Saturday, January 25, 2014

Applying Tobacco Control Strategies to 'Obesity' Prevention

[Note: In this post, I use the terms ‘junk food’ and ‘less healthy’ foods in quotes and interchangeably to mean foods and beverages which are high in calories but low in nutrients.  I am using the same terms that a consensus of nutrition researchers use; I am not making a value judgement.]

Being over fat (i.e., having excess adipose tissue) increases inflammation and disease.  Increased body size stresses joints and increases musculoskeletal instability.  Reducing the personal, societal, medical and economic burden resulting from these conditions is not going to be easy.  Some suggest that strategies from tobacco control may help.  I agree that we can use or modify tobacco control strategies to address ‘obesity’, but at the same time, we should recognize that some of those strategies, e.g., shaming people and offering one on one behavior change counseling are not likely to be effective. 

Instead, I suggest we apply tobacco related strategies to the structural causes of over fatness.  The strategies that had the greatest influence on decreasing the prevalence (percent of the population) of smoking targeted the physical and social environment, not individual smokers.  Successful strategies included price increases thru state and federal taxes, age limits, clean air laws, advertising limits and display bans.  (Warning labels are another strategy meant to deter tobacco use, but they are focused on the individual and do not have much success with current smokers.)

We can apply several of the above tobacco strategies to ‘obesity.’  The first is price.  A sin tax or ‘junk food’ tax is unpopular, but it is effective in changing food/beverage purchasing behavior according to some small studies.  In order to implement such a tax, we have to rely on current nutritional evidence about food ingredients and then determine the best way to increase prices of items that contain these ‘ingredients of concern’.  For example,  we know that adding sugar and solid fats to foods and beverages makes them calorie dense and calorie dense foods and drinks appear to be the main drivers of excess calorie ingestion and over fatness in the US and similar countries.  It is possible that taxing the ingredients themselves, as some countries have done, will lead food manufacturers to reduce their liberal use of sugar and solid fat. Another option is to tax the product itself, such as sugar-sweetened beverages. This strategy could lead people to purchase less of the taxed foods and beverages.  A result of taxation could be that companies start providing less calorically dense versions of their products (and not simply by reducing the portion size!) or people start buying different products. These are not mutually exclusive.

Another strategy we can apply is a modification of ‘clean air laws.’ The overwhelming presence or availability of calorie rich, ‘junk food’ also drives ‘junk food’ consumption.  Tasty, cheap, calorie dense foods and beverages are everywhere and even when people have the same access to fresh, nutritious low calorie foods they tend to choose the ‘less healthy’ ones.  My colleagues talk of food deserts – where fresh produce is scarce -but I focus on food swamps.  The main reason I believe food swamps, more than food deserts, influence food choices relates to my work in tobacco cessation and alcohol treatment programs.  Consider being in a meeting or rehab and counseled to not smoke or drink and then you leave the meeting and everywhere you go there are displays of alcohol and cigarettes and people smoking and drinking. [Hence the advice to alcoholics in recovery and recently quit smokers to change their playgrounds].  I have had smokers tell me that they want their work places – and restaurants and bars -to be smoke free (clean air laws), because it makes it easier for them to work through their cravings.  Their personal stories are evidence that whatever makes smoking harder (or less convenient, or less acceptable) makes quitting easier and smokers DO want to quit. They just aren’t too keen on failing over and over again.  The same desire and fear exists for people who understand that certain foods are less healthy for them.  People who struggle with calorie moderation (i.e., all of us) have even more challenges.  Because calorically dense foods are everywhere – neighborhoods, stores, restaurants, worksites, schools – there is no other playground for people to visit.  The playground (i.e., food swamp) is what must be changed.

The parallel to clean air laws for ‘obesity’ prevention are the steps we take to break up food swamps – for example:  zoning limits on the density of fast food restaurants and convenience stores, work site policies (e.g., ‘junk food’ free meetings), and candy free grocery checkout aisles. 

The low cost and constant presence of ‘junk food’ is not the only challenge to a maintaining an appropriate calorie level. We need to adopt tobacco strategies related to advertisement and age as well.  Food companies promote ‘less healthy’ food and beverages on billboards, in TV shows and TV commercials, through other media and in store displays.   The ads are entertaining, constant and often associated with celebrities.  The food industry shapes the environment, it shapes our tastes and it shapes our preferences. It makes sense for us to push back against THEIR influence on our behavior and our health.

