My remarks from the Wichita Business Coalition on Health Care's Obesity Forum this morning

Thanks for inviting me to kick off this very important event. Let’s start with a healthy dose of intellectual honesty. Obesity is a disease. It has arguably been so since the beginning of time, but it was made official in this country in 1985 when the National Institutes of Health issued a statement following its Consensus Development Conference on Obesity. This was followed by the report of the World Health Organization’s Consultation on Obesity and then the report of a committee of the Institute of Medicine, now known as the Health and Medicine Division of the National Academy of Sciences. Finally, the American Medical Association in 2013. Obesity is a disease because it is a “definite, morbid process with characteristic symptoms which affects the entire body; and has a known pathology and prognosis.” Obesity shouldn’t need this label in order to be taken seriously. Whether we--our institutions and organizations--pay for obesity treatment should ultimately depend more on what outcomes we value and the cost of achieving those outcomes. That is, the material inputs and outputs of the process, not our opinions of the people or behaviors that lead to them. A materialist versus spiritualist argument. I recently spoke at the Chronic Disease Alliance of Kansas meeting. Some of you were there. I made the argument that even if you are a spiritualist by nature, if you’re interested in medicine or public health, you must invest in a materialist point of view. That means you have to provide evidence for your assertions. How does this little philosophical cul-de-sac apply to obesity? Because I would argue that in spite of ample evidence and the label of disease applied by the NIH, the National Academy of Sciences, the AMA, and others, we don’t treat obesity in this country as a disease.

Think of what happens if you have, say, osteoarthritis of the knee. If you go to the doctor complaining of knee pain that fits the pattern of knee osteoarthritis, within some small confidence interval, you’ll get the same treatment regardless of what doctor you visit: x-rays to confirm the diagnosis, then some initial combination of anti-inflammatory drugs plus or minus strength training or physical therapy; then possibly an injection of hyaluronate or another agent; then a surgical procedure. All backed by some degree of clinical evidence as to their efficacy, with a set of professional guidelines that dictate the order and intensity in which they’re used.

And treatment for the disease--osteoarthritis still--is not limited to the clinical environment. We live under a robust set of laws, regulations, and expectations surrounding the humane treatment of people with osteoarthritis: handicapped parking stalls, construction standards around accessibility (curb cuts and whatnot). Furthermore, an enormous industry exists which caters to osteoarthritic people’s needs: handrails, higher toilets, special bathtubs, purpose-designed kitchen utensils, and others. For all its imperfections, this set of guidelines and expectations has the hallmarks of science: organization of knowledge, adaptability, the ability and willingness to change as evidence evolves.

But what happens if a patient goes to see his or her doctor for obesity? Even if the patient is lucky enough to encounter a doctor that considers obesity a disease and not a personal character failing, no such predictability exists. Doctor one may prescribes meal replacements, a la Nutrisystem, Weight Watchers, or dozens of competitors. Doctor two recommends avoiding “carbs.” (once called Atkins, now called paleo or ketogenic diet; it never goes away, we just change the name every ten years or so to convince people to avoid whole grains, the single most protective dietary component against diabetes) Doctor three prescribes phentermine, or if the patient is lucky, one of the drugs actually approved by the FDA for weight loss, all of which are exorbitantly expensive and modestly effective. Doctor four recommends the Diabetes Prevention Program. Doctor five recommends bariatric surgery. Doctor six recommends probiotics or another microbiome-directed treatment.

When the patient leaves the doctors office, she enters a built environment designed to be maximally obesogenic. Four-lane arterial roads replacing walkable, bikeable streets, even though we know beyond certainty that trips taken by car, rather than by bike, foot, or public transportation, are perfectly, directly related to the obesity rate in any community. And the amount of money any community spends on car-related transportation is perfectly aligned with obesity rates. Our patient pays sales taxes on obesogenic foods (red meat, refined carbohydrates, sugared beverages, and fats) at exactly the same rate as protective, high-fiber, unprocessed fruits, vegetables, and whole grains, in spite of evidence that Pigovian taxation, in which unhealthy foods are taxed at a rate equal to their the social cost and healthy foods are subsidized, has a powerful effect. Similarly, crop insurance and subsidy programs--in whatever form they take--favor meat and dairy production over fruits and vegetables.

