A Sign of the Times

Every now and then, I venture out to go shopping at mainstream chain clothing stores.  Although I find it onerous, there are certain things I can't get at thrift stores.  For example, I can never find nice jeans.

The last time I set foot in these stores was about two years ago.  It was tough to find pants my size at that time-- many stores simply didn't sell pants with a 30 inch waist.  This year, it was even harder, since some of the stores that formerly carried 30W pants no longer did.  I managed to find my usual 30W 30L size in two stores, but I had a bizarre experience in both cases.   I put them on, and they were falling off my waist.  Since my waist size hasn't changed in two years, and my old 30W 30L pants of the same brand still fit the same as they did when I bought them two years ago, I have to conclude that both stores have changed their definition of "30 inches".  My new size is 28W 30L, which is tough to find these days.
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60 Minutes Report on the Flavorist Industry

A reader sent me a link to a recent CBS documentary titled "Tweaking Tastes and Creating Cravings", reported by Morley Safer.

Safer describes the "flavorist" industry, entirely dedicated to crafting irresistible odors for the purpose of selling processed and restaurant food.  They focused on the company Givaudin.  Dr. David Kessler, author of The End of Overeating, makes an appearance near the end.

Here are a few notable quotes:

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Palliative Care Report: ‘Travelling alongside’ Patients’, Carers’ and Health Care Professionals’ Experiences of the Calvary Health Care Bethlehem Model of Specialist Palliative Care

Researchers from the Menzies Centre for Health Policy have recently published a report on the Calvary Health Care Bethlehem Model of Specialist Palliative Care. The Menzies Centre for Health Policy was commissioned by Calvary Health Care Bethlehem (CHCB), Caulfield, Melbourne to describe their specialist palliative care service, with emphasis on the experiences of patients, carers and health care professionals (HCPs). CHCB, a service of Little Company of Mary Health Care (LCMHC), is a public, level 3 specialist provider of inpatient and community-based palliative care services for people residing in the Inner South East area of Melbourne, covering five Local Government Areas.

The study is a prospective, mixed-method study that describes the CHCB model of specialist palliative care from four perspectives – that of the patient, their nominated carer, nominated health care professional (HCP) and the team at CHCB. This multi perspective approach is new in the Australian context. The descriptive analysis details a model of specialist palliative care and highlights several key features of the model, which provides flexible, integrated care to maintain and enhance the quality of life of patients and their carers and families.

Click here for a copy of the report

New Review Papers on Food Reward

As research on the role of reward/palatability in obesity continues to accelerate, interesting new papers are appearing weekly.  Here is a roundup of review papers I've encountered in the last three months.  These range from somewhat technical to very technical, but I think they should be mostly accessible to people with a background in the biological sciences. 

Food and Drug Reward: Overlapping Circuits in Human Obesity and Addiction
Written by Dr. Nora D. Volkow and colleagues.  This paper describes the similarities between the mechanisms of obesity and addiction, with a focus on human brain imaging studies.  Most researchers don't think obesity is an addiction per se, but the mechanisms (e.g., brain areas important for reward) do seem to overlap considerably.  This paper is well composed and got a lot of media attention.  Dr. Volkow is the director of the National Institute on Drug Abuse, a branch of the National Institutes of Health.  The NIH is the main source of biomedical research funding in the US, and also conducts its own research.

Here's a quote from the paper:

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Another Simple Food Weight Loss Experience

Whole Health Source reader Sarah Pugh recently went on a six-week simple food (low reward) diet to test its effectiveness as a weight loss strategy, and she was kind enough to describe her experience for me, and provide a link to her blog where she discussed it in more detail (1). 

Consistent with the scientific literature and a number of previous reader anecdotes (2), Sarah experienced a reduction in appetite on the simple food diet, losing 15 pounds in 6 weeks without hunger.  In contrast to her prior experiences with typical calorie restriction, her energy level and mood remained high over this period.  Here's a quote from her blog:

Well, it looks like the theory that in the absence of nice palatable food, the body will turn quite readily to fat stores and start munching them up, is holding up. At the moment, the majority of the energy I use is coming from my insides, and my body is using it without such quibbles as the increased hunger, low energy, crappy thermo-regulation or bitchiness normally associated with severe calorie restriction.

I can't promise that everyone will experience results like this, but this is basically what the food reward hypothesis suggests should be possible, and it seems to work this way for many people.  That's one of the reasons why this idea interests me so much.

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A Brief Response to Taubes's Food Reward Critique, and a Little Something Extra

It appears Gary Taubes has completed his series critiquing the food reward hypothesis of obesity (1).  I have to hand it to him, it takes some cojones to critique an entire field of research, particularly when you have no scientific background in it, and have evidently not read any of the scientific literature on it.  As of 2012, a Google Scholar search for the terms “food reward” and “obesity” turned up 2,790 papers.

The food reward hypothesis of obesity states that the reward and palatability value of food influence body fatness, and excess reward/palatability can promote body fat accumulation.  If we want to test the hypothesis, the most direct way is to find experiments in which 1) the nutritional qualities of the experimental diet groups are kept the same or at least very similar, 2) some aspect of diet reward/palatability differs, and 3) changes in body fat/weight are measured (for example, 2, 3, 4, 5, 6, 7, 8, 9).  In these experiments the hypothesis has both arms and one leg tied behind its back, because the most potent reward factors (energy density, sugar, fat) have nutritional value and therefore experiments that modify these cannot be tightly controlled for nutritional differences.  Yet even with this severe disadvantage, the hypothesis is consistently supported by the scientific evidence.  Taubes repeatedly stated in his series that controlled studies like these have not been conducted, apparently basing this belief on a 22-year-old review paper by Dr. Israel Ramirez and colleagues that does not contain the word 'reward' (10).

