Monday, May 30, 2011

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,

Sunday, May 29, 2011

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

Thursday, May 26, 2011

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. 

Read more »

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

Tuesday, May 24, 2011

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!

Monday, May 23, 2011

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

Sunday, May 22, 2011

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):
Read more »

Saturday, May 21, 2011

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

Thursday, May 19, 2011

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

Wednesday, May 18, 2011

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:
Read more »

Tuesday, May 17, 2011

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.
Read more »

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

Sunday, May 15, 2011

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

Friday, May 13, 2011

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.

Read more »

Tuesday, May 10, 2011

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.

Read more »

Sunday, May 8, 2011

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.
Read more »

Saturday, May 7, 2011

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

Friday, May 6, 2011

Food Reward: a Dominant Factor in Obesity, Part II

How to Make a Rat Obese

Rodents are an important model organism for the study of human obesity. To study obesity in rodents, you have to make them fat first. There are many ways to do this, from genetic mutations, to brain lesions, to various diets. However, the most rapid and effective way to make a normal (non-mutant, non-lesioned) rodent obese is the "cafeteria diet." The cafeteria diet first appeared in the medical literature in 1976 (1), and was quickly adopted by other investigators. Here's a description from a recent paper (2):

In this model, animals are allowed free access to standard chow and water while concurrently offered highly palatable, energy dense, unhealthy human foods ad libitum.
In other words, they're given an unlimited amount of human junk food in addition to their whole food-based "standard chow." In this particular paper, the junk foods included Froot Loops, Cocoa Puffs, peanut butter cookies, Reese's Pieces, Hostess Blueberry MiniMuffins, Cheez-its, nacho cheese Doritos, hot dogs, cheese, wedding cake, pork rinds, pepperoni slices and other industrial delicacies. Rats exposed to this food almost completely ignored their healthier, more nutritious and less palatable chow, instead gorging on junk food and rapidly attaining an obese state.

Investigators have known for decades that the cafeteria diet is a highly effective way of producing obesity in rodents, but what was interesting about this particular study from my perspective is that it compared the cafeteria diet to three other commonly used rodent diets: 1) standard, unpurified chow; 2) a purified/refined high-fat diet; 3) a purified/refined low-fat diet designed as a comparator for the high-fat diet. All three of these diets were given as homogeneous pellets, and the textures range from hard and fibrous (chow) to soft and oily like cookie dough (high-fat). The low-fat diet contains a lot of sugar, the high-fat diet contains a modest amount of sugar, and the chow diet contains virtually none. The particular high-fat diet in this paper (Research Diets D12451, 45% fat, which is high for a rat) is commonly used to produce obesity in rats, although it's not always very effective. The 60% fat version is more effective.

Consistent with previous findings, rats on every diet consumed the same number of calories over time... except the cafeteria diet-fed rats, which ate 30% more than any of the other groups. Rats on every diet gained fat compared to the unpurified chow group, but the cafeteria diet group gained much more than any of the others. There was no difference in fat gain between the purified high-fat and low-fat diets.

So in this paper, they compared two refined diets with vastly different carb:fat ratios and different sugar contents, and yet neither equaled the cafeteria diet in its ability to increase food intake and cause fat gain. The fat, starch and sugar content of the cafeteria diet was not able to fully explain its effect on fat gain. However, each diets' ability to cause fat gain correlated with its respective food reward qualities. Refined diets high in fat or sugar caused fat gain in rats relative to unpurified chow, but were surpassed by a diet containing a combination of fat, sugar, starch, salt, free glutamate (umami), interesting textures and pleasant and invariant aromas.

Although the cafeteria diet is the most effective at causing obesity in rodents, it's not commonly used because it's a lot more work than feeding pellets, and it introduces a lot of variability into experiments because each rat eats a different combination of foods.

