Tag Archive for: obesity

Addressing the Systems of Health and Disease

/in /by

A systems approach to dealing with diseases and conditions is not what we currently do: if you have pain, you want to relieve the pain. That approach may fix the symptom, but it also may not fix the failure of a complex system that caused the problem. If you’ve broken a bone or had a torn ligament surgically repaired, that was not a system failure, but the approach to get things back to normal would be the same. Multiple systems would be involved, not just pain control.

To illustrate the point, I’m going to talk about one of the most complicated conditions: carrying too much body fat. It affects 70% of the population of the U.S. and is a growing problem around the world. My advice for dealing with it goes like this: Eat less. Eat better. Move more. Those recommendations really don’t change, but to permanently lose the weight and keep it off, the number of systems involved is staggering.

A Systems Overview of Obesity

Here are some of the questions yet to be answered about organs and systems that are involved in weight reduction:

  • What will happen to fat cells? The fat cells manufacture hormones that can impact appetite and hunger. At this point, there’s no research to suggest they’re ever reabsorbed.
  • The pancreas produces digestive enzymes and insulin. How will less food or different foods along with more exercise impact their involvement in digestion and metabolism?
  • Our taste buds have developed over the years. Will they change to reduce the taste and feel of sugar, fat, salt, and umami we may crave?
  • Can the impact of insulin on the liver change? Your liver develops a process to convert carbohydrate to fat and store it. Will that be reversed?
  • Will the adrenal gland respond to the decrease in fat intake and cholesterol production to reduce the production of cortisol and lower inflammation?
  • What happens to the microbiome in the long term? Does it adapt? Does it stimulate hunger or decrease it?

I could go on and on, but I think you get the point. It’s complicated to deal with complex systems. We don’t have the answers yet because we haven’t been asking the right questions.

The Impact of Aging on Complex Systems

We know as people age, we lose muscle mass, gain body fat, and lose bone density among many other changes. What we don’t know much about is the specific changes in every type of cell, organ, or system. If we don’t have that, we may not be able to address the correct cog in the system. That doesn’t mean we shouldn’t try; we can take what we currently know about how our bodies change over a lifetime and use that as a starting point. The earlier in life the better, but we still have to deal with individuals and the bodies they have right now.

We live a lot longer than we did 100 years ago. It’s time we began making those years better in every way rather than simply managing pain and other infirmities.

The Bottom Line

This challenge lies before us: Find a way to manage complex systems in order to not just survive but thrive throughout our entire lives. That’s where I’m headed in developing Aging with a Vengeance. We have to deal with the changes from aging that contribute to where we are today, regardless of age. Along the way, we’ll find out the optimal age for preventing some of those issues or at least slowing them down. I’m pumped for this journey to be the best version of ourselves, regardless of our current age or physical state. We just have to keep our heads in the game.

What are you prepared to do today?

        Dr. Chet

Metabolically Healthy and Obese

/in /by

The researchers in Germany continued to determine which factors associated with being obese were the most predictive of mortality from any cause and from cardiovascular disease. While not explicitly stated, it seems to me that they attempted to use variables that were simple to assess. With that in mind, here are the variables which demonstrated whether someone was metabolically healthy or not, regardless if they were normal weight, overweight, or obese.

Criteria for Metabolic Health

  • Systolic blood pressure less than 130 and no use of blood pressure lowering medication
  • Waist-hip ratio less than 0.95 for women and less than 1.03 for men
  • No prevalent diabetes

These criteria are simple enough for most people to determine for themselves, no doctors necessary. People usually know whether they’re diabetic, and they also know whether they’re taking medication to lower their blood pressure. Most people have a home BP cuff to assess systolic blood pressure or have access to one in a store.

The waist should be measured at its widest point and hip should be measured at the bony process of the femur. Divide the second number into the first, and that gives you the waist hip ratio.

The Results

The subjects who were considered metabolically healthy and obese had no greater risk of mortality from all causes or from cardiovascular disease then did normal weight, metabolically healthy subjects. This study examined only the death rate, not the rate of disease. Still, I think that if someone is working towards becoming a healthier version of themselves, intermediate goals can be very motivating.

