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

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

 And why economics may well turn out to be the one and only way to getting you to exercise and reduce your weight. And, no, with economics I don't mean punishing you with penalty premiums on your health insurance and punitive taxes on your fast food. Let's leave such uninspired nonsense to the politicians. We can do better than that. Before I get to that point, let's pick up the thread from where we left it in the previous post. 

There I introduced you to the fact that the amazing arithmetic of sicker-equals-cheaper has been introduced by economists working in the employment of public health agencies. They are interested in the financial health of their government, not of a health insurance company. From that point of view, convincing smokers to quit and obese people to slim down doesn't seem to make much sense either. Here is why:

When smokers quit, their near-term health care costs may go down, but in the long run they will be offset by higher medical bills for causes unrelated to smoking but related to a longer life [1]. This longer life hurts the government twice. First, when smokers stop lighting up they also stop paying tobacco taxes to the government. Second, with longer lives come longer pension payments. In fact, if all smokers would quit today, we would have very unhappy finance ministers. Ours, here in Germany, would have his tax revenues reduced by € 14.5 Billion per annum. 

What goes for smoking goes for obesity, too. So, how sincere are our politicians with their professed concerns for our health? Is this a pretext for soon taxing your consumption of sugar and fast food? Well, they certainly have the backing of the World Health Organization. The WHO recommended the introduction of punitive taxes in their 2010 Global status report on noncommunicable diseases. What our politicians apparently don't have is the ingenuity to come up with a more innovative solution, for once. Which is why we have to find it. By looking a little closer at the economics of health.  

So, I'm asking you: aside from you personally, who benefits from your health so much, that promoting it makes economic sense? Your employer, for instance. Not only is a healthy employee less often absent from work, he is also more productive while he is at work. The costs related to work absence have been appropriately termed absenteeism, which makes you immediately understand what is meant with its twin, presenteeism. It describes the costs of being less productive while at work. 

As it turns out, presenteeism clobbers companies' profits much more than absenteeism. In fact, for cardiovascular disease and diabetes, the costs of reduced productivity, while at work, exceed those of absenteeism by a factor of 10 [2]. Admittedly, the calculation of presenteeism is not an exact science. But all available evidence points to a substantial return on employers' investments into preventing those chronic diseases, which produce chronically less productive workers. Across companies and nations, the overall cost:benefit ratio has been found to be in the region of 1:2.2 [3]. Which means, for every dollar spent on corporate health promotion, 2.2 dollars are gained. Not bad. But it could be a lot better if you really did prevent those chronic diseases.

Only, you don't. How do I know? By looking at the trends for the 7 metrics used by the American Heart Association (AHA) as the Strategic Impact Goals for improving cardiovascular health. By 2020 cardiovascular health shall be improved by 20%. That doesn't sound very ambitious. But in all likelihood it is way too ambitious. Here is why: Let's look at obesity, which the IOM has just branded a "catastrophic" problem in the U.S.
Instead of falling, the percentage of obese people has been on the rise, again, over the past 10 years, with now 34% of women and 32% of men being obese [4]. Physical activity levels have not improved significantly, neither did dietary habits. Blood sugar control has actually worsened, and blood pressure control has only slightly improved in men. Based on these data the improvements of cardiovascular health in 2020 will be around 6%, not 20%.

That's how I know that you aren't following your employer's corporate health program. Why would you when you don't follow public health's promotions and recommendations in the first place? Unless, of course, your employer makes you an offer you can't refuse. What would you do if your employer rewarded your participation in his health promotion program with hard cash, additional leave, or a tangible good you desire? What if he tied those benefits to your effort (e.g. your participation rate), or your measurable outcome (e.g. kgs of weight lost, or weight maintenance), or any mixture of effort and result? Would that entice you to pick up healthier habits?

As I have pointed out before, the argument that people who live healthy generate less health care costs than their unhealthily living peers is unsubstantiated. But that should not make us eliminate economics as a metric when it comes to promoting health. On the contrary. By making health an economic good we bring to the table what motivates people most: tangible rewards. The question is, would it get you to pick up exercise, if you didn't do it already, and would it get you to lose weight, if you needed to?

