Category Archives: nutrition

data saving lives, healthy habits, nutrition, quantified self, rapid learning health systems, research methodology, technology

SMS provides for an effective weight loss intervention

 

Source: http://www.fiercemobilehealthcare.com/story/study-texting-effective-intervention-tool-weight-control/2013-11-21?utm_medium=nl&utm_source=internal

Citation: http://www.jmir.org/2013/11/e244/

Study: Texting effective intervention tool for weight control

November 21, 2013 | By 

Daily text messaging may be a useful self-monitoring tool for weight control, particularly among racial/ethnic minority populations most in need of intervention, according to Duke University study results published in a Journal of Medical Internet Research article.

“Recent studies show that racial/ethnic minorities are more likely than white individuals to own mobile phones,” states the article. “The high familiarity with and penetration of mobile technologies makes text messaging an ideal intervention platform among these populations.”

The purpose of the randomized controlled pilot study was to evaluate the feasibility of a text messaging intervention for weight loss among predominantly black women, who “have alarmingly high rates of obesity as compared with other gender and racial/ethnic groups.” The secondary aim of the study was to evaluate the effects of the intervention on weight change relative to an education control arm.

Fifty obese women aged 25-50 years were randomized to either a six-month intervention using a fully automated system that included daily text messages for self-monitoring tailored behavioral goals (e.g., 10,000 steps per day, no sugary drinks) along with brief feedback and tips (26 women) or to an education control arm (24 women). The article states that weight was objectively measured at baseline and at six months, while adherence was defined as the proportion of text messages received in response to self-monitoring prompts.

At six months, the article reports that the intervention arm lost a mean of 1.27 kg, and the control arm gained a mean of 1.14 kg. The average daily text messaging adherence rate was 49 percent with 85 percent texting self-monitored behavioral goals two or more days per week. Moreover, about 70 percent strongly agreed that daily texting was easy and helpful and 76 percent felt the frequency of texting was appropriate.

“Given that the majority of evidence indicates that greater adherence leads to better outcomes, our study suggests that mHealth-based approaches to self-monitoring may enhance engagement and reduce the burdens commonly associated with other modes,” concluded the article. “Our intervention was relatively low intensity and has greater potential for dissemination compared to higher intensity interventions. As technology penetration increases in the target population, the use of this modality will become increasingly relevant and helpful as an intervention tool for weight control.”

Earlier this year, an article published in the Journal of American Medical Informatics Association revealed that mobile app self-monitoring of physical activity and dietary intake among overweight adults participating in a weight loss program are more effective than traditional methods. The study involved a post hoc analysis of a six-month randomized weight loss trial among 96 overweight men and women, which found that physical activity app users self-monitored exercise more frequently over the six-month study and reported greater intentional physical activity than non-app users.

To learn more:
– read the article in JMIR

facts & data points, healthy habits, nutrition, policy, research methodology

A behavioural economist’s view on obesity…

This is a typically obtuse, academic view of obesity, breathlessly attempting to cite the immense complexity of the disease, capping it with a plea for more research dollars, or at least a reallocation of research dollars.

There are a couple of interesting snippets:

  • pets are also getting obese – 58.3% of cats were obese in 2012
  • lab animals too are getting obese – 11.8% per decade from 1982 to 2003
  • is this due to antibiotic-mediated changes to gut bacteria that not just change how we digest, but also how we behave?
  • socially mediated effects?

So surprising that a behavioral economist’s view could be so dismal.

 

Source: http://www.nytimes.com/2013/11/10/business/the-co-villains-behind-obesitys-rise.html?_r=2&

The Co-Villains Behind Obesity’s Rise

Waltraud Grubitzsch/European Pressphoto Agency

Researchers have compared tissue samples from obese mice with those of normal mice to try to determine which behavioral or biological factors might cause humans to gain weight. Here, a 2012 experiment in Leipzig, Germany.

By SENDHIL MULLAINATHAN
Published: November 9, 2013

Why is obesity soaring? The answer seems pretty clear. In 1955, a standard soda at McDonald’s was only seven ounces. Today, a medium is three times as large, and even a child’s-size version is 12 ounces. It’s a widely held view that obesity is a consequence of our behaviors, and that behavioral economics thus plays a central role in understanding it — with markets, preferences and choices taking center stage. As a behavioral economist, I subscribed to that view — until recently, when I began to question my thinking.

