled trials lasting from 2-12 months and enrolling 1,910 participants (1).  What sets this review apart is it only covered studies that did not include instructions to restrict calorie intake (ad libitum diets).  On average, low-fat dieters reduced their fat intake from 37.7 to 27.5 percent of calories.  Here's what they found:
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Clarifications About Carbohydrate and Insulin

My statements about carbohydrate and insulin in the previous post seem to have kicked up some dust!  Some people are even suggesting I've gone low-fat!  I'm going to take this opportunity to be more specific about my positions.

I do not think that post-meal insulin spikes contribute to obesity, and they may even oppose it. Elevated fasting insulin is a separate issue-- that's a marker of insulin resistance.  It's important not to confuse the two.  Does insulin resistance contribute to obesity?  I don't know, but it's hypothetically possible since insulin acts like leptin's kid brother in some ways.  As far as I can tell, starch per se and post-meal insulin spikes do not lead to insulin resistance.
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Powerful Men with Powerful Flaws

aArnold Schwarzenegger's revelation about his long-term  affair with his household employee that involved a child being born is the latest in a string of powerful men with career ending flaws.  Add to that the  shocking arrest this week of powerful Dominique Strauss-Kahn for allegedly raping a hotel maid and we must ask, "What the heck is going on with these guys?"

 I can't count the number of

Real Food Doesn't Need Hype

The article from The New York Times about "Foods with Benefits" is a great read.  (Don't click now...read this post first and then read the article).  It talks about what consumers are seeing at the grocery aisles as well as in advertising.  Food is being packaged and advertised as a miracle for good health.  They say certain foods can lower cholesterol, fix irritable bowel, cause weight loss or

Healthy Skeptic Podcast and Reader Questions

Chris Kresser, Danny Roddy and I just finished recording the podcast that will be released on May 24th.  It went really well, and we think you'll find it informative and maybe even practical!

Unfortunately, we only got around to answering three of the questions I had selected:

1. How does one lose fat?
2. What do I (Stephan) eat?
3. Why do many people gain fat with age, especially postmenopausal women?

I feel guilty about that, so I'm going to answer three more right now.

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NSAIDs are a problem for Cardiac Patients

New information published in Circulation advises against using any nonsteroidal anti-inflammatory drugs (NSAIDs) in patients who have had a prior heart attack.  These over-the-counter drugs are commonly used  like Advil, Aleeve, Diclofenac, Ibuprofen.  Using NSAIDs for even as little as one week was associated with a 45% increase for death or recurrent myocardial infarction (MI).  The researchers

Administrative Note

My blog is being mercilessly ripped off by cheesy feed aggregators that are using my material for commercial gain, often without attribution.  I was able to ignore them when there were only one or two, and when they appeared far down the list on Google searches.  But at this point, there are 20+ rip-off sites that ride my coattails under questionable circumstances, and are getting decent Google rankings, so I've had enough.  I'm changing my feed settings so that I only partially syndicate my posts, and I'm adding a short plagiarism warning to each post.

What that means is that if you're using an RSS reader, you'll have to click through to my blog to read my material in full.  I apologize for the inconvenience, but I don't see any other solution.

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Ask Me a Question

On May 13th, I'll be recording a podcast with Chris Kresser of The Healthy Skeptic. Chris interviewed me about a year ago, and I thought it went well. Chris is a good host and asks interesting questions.

This time around, we're going to do things a bit differently. I'll start with a little overview of my current thoughts on obesity, then we'll answer reader questions. The show is going to be mostly about obesity and related matters, but I may answer a couple of questions that aren't related to obesity if they're especially interesting. There are two ways to leave questions: either in the comments section of this post, or the comments section of Chris's post. The show will air on May 24th.
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Best and Worst Place to be a Mother in the World

Happy Mothers Day to mothers everywhere.  It is an important day for us to honor women and acknowledge the incredible hard work of mothering. There are some places in the world where being a mother is positively life threatening.  The worst place to be a mother is Afghanistan.

Childbirth in Afghanistan is  primeval.  One in 8 women in Afghanistan die during pregnancy or childbirth, more than any

Answer to Medical Challenge

The answer to yesterday's medical challenge is....drumroll.....

#4 -  Sugar

Plain granulated sugar can be applied to the mucosa of the prolapsed structure (such as the ileum in this case) to promote the osmotic shift of fluid out of the edematous tissue.  In this case, within 2 minutes, the edema had diminished sufficiently to allow spontaneous reduction of the prolapse.

Thanks to all who made

The Hardest Image Challenge

 Q:  A prolapse such as this can be effectively reduced by applying what common household substance to the tissue?
1.  Baking powder
2.  Flour
3.  Salt
4.  Sugar
5.  Tea


This is the hardest image challenge from the New England Journal Of  Medicine that I have seen.  Fellow physicians, and EverythingHealth readers, I want you to go out on a limb and give me the answer. 