The reason why I'm asking you is, because as a public health scientist, I'm utterly disillusioned with the success rate of our preventive efforts. On one hand, we have this wonderfully simple and enormously effective preventive tool called exercise and weight loss. And on the other hand we have 4 out of 5 people not using this tool. On one hand, we have the new guidelines for the treatment of diabetes [5] and for the prevention of cardiovascular disease  [6], both of which have been released over the past few weeks. Both guidelines acknowledge lifestyle change as the first line of defense against those diseases. But on the other hand we have less than 2% of the population achieving the 7 simple health metrics of the AHA. Guidelines won't change that. So, how can we make the remaining 98% of the population achieve the 7 metrics? Obviously not with the same song and dance that didn't get the job done in the past.

Which is why we need to explore new ways. Taxing your consumption of the foods you enjoy isn't new. Making health an investment good, that's new. But without attracting those people who we haven't reached in the past, it won't work either. Now what do you think?

Will tangible rewards make employees exercise and lose weight?

1.          Temple, N.J., Why prevention can increase health-care spending. The European Journal of Public Health, 2011.

2.          Collins, J.J., et al., The assessment of chronic health conditions on work performance, absence, and total economic impact for employers. J Occup Environ Med, 2005. 47(6): p. 547-57.

3.          Dietmar Bräunig and T. Kohstall, The return on prevention: Calculating the costs and benefits of investments in occupational safety and health in companies, 2012, ISSA: Geneva, Switzerland.

4.          Huffman, M.D., et al., Cardiovascular Health Behavior and Health Factor Changes (1988-2008) and Projections to 2020: Results from the National Health and Nutrition Examination Surveys (NHANES).Circulation, 2012.

5.           Inzucchi, S.E., et al., Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diab tologia, 2012.

6.           Perk, J., et al., European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts) * Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). European Heart Journal, 2012.

Temple, N. (2011). Why prevention can increase health-care spending The European Journal of Public Health DOI: 10.1093/eurpub/ckr139
 
Collins, J., Baase, C., Sharda, C., Ozminkowski, R., Nicholson, S., Billotti, G., Turpin, R., Olson, M., & Berger, M. (2005). The Assessment of Chronic Health Conditions on Work Performance, Absence, and Total Economic Impact for Employers Journal of Occupational and Environmental Medicine, 47 (6), 547-557 DOI: 10.1097/01.jom.0000166864.58664.29
 
Huffman MD, Capewell S, Ning H, Shay CM, Ford ES, & Lloyd-Jones DM (2012). Cardiovascular Health Behavior and Health Factor Changes (1988-2008) and Projections to 2020: Results from the National Health and Nutrition Examination Surveys (NHANES). Circulation PMID: 22547667
Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, Peters AL, Tsapas A, Wender R, & Matthews DR (2012). Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia, 55 (6), 1577-96 PMID: 22526604
 
Authors/Task Force Members:, Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, Albus C, Benlian P, Boysen G, Cifkova R, Deaton C, Ebrahim S, Fisher M, Germano G, Hobbs R, Hoes A, Karadeniz S, Mezzani A, Prescott E, Ryden L, Scherer M, Syvänne M, Scholte Op Reimer WJ, Vrints C, Wood D, Zamorano JL, Zannad F, Other experts who contributed to parts of the guidelines:, Cooney MT, ESC Committee for Practice Guidelines (CPG):, Bax J, Baumgartner H, Ceconi C, Dean V, Deaton C, Fagard R, Funck-Brentano C, Hasdai D, Hoes A, Kirchhof P, Knuuti J, Kolh P, McDonagh T, Moulin C, Popescu BA, Reiner Z, Sechtem U, Sirnes PA, Tendera M, Torbicki A, Vahanian A, Windecker S, Document Reviewers:, Funck-Brentano C, Sirnes PA, Aboyans V, Ezquerra EA, Baigent C, Brotons C, Burell G, Ceriello A, De Sutter J, Deckers J, Del Prato S, Diener HC, Fitzsimons D, Fras Z, Hambrecht R, Jankowski P, Keil U, Kirby M, Larsen ML, Mancia G, Manolis AJ, McMurray J, Pajak A, Parkhomenko A, Rallidis L, Rigo F, Rocha E, Ruilope LM, van der Velde E, Vanuzzo D, Viigimaa M, Volpe M, Wiklund O, & Wolpert C (2012). European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by re European heart journal PMID: 22555213

Who says being fat is bad?