When a peer gets cancer, we offer words of encouragement and give her rides to the doctor. We judge those with obesity and say they’re getting what they deserve for their weakness and sloth. We consider people who are competent, functioning members of society to be somehow constitutionally flawed and subject them to various levels of social discrimination. Obesity, along with intelligence, seems to be one of the final acceptable targets of discrimination; we casually make jokes about fat people and stupid people with none of the anxiety that accompanies insensitive remarks about race or sexual orientation. This is surely short-lived; over 80 million people in the U.S. have an I.Q. less than 90, and over 100 million are obese by body mass index criteria. These are groups large enough to fight back.

Viewed by an outsider, this set of circumstances does not resemble science. This is not the end result of a materialist view of the world. It resembles religion: a cultural system of competing behaviors, world views, and ethics that relate humanity’s problems not to the laws of the universe, but to supernatural elements. This elevation of the spiritual realm above the material realm is perfectly fine on Sunday mornings. I’m not here to make an anti-religion argument. Religion and spiritualism are vital in mobilizing public passion and opinion. NIH director Francis Collins, who discovered the gene mutation responsible for cystic fibrosis and later directed the Human Genome Project, is an evangelical Christian who advocates that religious belief can not only be reconciled with acceptance of scientific evidence, but that spirituality is vital to the responsible advancement of science. But spiritual thought in the absence of material evidence is unacceptable in the pursuit of a public health solution.

So how should we handle obesity as a health problem? As Kansans, we’re lucky to have perhaps the best model in our collective memories. We have Samuel Crumbine, early 20th century Dodge City physician who revolutionized the treatment of tuberculosis and other infectious diseases. At the outset of Dr. Crumbine’s career, infections were the leading cause of death by far and were dealt with in a quasi-spiritual manner. The consumption of tuberculosis was seen as God’s wrath. But Dr. Crumbine applied common sense strategies to limit the spread of the disease. He helped established sanitaria for tuberculosis patients, to isolate them from the public until they were no longer contagious. He spearheaded laws against spitting on the sidewalk (remember the bricks?), against shared drinking cups (you have him, indirectly, to thank for the modern bubbler-style drinking fountain), and against shared towels in public bathrooms. He advocated for fly-swatting campaigns. And all the while, he still promoted medical interventions for people already infected. Better antibiotics were developed. The entire specialty of cardiothoracic surgery grew not out of a need for coronary artery bypass grafting, but out of the need to drain tuberculous abscesses from the chests of infected patients.

When applied to obesity, I’m aware that lines blur. Calling something a disease moves individuals across a gauzy barrier between personhood and patienthood. You’re a person up until you’re labeled with a disease, then you’re a patient. The label inherently causes the patient to adopt a role in which he or she is excused from responsibility for his/her condition. This is healthy and appropriate; we know that the vast majority of lung cancers are caused by cigarette smoking, but we do not argue that smokers should be denied treatment. And the label creates an obligation for treatment that many obese people may not want. Roxane Gay and others have argued eloquently against the over-medicalization of body weight. And if this process (labeling of a disease, applying that label to people) entails an obligation for treatment, who will consent to pay the costs for that treatment? This social negotiation is just as big a part of what we need to address as any specific decision on the appropriateness or order of interventions.

I’m no Samuel Crumbine. I don’t even have a mustache. But if I channel Dr. Crumbine, I can see continued progress starting today. I can see the further development of a bike and pedestrian infrastructure, sensible parking policies, and street design that encourages higher density development with widely available green spaces. This can be partnered with local laws and regulations, a more sensible crop subsidy program, and a food tax system that encourages the production and consumption of quality foods over obesogenic foods. For patients who choose to seek help from their doctor, I can see a set of community-wide standards that promote a practical, stepwise approach to treatment that incorporates dietary and behavioral interventions alongside policies that make proven drug and surgical interventions more affordable. I can advocate for the development of a unified, science-based approach to obesity, motivated by spirituality but guided by material evidence.

