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.

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. 

Link dump - March 8, 2017

Fewer and fewer Americans report trying to lose weight. We may be settling into our role as the one of the fattest countries on earth (we're coming for you, Tonga...). I can't help but think this is because of the many, many, many shitty options that people have had pushed on them that didn't work. Now they've given up. *sigh*

The search for the perfect artificial sweetener continues

"Let us pause here to acknowledge the sugar-frosted codependent embrace of Big Food and the American consumer. You could rightly fault consumers for their insistence on an oxymoronic product. But who has been indulging their fantasies for decades now, promising sweet, satisfying taste and no calories? Big Food, of course. Now customers are upping the stakes—and it’s not at all clear that companies can pass the test."

In what seems like a just reversal of a law that had the unintended consequence of highlighting the law of unintended consequences, after 60 years, street hockey will once again be legal in Hamilton, Ontario, under the following conditions:

  • The roadway has a speed limit of 40 km/h or less and is a local road.
  • Play happens in a place that is "safe and suitable."
  • People play no earlier than 9 a.m. and no later than 8 p.m.
  • No one plays during periods of limited visibility from fog, snow or rain.
  • Play is stopped for any vehicles. ("Car!")

Having robot minions control the lights for them may be turning kids into a bunch of lazy, entitled monsters.

No one can get you to take your medicines but you. Three reminder devices to take your medications were no better than no notification or device in a randomized controlled trial

Go. To. Bed. People who get out of bed in the morning tend to eat better and earlier in the day than night owls. Original paper here.

"We found that night owls had postponed timing of food intake, and less favorable eating patterns with higher intakes of sucrose, fat and saturated fat in the evening hours than early birds," said Maukonen, a doctoral candidate in the department of public health solutions.