Another way to test the hypothesis is to see if people with higher food reward sensitivity (due to genetics or other factors) tend to gain more fat over time (for example, 11, 12, 13, 14, 15, 16).  In addition, studies that have examined the effect of palatability/reward on food intake in a controlled manner are relevant (17, 18, 19, 20, 21, 22), as are studies that have identified some of the mechanisms by which these effects occur (reviewed in 23).  Even if not all of the studies are perfect, at some point, one has to acknowledge that there are a lot of mutually buttressing lines of evidence here.  It is notable that virtually none of these studies appeared in Taubes's posts, and he appeared unaware of them. 
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Two Recent Papers by Matt Metzgar

This is just a quick post to highlight two recent papers by the economist and fellow health writer Matt Metzgar.

The first paper is titled "The Feasibility of a Paleolithic Diet for Low-income Consumers", and is co-authored by Dr. Todd C. Rideout, Maelan Fontes-Villalba, and Dr. Remko S. Kuipers (1).  They found that a Paleolithic-type diet that meets all micronutrient requirements except calcium (which probably has an unnecessarily high RDA) costs slightly more money than a non-Paleolithic diet that fulfills the same requirements, but both are possible on a tight budget. 

The second paper is titled "Externalities From Grain Consumption: a Survey", with Matt Metzgar as the sole author (2).  He reviews certain positive and negative externalities due to the effects of grain consumption on health.  The take-home message is that refined grains are unhealthy and therefore costly to society, whole grains are better, but grains in general have certain healthcare-related economic costs that are difficult to deny, such as celiac disease.

There are a lot of ideas floating around on the blogosphere, some good and others questionable.  Composing a manuscript and submitting it to a reputable scientific journal is a good way to demonstrate that your idea holds water, and it's also a good way to communicate it to the scientific community.  The peer review process isn't perfect but it does encourage scientific rigor.  I think Metzgar is a good example of someone who has successfully put his ideas through this process.  Pedro Bastos, who also spoke at the Ancestral Health Symposium, is another example (3).

Anti-vaccine ads on Delta planes; Magic and Ellen as celebrity champions for HIV/AIDS prevention...and more- What Am I Reading This Week?

New pop culture and public health stories to check out this week:

1. Darrell Hammond of Saturday Night Live fame reveals that child abuse led to alcohol/drug use and cutting. He details the horrific abuse in a new memoir, "God, If You're Not Up There, I'm F*cked".

2. Fellow Boston University School of Public Health alum Elizabeth Cohen reports on the 20th anniversary of Magic Johnson's announcement that he is HIV positive. His announcement had an incredible impact on the public's health- both in terms of reducing stigma of those diagnosed and proving that the diagnosis is not always a death sentence.

3. Delta airlines is seeing backlash from public health organizations and other flu vaccine advocates after airing a 3-minute PSA from the National Vaccine Information Center that describes alternate ways to avoid the flu (besides getting the flu shot).

4. Ellen DeGeneres is named global envoy for AIDS awareness. The hope is that Ellen's enormous platform (from both her TV show and social media channels) will allow her to reach millions of people with the prevention message. Ellen is a partner in other important public health issues, for example- bullying prevention.

5. This week, Evelyn Lauder passed away from Ovarian Cancer. Evelyn was one of the powers behind the creation of the pink ribbon campaign for breast cancer awareness.

How about you? What are you reading this week?

"Starving Secrets": Does Lifetime's New Reality Show on Eating Disorders Offer a Path to Recovery or a How-To Guide to Disordered Eating?

Last night, a public health colleague (@bethg24) tweeted about the new Lifetime reality show called "Starving Secrets". The show will be hosted by Tracey Gold (who had her own very public battle with an eating disorder) and feature real individuals struggling from anorexia, bulimia and other eating disorders.

According to the National Eating Disorders Association (NEDA), as many as 10 million females and 1 million males suffer from an eating disorder in the United States. Therefore, it is a serious and relevant public health problem that (not surprisingly) gets media attention. "Starving Secrets" is not the first movie or television show to take a documentary-style approach to portraying those that suffer from these disorders:

1. MTV's series "True Life" (which I have long admired for their portrayal and stigma reduction efforts regarding various medical conditions...I have been less impressed by episodes like "I'm a Jersey Shore girl"). True Life aired "I have an eating disorder" on April 3, 2003.
   


2. HBO documentary "Thin": This special followed four women during their in patient stays at the Renfrew Center in Coconut Creek, Florida. It premiered on November 14, 2006. I remember this being both incredibly powerful and difficult to watch.



3. E! "What's Eating You?": Admittedly, I only watched one episode of this show. True to E! form (Ahem- Kim's Fairytale Wedding), they are more about sensationalism versus journalism and stigma reduction as compared to other networks.

As with the portrayal of other mental health disorders in the media, I hope that these shows will do something positive. Specifically- reduce the stigma around these disorders and normalize help seeking behaviors.

