Selasa, 31 Mei 2011

Google Continues to Use its Power for Public Health Good


Yesterday, Google announced its new surveillance system for Dengue Fever. Dengue Fever is a disease caused by four related viruses spread by a particular species of mosquito. It can cause high fever, rash, muscle and joint pain, and in severe cases- bleeding, a sudden drop in blood pressure (shock) and death. Millions of cases of Dengue infection occur worldwide each year. Most often, dengue fever occurs in urban areas of tropical and subtropical regions.

The system is similar to that which was previously released as their Google Flu Trends program. These systems use search queries within Google (for example those that enter the disease's name and/or symptoms) to identify trends. The Dengue system also takes advantage of a new feature called Google Correlate, which shows previously unknown correlations between search terms. These correlations allow researchers to model real world behaviors by examining internet search trends. For those who may be skeptical of this model, you should check out a publication (co-authored by Google and the Centers for Disease Control and Prevention-CDC) in the 2009 Nature Journal . The article reports that "because relative frequencies of certain queries were highly correlated with the percentage of physician visits in which a patient presents with influenza-like symptoms, we can accurately estimate the current level of weekly influenza activity in each region of the United States, with a reporting lag of about one day."

This is a pretty exciting addition to public health surveillance (where the goal is systematic, ongoing, data collection that is used to monitor trends, identify priorities, direct resources, identify emerging hazards, and evaluate interventions).

This is not the first time that Google has jumped into the public health field with an impressive contribution. In 2010, Google searches related to suicide started appearing with a message guiding users to the toll-free number for the National Suicide Prevention Lifeline. The number is 1-800-273-8255. Triggered by searches such as "I want to die" or "ways to commit suicide," the number is listed next to an icon of a red telephone, at the top of the search results.

The addition of the Lifeline number came shortly after (at the suggestion of a Google user), the company started displaying the hotline for the American Association of Poison Control Centers after searches for "poison emergency."

These cases of Google's work in public health are great examples of effective health communication and public health principles:
  • Identifying the primary channels through which your audience searches for health information (more and more are utilizing the internet) and delivering accurate and effective information and/or interventions via those channels.
  • Maximizing data driven surveillance systems- using existing data (e.g., internet searches) to identify public health trends.
  • Building strong partnerships (as evidenced by the publication by Google and CDC) CDC has partnered with a company with specific expertise and resources in an area that can be invaluable to their work.

Kamis, 26 Mei 2011

Food Reward: a Dominant Factor in Obesity, Part IV

What is Food Reward?

After reading comments on my recent posts, I realized I need to do a better job of defining the term "food reward".  I'm going to take a moment to do that here.  Reward is a psychology term with a specific definition: "a process that reinforces behavior" (1).  Rewarding food is not the same thing as food that tastes good, although they often occur together. 

Read more »

Selasa, 24 Mei 2011

Healthy Skeptic Podcast

Chris Kresser has just posted our recent interview/discussion on his blog The Healthy Skeptic.  You can listen to it on Chris's blog here.  The discussion mostly centered around body fat and food reward.  I also answered a few reader questions.  Here are some highlights:
  • How does the food reward system work? Why did it evolve?
  • Why do certain flavors we don’t initially like become appealing over time?
  • How does industrially processed food affect the food reward system?
  • What’s the most effective diet used to make rats obese in a research setting? What does this tell us about human diet and weight regulation?
  • Do we know why highly rewarding food increases the set point in some people but not in others?
  • How does the food reward theory explain the effectiveness of popular fat loss diets?
  • Does the food reward theory tell us anything about why traditional cultures are generally lean?
  • What does cooking temperature have to do with health?
  • Reader question: How does one lose fat?
  • Reader question: What do I (Stephan) eat?
  • Reader question: Why do many people gain fat with age, especially postmenopausal women?
The podcast is a sneak preview of some of the things I'll be discussing in the near future.  Enjoy!

