Category Archives: nutrition

complex adaptive systems, healthcare, healthy habits, nutrition, policy, rapid learning health systems, research methodology

NYT: The Challenge of Diabetes for Doctor and Patient

..or why managing diabetes doesn’t fit with how doctors have been taught, and therefore generally like, to treat patients >>> we need a radically new approach not involving doctors, busy doing other things – see Iora Health post re. health coaches.

The good news: lifestyle change for the obese or those with prediabetes may have lower progression to diabetes
http://archinte.jamanetwork.com/article.aspx?articleid=1485081

The average news: childhood obesity is plateauing [PN: ??from a scandalously high base]
http://www.nytimes.com/2012/12/11/health/childhood-obesity-drops-in-new-york-and-philadelphia.html?_r=0

The bad news: Intensive lifestyle change for diabetics did not reduce the risk of stroke or heart attack, even though these patients were able to lose weight, improve their overall quality of life, take fewer medications and even decrease costs.

Lifestyle changes — diet and exercise — require huge and ongoing investment efforts for patients; we’d like to think it pays off for the big-ticket clinical outcomes. Hopefully future studies will show benefits.

 

OCTOBER 17, 2013, 3:43 PM

The Challenge of Diabetes for Doctor and Patient

By DANIELLE OFRI, M.D.

My patient was miserable — parched with thirst, exhausted and jumping up to go to the bathroom every few minutes. His vision was blurry and he’d been losing weight the last few weeks, despite eating voraciously. I’d only just met him, but I was able to diagnose diabetes in about a minute. What was unusual was that this was a scheduled office visit; usually, patients with such overwhelming symptoms are the provenance of emergency departments and urgent care centers.

A quick shot of insulin and five glasses of water and my patient felt like a new man, with no need to go to the E.R. But now, of course, the hard work would begin. A new diagnosis of diabetes is an enormous undertaking — lots to explain, major life changes to contemplate, myths to dispel, consultations with a nutritionist and a diabetes nurse.

Two days later I had another new patient for a scheduled visit — thirsty, tired, losing weight, eating and drinking like mad, eyes so blurred he could hardly see. We’d barely gotten past the introductions before I’d made another new diagnosis of diabetes. Another shot of insulin, another five glasses of water, and then the plunge into the thicket of diabetes education.

Most of my regular office visits with diabetic patients — even newly diagnosed patients — don’t involve such dramatic presentations. More often the disease is found when we screen patients who have risk factors like obesity or a family history of the disease, or who have commonly co-occurring illnesses like hypertension, heart disease or elevated cholesterol.

These two patients highlighted the outsized role that diabetes plays in the primary care setting. The tidal wave of diabetes over the last two decades has made it one of the most common diseases that internists and family doctors treat. Right now feels like a good-news-bad-news time on the diabetes front, which in a general medical clinic can sometimes feel like the only front there is.

The good news is that childhood obesity rates have begun to inch downward in some cities, including among poor children, the first positive sign in the obesity epidemic in years. Obese children are potential future diabetic patients, so even incremental progress is a public health victory to celebrate.

Also good news is a study in which adults with obesity and pre-diabetes were able to lose weight with sensible lifestyle changes and coaching. This took place in a primary care setting, not a research setting, so this also suggests that we might be able to bend the curve of new diagnoses of diabetes.

But there’s also bad news. Intensive lifestyle changes for patients with diabetes, disappointingly, did not reduce the risk of stroke or heart attack, even though these patients were able to lose weight, improve their overall quality of life, take fewer medications and even decrease costs. Lifestyle changes — diet and exercise — require huge and ongoing investment efforts for patients; we’d like to think it pays off for the big-ticket clinical outcomes. Hopefully future studies will show benefits.

Even with all the research and new treatments available, combating diabetes can feel like a Sisyphean task. The bizarre contradiction of junk food being cheaper than healthy food, combined with a bombardment of advertising — especially toward children — make it a challenge even for motivated people to eat healthfully. Sugary drinks in monster-size containers abound. And our fixation with screens large and small keeps us increasingly sedentary.

But even with all the uphill challenges, there are successes, even if not perfect ones. Both of my patients who came to my office with florid diabetes that week have improved. Perhaps it was the concreteness of their symptoms that motivated them, but they have both made steady progress getting their diabetes under control.