At this time, the only parallel to tobacco control for advertising is predicated on age.  Food companies have voluntarily agreed to limit ‘junk food’ commercials during the airing of children’s television.  Another age related parallel could be the restriction of vending machine use or vending machine content in schools.  The candy free grocery aisles are also focused more on children than adults.

Lastly, nutrition information disclosures at restaurants and vending sites may be a parallel to warning labels on tobacco products IF those disclosures come with some type of interpretive label.  For example, an entrĂ©e with 900 calories and 15 grams of sugar should be labeled as HIGH in those two ingredients.  This is a more acceptable but weaker strategy.
It is important to remember that progress in reducing the burden of disease from tobacco is taking many years, but it began when people started to smoke less.  We should start seeing a decline in lung cancer and other smoking related conditions now as the prevalence of smoking has gone from 42% (1965) to 18 % (2013).  The strategies that led to a decrease in smoking were rolled out over time and met with great resistance, especially from the tobacco companies.  In fact, it took a near 50 state attorneys’ general lawsuit for tobacco companies to admit that their product was harmful.
We have a long way to go in reducing the personal, societal, medical and economic burden resulting from over fatness, but cajoling people to eat less and exercise more in an environment that makes it ridiculously easy to do neither is fruitless.
It’s the environment, stupid and it is time we stopped letting the food industry control it.

Sunday, January 19, 2014

The other effect of a national restaurant menu labeling law

You have probably read news stories suggesting that calorie information on restaurant menus and menu boards does not work.  It does appear that state or city nutrition menu labeling laws have not had a big impact on the average amount of calories customers purchase.  However, I have noted several research studies that are exceptions to these findings and I continue to believe that providing nutrition information at the point of decision making is a good idea.  The labeling can help reduce the over consumption of calories that occurs when people eat out.  I also believe, based on the research of others (see e.g., Ellison), that using a traffic light presentation (i.e., green, amber or red based on calorie amount) will enhance the effectiveness of menu labeling.  

For the most recent scientific review of menu labeling please click here.

Today I want to mention progress on another hoped for outcome related to menu labeling - changing the amount of calories in meals restaurants offer. The FDA still hasn't issued the final rule on how restaurants are to present the information, but in expectation, it would seem, restaurants are promoting special menus that offer lower than 'usual' calorie amounts.  (Recall the studies I have cited in past posts which showed the average chain restaurant meal having over 900 calories.)

In my anecdotal review (i.e., I have not systematically studied restaurant menus before and after the legislation was passed, or as the final rule approaches, or controlled for the fact that it is the first of the year), I found at least 9 major chain restaurants (e.g., Apple Bees, Outback, Macaroni Grill, Subway, McAlisters, Long John Silvers, IHOP, TGIF) who are promoting entrees with 500 to 600 calories or less.  Subway is advertising breakfast options at 200 or less.

One of the distal (or immediate) outcomes of a menu labeling law is that it heightens peoples awareness of calories and makes calories seem more important. I believe that menu labeling IS effective for these outcomes. The restaurant industry is aware of this and that is why menu labeling laws also work to change what is available - in other words, law can change the environment. Law can have a greater impact on population health than interventions aimed at individuals.  I am confident that once the labeling rule is published and restaurants nationwide fulfill their obligations to post calorie information, we will begin to see a change in the amount of calories purchased and in the future, perhaps, a reduction in the prevalence of diseases associated with being over fat.

Tuesday, January 14, 2014

McDonalds and Twinkies.. Ridiculous Ideas from educated people

Two unusual diets that led to weight loss and the improvement of metabolic profiles have been in the news lately.  In an earlier draft of this paragraph, I was harsh in calling out both dieters – a science teacher and a nutrition professor. I felt and still feel that they should be mindful of their positions of influence and temper their enthusiasm for diets that are probably unhealthy and suspiciously fad-like.  In addition, both men offer simplistic explanations for obesity and unrealistic advice for groups they appear to be judging.

In the first example, a high school science teacher, John Cisna, eats meals from McDonald’s for 90 days, loses weight, and improves his metabolic profile (i.e., his blood fat and cholesterol levels). Mr. Cisna refers to his self-imposed diet as an experiment and determines that the choices people make, not the food sold at McDonalds, makes them fat. 