For many health problems, of course, behavior plays some role but biology is often a major villain. “Biology” here is my catchall term for the myriad bodily mechanics that are only weakly connected to our choices. A few studies have led me to wonder whether the same is true with obesity. Have I been the proverbial owner of a (behavioral) hammer, looking for (behavioral) nails everywhere? Have I failed to appreciate the role of biology?

A first warning sign comes from looking at other animals. Our pets have been getting fatter along with us. In 2012, some 58.3 percent of cats were, literally, fat cats. That is taken from a survey by the Association for Pet Obesity Prevention. (The very existence of this organization is telling.) Pet obesity, however, can easily be tied to human behavior: a culture that eats more probably feeds its animals more, too.

And yet, a study by a group of biostatisticians in the Proceedings of the Royal Society challenges this interpretation. They collected data from animals raised in captivity: macaques, marmosets, chimpanzees, vervets, lab rats and mice. The data came from labs and centers and spanned several decades. These captive animals are also becoming fatter: weight gain for female lab mice, for example, came out to 11.8 percent a decade from 1982 to 2003.

But this weight gain is harder to explain. Captive animals are fed carefully controlled diets, which the researchers argue have not changed for decades. Animal obesity cannot be explained through eating behavior alone. We must look to some other — biological — driver.

Fittingly, the study is titled “Canaries in the Coal Mine.” Could our inability to explain animal obesity with behavior be a warning sign? Perhaps we are also overlooking biological drivers for human obesity. But what might these culprits be?

A particularly interesting candidate resides in your gut. Your digestive system is actually a complex ecosystem, playing host to hundreds of species of bacteria that do things as diverse as fermenting undigestedcarbohydrates and providing vitamins. They also regulate how much fat your body stores.

Not everyone, however, has the same gut bacteria. And, interestingly, the composition of this bacteria correlates with obesity. Of course, this relationship could be simple: the obese eat differently, and therefore they have different bacteria.

But a recent study in the journal Science showed that cause and effect could go the other way as well. Researchers harvested bacteria from pairs of human twins, where one twin was obese and the other was not. Then they transplanted these bacteria into mice. The mice who received bacteria from the obese twin gained weight, while the others did not. The mice did not eat more: Their metabolism changed so that they put on more weight even with the same caloric input.

What, then, determines your gut bacteria? It could be antibiotics or environmental toxins or how processed your food is. Another possibility is raised by a study in The New England Journal of Medicine that shows that obesity seems to “spread” across social networks, with people infecting their friends and neighbors. I had always assumed that was because birds of a feather flock together — and that is surely part of the explanation. But because gut bacteria can also spread among people in close proximity, perhaps the obesity epidemic really is, well, an epidemic?

I’m not arguing that behavior does not matter. Biology and behavior often interact; the spread of flu depends on whether we wash our hands. Similarly, the bacteria study found that the “obese gut bacteria” had an impact only when the mice were fed diets heavy in saturated fats.

Perhaps most interestingly, changing biology may even be changing cravings. Some biologists have hypothesized that our gut bacteria actually drive cravings for certain unhealthy foods. A focus on biology doesn’t mean a reduced emphasis on behavior, just a richer understanding of it.

These and other studies raise important possibilities, which deserve more research and attention. At the very least, we should invest as many obesity research dollars in uncovering and understanding these biological channels as we do in understanding behavioral channels. And this is a behavioral economist talking!

After all, this could radically change the way we think about policies to curb obesity. As one newspaper editorial pronounced:

“A little town in Sweden has put a local tax on fat men. It is declared that ‘the fat man stands accused by the very fact of his too solid flesh’ (vide “Hamlet”) ‘of gluttony and laziness.’ Millions of fat men throughout the world may rise up and denounce as liars the town councillor who drew up this cruel indictment and those who voted for it, but the gentler way of reproving them would be to point out the tritely recognised danger of generalisation in almost any statement of supposed fact. Not all fat men are lazy and gluttonous. Obesity is in many a congenital habit of body; in others a disease.”

That editorial was written in 1923, for the paper known as The Paris Herald. Maybe the writer was on to something.

SENDHIL MULLAINATHAN is a professor of economics at Harvard.

