Sleep and Genetic Obesity Risk

Evidence is steadily accumulating that insufficient sleep increases the risk of obesity and undermines fat loss efforts.  Short sleep duration is one of the most significant risk factors for obesity (1), and several potential mechanisms have been identified, including increased hunger, increased interest in calorie-dense highly palatable food, reduced drive to exercise, and alterations in hormones that influence appetite and body fatness.  Dan Pardi presented his research at AHS13 showing that sleep restriction reduces willpower to make healthy choices about food.

We also know that genetics has an outsized influence on obesity risk, accounting for about 70 percent of the variability in body fatness between people in affluent nations (2).  I have argued that "fat genes" don't directly lead to obesity, but they do determine who is susceptible to a fattening environment and who isn't (3).  I recently revisited a 2010 paper published in the journal Sleep by University of Washington researchers that supports this idea (4).

Read more »

Facebook Is Revolutionizing The Search For An Organ Donor, But Is It Fair?

This week The New Yorker ran a fascinating article called, "To Donate Your Kidney, Click Here".  More and more people are turning to Facebook to try and find living organ donors.  And while many have found tremendous success using this strategy, the article highlights the serious ethical concerns that now face the medical and public health communities in light of this trend.

Concerns About Disparities

The Advocates

While data show that Facebook is the most popular social networking site among online adults, we do not know how social media advocacy skills translate across demographic variables.  In The New Yorker article, Dr. Dan O'Connor of Johns Hopkins University asks "“Whenever you’re using platforms like Facebook, the question is, what kind of person, what demographic profile has the time and energy and communication skills to make this work?” [bolding added]

The Donors

Dr. Michael Shapiro (who chooses not to perform kidney transplants on donor-recipient pairs who met through online advertising) said, “It’s not hard to imagine that if you’re attractive and young and appealing, it’s easier to get people to donate to you than if you’re short or ugly or have a hunchback. And that’s not the way we want the system to work." [bolding added]

While there is limited research regarding Facebook donor-recipient matching, research out of Loyola University offers support for Dr. Shapiro's concerns.  After examining Facebook pages seeking kidney donation, the researchers found that certain types of pages (i.e., white patients and those with more posts) were more likely to have people come forward and get tested to be a possible donor.

Leveling The Playing Field

As with any health or access disparity, public health needs to innovate solutions to narrow the gap.  The New Yorker article discussed Dr. Andrew Cameron (a transplant surgeon at Johns Hopkins) who is working on one possible solution.  He is developing a smartphone application which may level the playing field for patients/families for which social media tools and advocacy resources are less intuitive or accessible.  The app would offer a “template” for those in need of organs to tell their story, and would provide a system for those users to connect directly with transplant centers and social media resources.

What Do You Think?

• Does donor matching on Facebook provide an advantage to certain demographic groups?
• What can we do to level the playing field for those patients/families with (1) limited access to social media tools or advocacy skills? (2) stories that may be "less attractive" to the public?
• Are you surprised that some surgeons (e.g., Dr. Michael Shapiro profiled in The New Yorker) choose not to operate on pairs who meet through online advertising?

Bonus Read: This is not the first time that Facebook has been part of the organ donation dialogue.  Last May I wrote about Facebook's "share life" tool, which allows users to share their organ donation status on their timeline.  Since then, research has shown that the tool is effective in increasing donor numbers.

Speaking in Lisbon on October 5

My friend Pedro Bastos graciously invited me to speak at a conference he organized in Lisbon on October 5 titled "Food, Nutrition and the Prevention of Chronic Diseases".  I will give two talks:

• "Ancestral Health: What is Our Human Potential?"  This talk will explore the health of non-industrial cultures in an effort to understand how much of our modern chronic disease burden is preventable, and it will briefly touch on one major aspect of non-industrial life that may protect against the "diseases of civilization".  This presentation will focus on age-adjusted data from high quality studies.  
• "Why Do We Overeat: a Neurobiological Perspective."  This talk will attempt to explain why most of us consume more calories than we need to maintain weight-- a phenomenon that is a central cause of morbidity and mortality in the modern world.  It will touch on some of the brain mechanisms involved in ingestive behavior, and outline a framework to explain why these mechanisms are often maladaptive in today's environment.

Pedro will speak about dairy consumption, vitamin D, and chronic disease.  

The conference is targeted to health professionals and students of nutrition, however it's open to anyone who is interested in these topics.  It's sponsored by NutriScience, a Portuguese nutrition education and consulting company.  Sadly, I don't speak Portuguese, so my talks will be in English.  

Access the full program, and register for the conference, using the links below:

Program

Registration

Panera Bread CEO Eats On $4.50 Per Day: Good for Public Health or Just Good for PR?

The issues of food insecurity and the Supplemental Nutrition Assistance Program (SNAP- formerly known as Food Stamps) are quite timely.  September is Hunger Action Month and the House has just passed a bill that will cut $39 Billion from SNAP.  Acknowledging this, I wanted to talk about the CEO of Panera Bread.  Over the past week, Ron Shaich has undertaken a well-publicized Feeding America SNAP Challenge.  His goal was to shop for meals with the daily average per person ($4.50) benefit provided by SNAP in order to get a sense of the challenges faced by those struggling to put food on the table.  Feeding America encourages those participating in the challenge to share their experiences in order to raise awareness of “this critical nutrition program”.  Ron wrote about his experience on his LinkedIn Blog from September 9-20, 2013.

I thought his initial posts did a good job of outlining realistic goals:

• (1) To help bring awareness to the issue [I’ll take it- even though all Pop Health readers know I hate the term “awareness”] and 
• (2) Spark deeper conversations about food insecurity and possible solutions.  

Ron also highlighted an important caveat: His experiences from the challenge week are not meant to provide an authentic representation of food insecurity in America.  He understands that the issue is much more complex.  Over the course of the week, he discussed how his shopping and eating habits changed during the challenge.  For example, he visited a supermarket known for their low prices.  He also swapped out typical fresh goods like yogurt for “filling” foods like grains.  He documented the mental and physical side effects of his altered diet such as fatigue, irritability and resentment.  Some of his major take-aways from the challenge were:

• (1) One week is not sufficient to truly understand food insecurity, 
• (2) Food dominates your thoughts when it is not readily available, 
• (3) Increased empathy for those who struggle, and 
• (4) The importance of eliminating judgment and preconceived notions about those who are food insecure and/or require assistance from the SNAP program.

