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

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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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