Mr. Cisna is correct; our choices have everything to do with our outcomes.  He is incorrect in assuming that everyone has the same choices available to them. In his pseudo experiment (more on that in a moment), he had his students choose his daily meals within certain parameters.  The parameters were that he consume 2000 calories a day and stay within the recommended daily allowances of certain macronutrients (e.g., total and saturated fat).  The local McDonald’s franchise covered the cost of the meals.  In news stories about his 90 day diet, Mr. Cisna points out that he had to be smart about what he was doing.  If he ate a high fat breakfast, he would have to choose a lower fat lunch or dinner in order to stay within his parameters. This is exactly what the Dietary Guidelines for Americans tell us to do, and what so many of us have trouble doing.  Mr. Cisna is an educated man with above average numeracy who had 3 people watching the numbers with him. He was also able to make choices among all price ranges. In some of Mr. Cisna’s interviews, he suggests that people who blame McDonalds for their obesity lack self-control. I do not expect, nor should he, that the average McDonald’s customer has his same math skills or assistants to help them track their calories. And tracking calories and other macronutrient amounts IS important. We already know from scientific study that fast food and sit down restaurants generally serve foods that contain at least a half a day’s worth of calories, fat, sugar and salt.  People who obtain most or all of their meals from fast food and sit down restaurants, especially in the absence of nutrition labeling – and math skill - are at great risk for consuming a diet that is harmful to their health. 

In addition to controlling his calories, which he did not do before the McDonald’s diet, he also began exercising for 45 minutes a day.  

Mr. Cisna’s diet plan was not an experiment and we cannot make causal inferences from his personal results. An experiment by definition requires multiple subjects randomized into treatment conditions, including one in which nothing changes.  In most situations, if a person reduces their caloric intake and increases their exercise they will begin to lose weight and this initial weight loss will improve their metabolic profile, especially if they are following the recommended nutritional guidelines.  Because Mr. Cisna’s 90-day diet was not in any way an experiment, I am left with a few questions: What would happen if he did this for 90 more days?  What if he ate at McDonald’s but did not have the nutrition information available to help him stay within his parameters?  What if he had very little money with which to purchase the food?  What would happen if a woman followed his exact plan?  Or a younger person or an older person or a person of a different ethnicity?  What if he did this for 6 mos. or a year or for his whole life, as some seem pressured to do?   

In the second example, a nutrition professor, Dr. Mark Haub, eats Twinkies, etc., for 10 weeks, loses weight and improves his metabolic profile. He refers to his diet as a class project stemming from his teachings in nutrition.  I am just aghast by this, but as I researched him a little further, I saw that his doctorate is not in nutrition; it is in exercise science/physiology.  Dr. Haub has also been vocal about his results and suggests that the convenience store diet – something people living in food deserts might be forced into – are not necessarily bad and will not lead to obesity– as long as one makes the right choices.  

I feel that Dr. Haub’s extrapolations are out of place and far too simplistic.  It feels like an example of an over educated, privileged person suggesting he knows what an ‘other’ less privileged person is experiencing.  

He claims that his convenience store diet, which for him meant that 2/3 of his calories came from snack foods, caused his weight loss and improved his metabolic profile.  Like Mr. Cisna, Haub did not conduct an experiment and headlines misrepresent what he actually did. 

Professor Haub consumed a lot of sugary, processed snacks similar to and including Twinkies, but he also ate some vegetables, took a multivitamin and drank protein shakes.  In addition, and this is huge, he reduced the amount of calories that he consumed - from 2600 to 1800.  

I have the same concerns and questions about this diet as I did the McDonald’s one.  I suspect that the reason for Dr. Haub’s weight loss is that he reduced his intake by 800 calories.  (He has told reporters that he monitored this closely by writing down everything he ate.) I further suspect - and evidence supports - that over time, a diet high in processed, sugary cakes will lead to metabolic irregularities and poor health.  Lastly, and most importantly, he made a statement to one reporter that he wanted to be able to say that the diet was unhealthy, but the “data doesn’t support that.”  The data do not support anything… it was not an experiment or a quasi-experiment.  It was not research – there are no ‘data’. 