I like this study for two reasons. First, it confirms what I thought for many years: people who are overweight or obese can be metabolically healthy. Second, it means that instead of trying to lose all the weight a person needs to lose, there can be intermediate steps on the way to becoming the best version of yourself; in fact, you don’t even need to be trying to lose weight to start being healthier.

The study also found that some people who were metabolically unhealthy and normal weight or slightly overweight were at higher risk for cardiovascular disease and total mortality. Could it be that the reason for the reduced risk was exercise? It was not considered, but it would be interesting to see further analysis on the data to determine if fitness was a contributing factor in metabolic health.

The Bottom Line

This study provides a basis for assessing risk of mortality on more than just BMI. What it shows is that even though you may be carrying too much weight, that doesn’t mean that you’re automatically at risk for death due to cardiovascular disease or other causes. I believe regular exercise is critical to achieve metabolic health and thus reduce your mortality risk, so that’s your first step to becoming and staying metabolically healthy.

What are you prepared to do today?

        Dr. Chet

Reference: JAMA Net Open. doi:10.1001/jamanetworkopen.2021.8505

Can You Be Obese and Healthy?

/in /by

The research question that was most interesting to me as a graduate student was this: could you be overweight, even obese, and still be healthy? That question still interests me today, and for good reason: 70% of the U.S. population is overweight or obese, and we’ve just passed 40% of the entire population falling into the obese category. And it’s not just the U.S.; we’ve exported our poor fitness and diet habits around the world.

Research done decades ago from by Cooper Institute, most often under the direction of Steven Blair, demonstrated that you could be fat and fit. Their research showed that people who were obese, meaning they had a BMI greater than or equal to 30.0, were no more at risk for death from cardiovascular disease or all-cause mortality if they were in the high fitness category.

That’s not the same question as this: could you be metabolically healthy and at no more risk for death from cardiovascular disease or all-cause mortality than someone with a normal BMI (18.5-24.9 kg/m2)? Researchers from Germany decided to examine that question. They used data collected from the National Health and Nutrition Education Survey III, which included over 12,000 subjects, and the U.K. Biobank, which contained over 374,000 subjects. Then they examined the statistical relationship between many different variables such as triglycerides, total cholesterol, hemoglobin A1C, C-reactive protein, systolic blood pressure, and on and on. Once they had a series of statistical relationships between obesity and mortality, then they sought to derive as simple an algorithm as they could to develop a profile of someone who would be metabolically healthy and obese. I’ll tell you more about that in Saturday’s memo.

Meanwhile, have you examined that map that was part of the CDC atrial fibrillation primer? Here’s what I saw: I’ll call it the I-75 Corridor of A-fib. Starting in Flint, MI, if you follow the pattern of the deepest red, it follows I-75 through Detroit to Toledo, OH, then Cincinnati, OH, and all the way down through Georgia to Florida. That’s the I-75 Corridor of A-Fib. What does it mean? Nothing, as far as I know; it doesn’t correspond to race or income or temperature. It’s an observation, nothing more, but maybe some epidemiologist or statistician somewhere will look into in more deeply.

What are you prepared to do today?

        Dr. Chet

Reference: JAMA Net Open. doi:10.1001/jamanetworkopen.2021.8505

Obesity Game Changer?

/in /by

Obesity is a serious issue in the U.S. and around the world; type 2 diabetes, hypertension, CVD, and other diseases associated with obesity have significant health costs. That’s why a real game changer would be important to help people lose weight and maintain their weight loss. The latest candidate is semaglutide, an anti-diabetic medication used for the treatment of type 2 diabetes by increasing insulin secretion. In my opinion, the results of this study do not achieve game-changing status. Let’s take a look at the details.

There Was Limited Weight Loss

The mean weight loss was 14.9% which translated to 34 pounds in 68 weeks. That’s really not impressive; most people can lose a half pound a week by paying more attention to their diet and increasing their activity level. The rate of weight loss in the placebo group stabilized at about 20 weeks, and that’s where it stayed for the rest of the study. In the experimental group, the rate of weight loss declined twice; first at about 20 weeks and then again at 52 weeks. By 60 weeks, the experimental subjects did not appear to be losing any more weight.