Disclaimer: Health ICT was also a presenter, and the Forum was supported through a grant offered by the National Alliance of Healthcare Purchaser Coalitions and Novo Nordisk.

How to break up with your phone, Double Arrow Metabolism edition, days 16 and 17

Day 16 was to Practice Pausing. In ironic honor of this, I decided to try to write this blog post while listening to a podcast. Couldn't do it. I've never been a good multi-tasker. I'm so bad at it that I suspect anyone who says they can multitask is a liar. Which I suspect is exactly what Catherine would say. So I've proved her point. 

Anyway. The idea for Tuesday was to deliberately practice being still. To embrace boredom. She told me to pick a situation when I find myself reaching for my phone to kill some time. As I've said before, this time for me is almost exclusively potty time. And it's a problem. I go in for what ought to be a very simple procedure, and I walk out ten minutes later because I've been sucked into a New Yorker article about the Steele Dossier, and anyone in the vicinity mistakenly thinks I'm suffering from weapons-grade constipation when I've really just had a driveway moment on the toilet. 


So I committed to doing it the old-fashioned way. Not by dragging a newspaper into the stall with me. I don't have that kind of self-confidence. By staring at the stall door, or by wondering why the screws on bathroom partitions are always loose even though they use those one-way screws:


And it worked! I mean, I didn't time myself, even though the little scientist in me said that I should. I was in and out of there in no time. Nobody in the office thinks I'm all bound up over the last couple days. Good stuff. 

What I didn't experience was any kind of zen moment of really having my brain lock in on something profound. But it's early in this experiment.

Day 17 was to Exercise My Attention Span. This is like weightlifting, but for my brain. Catherine tells me that my newfound phone-free time can be spent doing something as simple as reading (done), something just for the sake of it, like practicing math in my head, or putting focus toward more meaningful tasks. I chose option 3. Yesterday I decided to spend some down time planning out a strategy for a clinic I'm consulting with to incorporate team-based strategies into their routine clinical care. In a ten-minute session, I planned out several steps to get a diabetes educator trained for the clinic, to get the clinic hooked up with their local pharmacy for a collaborative practice agreement around medication adherence, and to track outcomes related to these interventions. I raced to write all the steps and contact information down because I was afraid of forgetting it. But that's okay. The exercise made me feel like a downmarket Cal Newport.

Super four-pack of links July 11, 2017: the five percent and healthcare money, video game addiction, exercise to prevent diabetes, activity inequality, and evil coconut oil

Super-user sounds great, right? Who doesn't want to be super at something? Only this video (in Memphis-style) refers to the 5% of Americans that account for ~50% of health care spending in a year.

To paraphrase the end of the video: "There's almost nothing insurance companies won't charge, and Americans won't pay." How do you keep yourself from becoming a super-user? Everything medical is a matter of risk, so don't believe anyone who tells you there's a rock-solid simple way to keep from falling into that 5%, at least temporarily. But overwhelmingly, if you can keep a steady job you don't hate, if you can abstain from smoking, if you can get even a small amount of daily exercise (more is better, obviously), if you can keep your alcohol intake to a minimum, if you can abstain from recreational drugs (this includes marijuana, obviously), and if you can choose to eat mostly plant-based foods in semi-sane quantities, you're gonna stay out of The Five Percent.

What does excess immersion into video games mean for young men?