Would you have guessed that, one fine day, health insurers will regret the demise of big tobacco and its contribution to health care costs? Would you have guessed that, when that day arrives, health insurers would also learn to love other frowned-upon-vices of their policy holders, such as getting fat and lazy? Your answer is probably "no, I wouldn't have guessed that in my dreams.". 

And also very probably this answer is based on what you typically read in the media, such as this piece of news titled "Obesity Adds More to Health Care Costs Than Smoking, Study Suggests." released on April 3, 2012, on sciencenews.com. The article text wraps the title message into a substantially larger amount of unsubstantial words, before it concludes what you would probably subscribe to blindfolded: the  "...study [1] provides new insights into the long-term costs of obesity and smoking, showing that both risk factors lead to persistently higher health costs throughout a seven-year follow-up period.". Dah, what else is news?

Well, for one, that the Joe Camels and the lardbuckets, with all their vices, cost their health insurers actually LESS money than Mr. and Mrs Healthy. For one simple reason: the "vice guys" die earlier.

But let's hold that thought for a moment and let's look at the figures. In a Dutch study performed by Pieter van Baal and colleagues, the authors compared the annual and lifetime health care costs of three cohorts, namely the obese, the smokers, and the healthy living people [2]. As the basis of their calculations they used the Dutch National Institute's of Public Health and the Environment (RIVM) chronic disease model, which, the authors assure us, has been widely used and validated in disease and cost projection analyses.

To make their results more comparable internationally, they ran their analyses with altogether 7 different scenarios, to account for different health care systems and for different mortality risk estimates. The latter had been drawn from observations in the U.S. published by Flegal and colleagues [3] who had found declining mortality risks in the obese cohorts. I mention this because I don't want you to suspect that the Dutch authors had based their calculations on an unrealistically high keeling-over rate for the obese. Now, fast forward to the astonishing results.

In all 7 models, as well as in the unadjusted base case scenario, the financially most attractive "villains" to health insurers are the smokers. The most expensive are always the goody-two-shoes healthy-living people. Somewhere in-between are the fat ones. In the model which assumed a yearly 1% increase in health care costs, the lifetime costs for an obese person amounted to € 399,000, compared to which the smoker comes at a 14% discount of € 341,000, but the healthy living person with a 17% premium at € 468,000.

How can that be? The answer is not where you and I would have looked first: The diseases which directly associate with smoking and obesity (heart disease, cancer, diabetes, pulmonary diseases, musculoskeletal disorders). They account only for 20% of total disease costs. The remaining 80% are for ailments and conditions, which come with age. But when that age doesn't come, because you die earlier, then those costs don't come either. And Joe Camel and Ronald McDonald are rather effective in cutting years out of your life, and thereby costs out of your health insurers balance sheet. For 7 and 5 years respectively, to be precise.   

So, where are the premium discounts for the obese and the smoking policy holders? Why are the healthy living people permanently miffed about not getting premium discounts, when they actually cost more? I have to admit, I belong to the latter, too. But recently, after having listened to one of my talks at a conference, a friend of mine, the CEO of a German health insurer, took me aside and told me, that my indignation about the healthy people having to share the cost burden of their willfully negligent peers, was unfounded.

As much as I wanted to disbelieve, I also knew that these insurance guys do one thing very well: calculating risk and premiums. So I had to give him the benefit of the doubt. Which is why I began to check. And by checking, I came to know about quite a number of studies confirming my friend's argument. One of those studies was van Baal's, which I chose to quote from because he is actually working for the Dutch National Institute of Public Health and the Environment. Not that I'm biased in favor of the Dutch. I'm biased in favor of anyone who articulates a viewpoint which is in stark contrast to what I would expect merely on the basis of his association. I mean, here you have someone telling you to NOT confuse health with health care cost savings, when his employer is actually trying to make everyone with a cigarette or a burger in his mouth feel guilty about sending health care costs sky high.  