My thoughts:

• The Challenge and blog posts did not reveal anything unexpected; however it is worth it to read his posts just for the reader comments.  I am always impressed with how social media can solicit engagement and dialogue about public health topics.  While some readers were very supportive and applauded Ron for his efforts, others were quite critical- highlighting important limitations of his undertaking.  For example, its simplicity.  Readers pointed out that it is not just about food insecurity.  It is the stress of having your home, food, job, and transportation be unstable all at once.  They also pointed out how easy it was for him to jump in his car to visit a less expensive grocery store.  Families that are limited by transportation and geography do not have that option.   

• For me, this simplicity was highlighted in the juxtaposition of Ron’s SNAP challenge with many of the photographs that he used to accompany his blog posts.  For example, on day #4 we see Ron cooking his inexpensive dinner in a gorgeous kitchen.  On days #5,6,7 we see Ron eating in his beautifully outfitted office and building kitchen.  

• The readers/commenters did a great job (better than Ron in my opinion) of highlighting community and society-level contributors to food insecurity.  They discussed implications of current minimum wage pay.  They discussed families stuck “in the middle”- not qualifying for SNAP but not making enough money for their families to eat.  They discussed the underemployed- those working multiple low-paying part-time jobs without benefits.  They discussed how the culture of our country has changed- citing examples from past generations when employees were highly valued.  They discussed the high cost of food- and the lack of healthy options for those living on a strict budget.  I was especially moved by the first comment on his day #5 post.  The comment comes from a former Panera worker who left after 4 years due to low wages that rendered her unable to support herself.  She writes that “many employees at the stores I worked at are food insecure, as well as myself.”  While she acknowledged Panera’s philanthropic efforts, she asked Ron “why not look in your very own kitchens for people to help as well?”   

• I also took note of Ron’s communication channel selection.  He used his existing blog on LinkedIn.  I’m hoping to track down reliable data on the demographics of LinkedIn users (e.g., education and income levels) so that I have a better sense of his targeted audience.  According to Pew Internet research, only 20% of online adults use LinkedIn (as of August 2012).  Therefore, it just made me wonder: who might be left out of the conversation due to the blog’s location?  [*If any readers can share a reliable data source on demographics of LinkedIn users, that would be great!]

• Since Ron’s goal is to spark deeper conversations about food insecurity and solutions, only time will tell if his company's actions will change as a result of this SNAP challenge.  Hopefully they will build upon existing efforts (like Panera Cares) to help address food insecurity at the community, society, and policy levels.

What do you think?

#NotDeadYet: Slate Sparks An Awesome Online Discussion of Life, Medicine, and Public Health

Last Thursday Slate, a daily web magazine, kicked off a series on life expectancy.  I highly recommend taking the time to read the articles, which cover everything from notable public health advances to improving maternal/child health outcomes.  I was very pleased to see many public health organizations sharing these articles with their followers.

While the content was enough to draw me in, I was particularly intrigued by the online dialogue that was sparked by this series.  Over the past week, my Twitter feed has been filled with colleagues participating in the discussion using the hashtag #NotDeadYet.  In the series' first post, "Why Are You Not Dead Yet?", Laura Helmuth explores why life expectancy has doubled in the past 150 years.  At the end of the post, Laura asked readers to send their #NotDeadYet survival stories to Slate's twitter or email accounts.  A selection of the submitted stories ran today to wrap up the week-long series on life expectancy.

With so many newspapers and blogs (mine included) heavily depending on the comment section to initiate discussion, I was intrigued by the idea of starting an accompanying Twitter hashtag thread.  Impressed by the high participation rate just on my own feed, I reached out to Laura Helmuth to gather more information about her dialogue with readers.  She was very gracious to respond to my questions during what I assume has been a very busy week with the series!    

She shared that Slate received more than 200 emails from people sharing their stories (some of them quite elaborate). They also received about 800 responses on Twitter.  In terms of story content:

• About a quarter of the emails concerned childbirth- women who would have died giving birth and people who would have died when they were born. 
• Many of the Twitter messages were also about childbirth, including a lot of men who tweeted that they would be childless widowers right now if it were not for modern medicine. 
• Slate also heard from a lot of people who survived a burst appendix. Lots of people were saved from nasty infections by antibiotics. And some had gruesome accidents that were patched up in surgery. Lots of people have had heart surgery. Many people credited their anti-depressants for keeping them alive. A surprising number mentioned that they were treated with antivenins for snakebite! 

Laura noted that this hashtag thread was especially heartwarming because "people were taking a moment to share their scariest stories and express gratitude that they’re ALIVE".  She also said that "it’s a great reminder that so many of the people we know would be dead if it weren’t for treatments we sometimes take for granted". A big thank you to Laura for sharing these responses and her reactions!

After putting this post together, I have two messages- one about the content and one about the strategy that Slate used for communicating this story.  

• (1) It is important to look back and inventory the medical and public health advances that we take for granted.  Last year I wrote about the wonderful Frontline documentary, "The Vaccine War".  When discussing fears of vaccination and the decrease in childhood vaccination rates, the documentary noted that this new generation of parents are too young to know the devastating effects of vaccine-preventable diseases like polio.  One interviewee used a term that I really like- "Community Recollection".  As Community Recollection of these diseases disappears, we can become complacent.  We are seeing the devastating results of this complacency with outbreaks of preventable disease (for example the outbreak of Measles just a few weeks ago in Texas). 

• (2) We in public health should take note and learn from the strategies that Slate has used to engage readers.  We are always looking for ways to initiate conversation beyond the articles we publish or the classes we teach or the webinars or twitterchats that we facilitate.  A few observations:
• The hashtag thread allowed them to take the discussion beyond the comment section onto Twitter.  
• Hashtags are easily searchable, so new participants could quickly be gained that did not originally follow or read the magazine.  
• The hashtag #NotDeadYet was innovative and "catchy" not boring like #PublicHealthAdvances.  
• Readers also had an incentive to share their stories, since Slate was selecting the top 50 to wrap up the series.   