The Lifestyle-Change Program Was Ineffective

With 35 years of experience in weight loss programs, my hunch is that by 20 weeks, both the placebo and the experimental group had reverted to their prior eating patterns. We don’t know for sure because no nutritional data were presented, but that would explain the lack of continued weight loss in the placebo group and slowing weight loss in the experimental group. The drug may be game-changing, but without permanent lifestyle changes, it’s just another weight loss drug.

The medication was effective in continuing weight loss in the experimental groups, but we don’t know how. Insulin is the most powerful hormone in the body, but we don’t know exactly how semaglutide helped these subjects lose weight. Did it influence appetite? Did it impact insulin levels alone?

At What Price?

The lowest price I could find with insurance coverage was $800 per month. This would be cost-prohibitive for most people. Another way of looking at: it cost $376 per pound of weight lost. I’m not sure that’s worth the price because we still don’t know if the drug will help maintain the loss for a significant period.

And besides the monetary cost, what physical cost did the drug have? Every drug has side effects. That’s why in most cases I recommend trying lifestyle changes before adding a medication; if unhealthy habits helped create the problem, changing those habits is the best place to start. Even if a healthier diet and increased activity don’t solve the problem, those changes may mean you can take a lower dose of the med, thus reducing side effects. Except in urgent cases, most doctors will give you some time to try lifestyle changes before adding a medication.

The Bottom Line

I consider the study a failure because the subjects in both groups never learned how to change their food intake and exercise behaviors. Yes, those people taking the pharmaceutical did better related to weight loss, and because of that, some metabolic factors improved. But the rate of weight loss slowed down as the study progressed and eventually appeared to stop. Maybe this drug will give some people an edge with initial weight loss and thus improve their odds of long-term success, but if they don’t permanently change their behaviors, they won’t permanently lose weight.

We have to quit thinking of a healthier diet as a temporary change. The challenge is not losing weight; the challenge is in maintaining the lost weight. If you go back to your old eating habits, you’ll go back to your old weight; if you won’t commit to changing your diet and activity, taking a pill isn’t going to help you for very long.

While interesting, this study doesn’t change the game. The game was, is, and always will be eat better, eat less, and move more. For life.

What are you prepared to do today?

        Dr. Chet

Reference: NEJM. 2021. DOI: 10.1056/NEJMoa2032183

“Game-Changing” Treatment for Obesity!

/in /by

If ever a health headline gets your attention, it’s one that proclaims there’s a better way to lose weight. “A game changer” said one of the principle authors of the study in a news release about the study. The results of any study that suggests “game-changing results” just has to be reviewed, and that’s what I’ll do in this week’s Memos.

The study was a trial of 1,961 subjects conducted at 129 sites around the world. The subjects were randomly assigned to the experimental group and placebo group in a 2:1 ratio. The experimental group received once-weekly injections of semaglutide, currently approved as a diabetes treatment, while the controls were injected with a placebo. Both groups received individual counseling sessions every four weeks to help them adhere to a reduced-calorie diet and increased physical activity. The study was 68 weeks long.

After 68 weeks, the mean change in body weight from baseline to week 68 was 14.9% or 34 pounds in the semaglutide group as compared with 2.4% in the placebo or about six pounds. Anthropometric measures, BMI, and cardiovascular and metabolic measures were better in the semaglutide group compared to the controls.

The results of the trial have already caused the manufacturer to apply for a rapid approval review as a weight loss drug. The question is this: is it really a game changer in the treatment for obesity? I’ll talk about that on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: NEJM. 2021. DOI: 10.1056/NEJMoa2032183

How the Quality of Your Diet Changes Your Mycobiome

/in /by

In the experiment I told you about on Tuesday, the researchers established that environment—exposure to light, temperature, and other environmental factors—affects the microbiome, including the fungi or mycobiome. The researchers then tested the changes in the mycobiome (the fungus part of the microbiome) after feeding the mice a highly processed diet compared with mice eating conventional mice chow. They also monitored changes in body composition, triglycerides, and other hormones related to obesity.

After eight weeks on the highly processed diet, there were differences in the quantity of fungi. Some groups of related organisms increased while others decreased. Because not every group has known roles in digestion and metabolism, the researchers examined metabolic changes in response to the dietary change; they found an increase in body fat and triglycerides in the male mice along with concurrent changes in hormones that signified a move toward prediabetes. (For some reason, the female mice in this species are protected from those effects.)