Over the past few months they’ve been eating more moderately, and exercising more regularly. We’ve been calibrating their medications so that their blood sugars have left the stratospheric levels and are now only moderately elevated. Medication side effects, cost of glucose meter supplies, real-life logistics, and concomitant issues of blood pressure and cholesterol control have made it a challenge to get to normal. We’d still be dinged as “failures” in the quality-measures department for not achieving the recommended clinical goals, but both patients feel vastly better and are much healthier now.

So there’s bad news and good news. But the real news for these two patients – and for many, many more like them — is that diabetes is a marathon, not a sprint. Although there have been a flurry of life changes right now, diabetes is something they will live with for the rest of their lives. They will always have to be cognizant of what they eat. They will have to keep track of medications, glucose levels, carbohydrate intake, doctors’ appointments, exercise, and weight.  They will have to be on the lookout for the many complications that diabetes can bring. This of course is not news to anyone who has diabetes or treats diabetes, but for these two patients this was news.

Now, we gear up for the long haul, the messy, complicated, occasionally gratifying business of living with a lifelong chronic illness.

Dr. Danielle Ofri’s newest book is “What Doctors Feel: How Emotions Affect the Practice of Medicine.” She is an associate professor of medicine at NYU School of Medicine and editor in chief of the Bellevue Literary Review.

http://well.blogs.nytimes.com/2013/10/17/the-challenge-of-diabetes-for-doctor-and-patient

musings, nutrition, policy

What REALLY Kills Us

Terrific Daniel Katz piece on LinkedIn on the actual causes of death.

Heart disease, cancer, stroke and diabetes are not causes, they are diseases.

The 1993 JAMA article “Actual Causes of Death” lays it out, and the top three causes of premature death, which account for 80% of the risk, are:

  1. tobacco
  2. diet
  3. exercise

Population-based research published in 2009 showed that people who ate well, exercise routinely, avoided tobacco, and controlled their weight had an 80% lower probability across their entire life span of developing ANY major chronic disease- heart disease, cancer, stroke, diabetes, dementia, etc.- than those who smoked, ate badly, didn’t exercise, and lost control of their weight

 http://www.linkedin.com/today/post/article/20131110133420-23027997-what-really-kills-us

What REALLY Kills Us

Heart disease is not the leading cause of death among men and women in the United States. Cancer, stroke, pulmonary disease, diabetes, and dementia are not the other leading causes of early mortality and/or chronic malady either.

Don’t get me wrong- these are the very diseases immediately responsible for an enormous loss of years from life, and an even greater loss of life from years. In that context, heart disease is indeed the most common immediate precipitant of early death among women and men alike. Cancer, stroke, and diabetes do indeed follow close behind. It’s just that these diseases aren’t really causes. They are effects.

We got this message loud, clear, and first- at least in the modern era- in what really should have been a culture-changing research paper published in JAMA in 1993 entitled ‘Actual Causes of Death in the United States.’ In that analysis, two leading epidemiologists, Drs. William Foege and J. Michael McGinnis, looked into the factors that accounted for the chronic diseases and other insults that immediately preceded premature deaths. When they were done crunching numbers, they had a list of ten factors that accounted for almost all of the premature deaths in our country every year.

Let’s digress to note we cannot ‘prevent’ death. But what makes death tragic is not that it happens- we are all mortal- but that it happens too soon. And even worse, that it happens after a long period of illness drains away vitality, capacity, and the pleasure of living. Chronic disease can produce a long, lingering twilight of quasi-living, before adding to that injury the insult of a premature death. And that, we can prevent. We can preserve vitality, and we can postpone death to its rightful time, at the end of our full life expectancy.

Now back to our regularly scheduled program. There were two astounding things about McGinnis and Foege’s list of ten factors*. First, we as individuals have substantial control over everything on the list, and virtually complete control over most of the entries. Second, just the first three factors on the list – tobacco, diet, and physical activity – accounted for fully 80% of the action. In other words, the actual, underlying “cause” of premature death in our country fully 8 times in 10 comes down to bad use of our feet (lack of physical activity), our forks (poor dietary choices), and/or our fingers (holding cigarettes).

I trust you immediately see the up-side to this. If bad use of feet, forks, and fingers accounts for 80% of premature deaths (and a bounty of chronic disease), it stands to reason that optimal use of feet, forks, and fingers could eliminate up to 80% of all premature mortality and chronic illness. This proves to be exactly true. Feet, forks, and fingers are the master levers of medical destiny.