I've tried to set the Weeds audio above to play at about the 46 minute mark. But if that doesn't work, fast forward to the 46 minute mark. Not because the discussion of what "Trumpism" is isn't interesting (it is), but because the discussion that follows helped me think more deeply about the problem of excess immersion into video games that young people, especially young men, are experiencing. I've blogged about this before, and I talked about it at a recent speaking engagement. We seem to be creating a generation of youths who are increasingly isolated in very immersive video games, and then they're growing up into increasingly isolated and lonely people, particularly after age 40. As Ezra Klein says in the piece: if this were a problem of drug abuse, I think we would be acting collectively to do something about it. That's an apt comparison, since game addiction and drug addiction seem to have some physiology in common. But since the solution to technological problems currently seems to be "more technology," we are kinda-sorta just plowing ahead and hoping that video games fix themselves. I'm not optimistic. I think we need to start introducing programs to help kids moderate their exposure to video games and increase their exposure to the world at a young age. Dylan Matthews, who generally defends the idea of video games as a pacifying technology for people who can't or won't work, ends with this quote: "When we're in our eighties, we're all gonna be doing, like, flight simulator stuff. That's, like, how we'll spend--or, VR stuff, at least--that's what retirement's going to look like." Yuck. No. No. No. 

A new meta-analysis shows that African-Americans who exercise may not derive the same protective benefit from type 2 diabetes as other races

(brief Healio write-up here)

 I'm not ready to sign on to this point; race is a very blunt instrument when it comes to genetics. As the cost of gene sequencing falls, I think we'll not only be able to tease out drug effects in people with specific genetic features; we'll be able to more precisely target interventions like physical activity. Maybe certain people in this collection of studies would have benefited more from strength training, while others needed more endurance-oriented activities. Maybe some would have benefited from a specific combination of drug and activity. We don't know the answers to these things now, but we will soon. 

Smartphone data shows that countries with the highest "activity inequality" are more likely to have large obese populations: 

More differences in activity within the population equals more obese people. 

More differences in activity within the population equals more obese people. 

So it isn't a surprise that the same investigators found that the higher the walkability of a city, the lower the "activity inequality":

Texas is not a place with a great deal of walkability. 

Texas is not a place with a great deal of walkability. 

The cynical take on this study is something like, "Of course people who are inactive weigh more!" Fair enough. But the obvious policy implication of the study is that, to affect the activity level of the inhabitants of a city, the built environment must give opportunities for activity.

ADDENDUM (make it a five-pack): How coconut oil got a reputation for being healthy in the first place. I don't love coconut oil, but even if I did, I'd think of it like I think of butter: an ingredient to be used sparingly, mostly for flavor. 

June 6, 2017 link-a-dink

The idea that good diabetes care isn't strictly an obsessive quest for an A1c level of 7% or less is finally hitting the mainstream press. This article also touches on the very real dilemma that doctors and patients face: Do we use old, cheap drugs that are effective at lowering the hemoglobin A1c level, or do we use new, astonishingly expensive drugs that have better evidence of actually reducing death?

Most people will never understand my eating disorder. "I am six feet tall and between 180 and 190 pounds, depending on the month. I am by no means the picture of health or even particularly muscular-looking—not for someone who exercises this much, and definitely not compared to most of the men I see at my gym. Or maybe I am? That's the problem, or one of them: What I see when I look in the mirror doesn't correspond with reality. I see a fat piece of shit, and then I think to myself that it's time to punish my body for letting me down."

Do patients make mistakes during doctor visits because they're put in a position that forces them to rely on intuition and makes them vulnerable to biases? 

Linkfest March 15, 2017

Watch a professional cyclist's carbon wheel melt before your very eyes:


Some people think going gluten-free may be risky for diabetes. Hmmm. Gluten-free diets are, for the most part, a waste of time and effort unless you have celiac disease. And whole grain intake is generally associated with a decreased risk of diabetes, which is consistent with the alleged findings of this study. And this paper (not yet published) comes from Harvard, which gives it a certain cachet, but I'm always skeptical of big, splashy pronouncements like this when they're made ahead of publication. Too many of these studies end up having fatal flaws.

Bikes now officially outnumber cars in Copenhagen. "When Copenhagen first began manually counting cars and bikes in 1970, there were 351,133 cars and 100,071 bikes on the roads—a ratio of about 3.5 to 1. That's important, because it means not only are more people riding—about 150 percent more over 46 years—but also, fewer people are driving."