I'd love to hear from my readers!

• Did you read the Slate life expectancy series?  Reactions to share?
• Have you tried similar strategies to engage readers with the content that you distribute?  Success stories or lessons learned to share?

Research Notes: Alcohol Brand References in U.S. Pop Music

Today I'm launching a new feature on Pop Health called "Research Notes".  This feature will highlight new peer-reviewed research that integrates public health and pop culture.

Researchers from the Boston University School of Public Health and the Johns Hopkins Bloomberg School of Public Health have recently released a study that examined alcohol references in popular music.  The study is published early online in the journal Substance Use & Misuse:

Alcohol Brand References in U.S. Popular Music, 2009–2011

Michael Siegel, Renee M. Johnson, Keshav Tyagi, Kathryn Power, Mark C. Lohsen, Amanda J. Ayers and David H. Jernigan

(Posted online on August 23, 2013; doi:10.3109/10826084.2013.793716)

The study highlights several interesting findings:

• Four alcohol brands (Patron tequila, Hennessy cognac, Grey Goose vodka, and Jack Daniel’s whiskey) accounted for more than half of alcohol brand mentions in the songs that mentioned alcohol use in Billboard’s most popular song lists in 2009, 2010 and 2011.

• Alcohol mentions were most common in urban songs (rap, hip-hop and R&B – 37.7% of songs mentioned alcohol), followed by country (21.8%) and pop (14.9%).

• Alcohol use was portrayed as overwhelmingly positive, with negative consequences rarely mentioned.

In the study's press release, researchers highlight several practice implications of these findings:

• “Given the heavy exposure of youth to popular music, these results suggest popular music may serve as a major source of promotion of alcohol use among youth,” said study co-author David Jernigan, PhD. “The findings lay a strong foundation for further research.”

• “A small number of alcohol brands and beverages appear to make frequent appearances in popular music,” said Michael Siegel, MD, MPH, professor of Community Health Sciences at the Boston University School of Public Health. “If these exposures are found to influence youth drinking behavior, then further public health efforts must be focused on youth exposure to alcohol portrayals in popular music.”

What Can “Chronic Resilience” Teach Public Health Practitioners? An Interview With Author Danea Horn

Last month I had the pleasure of receiving an advanced review copy of "Chronic Resilience: 10 Sanity-Saving Strategies for Women Coping with the Stress of Illness".  As I read through the book, I made note of many issues that are relevant to public health practitioners.  Therefore, it is a pleasure to have Danea Horn expand her comments on these topics for Pop Health readers. 

If you would like to connect with Danea, you can visit her website or twitter.

Leah:  In public health, we talk a lot about how our society’s “culture” can promote or harm health.  In several places in your book, you talk about the connection between our societal values and our health.  For example:

Page 33: “Part of the reason we try to be all things to all people is our culture.  Have you ever sat through a business meeting while someone is sniffling and sneezing and exposing everyone else to their cold?  In that moment they are valuing achievement, money, or appearances above their health and the health of everyone else in the room.”

How can we expand your strategies beyond the individual level?  How can we identify and live our health values at the neighborhood, community, and organization levels?

Danea:  It only takes one person to start a conversation that can become the catalyst for big changes. Start talking to people at your work and in your community to get a feel for what is valued currently. The policies (written and unwritten) in our offices and items at our potlucks will say a lot about what we collectively value. If you find inconsistency or confusion in your conversations, open up a dialogue with the leaders in your organization or community to discuss what you would like to collectively choose to value. From here you can brainstorm together ways to influence change. They can be small changes like creating a healthy living block party where people share nourishing dishes and swap good-for-you recipes or larger changes like paid sick leave (which is not mandatory in every state…yet). Never be afraid to speak up. A big theme in Chronic Resilience is controlling what you can control and talking is in your control. 

Leah:  In Chapter #6, you write “It is up to you to decide how public to make your health.”  You and several of the women you interviewed for your book have blogs that document your health journey in a very public way.  Public health researchers Ressler et al (2012) have identified many benefits of patient blogging (e.g., patients report a decrease in feelings of isolation).

What benefits have you experienced as a result of writing about your health?  What challenges have you encountered during the process of sharing your story publicly?

Danea:  Writing helps me process what is going on from a different perspective. I am all about learning from our challenges, so each post I write is a search for a lesson or message that my diagnosis is pointing me toward. I can feel frustrated about the progression of my disease and start out writing a rant, but I find that I naturally end up with a message about letting go of my ideals or acceptance. Reframing my health in this way has been very empowering.

I haven’t encountered many challenges by being public with my health journey. Commenters have been very supportive. That said, I am discerning about what I choose to share and do keep some things private. Challenges I know other people have faced, and someone who blogs publicly about their health should be prepared for, are people sharing remedies, treatment recommendations, cure-all solutions and pleas to have faith in a deity they may or may not believe in. While these all come from a caring place they may feel intrusive. Also, you may want to give a heads-up to your close family and friends before you post anything particularly revealing, emotionally or otherwise, that you haven’t shared with them in private first.

There are a number of ways to benefit from writing about your health. Doing it publicly on a blog can create a sense of support and community, but if that feels too invasive, you can join support forums anonymously, create a private blog or journal pen and paper old school style.

Leah:  In Chapter #7 (“Empower Yourself With Research”), I was thrilled to see your emphasis on helping patients evaluate the validity and safety of medical information found on the Internet.  This is a huge challenge in public health!  Our evidence-based messages and guidelines often compete online with anecdotal evidence and unscientific studies.

Why did you decide to dedicate a portion of your book to this discussion?  Why is it so important for patients to discuss what they find online with their medical team?

Danea:  Before I became discerning about what I read online about my diagnosis, I was completely stressed. I read way too much from too many random sources to properly sort out what I should believe. I also noticed that I was searching for how I was going to become sicker (the side effects, complications, and progression of my illness) instead of searching for how I could support my heath. Fortunately, I realized most of my stress was coming from worry created by endless Internet searching, and I decided to take a different approach.