However, I am also greatly concerned that shows like "Starving Secrets" will actually endanger vulnerable audience members by offering a "how-to guide" to having an eating disorder. The concern stems from research on pro-eating disorder websites. They can offer "thinsperation" to stay skinny by the images portrayed. They can also give tips and strategies for hiding/refusing food or getting rid of it. Sometimes people don't realize that by telling their story in vivid detail, they are actually sharing their "creative tips" for sustaining an eating disorder.

That said, I will definitely be setting the DVR on December 20 to see the show and assess it more accurately. What do others think? Do reality shows like these have the potential to endanger the public's health? Or do their "pros" (e.g., stigma reduction) outweigh the risks?

THE SYDNEY HEALTH POLICY NETWORK: TRANSLATING P-VALUES TO POLICY

Welcome to the Sydney Health Policy Network!

It has long been argued that departments in universities, governments and non-governmental organisations alike have a tendency to work in silos. Although it may be easier to work with people with the same philosophical, political, theoretical or practical background, the health policy problems that we face today require multidisciplinary solutions. For example, appropriate responses to mental health problems will likely include several different government sectors in their policy solutions. In response to the growing need for cross-sectoral, multidisciplinary research and policy, the Sydney Health Policy Network was formed in August 2010.  

The Sydney Health Policy Network aims to provide a structure to promote cross-disciplinary health policy research, education and advocacy. It links researchers, educators and advocates across the divisions of the University of Sydney, its teaching hospitals and research institutes. Although the Network is in its infancy, it already has over 200 members representing a range of different faculties including traditional health faculties/schools, such as Medicine, Public Health, Dentistry, Pharmacy, Health Sciences, as well as faculties of Engineering, Law, Agriculture, Arts, Education and Social Work, among others.

In addition to the Network’s general membership, it is in the beginning stages of establishing Special Interest Groups in Workforce policy, Disease Prevention, Health Governance and a multidisciplinary postgraduate student group. These groups seek to include external members from the state and commonwealth governments, non-governmental organisations and consumer groups to encourage focused policy discussions among experts with a variety of different backgrounds and perspectives.

The Network hopes to facilitate dialogue among researchers, practitioners and policy makers and move towards identifying feasible policy solutions to the health policy problems that we currently face. In doing so, we hope to translate p-values to practical policy with the potential to improve the health of Australians.

If you are interested in joining the Network, please visit our website: http://sydney.edu.au/health-policy-network/

We look forward to your contributions to the Network! Please contact shpn@sydney.edu.au if you have any questions about the Network or if you want to get involved.

Does High Circulating Insulin Drive Body Fat Accumulation? Answers from Genetically Modified Mice

The house mouse Mus musculus is an incredible research tool in the biomedical sciences, due to its ease of care and its ability to be genetically manipulated.  Although mice aren't humans, they resemble us closely in many ways, including how insulin signaling works.  Genetic manipulation of mice allows researchers to identify biological mechanisms and cause-effect relationships in a very precise manner.  One way of doing this is to create "knockout" mice that lack a specific gene, in an attempt to determine that gene's importance in a particular process.  Another way is to create transgenic mice that express a gene of interest, often modified in some way.  A third method is to use an extraordinary (but now common) tool called "Cre-lox" recombination (1), which allows us to delete or add a single gene in a specific tissue or cell type. 

Studying the relationship between obesity and insulin resistance is challenging, because the two typically travel together, confounding efforts to determine which is the cause and which is the effect of the other (or neither).  Some have proposed the hypothesis that high levels of circulating insulin promote body fat accumulation*.  To truly address this question, we need to consider targeted experiments that increase circulating insulin over long periods of time without altering a number of other factors throughout the body.  This is where mice come in.  Scientists are able to perform precise genetic interventions in mice that increase circulating insulin over a long period of time.  These mice should gain fat mass if the hypothesis is correct. 

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The Brain Controls Insulin Action

Insulin regulates blood glucose primarily by two mechanisms:

1. Suppressing glucose production by the liver
2. Enhancing glucose uptake by other tissues, particularly muscle and liver

Since the cells contained in liver, muscle and other tissues respond directly to insulin stimulation, most people don't think about the role of the brain in this process.  An interesting paper just published in Diabetes reminds us of the central role of the brain in glucose metabolism as well as body fat regulation (1).  Investigators showed that by inhibiting insulin signaling in the brains of mice, they could diminish insulin's ability to suppress liver glucose production by 20%, and its ability to promote glucose uptake by muscle tissue by 59%.  In other words, the majority of insulin's ability to cause muscle to take up glucose is mediated by its effect on the brain. 

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Miami Dolphin Brandon Marshall's New PSA for Borderline Personality Disorder

In July 2011, Brandon Marshall revealed that he was diagnosed with Borderline Personality Disorder (BPD). According to the National Education Alliance for Borderline Personality Disorder, this serious mental illness centers on the inability to manage emotions effectively. The condition which has strong heritability (68%) and a high suicide rate (10% of adults with BPD die by suicide), produces symptoms such as impulsivity, anger, and chaotic relationships.

When Brandon announced his condition this summer, he vowed to become the face of borderline personality disorder. He seems to be following through on his promise, as he has just released a public service announcement (PSA) in collaboration with the National Education Alliance for Borderline Personality Disorder. The 33-second video is primarily focused on 3 key messages:

1. Prevalence of this condition is high (15 million Americans)
2. There is hope (treatment exists for those who suffer and education exists for families coping with the disorder)
3. There are resources: visit the NEABPD website or follow Brandon on Twitter (@BMarshall19) for more information

I like the PSA for several reasons. It is simple with clear messages (above). The messages are delivered both verbally by Brandon and visually with key words appearing on the screen. The "call to action" is clear. Viewers are directed to the NEABPD website and Brandon's Twitter feed for more information.