This article has been revised to reflect the following correction:

Correction: November 17, 2013

Because of an editing error, the Economic View column last Sunday, about possible causes of obesity, misstated the source of bacteria that were transplanted into mice as part of an obesity study. The bacteria came from human twins, not from other mice.

 

A version of this article appears in print on November 10, 2013, on page BU6 of the New York edition with the headline: The Co-Villains Behind Obesity’s Rise.
healthy habits, nutrition

Katz: lifestyle = breakthrough medical cure = lifestyle = medicine

http://www.linkedin.com/today/post/article/20131124153502-23027997-lifestyle-as-medicine-at-a-fork-in-the-road-who-s-got-a-spoon

Lifestyle as Medicine: At a Fork in the Road, Who’s Got a Spoon?

November 24, 2013
 

Hippocrates recognized the power of lifestyle as medicine some 2500 years ago, testimony to his wisdom and prescience. As president-elect of the American College of Lifestyle Medicine, I celebrate the possibility of finding our way back to a future informed by such insight.

But for now, in the immediate aftermath of announcement, and on-going debate about just how many of us should take statins, let’s consider what Big Pharma would have to do to compete on an even playing field with the power of lifestyle.

Imagine, for instance, if the news were to break tomorrow – on the landing page of your favorite site, or front page above the paper crease for you traditionalists, in whatever news source you like best – that there is a new prescription drug. The drug is stunningly effective, and shockingly free of side effects. It is astoundingly safe – safe enough for newborns and octogenarians alike. It is available in bountiful supply, and remarkably inexpensive. In fact, you might be able to get it without spending any extra money at all – maybe even save money by taking it.

And, here’s the punch line. If you take this pill – which everyone else in your family can take along with you – once daily for the rest of your life, it would reduce your risk of EVER getting ANY major chronic disease – heart disease, cancer, stroke, diabetes, dementia, etc. – by 80%.

The only question here is which would be a better idea and the more immediate priority: calling your doctor to get a prescription for this wonder drug, or calling your broker to get some share of stock in the company holding the patent.

But, of course, there is no such drug. There never has been any such drug. And in my opinion, there never will be any such drug. But lifestyle is exactly that medicine, and we have known about it …well, since Hippocrates.

But we know about the power of lifestyle as medicine in the modern age in ways unavailable to Hippocrates. A seminal epidemiologic study published in 1993 in the Journal of the American Medical Association famously pointed out that the leading, actual causes of premature death in the United States are not heart disease, cancer, and so on – but the things that cause heart disease, cancer, and so on. Those factors sum up to a list of ten exposureswe each, overwhelmingly have the capacity to control in our daily lives. That list of ten is, in turn, overwhelmingly dominated by just the first three: tobacco use, dietary pattern, and physical activity pattern. Or, as I like to call them – how we use our feet, our forks, and our fingers.

That initial study spawned a whole branch of the epidemiologic literature, reaffirming over a span of decades now that lifestyle is by far the best medicine ever conceived – or, if neglected, a source of years lost from life, and life lost from years. Study, after study, afterstudy, after study, after study…has shown that feet, forks, and fingers are nothing less than the master levers of medical destiny. Add to these three the management of sleep, stress levels, and loving relationships in our lives, and the control over our medical destinies is astounding.

And, in tandem with the literature showing how these factors overmaster our fate with regard to chronic disease risk, there is a burgeoning literature showing that they have the capacity toalter gene expression, too. The Genomic Age has served up a powerful insight, albeit not the one we were expecting: DNA is not destiny. To a greater extent, dinner is destiny – because dinner, and lifestyle, can alter the behavior of our very genes. The nature/nurture debate is rather an unfortunate distraction, because we can, in fact, nurture nature.

Lifestyle is then, irrefutably, the greatest of all medicine. But as we learned from Mary Poppinsif not elsewhere, there is the separate challenge of getting the medicine to go down. Certainlythe last thing we need in this case is more spoons full of sugar!

Lifestyle is the greatest of all medicine, but it may feel in this morbidigenic, obesigenic world of ours that we can’t get it to go down, because we just don’t have the right spoon. It may feel that we can’t get there from here.

That is, in a word, wrong. We can get there from here.

Doing so begins by embracing the destination – by acknowledging that lifestyle is medicine we all want. Then, we have to acknowledge that we do indeed know just what destination we mean, that we know what healthy living looks like. We do – including diet – and if we could get past the distractions of competing dogma, we would have the destination clearly in our sights. I have written extensively about that destination before, in columns, peer-reviewed papers, and textbooks– so if you want more on the topic, just follow the links.