I found a few sources from trusted physicians and nutritionists to study and implement. I decided to stay focused on my personal symptoms, medications and prognosis instead of what other people I didn't even personally know had experienced. I also started a more open dialogue with my doctors about the diet I wanted to try and some of the studies I had read. When we research and experiment with our health without informing our doctors, we may have conflicting approaches which can create drug interactions or other harmful complications. Doctors are there to support us. If you are uncomfortable talking with yours, it’s time to find one that you trust enough to be completely open and honest with. We should all have a doctor who will work with us to find treatment solutions we feel comfortable with.

Leah:  A big thank-you to Danea for making the time for Pop Health!  "Chronic Resilience" is a great read for those with a personal and/or professional connection to chronic illness.  For public health clinicians, practitioners, and researchers who work in the chronic illness arena:  I think you will get a unique first-hand view into (1) the mental, physical, and emotional challenges that affect this population, (2) the incredible resilience that those with chronic illness show on a day-to-day basis (what can we learn from them??), and (3) specific strategies that can be employed to support patients with chronic illness.  As Danea and I discuss above, these strategies have the potential to be expanded from the individual level to offer support to entire communities.

Is Refined Carbohydrate Addictive?

[Note: in previous versions, I mixed up "LGI" and "HGI" terms in a couple of spots.  These are now corrected.  Thanks to readers for pointing them out.]

Recently, a new study was published that triggered an avalanche of media reports suggesting that refined carbohydrate may be addictive:

Refined Carbs May Trigger Food Addiction
Refined Carbs May Trigger Food Addictions
Can You be Addicted to Carbs?
etc.

This makes for attention-grabbing headlines, but in fact the study had virtually nothing to do with food addiction.  The study made no attempt to measure addictive behavior related to refined carbohydrate or any other food, nor did it aim to do so.

So what did the study actually find, why is it being extrapolated to food addiction, and is this a reasonable extrapolation?  Answering these questions dredges up a number of interesting scientific points, some of which undermine popular notions of what determines eating behavior.

Read more »

More Thoughts on Cold Training: Biology Chimes In

Now that the concept of cold training for cold adaptation and fat loss has received scientific support, I've been thinking more about how to apply it.  A number of people have been practicing cold training for a long time, using various methods, most of which haven't been scientifically validated.  That doesn't mean the methods don't work (some of them probably do), but I don't know how far we can generalize individual results prior to seeing controlled studies.

The studies that were published two weeks ago used prolonged, mild cold exposure (60-63 F air) to achieve cold adaptation and fat loss (1, 2).  We still don't know whether or not we would see the same outcome from short, intense cold exposure such as a cold shower or brief cold water plunge.  Also, the fat loss that occurred was modest (5%), and the subjects started off lean rather than overweight.  Normally, overweight people lose more fat than lean people given the same fat loss intervention, but this possibility remains untested.  So the current research leaves a lot of stones unturned, some of which are directly relevant to popular cold training concepts.

In my last post on brown fat, I mentioned that we already know a lot about how brown fat activity is regulated, and I touched briefly on a few key points.  As is often the case, understanding the underlying biology provides clues that may help us train more effectively.  Let's see what the biology has to say.

Biology of Temperature Regulation

Read more »

Pop Health Hits 100! Revisiting 5 Favorite Posts.

In honor of Pop Health hitting the milestone of 100 posts, I wanted to take the time to look back, thank my readers (face to face!), and revisit some of my favorite posts.  I selected posts that (1) generated the most readers, (2) solicited the most comments, (3) connected me with colleagues, and/or (4) were just really fun to write and promote!

I am also celebrating this milestone with my first video post!


1.  "Bullying: Is Technology Helping Us Or Hurting Us?"  [October 5, 2010)

2. "Friends Don't Let Friends Drive Drunk:  How Soon Is Too Soon To Find The Teachable Moment In The Death Of Ryan Dunn?" [June 23, 2011]

3.  "Facebook Adds Organ Donation To Timeline: Should We Like It?"  [May 1, 2012]

4.  "Angelina Jolie's "Medical Choice" Dominates The Internet"  [May 14, 2013]

5.  "How And Why Should We "Pin" Public Health?" [June 18, 2013]

Reflections on the 2013 Ancestral Health Symposium

I just returned from the 2013 Ancestral Health Symposium in Atlanta.  Despite a few challenges with the audio/visual setup, I think it went well.

I arrived on Thursday evening, and so I missed a few talks that would have been interesting to attend, by Mel Konner, Nassim Taleb, Gad Saad, and Hamilton Stapell.  Dr. Konner is one of the progenitors of the modern Paleo movement.  Dr. Saad does interesting work on consummatory behavior, reward, and its possible evolutionary basis.  Dr. Stapell is a historian with an interest in the modern Paleo movement.  He got some heat for suggesting that the movement is unlikely to go truly mainstream, which I agree with.  I had the opportunity to spend quite a bit of time with him and found him to be an interesting person.

On Friday, Chris Kresser gave a nice talk about the potential hidden costs of eradicating our intestinal parasites and inadvertently altering our gut flora.  Unfortunately it was concurrent with Chris Masterjohn so I'll have to watch his talk on fat-soluble vitamins when it's posted.  I spent most of the rest of the day practicing my talk.

On Saturday morning, I gave my talk "Insulin and Obesity: Reconciling Conflicting Evidence".  I think it went well, and the feedback overall was very positive, both on the content and the delivery.  The conference is fairly low-carb-centric and I know some people disagree with my perspective on insulin, and that's OK.   The-question-and-answer session after the talk was also productive, with some comments/questions from Andreas Eenfeldt and others.  With the completion of this talk, I've addressed the topic to my satisfaction and I don't expect to spend much more time on it unless important new data emerge.  The talk will be freely available online at some point, and I expect it to become a valuable resource for people who want to learn more about the relationship between insulin and obesity.  It should be accessible to anyone with a little bit of background in the subject, but it will also be informative to most researchers.