I also like that this particular health issue has found a champion or spokesperson. Unlike other mental health conditions like depression with several celebrity spokespeople (e.g., Brooke Shields), less is known about BPD and those who suffer from it. Experts in mental illness stigma like Patrick Corrigan state that there are several strategies for reducing stigma...and one of those strategies is called "Contact". Contact challenges public attitudes about mental illness through direct interactions with persons who have these disorders. The contact does not have to be face to face, but instead can occur through a channel like a PSA.

The strategies that I see for improving this PSA are focused less on its composition, but instead on its distribution/promotion. Although the video has been on YouTube for 6 days, it only has 309 views. Announcements about the PSA are located primarily on football blogs (e.g., Shut Down Corner) or BPD specific websites. It does not seem that the PSA has been picked up by mainstream media or health blogs. This is in sharp contrast to PSAs I've spoken about previously on Pop Health, like in July 2011 when I discussed Kim Kardashian's ovarian cancer research spot which currently has 33,431 views.

Readers- please weigh in: which mental health advocacy organizations would have the best "reach" in promoting this PSA? What other strategies could they use for distribution/promotion?

Harvard Food Law Society "Forum on Food Policy" TEDx Conference

Last Friday, it was my pleasure to attended and present at the Harvard Food Law Society's TEDx conference, Forum on Food Policy.  I had never been to Cambridge or Boston before, and I was struck by how European they feel compared to Seattle.  The conference was a great success, thanks to the dedicated efforts of the Food Law Society's presidents Nate Rosenberg, Krista DeBoer, and many other volunteers. 

Dr. Robert Lustig gave a keynote address on Thursday evening, which I unfortunately wasn't able to attend due to my flight schedule.  From what I heard, he focused on practical solutions for reducing national sugar consumption, such as instituting a sugar tax.  Dr. Lustig was a major presence at the conference, and perhaps partially due to his efforts, sugar was a central focus throughout the day.  Nearly everyone agrees that added sugar is harmful to the nation's health at current intakes, so the question kept coming up "how long is it going to take us to do something about it?"  As Dr. David Ludwig said, "...the obesity epidemic can be viewed as a disease of technology with a simple, but politically difficult solution".

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Losing Fat With Simple Food-- Two Reader Anecdotes

Each week, I'm receiving more e-mails and comments from people who are successfully losing fat by eating simple (low reward) food, similar to what I described here.  In some cases, people are breaking through fat loss plateaus that they had reached on conventional low-carbohydrate, low-fat or paleo diets.  This concept can be applied to any type of diet, and I believe it is an important characteristic of ancestral food patterns.

At the Ancestral Health Symposium, I met two Whole Health Source readers, Aravind Balasubramanian and Kamal Patel, who were interested in trying a simple diet to lose fat and improve their health.  In addition, they wanted to break free of certain other high-reward activities in their lives that they felt were not constructive.  They recently embarked on an 8-week low-reward diet and lifestyle to test the effectiveness of the concepts.  Both of them had previously achieved a stable (in Aravind's case, reduced) weight on a paleo-ish diet prior to this experiment, but they still carried more fat than they wanted to.  They offered to write about their experience for WHS, and I thought other readers might find it informative.  Their story is below, followed by a few of my comments.

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Pink Fatigue? JCPenney's Sexist Merchandise. Smoking and its Box Office Impact. What Am I Reading This Week?

Here are the top 5 stories I'm following this week:

1. Amid breast cancer month- Is there pink fatigue? A very important public health story. "Awareness" does not equal behavior change (e.g., increased screenings or access to medical care). A related story appeared last week in Upstream: A forum on interdisciplinary health communication.

2. JCPenney CEO responds to petition to stop selling sexist clothing marketed to young girls like "I'm too pretty to do homework". The company is using this incident as a "teachable moment".

3. The use of social media in street protests can be effective for both protesters and police. A story in ScienceDaily.

4. Smoking is a drag at the box office. An analysis of top-grossing movies from the past decade shows that films with smoking make less money.

5. Video game can reduce fatigue in African American women with lupus. A pilot study to explore using Wii Fit to reduce fatigue.

What are you reading this week?

Dr. Pepper Ten: A "Manly" Campaign That Promotes Gender Stereotypes Instead of Health for Men

Yesterday while on the elliptical machine at the gym and watching ESPN (surprise! women watch ESPN), I had the displeasure of seeing the new commercial for Dr. Pepper Ten no less than five times.

Dr. Pepper Ten is a new 10-calorie drink being rolled out by the Dr. Pepper Snapple Group Inc after their client research revealed that men are hesitant to drink diet drinks because they aren't "manly" enough.

The TV commercials that I watched showed men with huge muscles driving through the jungle, shooting guns, and battling snakes. The men say things like, "Hey ladies. Enjoying the film? Of course not. Because this is our movie and this is our soda, you can keep the romantic comedies and lady drinks. We're good."

According to several online reports (e.g., the MSNBC link above), the campaign also developed a Facebook page which contains an application that allows it to exclude women from viewing content. In addition, the page includes games and videos aimed at being "manly." Several twitter users also report that the campaign encourages viewers to "rat on their friends for not being manly". If true, I have no idea how "unmanly" behavior is being reported.