Minggu, 22 Mei 2011

Fast Food, Weight Gain and Insulin Resistance

CarbSane just posted an interesting new study that fits in nicely with what we're discussing here.  It's part of the US Coronary Artery Risk Development in Young Adults (CARDIA) study, which is a long-term observational study that is publishing many interesting findings.  The new study is titled "Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis" (1).  The results speak for themselves, loud and clear (I've edited some numbers out of the quote for clarity):
Read more »

Rabu, 18 Mei 2011

Food Reward: a Dominant Factor in Obesity, Part III

Low-Fat Diets

In 2000, the International Journal of Obesity published a nice review article of low-fat diet trials.  It included data from 16 controlled trials lasting from 2-12 months and enrolling 1,910 participants (1).  What sets this review apart is it only covered studies that did not include instructions to restrict calorie intake (ad libitum diets).  On average, low-fat dieters reduced their fat intake from 37.7 to 27.5 percent of calories.  Here's what they found:
Read more »

Selasa, 17 Mei 2011

Clarifications About Carbohydrate and Insulin

My statements about carbohydrate and insulin in the previous post seem to have kicked up some dust!  Some people are even suggesting I've gone low-fat!  I'm going to take this opportunity to be more specific about my positions.

I do not think that post-meal insulin spikes contribute to obesity, and they may even oppose it. Elevated fasting insulin is a separate issue-- that's a marker of insulin resistance.  It's important not to confuse the two.  Does insulin resistance contribute to obesity?  I don't know, but it's hypothetically possible since insulin acts like leptin's kid brother in some ways.  As far as I can tell, starch per se and post-meal insulin spikes do not lead to insulin resistance.
Read more »

Jumat, 13 Mei 2011

Healthy Skeptic Podcast and Reader Questions

Chris Kresser, Danny Roddy and I just finished recording the podcast that will be released on May 24th.  It went really well, and we think you'll find it informative and maybe even practical!

Unfortunately, we only got around to answering three of the questions I had selected:
  1. How does one lose fat?
  2. What do I (Stephan) eat?
  3. Why do many people gain fat with age, especially postmenopausal women?
I feel guilty about that, so I'm going to answer three more right now.

Read more »

Minggu, 08 Mei 2011

Ask Me a Question

On May 13th, I'll be recording a podcast with Chris Kresser of The Healthy Skeptic. Chris interviewed me about a year ago, and I thought it went well. Chris is a good host and asks interesting questions.

This time around, we're going to do things a bit differently. I'll start with a little overview of my current thoughts on obesity, then we'll answer reader questions. The show is going to be mostly about obesity and related matters, but I may answer a couple of questions that aren't related to obesity if they're especially interesting. There are two ways to leave questions: either in the comments section of this post, or the comments section of Chris's post. The show will air on May 24th.
Read more »

Will New Ads in Georgia "Stop Childhood Obesity" or Increase Stigma and Bullying?

On Friday's Today show, there was an interesting analysis of a new campaign from the Georgia Child Health Alliance (GCHA) aimed at reducing childhood obesity. According to the GCHA website, the Warning: Stop Childhood Obesity media campaign "is part of a large-scale public awareness campaign designed to educate Georgians on the childhood obesity epidemic facing our state. Backed by market research, the campaign’s warning messages about obesity are developed to reach parents and children using communication vehicles such as billboards, television, radio and more".