For you non-physicians,

Pay It Forward With Organ Donations

With all of the news focus on Osama Bin Laden's death and memories of 9-11, it is time for a feel good story.  We have one compliments of Loyola University Medical Center in Illinois.   A total of 7 kidneys have been donated by perfect strangers and 5 of them were from hospital employees.  Loyola has set up a "Pay it Forward" program to inspire others to do the same.  When a person gets a good

The Top Ten Prescribed Drugs in the U.S.

 The top 10 prescribed drugs in the U.S. for 2010 in order of prescriptions written are:
  
Hydrocodone (combined with acetaminophen) -- 131.2 million prescriptions
Generic Zocor (simvastatin), a cholesterol-lowering statin drug -- 94.1 million prescriptions
Lisinopril (brand names include Prinivil and Zestril), a blood pressure drug -- 87.4 million prescriptions
Generic Synthroid (levothyroxine

Physicians Complicit in Gitmo Torture

As more and more facts come out of Guantanamo Bay prison, one of the worst is that physicians caring for the detainees may have been part of torture of the inmates.  Physicians for Human Rights researchers examined medical records, affidavits and third party examinations of nine prisoners who claimed they were tortured at Gitmo.  They found injuries that were highly consistent with torture and

Food Reward: a Dominant Factor in Obesity, Part I

A Curious Finding

It all started with one little sentence buried in a paper about obese rats. I was reading about how rats become obese when they're given chocolate Ensure, the "meal replacement drink", when I came across this:

...neither [obesity-prone] nor [obesity-resistant] rats will overeat on either vanilla- or strawberry-flavored Ensure.

The only meaningful difference between chocolate, vanilla and strawberry Ensure is the flavor, yet rats eating the chocolate variety overate, rapidly gained fat and became metabolically ill, while rats eating the other flavors didn't (1). Furthermore, the study suggested that the food's flavor determined, in part, what amount of fatness the rats' bodies "defended."

As I explained in previous posts, the human (and rodent) brain regulates the amount of fat the body carries, in a manner similar to how the brain regulates blood pressure, body temperature, blood oxygenation and blood pH (2). That fact, in addition to several other lines of evidence, suggests that obesity probably results from a change in this regulatory system. I refer to the amount of body fat that the brain defends as the "body fat setpoint", however it's clear that the setpoint is dependent on diet and lifestyle factors. The implication of this paper that I could not escape is that a food's flavor influences body fatness and probably the body fat setpoint.

An Introduction to Food Reward

The brain contains a sophisticated system that assigns a value judgment to everything we experience, integrating a vast amount of information into a one-dimensional rating system that labels things from awesome to terrible. This is the system that decides whether we should seek out a particular experience, or avoid it. For example, if you burn yourself each time you touch the burner on your stove, your brain will label that action as bad and it will discourage you from touching it again. On the other hand, if you feel good every time you're cold and put on a sweater, your brain will encourage that behavior. In the psychology literature, this phenomenon is called "reward," and it's critical to survival.

The brain assigns reward to, and seeks out, experiences that it perceives as positive, and discourages behaviors that it views as threatening. Drugs of abuse plug directly into reward pathways, bypassing the external routes that would typically trigger reward. Although this system has been studied most in the context of drug addiction, it evolved to deal with natural environmental stimuli, not drugs.

As food is one of the most important elements of survival, the brain's reward system is highly attuned to food's rewarding properties. The brain uses input from smell, taste, touch, social cues, and numerous signals from the digestive tract* to assign a reward value to foods. Experiments in rats and humans have outlined some of the qualities of food that are inherently rewarding:

• Fat
• Starch
• Sugar
• Salt
• Meatiness (glutamate)
• The absence of bitterness
  
• Certain textures (e.g., soft or liquid calories, crunchy foods)
• Certain aromas (e.g., esters found in many fruits)
• Calorie density ("heavy" food)
  

We are generally born liking the qualities listed above, and aromas and flavors that are associated with these qualities become rewarding over time. For example, beer tastes terrible the first time you drink it because it's bitter, but after you drink it a few times and your brain catches wind that there are calories and a drug in there, it often begins tasting good. The same applies to many vegetables. Children are generally not fond of vegetables, but if you serve them spinach smothered in butter enough times, they'll learn to like it by the time they're adults.

The human brain evolved to deal with a certain range of rewarding experiences. It didn't evolve to constructively manage strong drugs of abuse such as heroin and crack cocaine, which overstimulate reward pathways, leading to the pathological drug seeking behaviors that characterize addiction. These drugs are "superstimuli" that exceed our reward system's normal operating parameters. Over the next few posts, I'll try to convince you that in a similar manner, industrially processed food, which has been professionally crafted to maximize its rewarding properties, is a superstimulus that exceeds the brain's normal operating parameters, leading to an increase in body fatness and other negative consequences.


* Nerves measure stomach distension. A number of of gut-derived paracrine and endocrine signals, including CCK, PYY, ghrelin, GLP-1 and many others potentially participate in food reward sensing, some by acting directly on the brain via the circulation, and others by signaling indirectly via the vagus nerve. More on this later.