How to Make an Obese H
uman Lean

In 1965, the Annals of the New York Academy of Sciences published a very unusual paper (3). Here is the stated goal of the investigators:
The study of food intake in man is fraught with difficulties which result from the enormously complex nature of human eating behavior. In man, in contrast to lower animals, the eating process involves an intricate mixture of physiologic, psychologic, cultural and esthetic considerations. People eat not only to assuage hunger, but because of the enjoyment of the meal ceremony, the pleasures of the palate and often to gratify unconscious needs that are hard to identify. Because of inherent difficulties in studying human food intake in the usual setting, we have attempted to develop a system that would minimize the variables involved and thereby improve the chances of obtaining more reliable and reproducible data.
Here's a photo of their "system":
It's a machine that dispenses bland liquid food through a straw, at the push of a button. They don't give any information on the composition of the liquid diet, beyond remarking that "carbohydrate supplied 50 per cent of the calories, protein 20 per cent and fat 30 per cent. the formula contained vitamins and minerals in amount adequate for daily maintenance."

Volunteers were given access to the machine and allowed to consume as much of the liquid diet as they wanted, but no other food. Since they were in a hospital setting, the investigators could be confident that the volunteers ate nothing else.

The first thing they report is what happened when they fed two lean people using the machine, for 16 or 9 days. Both of them maintained their typical calorie intake (~3,075 and ~4,430 kcal per day) and maintained a very stable weight during this period.

Next, the investigators did the same experiment using two "grossly obese" volunteers. Again, they were asked to "obtain food from the machine whenever hungry." Over the course of the first 18 days, the first (male) volunteer consumed a meager 275 calories per day. The second (female) volunteer consumed a ridiculously low 144 calories per day over the course of 12 days, losing 23 pounds. Without showing data, the investigators remarked that an additional three obese volunteers "showed a similar inhibition of calorie intake when fed by machine."

The first volunteer continued eating bland food from the machine for a total of 70 days, losing approximately 70 pounds. After that, he was sent home with the formula and instructed to drink 400 calories of it per day, which he did for an additional 185 days, after which his total weight loss was 200 lbs. The investigators remarked that "during all this time weight was steadily lost and the patient never complained of hunger or gastrointestinal discomfort." This is truly a starvation-level calorie intake, and to eat it continually for 255 days without hunger suggests that something rather interesting was happening in this man's body.

This machine-feeding regimen was nearly as close as one can get to a diet with no rewarding properties whatsoever. Although it contained carbohydrate and fat, it did not contain any flavor or texture to associate them with, and thus the reward value of the diet was minimized. As one would expect if food reward influences the body fat setpoint, lean volunteers maintained starting weight and a normal calorie intake, while their obese counterparts rapidly lost a massive amount of fat and reduced calorie intake dramatically without hunger. This suggests that obesity is not entirely due to a "broken" metabolism (although that may still contribute), but also at least in part to a heightened sensitivity to food reward in susceptible people. This also implies that obesity may not be a disorder, but rather a normal response to the prevailing dietary environment in affluent nations.

A second study by Dr. Michel Cabanac in 1976 confirmed that reducing food reward (by feeding bland food) lowers the fat mass setpoint in humans, using a clever method that I won't discuss for the sake of brevity (4). I learned about both of these studies through the writing of Dr. Seth Roberts, author of The Shangri-La Diet. I'd also like to thank Dr. Stephen Benoit, a researcher in the food reward field, for talking through these ideas with me to make sure I wasn't misinterpreting them.

I'd like to briefly remark that there's an anatomical basis for the idea of two-way communication between brain regions that determine reward and those that control body fatness. It's well known that the latter influence the former (think about your drive to obtain food after you've just eaten a big meal vs. after you've skipped a meal), but there are also connections from the former to the latter via a brain region called the lateral hypothalamus. The point is that it's anatomically plausible that food reward determines in part the amount of body fat a person carries.

Some people may be inclined to think "well, if food tastes bad, you eat less of it; so what!" Although that may be true to some extent, I don't think it can explain the fact that bland diets affect the calorie intake of lean and obese people differently. To me, that implies that highly rewarding food increases the body fat setpoint in susceptible people, and that food with few rewarding properties allows them to return to a lean state.

In the next few posts, I'll describe how food reward explains the effectiveness of many popular fat loss diets, I'll describe how this hypothesis fits in with the diets and health of non-industrial cultures, and I'll outline new dietary strategies for preventing and treating obesity and certain forms of metabolic dysfunction.

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

Wednesday, May 4, 2011

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,

Monday, May 2, 2011

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