My analysis:

It is great that advertisers are using focus group and other data to develop products and ad campaigns. They taught many of us in public health the importance of these strategies and we are forever grateful. However...

This campaign promotes strict gender stereotypes: Men act like this and women act like this- no exceptions! This dangerous norm contributes to serious public health problems. For example, the traditional ideology of masculinity has been explored for its relationship to negative outcomes like bullying and high risk sexual behaviors.

This campaign attempts to encourage men to drink a "healthier" soda (less calories, real sweeteners) without making them feel like they are dieting...because after all- dieting is only for women. Too bad the obesity rate is hovering between 32-35% for both men and women.

I have seen weight loss/health for men done much more effectively by other companies without insulting viewers. For example, after they saw their services being utilized by more men, Weight Watchers and NutriSystem rolled out men's programs. Weight Watchers presents strategies for making healthy choices in settings where men may find themselves socially (e.g., at a BBQ or at the bar). To reduce the social stigma around participation, they recruited strong male role models like former NFL quarterback Dan Marino. An ABC story on the companies' programs says "Calorie Counting Can Be Macho".

The strategy used by NutriSystem and Weight Watchers to reduce the stigma around healthy behaviors will be much more effective long-term than simply tricking people into being healthy.

For those readers who think I'm only offended by the campaign because I'm a woman, please see a few tweets from Tuesday night...authored by men. The first by my husband, who wrote multiple posts on Dr. Pepper Ten before I ever voiced my disgust with this campaign:

@jeff_underscore: "Dr. Pepper 10 - I think your ad campaign is insane, insensitive and sexist and unfortunately everywhere".

@sorryeveryone: ".@drpepper i really liked your soda but you know what I like more? treating women like they're human beings and letting men be themselves".

Readers: What do you think of this campaign? Do you think it will be effective in getting men to drink these "healthier" sodas?

#NoHomos on Twitter, "50/50" looks at Cancer, Johnny Depp's Rape Comments, Chris Christie's Weight, and Steve Jobs: What Am I Reading This Week?

Whew- it has been a busy week for Pop Health! Here are the top 5 stories I've been reading:

1. Twitter is no place for #NoHomo: Should Twitter take a more proactive stance regarding hate speech that can result in trending topics?

2. "50/50"- A Hollywood movie takes on cancer: Cancer has been a theme in many movies (e.g., "Funny People") and TV shows (e.g., "The big C" on showtime)- how does this movie compare?

3. Johnny Depp offers apology for rape remarks: Depp offers an apology for comparing being chased by paparazzi to being raped. Forgivable?

4. Chris Christie's Weight- Big problem or none of our business?: Although Gov Christie has recently announced that he will not run for President in 2012, the conversation continues about his weight and its influence on his ability to be a successful Governor or President. What do you think?

5. Steve Jobs and Pancreatic Cancer: There have been many stories about the death of Steve Jobs and the contribution of pancreatic cancer to his passing. I thought Celebrity Diagnosis did a nice job of guiding readers through his diagnosis.

Please use the comment box to tell me what you think about these stories and about others that you are reading this week!

The Case for the Food Reward Hypothesis of Obesity, Part II

In this post, I'll explore whether or not the scientific evidence is consistent with the predictions of the food reward hypothesis, as outlined in the last post.

Before diving in, I'd like to address the critique that the food reward concept is a tautology or relies on circular reasoning (or is not testable/falsifiable).  This critique has no logical basis.  The reward and palatability value of a food is not defined by its effect on energy intake or body fatness.  In the research setting, food reward is measured by the ability of food or food-related stimuli to reinforce or motivate behavior (e.g., 1).  In humans, palatability is measured by having a person taste a food and rate its pleasantness in a standardized, quantifiable manner, or sometimes by looking at brain activity by fMRI or related techniques (2).  In rodents, it is measured by observing stereotyped facial responses to palatable and unpalatable foods, which are similar to those seen in human infants.  It is not a tautology or circular reasoning to say that the reinforcing value or pleasantness of food influences food intake and body fatness. These are quantifiable concepts and as I will explain, their relationship with food intake and body fatness can be, and already has been, tested in a controlled manner. 

1.   Increasing the reward/palatability value of the diet should cause fat gain in animals and humans

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(Dis)Connected: MTV Explores the Impact of Digital Drama on the Health and Safety of Young People

On Sunday October 10, 2011, MTV will premiere "(Dis)Connected". The movie will explore the experiences of four young people. They have never met in-person, but their lives collide online and are forever changed by their digital interactions.

The film supports the network's "A Thin Line" campaign which empowers youth to stand up against digital abuse of all kinds (e.g., bullying, discrimination, etc).

The movie is inspired (in part) by the tragic death of Abraham Biggs in 2008. Biggs, a 19-year old college student, live streamed his suicide on the internet, with some users egging him on and some trying to talk him out of it.

(Dis)Connected supports an ongoing discussion in public health regarding the question: "Does technology help us or hurt us when it comes to issues such as bullying or suicide?" The answer is not clear. There are examples on each side. One year ago today, I wrote the post "Bullying: Is Technology Helping Us or Hurting Us?" The post was inspired by the dialogue of how technology may have contributed to the suicide of Tyler Clementi but also how it was being used in a positive way to prevent bullying in the aftermath (e.g., the "It Gets Better" project).