After my talk, I attended several other good presentations.  Dan Pardi gave a nice talk on the importance of sleep and the circadian rhythm, how it works, how the modern world disrupts it, and how to fix it.  The relationship between sleep and health is a very hot area of research right now, it fits seamlessly with the evolutionary perspective, and Pardi showed off his high level of expertise in the subject.  He included the results of an interesting sleep study he conducted as part of his doctoral work at Stanford, showing that sleep restriction makes us more likely to choose foods we perceive as unhealthy.

Sleep and the circadian rhythm was a recurrent theme at AHS13.  A lot of interesting research is emerging on sleep, body weight, and health, and the ancestral community has been quick to embrace this research and integrate it into the ancestral health template.  I think it's a big piece of the puzzle.

Jeff Rothschild gave a nice summary of the research on time-restricted feeding, body weight and health in animal models and humans.  Research in this area is expanding and the results are pretty interesting, suggesting that when you restrict a rodent's feeding window to the time of day when it would naturally consume food (rather than giving constant access during both day and night), it becomes more resistant to obesity even when exposed to a fattening diet.  Rothschild tied this concept together with circadian regulation in a compelling way.  Since food is one of the stimuli that sets the circadian clock, Rothschild proposes to eat when the sun is up, and not when it's down, synchronizing eating behavior with the natural seasonal light rhythm.  I think it's a great idea, although it wouldn't be practical for me to implement it currently.  Maybe someday if I have a more flexible schedule.  Rothschild is about to publish a review paper on this topic as part of his master's degree training, so keep your eyes peeled.

Kevin Boyd gave a very compelling talk about malocclusion (underdeveloped jaws and crowded teeth) and breathing problems, particularly those occurring during sleep.  Malocclusion is a modern epidemic with major health implications, as Dr. Boyd showed by his analysis of ancient vs. modern skulls.  The differences in palate development between our recent ancestors (less than 200 years ago) and modern humans are consistent and striking, as Weston Price also noted a century ago.  Dr. Boyd believes that changing infant feeding practices (primarily the replacement of breast feeding with bottle feeding) is the main responsible factor, due to the different mechanical stimulation it provides, and he's proposing to test that hypothesis using the tools of modern research.  He's presented his research at prestigious organizations and in high-impact scientific journals, so I think this idea may really be gaining traction.  Very exciting.

I was honored when Dr. Boyd told me that my 9-part series on malocclusion is what got him interested in this problem (1, 2, 3, 4, 5, 6, 7, 8, 9).  His research has of course taken it further than I did, and as a dentist his understanding of malocclusion is deeper than mine.  He's a middle-aged man who is going back to school to do this research, and his enthusiasm is palpable.  Robert Corruccini, a quality anthropology researcher and notable proponent of the idea that malocclusion is a "disease of civilization" and not purely inherited, is one of his advisers.

There were a number of excellent talks, and others that didn't meet my standards for information quality.  Overall, an interesting conference with seemingly less drama than in previous years.

MANAGEMENT AND LEADERSHIP

August 10^th2013 

Address to University of Newcastle   Master of Clinical Medicine (Leadership and Management)   Workshop Dinner

Stephen Leeder

I congratulate everyone present at this workshop, whether as a fellow in the program or one of the program organisers or managers who support it or as contributors to this workshop. 

What you are all doing is critical to the future of the health service that we all work in.  Without high quality management, without leadership to point to a goal and remind us of why we do what we do, we will not give to the future the best of what we are capable.  But with management and leadership we can seize opportunities and overcome obstacles in ways that may surprise us and that will assure a positive legacy from the commitment of our lives to our profession.

I have followed the progress of the program from conception through birth to infancy and am impressed with it.

I have committed part of my life to medical education, so what is happening in this course is of special interest to me.

You are all great people. 

I know from my experience both in Newcastle and Sydney, with new educational programs, the agony and ecstasy of the first cohort of participants – they get the best and worst, they get the enthusiasm and the mistakes, rather like firstborn children.   

In 1986 I attended a one-day workshop in Sydney CBD on how to become a great leader, run by an American evangelist-type who talked with boundless enthusiasm and sold books and tapes.  At the start he asked us all: “Hand up if you are a first born child!”  Almost four-fifths of us indicated they we were firstborn.  Apparently as firstborn you are born to lead!  So as the firstborn of this new program, you folk are already at an advantage when it comes to leadership!

Your theme at this workshop is leadership and management.  A definition of good leadership that I heard years ago has stuck with me and it is that leadership is helping others achieve more than they thought possible, more than they thought they were capable of achieving.  Leadership provides direction.  It provides hope. It is optimistic.  Leaders take people with them.  Leaders stretch the people they are leading.  They say “Come on!” to the flagging spirits. They say “This way!” to those who are dithering. They say “Take my hand” to those who are stumbling or out of breath.  That’s what good leaders do and that is what good leadership is.

Managers in my experience are enablers.   Managers make things happen.  They understand the process of making decisions, they know how to allocate tasks and resources to match those tasks, they understand spread sheets, they enable, they discipline when needed. 

I have seen leaders who are good managers and vice versa.  I have also seen good leaders who were essentially devoid of management skills, and managers who could not lead. 

A couple of personal observations. 

First, doctors are not exceptionally good managers.  Of course, you can name half a dozen doctors you know, as can I, who are excellent managers.  But our training as doctors leads us to be individualistic, to make decisions in diagnosis and therapy that affect the lives of our patients and for which we and we alone, are accountable. Many doctors lead teams, but often you will find someone else manages those teams.  McKinsey Consulting hires a few – not many – doctors as management consultants.  So the skills of management do not come easily or naturally to many doctors. 

With regard to leadership you will find many doctors who have pioneered new ways of treatment, especially in surgery, that depend on effective leadership for success.  But the big picture, the vision, the attributes of leadership that I described before, are not common among doctors, at least in my experience, even in public health.  Halfdan Mahler, a physician from Denmark, served three terms as director-general of the World Health Organization 1973-1988 and is widely known for his effort to combat tuberculosis and his role in shaping the landmark Alma Ata Declaration that defined the Health for All by the Year 2000 strategy. He was a leader, a visionary man.   