We know this not just from McGinnis and Foege’s seminal paper, but from a steady drumbeat of corroborating research spanning the two decades since. Scientists at the CDC replicated the findings in the original paper in an update a decade later. Population-based research published in 2009 showed that people who ate well, exercise routinely, avoided tobacco, and controlled their weight had an 80% lower probability across their entire life span of developing ANY major chronic disease- heart disease, cancer, stroke, diabetes, dementia, etc.- than those who smoked, ate badly, didn’t exercise, and lost control of their weight. Flip the switch on any of these factors from bad to good, and the lifetime risk of serious chronic disease was reduced by nearly 50%. But firing on all four cylinders produced a greater net benefit than perhaps any advance in the history of medicine. These very findings have been replicated again, and again– and have been shown to extend that same influence over the expression of our very genes. DNA is not destiny, and to a substantial extent- dinner is. By changing what we eat and how we live, we can alter the expression of our very genes in a way that immunizes us against chronic disease occurrence, recurrence, or progression.

And so it is we have the knowledge to eliminate fully 80% of all chronic disease and premature death. The contention isn’t even controversial.

But knowledge, alas, isn’t power unless it is put to use. And for the most part, we have not leveraged the astounding memo we first got in 1993. Not only have we failed to slash rates of chronic disease, we are actually seeing them rise- with onset at ever-younger ages. We could bequeath to our children a world in which 8 times in 10, heart attacks and strokes and cancer simply don’t happen. Instead, should current trends persist, we will bequeath to them a world in which they and their peers succumb to just such preventable calamities more often and earlier than we.

So current trends cannot persist- and that, bluntly, is why I wrote Disease Proof. As a society, we clearly know the ‘what,’ but as individuals and families; spouses and siblings; parents and grandparents- most of us, just as clearly, don’t know how. How, despite the challenges of modern living, do we adopt, maintain, and enjoy a healthful diet? How, despite those same challenges, do we fit fitness in? How do we navigate around other challenges, from sleep deprivation and lack of energy, to overwhelming stress, to chronic pain?

These questions have answers, and I know them. I know them not because I’m special, but because it’s my job to know them. Pilots know how to fly planes; nuclear physicists know how to split atoms. I am a health expert, and I know how to get to health and weight control from here. Like any worthwhile thing, it requires a skill set- but we are used to that. We had to learn how to read and ride our bikes. We had to learn how to drive our cars and use our smart phones. Every worthwhile undertaking in our lives has involved someone who already knew how teaching us. Our job was to learn, and apply.

Health and weight control are exactly the same. In Disease Proof, I share the full skill set I apply myself.

We could, as a culture, eliminate 80% of all chronic disease. But my family and yours cannot afford to keep on waitin’ on the world to change. By taking matters into our own hands, we can lose weight and find health right now. We can reduce our personal risk of chronic disease, and that of the people we love, by that very same 80%. We can make our lives not just longer, but better.

What really kills us prematurely, and all too often imposes years of misery before hand, isn’t a list of chronic diseases, but the factors that cause those diseases. What really takes years from life and life from years is a willingness to know WHAT, yet neglect the opportunity to know HOW. What really kills us is the failure to turn what we know and have long known, into what we do. We can change that, and substantially disease-proof ourselves and those we love, any time we’re ready. I hope that’s now, because waiting- is really killing us.

-fin

DISEASE PROOF is available in bookstores nationwide and at:

Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org

http://www.facebook.com/pages/Dr-David-L-Katz/114690721876253
http://twitter.com/DrDavidKatz
http://www.linkedin.com/pub/david-l-katz-md-mph/7/866/479/

 

*the list is: tobacco, diet and activity patterns, alcohol, microbial agents, toxic agents, firearms, sexual behavior, motor vehicles, and illicit use of drugs

healthy habits, nutrition, policy

AdShame saying stop, or we’ll say stop again?

A commendable element of a multi-prong approach… every bit helps.

adShame showcases the ways the alcohol and food industry regularly flout the rules when it comes to responsible advertising.