From the Today show segment (which featured the campaign's Director, a child actor featured in the ads, and a child psychologist) we learned that this media campaign is part one of a three part campaign. The three parts were briefly outlined:

1- Raise awareness about childhood obesity; letting kids voice their struggle in their own words.
2- "Activate"- focus on healthy eating and activity
3- Focus on real solutions

While the GCHA outlines their strategic mission for this campaign, they are hearing some major objections to their approach and it continues to grab national headlines. The major concerns voiced by objectors such as Rebecca Puhl (a weight discrimination expert from Yale University), are that the ads will increase stigma for overweight kids (which could increase their experience of bullying) and that the ads will be ineffective due to their fear-based approach. In my review of the ads, I have mixed (mostly negative) feelings about their development and implementation:
  • Strike One: The goal of this campaign is listed as "raising awareness". These may be my two least favorite terms in all of public health. "Raising awareness" is too vague and does not lend itself to being evaluated. In actuality, campaign developers usually want to "increase knowledge" or "change perceptions" or "change behavior" (e.g., calling the 800 number on the screen). These are all things which can actually be measured and should be stated more clearly.
  • Strike Two: When the Today show asked the Campaign director about the audience for these ads, he replied "parents, kids, and educators". Again, this is way too vague. Your message and call to action (i.e., what you want the viewer to do after watching the ad) would be completely different for each of those audiences. For example, you may want educators to reach out to the parents of overweight kids in their classes or you may want kids to tell an adult if they are being bullied about their weight. These messages need to be tailored to each audience.
  • Strike Three: These ads definitely fall into the "fear-based" category. As you watch them, the ads read "WARNING" in bold red letters and you hear a "boom" (kinda like on "Law & Order) as the statistics run across the screen. As I have mentioned in previous blog posts, fear-based approaches have been found to be ineffective in other areas of prevention (e.g., alcohol and other drugs).
  • In terms of redeeming factors, it does seem that the campaign was developed using formative research which included focus groups with overweight kids. The results of these focus groups were used to develop the dialogue read by child actors in the ads so that it would be "in their words". If kids are the audience for these ads, then the age appropriate priorities and dialogue (with the inclusion of child actors) is positive. From health behavior theory (e.g., Social Learning Theory), we know that kids will respond better if they relate to those in the ads.
Of course, it is unclear if they also focus group tested the ads and billboards after initial development, before they were rolled out. It is also unclear how they are being evaluated and what the ultimate goals are (beyond "increased awareness"). I'll be interested to see parts two and three rolled out and hope to include follow up thoughts here on Pop Health.

Jumat, 06 Mei 2011

Food Reward: a Dominant Factor in Obesity, Part II

How to Make a Rat Obese

Rodents are an important model organism for the study of human obesity. To study obesity in rodents, you have to make them fat first. There are many ways to do this, from genetic mutations, to brain lesions, to various diets. However, the most rapid and effective way to make a normal (non-mutant, non-lesioned) rodent obese is the "cafeteria diet." The cafeteria diet first appeared in the medical literature in 1976 (1), and was quickly adopted by other investigators. Here's a description from a recent paper (2):

In this model, animals are allowed free access to standard chow and water while concurrently offered highly palatable, energy dense, unhealthy human foods ad libitum.
In other words, they're given an unlimited amount of human junk food in addition to their whole food-based "standard chow." In this particular paper, the junk foods included Froot Loops, Cocoa Puffs, peanut butter cookies, Reese's Pieces, Hostess Blueberry MiniMuffins, Cheez-its, nacho cheese Doritos, hot dogs, cheese, wedding cake, pork rinds, pepperoni slices and other industrial delicacies. Rats exposed to this food almost completely ignored their healthier, more nutritious and less palatable chow, instead gorging on junk food and rapidly attaining an obese state.

Investigators have known for decades that the cafeteria diet is a highly effective way of producing obesity in rodents, but what was interesting about this particular study from my perspective is that it compared the cafeteria diet to three other commonly used rodent diets: 1) standard, unpurified chow; 2) a purified/refined high-fat diet; 3) a purified/refined low-fat diet designed as a comparator for the high-fat diet. All three of these diets were given as homogeneous pellets, and the textures range from hard and fibrous (chow) to soft and oily like cookie dough (high-fat). The low-fat diet contains a lot of sugar, the high-fat diet contains a modest amount of sugar, and the chow diet contains virtually none. The particular high-fat diet in this paper (Research Diets D12451, 45% fat, which is high for a rat) is commonly used to produce obesity in rats, although it's not always very effective. The 60% fat version is more effective.