So what now? Shall we promote the vices and lower our health care costs in a decade-long smoking and feeding frenzy? Well, it's your choice, but I'm not convinced that we have got the reasoning or the arguments right just yet. We need to do a little more detective work to solve this case.

Now, you know how the French, at least in their novels, dish out that piece of advice to the detective: Cherchez la femme (look for the woman)? Maybe it works in the French universe. In mine, I have always found this one to work better: "Cherchez l'argent" (look for the money).

Which will lead us to another few surprising discoveries in the next post. And, of course, a couple more reasons to believe that there are quite some powerful players around who yearn for the good old times when Marlboro Man and Ronald McDonald delivered us from the risk of a costly long life.

PS: To meaningfully pass the time until the next post, watch this video on the calorie cartel

1.           Moriarty, J.P., et al., The effects of incremental costs of smoking and obesity on health care costs among adults: a 7-year longitudinal study. Journal of Occupational and Environmental Medicine, 2012. 54(3): p. 286-91.

2.           van Baal, P.H.M., et al., Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure.PLoS Med, 2008. 5(2): p. e29.

3.           Flegal, K.M., et al., Excess deaths associated with underweight, overweight, and obesity. Jama, 2005. 293(15): p. 1861-7.

Moriarty, J., Branda, M., Olsen, K., Shah, N., Borah, B., Wagie, A., Egginton, J., & Naessens, J. (2012). The Effects of Incremental Costs of Smoking and Obesity on Health Care Costs Among Adults Journal of Occupational and Environmental Medicine, 54 (3), 286-291 DOI: 10.1097/JOM.0b013e318246f1f4
van Baal PH, Polder JJ, de Wit GA, Hoogenveen RT, Feenstra TL, Boshuizen HC, Engelfriet PM, & Brouwer WB (2008). Lifetime medical costs of obesity: prevention no cure for increasing health expenditure. PLoS medicine, 5 (2) PMID: 18254654
Flegal, K. (2005). Excess Deaths Associated With Underweight, Overweight, and Obesity JAMA: The Journal of the American Medical Association, 293 (15), 1861-1867 DOI: 10.1001/jama.293.15.1861

It's not your genes, stupid.

Imagine traveling back in time and meeting your caveman ancestor of 10,000 years ago. Imagine telling him about what life is like today: that, with the tap of a finger you turn darkness into light, a cold room into a warm one and a tube in the wall of your cave into a spring of hot and cold water. You tell him...

you can fly from one place to another, and watch any place on this Earth without ever leaving your cave. You tell him you never have to run after your food, or fear that you run out of it. Your ancestor will have a hard time believing you. In his world only his gods can do all that.

Then you tell him how some of your friends think his way of life is preferable for health, which is why you are visiting him because you want to see for yourself. Before I get to your ancestor's most likely answer, let's get on the same page with those friends of ours first.

You have probably heard them talk about the past 10,000 years having done nothing to our genetic make-up. In other words, your ancestor's DNA blueprint was the same as yours. Today this blueprint collides  with a space age environment in which we don't expend any energy to get our food, and the food we acquire delivers far more energy and far less nutrients than what had been the case during 99.9% of human evolution. 

According to this view, today's epidemics of obesity, diabetes, cardiovascular diseases and cancer are simply the collateral damage of this collision. This explanation is so persuasive that it is being parroted by every media type and talking head who can spell the word  'genetics'. I'm afraid it is not that simple. Here is why:

Remember when the 3 billion letters, or base-pairs, of the human genome had first been decoded at the beginning of this century. This decryption had been delivered with the promise of revolutionizing medicine. Aside from new therapies, the hottest items were prognostic and diagnostic tools, which, we were made to believe, would lay in front of each individual his biomedical future. And with this ability to predict would come the ability to prevent, specifically all those diseases which result from an unfavorable interaction between genes and environment.