Finally, once the destination is clear – it’s a matter of following a route that leads there. And so we come to it: a fork in the road, where for far too long, a luminous opportunity for better health, and consequently better lives, has languished. A fork where health could remain alongthe road not taken, or find itself on a path of much lesser resistance. It’s time to choose.

Along one tine of our fork is perpetuation of the status quo, where we lose loved ones we don’t need to lose, long before their time. Or perhaps they lose us. It’s a road where we succumb to unnecessary miseries and lose both years from life, and life from years. And where we bequeath the same and even worse to our children – where they inherit along with our abdication an ever greater burden of chronic disease and premature death, at ever younger age. I think, and hope, this road is readily rejected.

Along another tine is a world that makes health more accessible, a better world. My career is devoted mostly to creating such a world. But it’s a long, slow, arduous process. This tine doesn’t lead to any immediate opportunity for each of us. Along this tine, some of us keep working, while the rest of us just keep on waiting on the world to change. It may happen, but I wouldn’t hold your breath.

And then there is the third tine, which leads promptly and without detour to the skill set we need to be the health we want to see for ourselves. It leads us to be the health we want to see for those we love. And of course, when enough of us have changed ourselves, it leads us tobe the changes we want to see in the world as well.

There is a place, an important place even, for lifestyle IN medicine – where health care professionals offer valuable guidance, and counseling that is both constructive and compassionate. But the power of this cannot compare to that of lifestyle AS medicine, where each of us pulls on the master levers of medical destiny every day. Think about the Blue Zones, those places around the world where people live the longest, healthiest, most vital lives. Those benefits are attributed to how they live and to their culture, not to the counseling they get from doctors. We are in control of how we live, if latently. We are in control of our culture-which begins at the level of household, where family values take hold. The cultivation of vitality could be a family value.

You can prescribe yourself lifestyle as medicine. You are the doctor in this case, for yourself and those you love. But as with all doctoring, it requires a skill set. If you don’t have it, you can get it. And frankly, there is no real alternative. No other medicine can do what lifestyle can do, and no one else can practice lifestyle for you. It’s your life, and only you can live it. If you empower yourself- if you acquire the requisite “skillpower” to take lifestyle as your medicine- it will almost certainly be a better life. Healthy people have more fun.

Lifestyle is the best medicine there is, ever was, and likely ever will be. At a fork in the road forhealth care, our economy, our culture, and what the future holds for our children and grandchildren- each of us holds the spoon that could get this medicine to go down.

healthy habits, nutrition

Eggers on fasting…

http://www.medicalobserver.com.au/news/a-fast-approach

A fast approach?

19th Nov 2013

Professor Garry Egger

CAN caloric restriction help individuals live longer?

Or does it just feel like it…

Two themes in nutrition have recently come together. The first, calorie restriction (CR), involves permanently reducing total energy intake by up to 30%.

CR has been shown consistently to increase the longevity of a number of different species of animal, as well as reduce weight.

The second theme, intermittent dieting (ID), or reducing energy intake on some days but not others, has spawned yet another diet craze that is dominating discussion at the dinner parties of middle suburbia.

Being battered and bruised by the numerous false starts in the dieting game, it’s tempting to pass off both of these as fads.

But the interest of some hard-nosed nutrition scientists makes a second look warranted.

Dr Eric Ravussen from the Pennington Institute in Arizona, is a world expert in energy metabolism and obesity.

For some time, he and several postgraduate students (including several Australians) have studied the mechanisms involved in CR.

The two forms of ageing

Speaking at a recent Australian and New Zealand Obesity Society (ANZOS) conference, Dr Ravussen described two forms of ageing: primary ageing, determined by genetics and natural factors; and secondary ageing, which is related to lifestyle and environmental factors.

Together these determine one’s maximum lifespan.

From animal studies it’s known that rats are able to run daily, live longer than those deprived of exercise.

But when a CR diet of about 30% total energy restriction is introduced, they live even longer.

Possible explanations for this are the reduced cellular oxidative stress from food, decreased DNA damage, decreased inflammation and auto-immunity, and increased metabolic efficiency.

For obvious reasons, such a study over a lifetime in humans has not yet been done.