On her blog "Promoting Hope, Preventing Suicide", Elana Premack Sandler writes about research and advice for preventing teen and adult suicide. Just in the past year, she has extensively explored the issue of technology/social media and its impact on suicide prevention. Some example posts include: Facebook Support Networks (September 21); YouTube Prevents Suicide? (May 4); and Promoting Hope Through Social Media (April 13).

Let's all check out (Dis)Connected on October 10 and let the dialogue continue.

If you or someone you know is in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK or visit their website here.

Kissing on Southwest Airlines, Over-hyped Reebok Toning Shoes and More- What Am I Reading This Week?

There are many great Pop Health (Pop Culture- Public Health) stories in the news each week, so it can be difficult to narrow down my focus for a weekly post.

Therefore, I'm starting a new feature called- "What Am I Reading This Week?" to link you to my runner-ups:

1. Reebok agrees to settlement over "over-hyped" claims that its EasyTone shoes could tone leg and butt muscles better than regular shoes.

2. Perfect for football Sunday: Cheeseheads take issue with anti-cheese billboard (from groups promoting vegan diets).

3. L-Word actress gets kicked off Southwest flight for lesbian kiss (they say it was based solely on behavior, not gender).

4. Lady Gaga wants to make bullying illegal- wants meeting with the president.

Use the comment box to tell me what you're reading this week!

The Case for the Food Reward Hypothesis of Obesity, Part I

Introduction

When you want to investigate something using the scientific method, first you create a model that you hope describes a natural phenomenon-- this is called a hypothesis.  Then you go about testing that model against reality, under controlled conditions, to see if it has any predictive power.  There is rarely a single experiment, or single study, that can demonstrate that a hypothesis is correct.  Most important hypotheses require many mutually buttressing lines of evidence from multiple research groups before they're widely accepted.  Although it's not necessary, understanding the mechanism by which an effect occurs, and having that mechanism be consistent with the hypothesis, adds substantially to the case.

With that in mind, this post will go into greater detail on the evidence supporting food reward and palatability as major factors in the regulation of food intake and body fatness.  There is a large amount of supportive evidence at this point, which is rapidly expanding due to the efforts of many brilliant researchers, however for the sake of clarity and brevity, so far I've only given a "tip of the iceberg" view of it.  But there are two types of people who want more detail: (1) the skeptics, and (2) scientifically inclined people who want mechanism.  This post is for them.  It will get technical at times, as there is no other way to convey the material effectively.

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Celebrities and their Health Causes: What Happens When They Do More Harm Than Good?

Often on this blog I have spoken about the role of celebrities as the spokesperson or "champion" for various public health issues. Many celebrity names are synonymous with particular health causes (Katie Couric- Colon Cancer; Michael J. Fox- Parkinson's Disease; Lance Armstrong- Testicular Cancer; to name a few).

Over the past few weeks, several stories have emerged which beg the question, "what happens if celebrities do more harm than good?" Those in the public eye have such a broad and extensive platform to communicate with the public...what if they disseminate erroneous information or even worse- cause a panic?

The week of September 12 was quite busy! In the Republican Presidential Debate (in the context of discussing mandated HPV vaccines for children), Rep. Michelle Bachmann claimed that the HPV (Human Papillomavirus) vaccine is linked to mental retardation. To support her claims, Bachmann repeatedly told the story of being approached by a woman whose daughter suffered mental retardation after taking the vaccine. As those of us in science well know, one self-reported story does not equal a true incident. Even if true, one incident does not equal a trend or an epidemic. This story has been quickly picked up by scientists who are even offering money if it is proven true.

This same week, Dr. Mehmet Oz of the Dr. Oz Show (you may remember him from numerous appearances on the Oprah Winfrey Show), claimed that apple juice contains unsafe levels of arsenic. These claims followed research conducted by the Show which had a laboratory examine three dozen samples from five different brands across the United States. The samples were compared to the limits of arsenic set for drinking water by the EPA. Since the claims, many scientists have spoken out regarding concerns about the study's protocols and conclusions (for example, not differentiating between organic and inorganic types of arsenic). Many were concerned about the widespread panic caused by these claims and likened it to shouting "fire" in a crowded theater.

Of course, this is not the first time celebrities have caused a scandal following potentially false and dangerous claims. Jenny McCarthy has dedicated her life to proving the cause between childhood vaccines and autism. Shortly after Brooke Shields released her book, "Down Came The Rain", which chronicled her battle with postpartum depression- actor Tom Cruise (a Scientologist) publicly criticized her for taking antidepressant medication.

So what happens when these celebrities cause more harm than good? What happens when their claims are misguided, misinformed, and/or not based on evidence or science? The answer: they can have huge and far-reaching public health consequences. For example, as we begin to see illnesses like measles reappear- we have to wonder- "Is this the Jenny McCarthy effect?"

Humans on a Cafeteria Diet

In the 1970s, as the modern obesity epidemic was just getting started, investigators were searching for new animal models of diet-induced obesity.  They tried all sorts of things, from sugar to various types of fats, but none of them caused obesity as rapidly and reproducibly as desired*.  1976, Anthony Sclafani tried something new, and disarmingly simple, which he called the "supermarket diet": he gave his rats access to a variety of palatable human foods, in addition to standard rodent chow.  They immediately ignored the chow, instead gorging on the palatable food and rapidly becoming obese (1).  Later renamed the "cafeteria diet", it remains the most rapid and effective way of producing dietary obesity and metabolic syndrome in rodents using solid food (2).