Almost ten years later we are nowhere near this goal. OK, we have identified some associations between some genetic variants and the propensity to become obese or get a heart attack or diabetes. But these associations are far from strong and they hardly help us to improve risk prediction. Just this year, Vaarhorst and colleagues had investigated the ability of a genetic risk score to improve the risk prediction of conventional risk scores which are based on biomarkers, such as the ones used in the Framingham score. Less than 3% of the study participants would have been reclassified based on the genetic risk score [1].

In a study which was released just yesterday, genetic markers for the development of diabetes in asymptomatic people at high risk, did not improve conventional biomarker risk scoring at all [2]. 

Obviously we are not simply our genes. This is because genes do not make us sick or healthy. Genes make proteins. And on the way from gene to protein a lot of things happen on which genes do not have any influence. To express a gene, as biologists call it, that gene must first be transcribed on RNA and then translated from RNA into the final protein. Whether a gene is transcribed in the first place depends on whether it is being made accessible for this transcription process. Today we know at least two processes which can "silence" the expression of a gene, even though it is present in your DNA. These processes are called DNA methylation and histone modification. Simply imagine them as Mother Nature's way of keeping a gene under wraps.

That's a good thing if the protein product of the silenced gene would be detrimental to your health. It could well be the other way round, too. Anyway, these happenings have been called epigenetics. Epigenetic mechanisms enable cells to quickly match their protein production with changing environmental conditions. No need to wait for modifications of the genetic blueprint which takes many generations and a fair element of chance to materialize. The most astonishing discovery is that these epigenetic changes may become heritable, too. Which means, there is really no need to change the genetic code. 

I believe you get the picture now. While it is true that your ancestor's genetic code is indistinguishable from yours 10,000 years later, the way your body expresses this code in the form of proteins and hormones can differ in many ways. Which is why researchers are now as much excited about epigenetics as they used to be about genetics 10 years ago.

I don't want to be the party pooper, but whenever I see such excitement I'm reminded of how it has often evaporated after some further discoveries. Here I'm skeptical because of the picture, which we are beginning to see. Insulin, for example, is known to regulate the expression of many genes. At least in rats it has been shown that insulin's suppressive effect on gene expression in the liver, can be altered by short term fasting [3]. That means, relatively minor behavioral changes may affect the way our organism expresses its genetic code.   

Observations like these support the idea that we are not our genes, but what we make of them. In plain words: let's not hide behind the "it's-our-stone-age-genes" excuse, to explain why we are fat and lazy and ultimately chronically sick.

Now, back to your ancestor and his response to your friends' suggestions that his way of life is preferable for health. When you also tell him you live a lot longer than the 40 years he has on average, he'll tell you: You have got some nutcase friends over there. Let me live like a god first and then I'll worry about health later.

Maybe, we are not so different from our stone age ancestors after all. 

1.           Lu, Y., et al., Exploring genetic determinants of plasma total cholesterol levels and their predictive value in a longitudinal study. Atherosclerosis, 2010. 213(1): p. 200-205.

2.           Schmid, R., et al., Current Genetic Data Do Not Improve the Prediction of Type 2 Diabetes Mellitus: The CoLaus Study.Journal of Clinical Endocrinology and Metabolism, 2012.

3.           Zhang, Y., et al., Insulin-Regulated Srebp-1c and Pck1 mRNA Expression in Primary Hepatocytes from Zucker Fatty but Not Lean Rats Is Affected by Feeding Conditions. PLoS ONE, 2011. 6(6): p. e21342.

Lu, Y., Feskens, E., Boer, J., Imholz, S., Verschuren, W., Wijmenga, C., Vaarhorst, A., Slagboom, E., Müller, M., & Dollé, M. (2010). Exploring genetic determinants of plasma total cholesterol levels and their predictive value in a longitudinal study Atherosclerosis, 213 (1), 200-205 DOI: 10.1016/j.atherosclerosis.2010.08.053 

Zhang Y, Chen W, Li R, Li Y, Ge Y, & Chen G (2011). Insulin-regulated Srebp-1c and Pck1 mRNA expression in primary hepatocytes from zucker fatty but not lean rats is affected by feeding conditions. PloS one, 6 (6) PMID: 21731709

Screw Your Health?!