After examining the composition of the highly processed chow, I’d like to have seen one more group of mice in the experimental group. Because the highly processed chow had no fiber, it would have been helpful to see what would happen to the entire microbiome if the amount of fiber was the same in the processed chow as the conventional chow. Maybe it wouldn’t have impacted the fungi at all, or the change could have been significant.

The Bottom Line

What lessons can we learn from this study? We’re not mice after all. I think it means that a highly processed, highly-refined carbohydrate diet may cause undesirable changes in our microbiome, including the fungal levels as well. For example, Candida albicans is a primary fungus in our digestive system, but it can cause all kinds of problems if it gets out of control. Reducing refined carbohydrates has a beneficial impact on keeping that fungus at beneficial levels.

Regardless of your current age, a better diet is part of Aging with a Vengeance. Reducing processed food, especially carbohydrates, can benefit your microbiome and all that it impacts. Time to start now.

What are you prepared to do today?

        Dr. Chet

Reference: Comm Bio (2021).4:281 https://doi.org/10.1038/s42003-021-01820-z

Does Exercise Intensity Affect Obesity?

/in /by

As I wrote on Thursday, exercise intensity did not seem to impact mortality, or death rate, in a large group of older women. Of course, living longer is important to many people. Could exercise intensity provide benefits as it relates to reducing the staggering 40% rate of obesity in the U.S.? Maybe. Let’s look at a recent study from Taiwan.

The Taiwan Biobank Study is a longitudinal study that recruits Han Chinese subjects 30 to 70 years old. Much like the All of Us study, researchers take anthropometric data such as height and weight as well as blood samples for multiple DNA analyses. They also collected data on physical activity; their objective for this part of the study was to see if exercise and the intensity of exercise impacted genetic manifestations of obesity.

Genes and Obesity 

What manifestations? Body mass index, percent body fat, and waist circumference among others. Researchers asked the subjects what type of exercise they did, how long they exercised, and how many times per month they exercised. Then they calculated a BMI Genetic Risk Score (BMIGRS) based on the genetic markers for five obesity-related gene combinations. This was complicated; you know I like to see raw data, but with over 16,000 subjects and all of the compounding variables, that’s not realistic.

When they divided the subjects into quartiles based on BMIGRS, they found that the exercise with the greatest impact on the obesity-related genes was jogging. That was followed closely by mountain climbing, walking, exercise walking, international standard dancing (the kind of ballroom dance you learn at a studio or see on Dancing With the Stars), and a longer practice of yoga. Those activities had an impact on the expression of the genes related to obesity. It means that it down-regulated those genes, which means that if you jog, your BMI is lower, you have a lower percent body fat, and your waist circumference will be smaller.

Do you have to jog? No. All the listed exercises had an impact on the obesity genes so if you can’t jog, that’s fine. Extended yoga and dance were also on that list, and they don’t have the impact on joints that jogging or even mountain walking would have.

There were also some other interesting findings. Joggers exercised less time, about 30 minutes, and fewer days per month, about every other day. Walkers walked nearly an hour at a time and walked two out of three days.

The Bottom Line      

One thing was clear: every type of exercise was better than no exercise. I’ve said many times before that exercise by itself is not a great way to lose weight because you have to invest so much time in it to have an impact, and no matter what exercise you choose, you still have to eat less. But if you want an advantage that will impact any obesity genes you have, higher intensity exercise is better. You have to adjust for orthopedic and any other issues, but the more intense the exercise, the better the results. If you’re going to walk 10,000 steps per day, walk them like you mean it.

What are you prepared to do today?

        Dr. Chet

 PLOS Genetics | https://doi.org/10.1371/journal.pgen.1008277.

Nutrition Education: The Best Solution

/in /by

The scientific paper about nutrition education programs from South America was an opinion piece derived from a student’s dissertation defense. It addressed nutrition labels in Brazil: the labels were too focused on the caloric content instead of the ingredient information.

The paper gives an example of two foods that have 97 calories but are vastly different in nutritional value. Chewy fruit-flavored candy had 21 grams of carbs, no protein, 1.5 grams of saturated fat, and no fiber; 14 almonds had 3.6 grams of carbohydrate, 3.5 grams of protein, 8.4 grams of healthy fat, and 2.1 grams of fiber. The almonds also had several vitamins and minerals while the chewy fruit candy had none.