But the eight Millennium Development Goals, established by the UN, were not developed, nor led, by doctors, but by Kofi Annan, the Secretary General of the UN and Jeffrey Sachs from the Earth Institute at Columbia University.  They pushed for a halving of poverty by 2015 through goals that addressed infant and maternal mortality, basic education and aid.  The goal of halving the number of people living on less than $1.50 a day was achieved three years early, in 2012.  That’s what leadership can do, through inspiration, tenacity, clarity of vision and passion.

So by now you’ll be wondering why your course organisers asked me to speak to you this evening as I bring dismal news.  Well, it is not all that dismal!  This is partly because we have many excellent managers, non-medical, in our health service and if you can find and engage with them, you will be very fortunate. 

That’s leadership, but what about management?  In the past two years I have chaired the board of the WSLHD.  We were in serious financial bother and morale was low.  Enter Danny O’Connor our CE who is a wonderful manager.  He has brought order and respect and conversation to that troubled district.  He came saying “I’m a team man” and he has been true to his word.  He has won the respect of clinicians.  He networks well.   And as chair of the board I see my job as being his body guard.  I don’t mess with his management.  I just take a whopping great stick to marauders. 

I have been involved in helping establish a new medical school in Newcastle in the late 1970s and 80s and then the reform of the Sydney medical program in the 90s.  Both required managerial and leadership skills and in many ways I acquired those as I went along.  I have been lucky – really lucky – that in those endeavours I have had wonderful colleagues who worked closely with me and educated me sometimes quite forcefully. 

You will acquire management and leadership skills through this course and you too will be lucky.  A lot of my mistakes are ones you will learn how to avoid. The future of the health service, in my opinion, depends on it being well managed.  One example: the introduction of ICT without change management is an easy way to waste billions of dollars.  Yet we need that ICT to achieve the connectivity that caring for people with chronic problems demands.  We need to manage efficiently or we will continue to do what we are doing now – asking people to pay more from their pockets (a great inequity) to cover the difference between public funding and the inefficient cost.   That this can be done is apparent from our Veterans Affairs health service.  It is also apparent in the US – Kaiser, Intermountain, Harvard, and Mayo for example.

Are there dangers in leadership and management for us as doctors?  Let me identify one risk with management and two with leadership.

We will get ourselves into an impossible tangle if as clinicians we follow our duty of care for patients at the same time as we try to be really smart managers and also do our best by our patients. On some management matters we need to stand aside for managers without clinical obligations. Decisions about resource allocation need to be made at a higher level than in the ward.

As leaders, we can get ourselves into bother if we construct for ourselves a reality that is too far out of common experience.

When I was dean of medicine in Sydney 1997-2002 I used to do a clinic a week at Blacktown to keep in touch with clinical reality.  Fortunately, medical leaders have the chance often of continuing to do some clinical work and that helps keep their reality clear and clean.  

The other danger with leadership is that it is charged with power and this can be used to good or bad purposes.  Hitler was an amazing leader.  Ironically, the Kennedy brothers, all of whom used rhetoric and vision to inspire their audiences, were fond of using a quote from George Bernard Shaw.  It was “You see things; and you say, ‘Why?’ But I dream things that never were; and I say, ‘Why not?’”  But while the quote does come from GBS, in fact it is drawn from a play that he wrote called Back to Methuselah. 

The words were words spoken by the serpent in the garden in the biblical story of Adam and Eve, where the serpent is the embodiment of evil, and it is tempting Eve to disobey God and eat from the tree of the knowledge of good and evil.  Strong words, inspiring words, but an abuse of power!  Leaders beware!

We are very lucky.  All of us – clinicians, managers and others – here this evening know why we do what we do in health care, what our goals are.  We know that our job is to express solidarity with suffering people, to prevent, cure, relieve and comfort.  This vision enables us to lead and be led, to manage and be managed, in pursuit of that vision.

So leadership and management are critical skills for effective future health care.  We need doctors who can lead and others who can contribute to massive management challenges of the future.  That’s YOU! 

I am delighted you are here, delighted you are doing this course, and delighted that our health service will be in such good hands.  I wish you all good fortune in your further careers. 

Thank you.

AHS Talk This Saturday

For those who are attending the Ancestral Health Symposium this year, my talk will be at 9:00 AM on Saturday.  The title is "Insulin and Obesity: Reconciling Conflicting Evidence", and it will focus on the following two questions:

1. Does elevated insulin cause obesity; does obesity cause elevated insulin; or both?
2. Is there a unifying hypothesis that's able to explain all of the seemingly conflicting evidence cited by each side of the debate?

I'll approach the matter in true scientific fashion: stating hypotheses, making rational predictions based on those hypotheses, and seeing how well the evidence matches the predictions.  I'll explore the evidence in a way that has never been done before (to my knowledge), even on this blog.

Why am I giving this talk?  Two reasons.  First, it's an important question that has implications for the prevention and treatment of obesity, and it has received a lot of interest in the ancestral health community and to some extent among obesity researchers.  Second, I study the mechanisms of obesity professionally, I'm wrapping up a postdoc in a lab that has focused on the role of insulin in body fatness (lab of Dr. Michael W. Schwartz), and I've thought about this question a lot over the years-- so I'm in a good position to speak about it.

The talk will be accessible and informative to almost all knowledge levels, including researchers, physicians, and anyone who knows a little bit about insulin.  I'll cover most of the basics as we go.  I guarantee you'll learn something, whatever your knowledge level.

Food Reward Friday

This week's lucky "winner"... cola!

Thirsty yet?  Visual cues such as these are used to drive food/beverage seeking and consumption behavior, which are used to drive profits.  How does this work?  Once you've consumed a rewarding beverage enough times, particularly as a malleable child, your brain comes to associate everything about that beverage with the primary reward you obtained from it (calories, sugar, and caffeine).  This is simply Pavlovian/classical conditioning*.  Everything associated with that beverage becomes a cue that triggers motivation to obtain it (craving), including the sight of it, the smell of it, the sound of a can popping, and even the physical and social environment it was consumed in-- just like Pavlov's dogs learned to drool at the sound of a bell that was repeatedly paired with food.

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Do Celebrities and the Media Combat or Perpetuate Stigma Around Breastfeeding?