Both Dr. Haub and Mr. Cisna put themselves on a diet to lose weight.  During the time that they were on the diets, counting calories and exercising, they lost about 30 pounds each.  This weight loss may have triggered improvement in their metabolic profiles as well – this is an assumption because we do not have a counter-factual or comparison group.  It makes sense that the weight loss did cause the improvement. It does not make sense to suggest that a long-term diet of processed foods high in sugar or fried foods high in fat and sodium is health promoting.  Science already tells us that there are adverse consequences to this kind of diet pattern.  Both men’s claims as presented in the media are misleading. Cisna did not eat McDonalds without careful attention to calories and the macro-nutrient content of his meals, his choices were not limited by cost and he significantly increased his exercise. Dr. Haub’s diet included vegetables, protein shakes and vitamins; this is not similar to a diet consumed by someone who has limited income and has to eat most of their meals from a convenience store.  

In my opinion, the headlines and the diets they report are pure sensationalism.  Please, choose your calories from foods with health promoting properties, like those recommended by the Nutrition Source at Harvard.

Friday, January 10, 2014

Easy Weight Loss

Sorry, there is no such thing. My headline should be, “Weight Loss Not Easy,” but then fewer people would read the post - and people need to read this post.  Right now, masses of people are searching for that one pill, powder, or cream that will melt away excess fat with no behavioral change required.  Said pill, powder, cream DOES NOT EXIST.  It does not! Think about this carefully.  There are more overweight/obese adults in the United States and similar countries than there are normal weight adults. Because excess fat is associated with disease and being overweight can affect ones physical and psychological health, a simple remedy would be groundbreaking.  If this remedy currently existed, 70% of the US would not be overweight.

Products promising weight loss – fast, substantial, permanent, and painless – are simply fraudulent.  Unfortunately, the makers of these products do not have to submit them to clinical trials where efficacy is established or to post market trials where effectiveness is established – i.e., the FDA does not regulate the products.   However, the companies that sell supplements/weight loss products must tell the truth about them in advertisements. 

Truth in advertising is a law and the Federal Trade Commission (FTC) is responsible for its enforcement.  The FTC is understaffed and it takes years for them to get a falsely advertised product off the market.  The FTC went after 4 companies this week – read here, and has started the year with increased efforts to protect consumers, updating their guidance to both businesses and consumers for the first time since 2003.

I like the guidance the FTC provides to businesses, because in their communication to them, the FTC enlists the support of businesses and suggests that by screening the ads that they publish, businesses are protecting themselves from being associated with a ‘bad’ company – an unscrupulous company.  This is a good strategy because if media polices the ads, the FTC caseload could be reduced.  The FTC could go after and prosecute violators quicker.  I will benefit, too.  There will be fewer sensational, commercials that raise my blood pressure.

The FTC encourages media to stop and think about an ad before publishing or airing it. They offer 7 ‘gut checks’, but I can be more concise.  If an advertisement sounds too good to be true, it is too good to be true. You cannot lose weight if you do not change something about your eating and activity: the number of calories you consume, the type of calories you consume, the amount of exercise you do, the type of exercise you do. It is best to address all of these, but research suggests that diet alone will work to some extent.

You can read all the claims for businesses to watch out for here.

The scientific study of fat gain and loss is dynamic.  It feels like we learn something new every day, and indeed some of the things we believed to be true are not.  (I didn’t ‘know’ this before grad school, but in science things are never proven, only disproved).  Nutrition scientists once thought that all fat was bad in excess, but that no longer appears to be true.  They, and we – the public, also believed that a calorie is a calorie, but that truism is under current scrutiny as well.  I tell you this because I know many of you have become frustrated with and distrustful of science.  That is no reason to turn to supplement makers, I assure you; the makers of weight loss supplements deserve much less of your trust.  The fact that we are learning more about fat gain and loss through science is a good thing.  One of the most important new findings is that being over fat – as a population or as individuals – is caused by multiple factors.  Researchers have not identified all the factors, and the ones they have identified are not completely understood.   But we know some things in the aggregate.  For example, calories (amount and type) matter most and genetics matter least (by matter, I mean the amount of impact these factors have on body fatness).  Somewhere in between these two extremes is the amount and type of physical activity one engages in and metabolism.  An important note about metabolism is this:  an individual’s metabolism is affected by what and how much he or she has eaten over his or her lifetime and the amount of body fat he or she has carried.  In other words, a metabolism can become dysfunctional and this individual dysfunction makes it hard for anyone to prescribe generic weight loss advice - not everyone who cuts their calories and increases exercise will have the same results.  This is the painful truth.  In addition, I’d like to disavow you of the notion of a set point weight.  Instead, consider this: if a person does a certain thing and loses 10 pounds but then stops doing that certain thing, their weight will return to its previous level.  That is not destiny – the weight returned to its previous level for a specific reason – a person’s actions. 