Consistent with previous findings, rats on every diet consumed the same number of calories over time... except the cafeteria diet-fed rats, which ate 30% more than any of the other groups. Rats on every diet gained fat compared to the unpurified chow group, but the cafeteria diet group gained much more than any of the others. There was no difference in fat gain between the purified high-fat and low-fat diets.

So in this paper, they compared two refined diets with vastly different carb:fat ratios and different sugar contents, and yet neither equaled the cafeteria diet in its ability to increase food intake and cause fat gain. The fat, starch and sugar content of the cafeteria diet was not able to fully explain its effect on fat gain. However, each diets' ability to cause fat gain correlated with its respective food reward qualities. Refined diets high in fat or sugar caused fat gain in rats relative to unpurified chow, but were surpassed by a diet containing a combination of fat, sugar, starch, salt, free glutamate (umami), interesting textures and pleasant and invariant aromas.

Although the cafeteria diet is the most effective at causing obesity in rodents, it's not commonly used because it's a lot more work than feeding pellets, and it introduces a lot of variability into experiments because each rat eats a different combination of foods.

How to Make an Obese H
uman Lean

In 1965, the Annals of the New York Academy of Sciences published a very unusual paper (3). Here is the stated goal of the investigators:
The study of food intake in man is fraught with difficulties which result from the enormously complex nature of human eating behavior. In man, in contrast to lower animals, the eating process involves an intricate mixture of physiologic, psychologic, cultural and esthetic considerations. People eat not only to assuage hunger, but because of the enjoyment of the meal ceremony, the pleasures of the palate and often to gratify unconscious needs that are hard to identify. Because of inherent difficulties in studying human food intake in the usual setting, we have attempted to develop a system that would minimize the variables involved and thereby improve the chances of obtaining more reliable and reproducible data.
Here's a photo of their "system":
It's a machine that dispenses bland liquid food through a straw, at the push of a button. They don't give any information on the composition of the liquid diet, beyond remarking that "carbohydrate supplied 50 per cent of the calories, protein 20 per cent and fat 30 per cent. the formula contained vitamins and minerals in amount adequate for daily maintenance."

Volunteers were given access to the machine and allowed to consume as much of the liquid diet as they wanted, but no other food. Since they were in a hospital setting, the investigators could be confident that the volunteers ate nothing else.

The first thing they report is what happened when they fed two lean people using the machine, for 16 or 9 days. Both of them maintained their typical calorie intake (~3,075 and ~4,430 kcal per day) and maintained a very stable weight during this period.

Next, the investigators did the same experiment using two "grossly obese" volunteers. Again, they were asked to "obtain food from the machine whenever hungry." Over the course of the first 18 days, the first (male) volunteer consumed a meager 275 calories per day. The second (female) volunteer consumed a ridiculously low 144 calories per day over the course of 12 days, losing 23 pounds. Without showing data, the investigators remarked that an additional three obese volunteers "showed a similar inhibition of calorie intake when fed by machine."

The first volunteer continued eating bland food from the machine for a total of 70 days, losing approximately 70 pounds. After that, he was sent home with the formula and instructed to drink 400 calories of it per day, which he did for an additional 185 days, after which his total weight loss was 200 lbs. The investigators remarked that "during all this time weight was steadily lost and the patient never complained of hunger or gastrointestinal discomfort." This is truly a starvation-level calorie intake, and to eat it continually for 255 days without hunger suggests that something rather interesting was happening in this man's body.