This week's guest post was written by Jennifer Breaux, DrPH, MPH, CHES.  She is an Assistant Teaching Professor & Director, Undergraduate Education at the Drexel University School of Public Health.  Her work is focused on maternal & child health, nutrition, and health as a human right.

Over the past month, Alicia Silverstone has entered the public health conversation once again by launching a vegan mother breast milk sharing program through her website The Kind Life.  The program has been featured by several national media outlets.  Although her idea of milk sharing is not a new one, it has reignited arguments and opinions on both sides.  For example, US Weekly ran a short piece about the proposed milk sharing program where it provided the information but did not give an opinion.  Unfortunately, many uneducated and harsh opinions were given in the comments section of this piece.  They ranged from stating that this was a horrible idea that would give babies diseases to questioning why someone would choose to give breast milk in this situation when there is formula.

I felt compelled to write this blog post because issues relating to breastfeeding and breastfeeding policies are extremely near and dear to me both personally and professionally.  The issue is also quite timely considering that August 1-7 is World Breastfeeding Week and the month of August is Breastfeeding Awareness Month.

Combating Stigma
Alicia’s program was first reported on by Good Morning America (GMA) and I was struck by the uncomfortable nature of the anchors when the health reporter presented breast milk on the table.  Seeing the breast milk out in the open resulted in a visceral reaction of unease for some of the hosts.  I was happy to see the reporter debunk some milk sharing myths like (1) the milk is unsafe, (2) it transmits disease and (3) it is an unnecessary service.  Overall, I thought that GMA did a balanced job of reporting the story.

Perpetuating Stigma
While stories like that on GMA  (in which a medical professional reinforced the safety of breast milk sharing) can help combat stigma, stories like the one in Life & Style can perpetuate it.  The Life & Style magazine ran a story with a quotation by TV host Wendy Williams who basically equated milk sharing with slave nurses and the Civil War.  

The roots of milk sharing date back to wet nursing and this practice actually dates back to before Christ and has been practiced through the centuries.  Yes, wet nursing did exist during times of slavery but it is also something that still exists today – largely invisible to the general population.  However, it did make main stream news outlets a few years ago when Salma Hayek breastfed a malnourished infant during a humanitarian trip to Sierra Leone.    The whole concept of wet nursing and milk sharing is not new and truly a selfless act that has become a life saving option for mothers who can’t or choose not to breastfeed.

The Facts About Safety
The Human Milk Banking Association of North America (HMBANA) was established in 1985 and remains the largest group to acquire breast milk.  It is a lifesaving organization for premature and ill infants and has locations across the country.  One of the main arguments against something like milk sharing is the spread of disease.  Milk that is obtained for the HMBANA meets rigorous standards.  Milk donors are screened and once the milk arrives at the bank it is:

• Pasteurized to eliminate harmful bacteria,
• Lab tested to make sure the milk is safe and free of any communicable diseases that are able to be spread in milk, and
• Once it is ruled free of any cultures, the milk is able to be shipped to recipients

These standards enable parents to give donated milk knowing that it is safe and what is best for their infant.

That being said, there are informal milk sharing programs that are not regulated; the milk does not go through the rigorous testing done by HMBANA, which could pose a public health risk for those receiving the milk.  However, those who choose to participate in these networks are aware of the risks and feel that the benefits provided by breast milk outweigh possible consequences because the amount of external substances absorbed in breast milk is quite small.   An additional reason that families may choose this alternative route is cost.  Babies drink A LOT of milk and to get certified milk from HMBANA for the first year of life is extremely expensive and is only covered by insurance under certain circumstances.

A Call To Action
We, as a society, have opinions on these types of breastfeeding programs, but the debate will continue until we deal with the root cause of the need for increased milk sharing - our poor breastfeeding rates.  According to the World Health Organization and the American Academy of Pediatrics, it is recommended that mothers exclusively breastfeed their infant for the first 6 months of life followed by breastfeeding, in combination with the introduction of complementary foods, until at least 12 months of age and continuation of breastfeeding for as long as mutually desired by mother and baby.  In 2012, the national breastfeeding rate of exclusive breastfeeding at 6 months was only 16.3% with certain subgroups falling far below this percentage.

Stigma surrounding breastfeeding and the lack of support on every level will continue to plague this issue. The irony is that the science is clear – breastfeeding has overwhelming positive benefits for the baby, mother and society.

Some of the proven positive health benefits for breastfed babies are reductions in/of:

• Hospitalization from lower respiratory infections
• Ear infections
• Serious colds, ear and throat infections
• Necrotizing entercolitis
• Sudden Infant Death Syndrome (SIDS)- after accounting for confounders
• Allergic disease
• Celiac disease
• Irritable Bowel Syndrome (IBS)
• Obesity
• Type I Diabetes
• Childhood Leukemia and Lymphoma

Some of the proven health benefits for the mother (time dependent) of breastfeeding:

• Decreased postpartum blood loss
• More rapid involution of the uterus (post childbirth)
• Increased child spacing (lactational amenorrhea)
• Possible decrease in postpartum depression
• Decreased risk of Type 2 Diabetes
• Inverse between breastfeeding and rheumatoid arthritis
• Reduction in hypertension, Cardiovascular Disease (CVD)
• Reduction in breast and ovarian cancer
• Reduction in osteoporosis

Additional benefits from breastfeeding annually:

• $13 million in direct health care savings
• Prevention of at least 5,000 cases of breast cancer
• Prevention of at least 54,000 cases of hypertension
• Prevention of at least 14,000 heart attacks
• Prevention of the three outcomes above result in about $860 Million in health care savings

Breastfeeding is good public health.  Maybe we should start investing more in making sure babies are able to be breastfed and, if not- afford them the ability to receive affordable and safe breast milk.  We MUST stop considering breastfeeding as a woman’s lifestyle choice and view it for what it really is:  an important health issue, a public health issue and a human right.

HBO Presents "The Crash Reel": Examining The Enormous Impact Of Traumatic Brain Injury (TBI)

Traumatic Brain Injury (TBI) is a public health problem.  We hear about it a lot in relation to the members of our Armed Forces.  In fact, TBI has been "one of the signature injuries of troops in Afghanistan and Iraq".  There has also been much discussion in the media (and here on Pop Health) about the impact of TBI on National Football League (NFL) players.