The question is whether labels alone can change the nutritional health of a nation. Hard to say. Brazil came up with a simple public health approach using three recommendations:

  1. Choose whole, minimally processed foods
  2. Cook those foods yourself
  3. Eat those foods with other people

I think that’s an excellent approach. It means that people may have to shop a little more often and spend more time preparing food. But when you consider travel to get take-out or fast food, or the expense of food delivery, we can get better and fresher quality foods with fewer preservatives and more nutrition for around the same price.

Eating those foods with other people, at a minimum, means that families eat at least one meal together daily, possibly two if we include breakfast. The other possibility is to invite neighbors, friends, or other family members. We don’t have to fix feasts; just fresh, healthier foods that are simple to cook and share.

The Bottom Line

I think the Brazilian approach could work in the U.S. If we were to use the public health nutrition education program from WWII with an emphasis on the benefits of the foods for our health along with videos people could use to prepare the foods simply, and even scale that down to individual communities where small groups could learn how to shop and cook, we can change the health of the nation.

I also think it begins with parents: they’ll have to lead the way if they expect children to eat better. When we visited Paula’s cousin, who has three children under two (a toddler girl and identical twin baby boys), we remarked at the variety of food their daughter was willing to eat. Her dad said that she may be the only kid in preschool asking, “Excuse me, where is the hummus?” It may mean that parents will have to learn more about healthier foods and how to prepare them. I think it’s a small price to pay to improve their kids’ potential for better health.

What are you prepared to do today?

        Dr. Chet

Reference: Adv. Nutr. 2019;10:549–556.

Improving Nutrition in South America

/in /by

One of the problems today with public nutrition education programs is that there’s an important element that would prefer it not be done. In fact, food manufacturers are doing all they can to avoid any approach that may impact sales of high-fat, high-sodium, high-sugar, and highly processed food. I get it—they want to sell as much as they can. But to suggest that ketchup is a vegetable in the school lunch program doesn’t make any sense. I’m not going to comment further because that could take a month of Memos.

Instead let’s look at what some countries in South America have done to address nutrition as their obesity and related disease rates rise. One of the most controversial steps was taken by Mexico: the government put a 10% tax on high-sugar drinks, snacks, and sugary cereals that have limited nutritional benefit compared to total calories. It was not easy because the people of Mexico, much like the U.S., are against paying any more in taxes. But as of 2019, consumption of sugary sodas has dropped 12% in the poorest segment of the population and 5% in more affluent segments.

One of the most innovative approaches is used in Chile: foods high in added sugar, saturated fats, sodium, and high in calories have to place black stop signs on the front of package labels, and those foods can’t be sold or promoted in schools or promoted on television. Children have been educated about the meaning of the label changes and are steering their parents away from foods with black stop signs on the labels.

These radical approaches had to fight the food industry all the way, but the good of the people outweighed the profits of the industry. There may be a better way yet, and that’s what I’ll talk about Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: https://www.washingtonpost.com/business/2019/07/16/latin-americas-war-obesity-could-be-model-us/

How Can We Improve Nutrition and Public Health?

/in /by

I recently read a couple of articles, one from a newspaper and another from a journal, that talked about South American countries and how their governments should deal with the obesity epidemic and how some are approaching this issue. There may be lessons we can use here for us in the U.S. and other parts of the world.

Some historical perspective: the last public health initiative that actually worked well in the U.S. was during WWII. To direct more meat to the people fighting the war, the government enlisted any and all means to convince the public that organ meats were actually delicacies. Instead of a simple call to support the war movement, the pitch was to help consumers understand how organ meats such as brains, intestines, liver, and kidneys were nutritious. Along with that, they provided recipes for how to prepare these special parts of cows and pigs. It worked and those cuts were really considered delicacies. After the war ended, the special nature of these parts gradually drifted away.

In my opinion, that was the most successful public health education program ever done. When you consider all that’s been done related to educating the public about cholesterol, fat, trans fat, and sugar, nothing has ever gotten people to change their habits; the nutrition facts label is often more confusing that helpful. It’s obvious we need help, but what and how? We’ll take a look at what these countries in South America have tried on Thursday.

What are you prepared to do today?

        Dr. Chet