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Primal Docs

Chris Armstrong, creator of the website Celiac Handbook, has designed a new non-commercial website called Primal Docs to help people connect with ancestral health-oriented physicians.  It's currently fairly small, but as more physicians join, it will become more useful.  If you are a patient looking for such a physician in your area, or an ancestral health-oriented physician looking for more exposure, it's worth having a look at his site:

Primal Docs

Update 9/22: apparently there is already another website that serves a similar purpose and has many more physicians enrolled: Paleo Physicians Network.

Fat Tissue Insulin Sensitivity and Obesity

In this post, I'll discuss a few more facts pertaining to the idea that elevated insulin promotes the accumulation of fat mass.  

Insulin Action on Fat Cells Over the Course of Fat Gain

The idea that insulin acts on fat cells to promote obesity requires that insulin suppress fat release in people with more fat (or people who are gaining fat) to a greater extent than in lean people.  As I have written before, this is not the case, and in fact the reverse is true.  The fat tissue of obese people fails to normally suppress fatty acid release in response to an increase in insulin caused by a meal or an insulin injection, indicating that insulin's ability to suppress fat release is impaired in obesity (1, 2, 3).  The reason for that is simple: the fat tissue of obese people is insulin resistant.

There has been some question around the blogosphere about when insulin resistance in fat tissue occurs.  Is it only observed in obese people, or does it occur to a lesser extent in people who carry less excess fat mass and are perhaps on a trajectory of fat gain?  To answer this question, let's turn the clocks back to 1968, a year before Neil Armstrong first set foot on the moon. 

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Hyperinsulinemia: Cause or Effect of Obesity?

Is Elevated Insulin the Cause or Effect of Obesity?

The carbohydrate hypothesis, in its most popular current incarnation, states that elevated insulin acts on fat cells to cause fat storage, leading to obesity.  This is due to its ability to increase the activity of lipoprotein lipase and decrease the activity of hormone-sensitive lipase, thus creating a net flux of fat into fat cells.  I'm still not sure why this would be the case, considering that fat tissue becomes more insulin resistant as body fat accumulates, therefore insulin action on it is not necessarily increased.  Total fat release from fat tissue increases with total fat mass (1), demonstrating that insulin is not able to do its job of suppressing fat release as effectively in people who carry excess fat.  But let's put that problem aside for the moment and keep trucking.

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Catered Paleo Dinner with Yours Truly

Gil Butler, organizer of the Western Washington Paleo Enthusiasts group, has organized a catered "paleo" dinner on Sunday, October 9th.  He will be screening the first episode of "Primal Chef", Featuring Robb Wolf and others.  He invited me to give a short (20 minute) presentation, which I accepted.  There are still roughly 30 spots remaining [update 9/21-- the event is full].

The event will be in the Ballard neighborhood of Seattle and the price is $15.76 per person.  I will not be paid for this talk, it's just an opportunity to share ideas and meet people. 

Click here to register.

Book Review: The End of Overeating

The End of Overeating was written based on the personal journey of Dr. David A. Kessler (MD) to understand the obesity epidemic, and treat his own obesity in the process.  Dr. Kessler was the FDA commissioner under presidents George HW Bush and Bill Clinton.  He is known for his efforts to regulate cigarettes, and his involvement in modernizing Nutrition Facts labels on packaged food.  He was also the dean of Yale medical school for six years-- a very accomplished person. 

Dr. Kessler's book focuses on 1) the ability of food with a high palatability/reward value to cause overeating and obesity, 2) the systematic efforts of the food industry to maximize food palatability/reward to increase sales in a competitive market, and 3) what to do about it.  He has not only done a lot of reading on the subject, but has also participated directly in food reward research himself, so he has real credibility.  The End of Overeating is not the usual diet book. 
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"What's Your Weapon?": Billie Jean King, Arthritis Foundation, Ad Council, and USTA Launch Arthritis Campaign

Before Twitter and the U.S. Open was a flutter this afternoon with the news of Venus Williams withdrawing due to the diagnosis of the autoimmune disease- Sjogren's Syndrome, the U.S. Tennis Association was focused on another health related issue. Today the press release went out that tennis legend Billie Jean King was joining the Arthritis Foundation, the Ad Council, and the US Tennis Association (USTA) to launch a public service campaign against arthritis (the leading cause of disability in America).



The ads, launched at the U.S. Open today, feature King (who has osteoarthritis- OA) and highlight the power of movement and exercise as "weapons" in the fight against arthritis. King tells viewers "tennis is my weapon" against arthritis. The ad then asks viewers, "what is your weapon against arthritis?" and directs them to the campaign's website in order to find out: Fight Arthritis Pain. On first view, I was not terribly impressed. The brief ad (33 seconds) does not tell you very much (e.g., King says tennis is her "weapon" but nothing is said about the benefits of movement). The goal of the ad simply appears to be motivating viewers to visit the website for additional information.



The other thing that is not clear in the ad (but clarified in the press release and website) is that this campaign is targeting OA specifically. While OA is the most common type of arthritis, it is not the only type. For example, in contrast to OA which breaks down cartilage, rheumatoid arthritis (RA) (a chronic autoimmune disease) causes inflammation of the lining of the joints. Would the exercise recommendations be the same no matter what type of arthritis? I would say that distinction is unclear for viewers.