On July 15, 2013 HBO premiered an incredible documentary called "The Crash Reel".  This film follows U.S. snowboarder Kevin Pearce as he rises through the ranks of the sport, dominates international competition in the run-up to the 2010 Olympics, survives a horrific training accident in Park City, Utah and launches a come-back to his life (and possibly) the sport he loves so much.

The documentary does an amazing job of examining both macro and micro public health issues as they relate to TBI.

Society:

During a poignant interview, Kevin's Dad says "we were all to blame" [for Kevin's injury].  The spectators, the families, the sponsors....he believes they all have a role in injury prevention and athlete safety. He asks why the halfpipe walls keep getting higher and higher (increasing speed, height, and risk of the tricks).

Risk culture and the role of spectators and sponsors in perpetuating this culture is called out in "Wrecks Over Reason", an article running in the August 5, 2013 issue of Sports Illustrated (SI).  Referencing the "X Games" specifically, athletes acknowledge that the audience is hoping to see crashes.  The author Austin Murphy writes, "Indeed, many of the events-at the X Games in particular and in the extreme sports world in general-seem designed to ensure a modicum of carnage.  That's what people are tuning in to see".  

Family and Friends:

Kevin's close-knit family is a big part of the documentary.  We hear them recount how they learned of his accident and through pictures and video, we see them assume the role of caretakers.  It is clear that TBI can have an enormous impact on a person's entire family.  His brother Adam quits his job to help Kevin through his rehabilitation.  His mother is by his side for almost every appointment.  His roommate helps to counter his memory loss by helping with organization and medication.

Having almost lost him and with their lives heavily impacted during his recovery, their fear is understandable when Kevin talks about getting back to snowboarding.   Although his physicians and family constantly reinforce the danger that a second head injury could bring (i.e., it could be fatal), Kevin is determined to return to the sport.  

Kevin:

The accident was caught on video and is horrific to watch. All things considered, Kevin makes a pretty amazing recovery.  He spends 3 months in the hospital and then participates in ongoing rehabilitation to address the lingering effects of his injury: double vision, impulse control problems, memory loss, and depression.  He wrestles with accepting that his injury is life-long and will forever change the trajectory of his life and career.

According to the Centers for Disease Control and Prevention (CDC), at least 1.7 million TBIs occur every year, either as an isolated injury or along with other injuries.  The costs of these injuries are huge- not just in terms of medical costs, but in terms of lost productivity for that individual (and their friends/family that serve as caretakers).  While it is important to focus on helmet use and other individual-level interventions, I applaud the tone of this documentary and the SI article above.  I hope they ignite a discussion of society-level (and sports-level) interventions for traumatic brain injury. 

Food Reward Friday

This week's lucky winner... salted nuts!!

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Potential article of interest on President Obama's Proposed Reform on Higher Education:
http://www.accreditedonlinecolleges.com/blog/2013/obamas-accreditation-reforms-on-higher-education/


 

Brown Fat: It's a Big Deal

Non-shivering thermogenesis is the process by which the body generates extra heat without shivering.  Shivering is a way for the body to use muscular contractions to generate heat, but non-shivering thermogenesis uses a completely different mechanism to accomplish the same goal: a specialized fat-burning tissue called brown fat.  Brown fat is brown rather than white because it's packed with mitochondria, the power plants of the cell.  Under cold conditions, these mitochondria are activated, using a specialized molecular mechanism called uncoupling* to generate heat.

The mechanism of brown fat activation has been worked out fairly well in rodents, which rely heavily on non-shivering thermogenesis due to their small body size.  Specialized areas of the hypothalamus in the brain sense body temperature (through sensors in the brain and body), body energy status (by measuring leptin and satiety signals), stress level, and probably other factors, and integrate this information to set brown fat activity.  The hypothalamus does this by acting through the sympathetic nervous system, which heavily innervates brown fat.  As an aside, this process works basically the same in humans, as far as we currently know.  Those who claim that rodent models are irrelevant to humans are completely full of hot air**, as the high degree of conservation of the hypothalamus over 75 million years of evolution demonstrates.

Two new studies concurrently published in the Journal of Clinical Investigation last week demonstrate what I've suspected for a long time: brown fat can be 'trained' by cold exposure to be more active, and its activation by cold can reduce body fatness.

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Zucchini: The Home Gardener's Worst Friend? With bonus garden-related rambling.

One of my main gardening goals has been to harvest more of something than I can eat, despite my limited gardening space here in the Emerald City.  I want the feeling of abundance that comes with having to preserve and give away food because I can't eat it all.

Enter zucchini.  My grandfather used to say that in New Jersey in summertime, you'd have to keep your car doors locked, otherwise the car would be full of zucchini the next time you got in!  In mid-May, I planted two starts from my local grocery store labeled "green zucchini", with no further information.  I put them in a bed that used to be a pile of composted horse manure, and that I had also cover cropped, mulched, fertilized, and loosened deeply with my broadfork.  They look pleased.

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#RoyalBaby Offers Public Health A Unique Opportunity To Advocate For Maternal and Child Health

As Catherine, Duchess of Cambridge, went into labor early yesterday morning, public health organizations and advocates took advantage of the opportunity to talk about maternal and child health.  Since much of the world was following the #RoyalBaby story, it made sense to make the connection to public health work.

Here are some of my favorite tweets and topics:

VACCINATIONS

 

 NEWBORN SCREENING

BREASTFEEDING

Andy's tweet was in response to this image from Oreo:

PRENATAL SMOKING

SUPPORT FOR NEW PARENTS

As I've noted in related posts, I hope these organizations are evaluating their communication strategies!

• Have they seen an increase in traffic to their websites and resources?
• Have they engaged a new audience by aligning with the #RoyalBaby news?
• What organizational resources are needed to develop communication plans that coordinate with timely global and pop culture news?
• What lessons learned can be applied to future communication efforts? 

What do you think?

• Are these types of communication strategies effective in reaching a broader audience?
• Are there other relevant public health tweets that you felt were creative and engaging?  Please share!!