How the world's heaviest man lost it all. "The only thing that gave him comfort in life was food. It was a drug of abuse, freely available, heavily marketed."

Is loneliness the biggest threat to middle-aged men? Well, Vivek Murthy is definitely qualified to say so, and I think we're self-isolating ourselves with suburban homes and gadgets, but "biggest" is a stretch when we still have tobacco and obesity/diabetes to contend with...

Big pharma is very nervous about possible Trump FDA deregulation. This one cuts both ways. On one hand, I'm afraid that ineffective drugs are going to start coming to market if deregulation goes too far. On the other hand, any deregulation that is opposed by big pharma is inherently attractive.

The ADA 2017 Standards of Care in Diabetes are out. "To help providers identify those patients who would benefit from prevention efforts, new text was added emphasizing the importance of screening for prediabetes using an assessment tool or informal assessment of risk factors and performing a diagnostic test when appropriate." It's a start.

You can't use drugs to "prevent" diabetes

Big, big disclosure here: I am a paid consultant for a CDC grant that aims in part to increase use of the Diabetes Prevention Program. So there. Read on.

Good to see you again, Mrs. D. You mind if I call you Mrs. D? Thanks. Reminds me of "Mrs. C" on Happy Days. You know, she was the only one with the cojones to call the Fonz "Arthur." So you can see the resemblance.

I'm glad you asked about the recent study that showed a medicine called "liraglutide" (brand names Victoza or Saxenda) "prevented" diabetes. You're a smart person, so you read some of the fine print in the study, and you know that ~2200 patients, most of them obese, were randomly given a daily shot of placebo or a daily shot of liraglutide, a chemical that mimics a gut hormone to trick the pancreas into producing more insulin. Liraglutide has the side effect of making people feel fuller sooner after eating. Doctors call this "early satiety." The tricky vocabulary's how we make so much money.

All of the patients had elevated blood sugars, but not so elevated that they could be labeled "diabetic." They were "pre-diabetic" in the current nomenclature, just like you. It means the same thing as "impaired fasting glucose" or "impaired glucose tolerance." The study set out to prove that liraglutide could "prevent" the onset of diabetes. Now you're probably wondering: If I'm taking a diabetes drug, what's the point of having "prevented" diabetes?

And you're on to something, Mrs. D. This is an absurd question at face value, but it keeps getting tested, mostly by drug companies. Not surprisingly, in most cases people getting the diabetes drug were less likely than those getting a placebo pill or shot to have their blood sugars rise high enough to be diagnosed with diabetes.

I'm about to get really, really snarky, Mrs. D, but before I do, it's important that I make this point: the prevention of diabetes is actually a HUGE deal, and not only because diabetes remains the number one cause of blindness, kidney dialysis, and foot amputation in the United States. It is astonishingly expensive. Of the $3.2 trillion (!) that Americans spend on health care annually, diabetes directly accounts for $101.4 billion, making it officially the most expensive disease in America. If you can prevent people from advancing from the just-a-little-abnormal-sugars "pre-diabetes" to old-fashioned diabetes, you save about $12,000 per year in expenses. Now, that's insurance company money, but we all pay for it in premiums.

This is where your insurance premiums are going.

This is where your insurance premiums are going.

And as I've pointed out before, a big chunk of that extra spending isn't insurance money at all; it's coming out of your pocket in the form of co-pays and whatnot. And it's not much better for the Medicare crowd, who we all pay for in taxes:

So let's perform a quick thought experiment. You came to see me because you weren't feeling your best, and I checked a blood sugar on a hunch, and it's slightly elevated at 106 mg/dl. That's in that pre-diabetic range I've been talking about.


Now, we've got some options here. But let's say I tell you that the best way to keep yourself from becoming diabetic is to inject yourself with 10 units of insulin every night before bed. That way, your blood sugars will go back to normal, and we can both wash our hands of the whole issue. Great, right? We've prevented a case of diabetes! Your blood sugars are normal, after all.