Those that have been carried out opportunistically for short periods (such as during wars and in the human biosphere study) show a negative bounce-back in weight gain and health after the CR period.

Molecular changes

Physiological studies carried out by Dr Ravussen’s group, however, show molecular changes that are reflective of potential longevity advantages.

There’s also no doubt that weight loss follows such a regime — if it can be maintained.

A different way of restricting calories is through intermittent dieting popularised by the 5:2 diet and TV doctor Michael Mosley.

ID involves two days each week of energy restriction of 500 calories for women and 600 for men, with ad-lib intake over the remaining five days.

Exponents claim not just weight loss but reduced chronic disease risk.

And while there are not a lot of data to support the latter, there is good support for the former — strangely even with an increased overall food intake.

Dr Amanda Sainsbury-Salis from Sydney University’s Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders and author of The Don’t Go Hungry Diet, is currently doing the tests in mice.

While the results are not yet published, she does believe there might be something in the 5:2 diet and that the approach could be improved by using different degrees of energy restriction.

So far, studies with humans suggest weight loss may be more (and easier) with an ID plan like this.

A panacea in middle-age?

Given that most people won’t have the opportunity to calorie reduce (at least in a healthy fashion) for life, the question becomes, what advantage is there for someone trying the process in middle life?

There’s little doubt that (short-term) weight loss at least will be an outcome, but adverse effects, according to Dr Ravussen, include cold intolerance, decreased libido, constant hunger and reduced desire to exercise.

Reversion could also lead to increased difficulties with weight.

Based on animal studies, Dr Ravussen has calculated that a 50-year-old human could be expected to live a measly two months longer! So is it really all worth it?

If not weight, then what?

The use of BMI in diagnosis of metabolic disorder has come under question. Weight over height squared measures mass only and doesn’t take account of body fat. This then discriminates against mesomorphic body shapes – like some short male athletes – and the aged, whose height may decrease with age while weight remains stable. On top of this, BMI is not a consistent measure of ill health, as illustrated by the ‘obesity paradox’.

Garvan Institute researcher Dr Dorit Samocha-Bonet has shown that almost 50% of expected risk can be explained by other, easily measurable factors. The cumulative of risk for each is:

HDL cholesterol 26%
HbA1c 35.5%
Systolic blood pressure 43.2%
Triglycerides (Tg) 46.7%

According to Canadian lipidology expert J-P Despres, a Tg of >2.0 and a waist circumference greater than that recommended for ethnic groups (usually around 100cm for men and 90cm for women – called the ‘triglyceride-waist’), adds even more to diagnostic value. It may all make BMI less relevant at the clinical level.

cool, data saving lives, entrepreneurship, healthcare, healthy habits, meaning, nutrition, policy, politics, quantified self, rapid learning health systems, research methodology, storytelling

Chronic Disease Fear Factor Ageing Messaging

Governments won’t be able to afford you if you are over 70 and can’t work
You will need to be productive
The current health market can only extend your life, but not your productive life
The new health system will have to do both if we are to preserve our standard of living
Sure, people will need to die sometime, but it’s the when, how and why they die that needs to evolve
This health system aims to deliver on this
Australia is well positioned to lead the world on this
Excitement

healthy habits, musings, nutrition, policy

Why diets fail…

That diets fail seems to be the only uncontested fact in the world of nutrition.

Why do you suppose that is?

Well the answer is pretty obvious when you think about it. Its because the idea of normal that people revert to after a diet is pathological.

The modern idea of a “normal” diet is actually sick. Too much food. And too much of the wrong, highly processed food.

The public health challenge is to change the idea of normal, because the current idea is killing us.

Eat only twice per day. No refined carbohydrates. Minimal meat consumption.

As Pollan says: Eat food, mainly plants, not too much.

Brilliant!

healthy habits, nutrition, policy, politics

MedObs: Govt changed food label system after industry lobbying

It’s clear the algorithm that DoHA established was stuffed if what they say about a glass of water vs chicko rolls is true.

The fact that dairy has held sway indicates the project has been undermined.

Never mind if it ever gets adopted, which is unlikely given AFGC’s mutterings at the press club recently.

Then finally, how much of an impact will food labeling actually have, given all the other drivers of the problem of fundamental overeating. I suspect industry is using food labelling as a straw man to keep the bureaucrats and academics tied up while industry marches on its merry way.