However, I did feel better when I read the press release and saw that these ads were tested in focus groups by the Ad Council. Testing your images and messages with your target population is incredibly important. It is reported that participants felt that the concept of "having a weapon" against arthritis was powerful and motivating. That is good news considering formative research by the Ad Council found that only 16% of OA sufferers surveyed felt "very confident" that they could manage their pain. Therefore, if an ad can make viewers feel empowered and confident- that is a good thing.



The press release did not describe the demographics of the focus group participants, but I am assuming they were similar to those originally surveyed (adults age 55+ with OA). If so, it would mean that Billie Jean King was an appropriate "Champion" for the cause and someone that audience admired, having watched her in the 1960s-1970s, her prime competitive years. However, I wonder if she would be the best choice for ads targeting arthritis sufferers in a younger demographic? After all, different types of arthritis can affect people of all ages. Again, this is another reason that I would have wanted to see a clearer definition of the audience for these ads. If we are focused on older adults with OA, then it is a great choice. If we are focused on people of all ages with all types of arthritis, then maybe not.



Overall, I give this campaign a "B". The impetus of the campaign is good in that it is based on research...research that shows that arthritis suffers are too sedentary and do not feel like they have control over their pain management. The campaign aims to address these barriers by empowering viewers with a "champion" who they admire and can model. The campaign also links them to a website with all the information they need about the benefits of exercise for arthritis. However, the execution of this campaign is not as strong as its foundation. It would have benefited from a more clearly defined audience and message.

A Roadmap to Obesity

In this post, I'll explain my current understanding of the factors that promote obesity in humans.  

Heritability

To a large degree, obesity is a heritable condition.  Various studies indicate that roughly two-thirds of the differences in body fatness between individuals is explained by heredity*, although estimates vary greatly (1).  However, we also know that obesity is not genetically determined, because in the US, the obesity rate has more than doubled in the last 30 years, consistent with what has happened to many other cultures (2).  How do we reconcile these two facts?  By understanding that genetic variability determines the degree of susceptibility to obesity-promoting factors.  In other words, in a natural environment with a natural diet, nearly everyone would be relatively lean, but when obesity-promoting factors are introduced, genetic makeup determines how resistant each person will be to fat gain.  As with the diseases of civilization, obesity is caused by a mismatch between our genetic heritage and our current environment.  This idea received experimental support from an interesting recent study (3).

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The East Coast Earthquake, Real Time Twitter Chat, and Facebook Applications for Disasters

Well! Today was an interesting day at the office. Up and down the east coast, many of us felt the tremors resulting from an earthquake in Virginia. While I would like to report that we all stayed calm and participated in orderly, safe, and well rehearsed evacuations...that was not the case. It appeared that the shock of experiencing an earthquake (such a rare event on the east coast) caused a little chaos. On my way into my office to grab my bag before hitting the stairs, I experienced a "George Costanza" type moment as a fellow staff person almost knocked me down in her rush to get out. I heard similar stories from my husband who works 4 blocks away. Upon recognition of the earthquake, his co-workers made a beeline for the safest escape route...the elevator?!



After the shaking took us down 13 flights of stairs, I quickly turned to the only reliable source for real time information- Twitter. Since I was the only one in the area who either grabbed my phone or had twitter, I quickly read off what I knew: "It is a 5.9 earthquake in Virginia"; "My colleagues felt it in- Baltimore, DC, Boston, NYC, North Carolina"; "No damage except one broken window is reported in Philadelphia". After being given the go ahead to return to the building and settling back into our work, we received an official text/email from the University reiterating the information Twitter delivered an hour before. According to Twitter's official profile tonight, within one minute of the #earthquake, there were more than 40,000 earthquake-related tweets. They reached 5,500 tweets per second (TPS).



As I discussed in a related post back in March 2011, the question for public health professionals continues to be- "What is the role of social media in emergency preparedness and recovery?"



I believe we are making some strides in answering that question. Just yesterday, the Office of the Assistant Secretary for Preparedness and Response (ASPR)- located within the US Dept of Health and Human Services (HHS)- launched a contest: The ASPR Lifeline Facebook Application Challenge. The goal of the contest is to create applications that prepare individuals for disasters and build resilient communities. Those who opt into the application will be able to identify "lifelines" or Facebook friends that agree to be an individual's emergency contact and act on their behalf in case of an emergency. They will also be able to create a personal preparedness plan and share that plan and the application with others.



Even without the formal application, we have seen social network sites be used for checking in with friends/family and for getting information out quickly. For example, I follow the Philadelphia Office of Emergency Management on Twitter, so I got the message quickly that our 9-1-1 system was being inundated with calls since the earthquake and we should only use it with a real emergency...for infrastructure damage, call 3-1-1 instead.



While the Facebook application sounds like a great addition to emergency preparedness, it is important to also consider implementation issues which will impact its reach and effectiveness:

• Is the application only available to Facebook members who download it ahead of time? Or will it be available to anyone via the mobile web?
• Do these Facebook members typically update their profile via mobile devices in addition to stationary computers (which may not be available during an emergency)?
• During the emergency, are there cell networks/wifi to support the communication? (e.g., many reported that cell networks were jammed immediately following the earthquake)
• Do these "electronic" preparedness plans need to be rehearsed the same way as "in person" plans in order to increase effectiveness?

The HHS-ASPR contest runs August 22-November 4, 2011. I look forward to seeing the winning applications and hearing about how the dissemination will be conducted and evaluated.



What were your experiences today during the east coast earthquake? What did you hear/see from your colleagues? How did you get/send information to others? Please share in the comments section below.