Of course we haven't prevented a case of diabetes! We've just put you on a diabetes drug that has (predictably) lowered your blood glucose levels. The entire assertion that we've prevented anything is as laughable as the assertion that we could "prevent" a diagnosis of hypertension by putting you on blood pressure medications.

To make the situation even more ridiculous with liraglutide, it costs a fortune: over $3,000 a month for the 3 mg dose! If you wanna know where that extra $12k a year is going, I think we're hot on the trail. Think what else we could do with that amount of money. And if you for some reason think the idea of "preventing" diabetes by taking a diabetes drug isn't patently absurd, it works only modestly better than metformin, a drug that can easily be obtained for $3-4 per month.

But the final insult, Mrs. D, is that liraglutide worked barely better in its study than a program called the "Diabetes Prevention Program," or "DPP." In the liraglutide study, roughly 2% of people receiving the drug went on to have blood sugars high enough to be diabetic in three years, versus 6% of people getting placebo, for what we call an 80% "relative risk reduction." (Drug companies love using relative risk because it makes the numbers sound so much more impressive) In the original version of the Diabetes Prevention Program, 4.8% of people getting counseling on diet and lifestyle by a coach went on to be diabetic, versus 11% getting placebo, for a 58% relative risk reduction. The numbers for both groups in the DPP were higher, which I blame on an older participant population.

The cost of the Diabetes Prevention Program? $429 per year. So you might not be surprised to know that in 2016, when CMS was debating whether to allow Medicare to cover the DPP, the Pharmaceutical Research and Manufacturers of America (PhRMA) fought against it, saying that twenty years of evidence was only "preliminary." They do. Not. Care. About your health or the seemingly inevitable transformation of America into a single, enormous insurance company that also happens to field a Navy. And we should all remember that back when insulin was discovered, the University of Toronto held the patent for insulin to keep any single company from exploiting the drug for unreasonable profit. How times have changed.

Okay. Deep, cleansing breaths. I'm calming down. Liraglutide is a good medicine for diabetes. It helps keep sugars down, it helps with weight loss, and it may even help prevent heart attacks. In diabetics, that is. But you're not diabetic, and you don't have to become diabetic, and all drugs come with a cost, financially and otherwise. I think we can agree that diabetes is expensive enough; we shouldn't use drugs to "prevent" it that are even more expensive than the disease itself.

So, Mrs. D. You'd be a great candidate for the DPP. But even if you weren't, do you know what the DPP asks of its participants? 150 minutes a week of physical activity and some dietary modifications to allow you to lose around 7% of your body weight. Let's think about what that might look like. The average bike commute in this country is around 19 minutes one-way. Do that five days a week, and you're at 190 minutes already! And that doesn't even count trips to the grocery store! And if you stop drinking insect bait and cut out the foods that aren't really foods:

If you cut those out from your diet and start eating most of your food from the produce aisle or from the canned fruits and vegetables aisle, don't you think that 7% weight loss sounds pretty modest? I bet you'd blow it out of the water. 

And besides, do you really want to cross that grim threshold from "person" to "patient?" Because the first time you put the needle of that Saxenda pen into your skin, that's what you'll have done. You'll have moved the wrong direction on the Double Arrow Metabolism Wellness Index. You'll have gone from a person with agency, someone who takes medicines to feel better or live longer, to someone who has yielded control to a chemical--a $30,000 a year chemical--to do something you could have done better yourself. You'll have succumbed to a philosophy of better living through chemistry.

Maybe Du Pont doesn't deserve this.

Maybe Du Pont doesn't deserve this.

Or do you want to be the person who SAVES thousands of dollars per year by ditching the fancy gas-powered wheelchair so you can propel yourself through space with your own legs and feet and by eating real foods you made with your own hands and eating them when you want, the way you want, and in the quantities you want? Do you want to live by a philosophy of self-determination, where you know that every healthy, happy day you live from now on was of your own making? 

If that life is what you want, then don't try to prevent diabetes with drugs. It can't be done.