This is a classic case of policy development driven by obsessions with process rather than focus on outcome.

Source: http://www.medicalobserver.com.au/news/govt-changed-food-label-system-after-industry-lobbying

Govt changed food label system after industry lobbying

THE Department of Health and Ageing has admitted it changed how it rated dairy products under a radical new food labelling scheme following lobbying from the industry – but staunchly defended its assessment methods.

In Senate estimates this week, department secretary Professor Jane Halton said the dairy industry had complained about how its products fared in the new star system designed to combat obesity.

“The concern that was raised in respect of the algorithm in respect of dairy was that it didn’t give dairy the right prominence,” she said.

“The [department’s] project group considered in great detail how dairy might be recalibrated. We’ve pulled dairy out and we’ve got different categories now.”

But Professor Halton rejected “in the strongest possible terms” suggestions the formulae were wrong after the Senate heard a glass of water would be rated as less healthy than some junk food products.

“It is highly robust and it has been tested across a large number of foods,” she said of the system.

Other industries had told the department they wanted their products rated “better” but she would not say which.

In a statement, Senator Bridget McKenzie said the new scheme risked sending the message that healthy products like milk and cheese were unhealthy.

“The fact that under this scheme a glass of water is less healthy than a Chiko Roll calls into question the whole basis of the front-of-pack labelling scheme,” she said.

Research showed healthy amounts of dairy were linked to reduced risk of several chronic diseases, including heart disease, hypertension, stroke and type 2 diabetes, she said.

The scheme is expected to have the star ratings on food packaging by mid-2014.

nutrition

Ingredion launches ‘clinically substantiated’ satiety ingredient

Ingredion launches ‘clinically substantiated’ satiety ingredient

This month Ingredion Inc. rolled out Weightain, a satiety ingredient the firm claims can reduce daily caloric intake by up to 50 or 100 calories per day.

Weightain contains a proprietary high-amylose whole grain corn (high in prebiotic natural resistant starch), along with a viscous hydrocolloid, added using a heat-moisture treatment process, which work together to impact satiety and calorie consumption, according to the company.

Starch fermentation in the colon triggers satiety, increased gastrointestinal viscosity prolongs absorption, reducing calorie consumption, and whole grains delay digestion, reducing hunger pangs.

Possible claims: helps reduce hunger, helps manage hunger, impacts satiety, increases satiety

http://www.foodnavigator-usa.com/Suppliers2/Ingredion-launches-clinically-substantiated-satiety-ingredient

WeightainSatietyIngredient

cool, facts & data points, healthy habits, nutrition, silly

Dubai offers gold for fat during Ramadan…

Good for them…

http://news.sky.com/story/1165863/gold-tips-scales-for-dubais-slimmers

Gold Tips Scales For Dubai’s Slimmers

More than £400,000 worth of gold was dished out to contestants in the Your Weight In Gold campaign, aimed at tackling obesity.

Hussain Nasser Lootah (L), Director General of Dubai Municipality, presents Syrian architect Ahmad al-Sheikh (C), 27, with the top award in a competition to shed weight

Ahmad al Sheikh took home 63g of gold after losing the most weight

Dubai dieters have been rewarded with gold for losing weight during the Muslim fasting month of Ramadan.

The Your Weight In Gold campaign gave away £474,000 worth of gold to about 3,000 contestants, who won one gram of gold for every kilogramme shed.

Contestants that lost more than five or 10 kg received a greater proportion of gold per kg.

Ahmad al-Sheikh, a 27-year-old Syrian architect, won the top prize of 63 grams of gold, worth £1,700, after he lost 26 kg.

“I actually registered 15 days later in the campaign and was worried at first, because I thought I lost a head start to all the other contestants,” he said.

He added that support from friends and family helped him achieve his goal.

“My friends and colleagues have also been of immense support when they found out I was trying to lose weight, so now I play football once a week and basketball twice every week as well,” he said.

Nearly 17 kg of gold was given away in the competition as more than 17,000 kg were shed by contestants.

Omar Ahmed al Marri, a public-relations executive from Dubai municipality, told The National that the gold was a key motivator in getting people to participate.

“Nobody tries to be healthy,” he said. “So we thought about how we could make them think about it. We found that you have to give them a gift, to motivate them.

“Most of the people, they first of all thought about the gold. And then afterwards, they thought about what they could do for their body.”