This machine-feeding regimen was nearly as close as one can get to a diet with no rewarding properties whatsoever. Although it contained carbohydrate and fat, it did not contain any flavor or texture to associate them with, and thus the reward value of the diet was minimized. As one would expect if food reward influences the body fat setpoint, lean volunteers maintained starting weight and a normal calorie intake, while their obese counterparts rapidly lost a massive amount of fat and reduced calorie intake dramatically without hunger. This suggests that obesity is not entirely due to a "broken" metabolism (although that may still contribute), but also at least in part to a heightened sensitivity to food reward in susceptible people. This also implies that obesity may not be a disorder, but rather a normal response to the prevailing dietary environment in affluent nations.

A second study by Dr. Michel Cabanac in 1976 confirmed that reducing food reward (by feeding bland food) lowers the fat mass setpoint in humans, using a clever method that I won't discuss for the sake of brevity (4). I learned about both of these studies through the writing of Dr. Seth Roberts, author of The Shangri-La Diet. I'd also like to thank Dr. Stephen Benoit, a researcher in the food reward field, for talking through these ideas with me to make sure I wasn't misinterpreting them.

I'd like to briefly remark that there's an anatomical basis for the idea of two-way communication between brain regions that determine reward and those that control body fatness. It's well known that the latter influence the former (think about your drive to obtain food after you've just eaten a big meal vs. after you've skipped a meal), but there are also connections from the former to the latter via a brain region called the lateral hypothalamus. The point is that it's anatomically plausible that food reward determines in part the amount of body fat a person carries.

Some people may be inclined to think "well, if food tastes bad, you eat less of it; so what!" Although that may be true to some extent, I don't think it can explain the fact that bland diets affect the calorie intake of lean and obese people differently. To me, that implies that highly rewarding food increases the body fat setpoint in susceptible people, and that food with few rewarding properties allows them to return to a leaner state.

In the next few posts, I'll describe how food reward explains the effectiveness of many popular fat loss diets, I'll describe how this hypothesis fits in with the diets and health of non-industrial cultures, and I'll outline new dietary strategies for preventing and treating obesity and certain forms of metabolic dysfunction.

Selasa, 03 Mei 2011

From The West Wing to the National Health Care Debate

Anyone who knows me well knows that "The American President" is one of my favorite movies. If it is a favorite of yours as well, you may recognize that the actress who plays Press Secretary Robin McCall also plays National Security Advisor Dr. Nancy McNally in "The West Wing". The actress is Anna Deavere Smith.

This week in my "Qualitative Research Methods in Community Health" class, we discussed ethnography. Specifically we discussed Ms. Smith's work as an example of performance ethnography. For over a decade, she has interviewed people across the country and used the "data" to develop a one-woman show. Her newest play is called "Let Me Down Easy" and its goal is to show the human side of the national health care debate. I highly recommend viewing the 10-minute excerpt and interview here.

I'm so sorry that I missed her play when it came to Philadelphia earlier this year because I think it is an amazing example of the richness of data collected using qualitative methods. It is often argued that qualitative methods are too "soft" and limited in view. I've heard them described as "basically just journalism". However, I would argue that qualitative methods are essential to the success of public health.

Instead of surveys and databases, these methods collect data via interview, discussion, and observation. The research is meant to discover the complex relationship between personal and social meaning, individual and cultural practices, and the material environment or context. In contrast to what we have learned since grade school science about the scientific method and generalizability of findings- here the focus is on obtaining a deeper understanding of a population or phenomenon.

Ms. Smith conducted over 300 interviews for "Let Me Down Easy" and ultimately condensed her findings to show the experience of contemporary health care through the eyes of 20 individuals. These kinds of stories are incredibly powerful in public health. They open our eyes to challenges that we never would have found via survey...because we wouldn't have known to ask the right questions. They allow us to share stories with policymakers so they can see the impact of their decisions beyond the sterile statistics often cited. They can allow us to explore experiences or illnesses that occur in too small a population to survey.

Ideally, quantitative and qualitative methods should be used together to create the strongest public health research design possible. It should not be us vs. them...but instead a joint effort. I encourage us all to see the human side of health care reform when Ms. Smith's play airs on PBS "Great Performances" next season.