Our aim is to show that self-regulation is not working, and changes are needed to ensure that regulation protects children and young people from the harmful effects of alcohol and unhealthy food advertising. 

http://www.adshame.org.au/

complex adaptive systems, data saving lives, entrepreneurship, healthcare, healthy habits, meaning, musings, nutrition, policy, quotes & aphorisms, rapid learning health systems, research methodology

The behaviour change arms race…

Behavior change is difficult, but to date it has dominated by industries, such as the processed food industry, who have mastered the art of mass market behaviour change through a withering combination of product research, development and engineering, marketing, advertising and promotion, all founded on an unstoppable and lucrative business model. At this moment in history, industry is the unopposed, global behaviour change super power. Serious capital investment with serious returns but with the unfortunate side-effect of producing a global epidemic of non-communicable disease.

The institutions charged with protecting the public’s health have been caught flat footed. Rather than trying to neutralise industry’s behaviour change efforts, medically-dominated health systems have instead chosen to layer their own lucrative pharmaceutical and surgical business model on top.

Doctors quite legitimately pay lip service to the “diet and exercise” mantra because they know it doesn’t work. And why doesn’t it work? Because anyone can say eat healthier food and exercise, thus making it difficult to justify their years of training and high fees. It’s much better for doctors to note “diet and exercise”, but then pump the drug and surgery options.

So what needs to happen?

A countervailing super power must be established. Not one founded around a powerful business model, but rather a movement of interested citizens, concerned by the grotesque monentization of the population’s health. In effect, a competing super power in the behaviour change arms race.

Key characteristics:

  • protect the children
  • use evidence, but don’t wait for conclusive results
  • empower with data
  • apply political dark arts

Funding sources:

  • social impact bonds
  • crowd sourcing
  • private health insurers
  • government (not a good time for this)

Inspirations

  • Purpose.com
  • GetUp.org.au

 

cool, healthy habits, musings, nutrition, recipe

The Broccoli make over…

I’ve been exploring the idea of becoming a broccoli magnate and what that would take. Michael Moss explored the idea of updating broccoli’s image in the NYTs recently with some interesting results…

Broccoli vs Kale

 

  • brocquet (it’s a flower)
  • broctober
  • in 2010, diet surpassed smoking as the biggest US risk factor for disease and death
  • nutritionists now consider fruit juice to be in the same category as soft drink
  • Nurses Health Study: 5 servings of vegetable/day = 28% reduced heart disease risk
  • DASH study: Plant-heavy diets achieve equivalent blood pressure drop to medications
  • Heart, Lung and Blood Institute’s Family Heart Study (2004): High vegetable and fruit consumption (4 or more servings a day) resulted in significantly lower LDL.
  • Less definitive evidence exists for a “buffering effect” on cancer (PN: vs. vegan?)
  • Health messages are overwhelmed by junk food messages
  • Jeffrey Dunn (former Coca-Cola president who now markets baby carrots) told a crowd of more than 1,000 at the Produce Marketing Association convention: “We must change the game. We can help solve the obesity crisis by stealing junk food’s playbook, by creating passion for produce, by becoming demand creators, not just growers and processors.”

http://www.nytimes.com/2013/11/03/magazine/broccolis-extreme-makeover.html

PDF: Broccoli’s Extreme Makeover – NYTimes

complex adaptive systems, cool, data saving lives, healthcare, healthy habits, nutrition, politics, rapid learning health systems, research methodology, technology

Institute for Health Metrics and Evaluation

 

This extraordinary resource by the Institute for Health Metrics and Evaluation was handsomely funded by the Gates Foundation and features interactive data visualisations across a range of country-based and global data sets. The data has been carefully curated and is very handy for looking at risk factors and causes.

IHME

http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram

healthy habits, nutrition, recipe

Kale Chips. Amazing.

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Drewstar introduced me to Kale Chips. Made my first batch last night after noticing kale stocked in the supermarket for the first time. Very simple. Very quick. Very tasty. Very healthy. Where have they been my whole life?

Ingredients:

  • Kale (1 bunch)
  • Olive/Macadamia Oil (1 tablespoon)
  • Salt (1 teaspoon)

Directions:

  1. Preheat an oven to 175 degrees C. Line a non insulated cookie sheet with parchment paper.
  2. With a knife or kitchen shears carefully remove the kale leaves from the thick stems and tear into bite size pieces.
  3. Wash and thoroughly dry kale with a salad spinner.
  4. Drizzle kale with olive oil and sprinkle with seasoning salt.
  5. Bake until the edges brown but are not burnt, 10 to 15 minutes.