So, what's your excuse for not exercising enough, for smoking, for not watching your diet, for getting fatter every year, and therefore having high blood pressure, and too much glucose and cholesterol in your blood?

 That's what the American Heart Association has been telling you for so many years NOT to do. How can I be sure that you, dear reader, are one of those people who only pay lip service to health? I can't, but as a numbers guy I go with the statistics. 

And when health is concerned the statistics tell me that there are obviously only two types of people. Those who do enough for their health, and those who merely think they do. The latter make up 98.8% of the population [1]. That is, only one in a hundred meets all 7 health metrics: not smoking, eating a healthy diet, no overweight, sufficiently physically active, normal blood pressure, normal levels of glucose and cholesterol. Four out of every 5 Americans meet 4 or less of those metrics. Actually, only one in four meets 4 metrics. How can that be when having at least 6 of those metrics will cut your risk of dying from cardiovascular disease by 75% compared to those who meet one criterion or none? How much more incentive do you want?

That's the frustrating question I'm asking myself every day. Because whether it is in the US, in Germany or anywhere else in this world, maintaining health and preventing disease is a frustrating service to provide. I used to think this is so, because when you don't feel it, it is health. And what you don't feel, you don't appreciate. But if that was true, the first diagnosis of a chronic condition, such as heart disease or diabetes, should surely be a wake-up call. But it isn't. Only 40% of smokers quit when  being told that they have such a chronic disease, and that smoking will make it worse [2]. That's still a lot compared to the behavior change in exercise: Nil, no change at all.  And for every American who quit smoking in 2011 another American became obese. 

If you have read my earlier blog posts, you'll remember that I'm a strong advocate of recognizing the autonomic neurohormonal mechanisms which certainly drive our eating and exercising behaviors. But we are not exclusively controlled by those. We still have a few brain centers which give us the abilities and skills that make us human: volition, reasoning, intelligence. Of course you can use them to find the most elaborate excuses for your health behaviors, or rather for the lack thereof. But he who is good for making excuses is seldom good for anything else. That's what Benjamin Franklin said. Are you good for something else? Make that something your health. And start today. Here!

1.           Yang, Q., et al., Trends in Cardiovascular Health Metrics and Associations With All-Cause and CVD Mortality Among US Adults. JAMA: The Journal of the American Medical Association, 2012.

2.           Newsom, J.T., et al., Health Behavior Change Following Chronic Illness in Middle and Later Life. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 2011.

Yang, Q., Cogswell, M., Flanders, W., Hong, Y., Zhang, Z., Loustalot, F., Gillespie, C., Merritt, R., & Hu, F. (2012). Trends in Cardiovascular Health Metrics and Associations With All-Cause and CVD Mortality Among US Adults JAMA: The Journal of the American Medical Association, 307 (12), 1273-1283 DOI: 10.1001/jama.2012.339 

 Newsom, J., Huguet, N., McCarthy, M., Ramage-Morin, P., Kaplan, M., Bernier, J., McFarland, B., & Oderkirk, J. (2011). Health Behavior Change Following Chronic Illness in Middle and Later Life The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 67B (3), 279-288 DOI: 10.1093/geronb/gbr103

Are fat people just lazy?

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

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

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

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

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

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

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

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

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

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

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

Into the age of chronic health.

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

Incentivize health! 

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

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

Outfox your brain!

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

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

Take Biomedicine's most powerful tools!

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

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

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

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

I'm looking forward to meeting you there. 

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

Into The Age of Chronic Health

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

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

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

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

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

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

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

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

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

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

Food addiction

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

Hormones

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

Hyperbole

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

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

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

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

How to admire obese people? The Token Fat Girl

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

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

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

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

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

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

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

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

   

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

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

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

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

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

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