In summary and in closing, no diet supplement leads to easy weight loss.  In the absence of disease, body fat does not melt away. Please consider this before you spend your money and invest your hopes in a weight loss supplement. The FTC is cracking down on companies who market products as if the products were weight loss miracles, and is asking businesses to give ads a ‘gut check’ before they agree to publish them.  Losing excess body fat is important and safe ways to do so exist.  One way to maintain a healthy weight is to follow the guidelines suggested by the Harvard Nutrition Source and to commit to daily or near daily exercise that increases your heart rate for 30 or more minutes.

Tuesday, January 7, 2014

Giving Smokers a False Sense of Security: New Lung Cancer Screening Guidelines

   In December the United States Preventative Task Force completed its review of the available science on whether using a  low dose CT scan could reduce the number of lung cancer deaths.  Lung cancer is the most lethal cancer, likely due to its late detection.  Treatment in late stage lung cancer is seldom successful, and is invasive (i.e., surgery, radiation, chemotherapy).
    The task force members reviewed 6 effectiveness studies and 20 studies that explored adverse effects from low dose CT - including exposure to radiation, the rate of false positives and the associated stress and unnecessary procedures that follow false positives.  You can read the summary and full report from the task force here
   It appears that only one of the studies that found a protective effect from low dose CT  was of high quality.  That study showed reduced lung cancer death as well as reduced death from any cause (all cause mortality) in the smokers who received the CT. The evidence from this study and several moderate quality studies was convincing enough to some to recommend the screening change.
    I am addressing the issue in my blog for two reasons, 1) I have worked in the smoking cessation field and 2) I often post about medical radiation and my grave concern over excessive use of imaging.  Almost four years ago, I wrote this post which was an over view of chapter 4 in the President's Cancer Panel report on Reducing Environmental Cancer Risk.  Chapter 4 is Exposure to Hazards from Medical Sources.  From that chapter we learned that CT scans are over used, that they expose the patient to high levels of radiation (higher levels than are necessary for the scans to be effective) and that the radiation dose from a CT scan can increase a person's risk for cancer.
   The new recommendations are for physicians to offer the low dose CT (LDCT) to persons who are between the ages of 55 and 74 who have smoked 1 pack of cigarettes per day for 30 years or 2 packs per day for 15 years, or any other combination that would equal 30 pack years.  If a person has this smoking history, but has quit smoking, they should still have the screens if they have been smoke free for less than 15 years.  [Notice the significant screening criteria - SMOKERS only.  To me this is as strong a declaration on the lethal consequences of smoking as one will ever hear.]
   According to the task force, 20% more lung cancer deaths could be prevented if these heavy smokers were screened with LDCT instead of a chest x-ray.  I do not know what this means in actual numbers, i.e., 20% of how many - how many do X rays find?  
   What I did spend time looking for was the amount of radiation a low dose CT provided.  Recall from chapter 4, not all imaging machines deliver the same amount per test .. so a rough estimate is the best we can do. The estimate is that low dose CT delivers the radiation equivalent of about 15 xrays.  Fifteen!  Radiation in this case is measured as millisieverts, or mSv.  A regular chest CT has 5 to 20 mSv and the low dose CT has 1 to 4 mSv.  Better - still a heck of a lot and more than I would routinely expose myself to.  (To be fair, some estimates of  the radiation in regular chest CT suggest the equivalence of 350 Xrays... yes that is three hundred - so to answer my question; indeed, the low dose CT is a lower dose of radiation)
   In the summary from the report, it is clearly stated that most lung cancer is caused by smoking and that the most important thing we can do to reduce death and disease from lung cancer is to reduce smoking.
    I am really concerned that smokers will keep smoking because they believe that this screening will find a tumor in time to remove it.  That is a HUGE risk.  Click here to learn more about quitting.. I did it, so can you.

Wednesday, January 1, 2014

Women: Is the 3D Mammogram Right for You?

In a word, NO.  That was rather simple and probably not fair and certainly out of my professional realm.   It's more appropriate for me to recommend that you think twice before having a 3D mammogram.  At this time, there is little evidence that the 3D scan is more effective at detecting cancerous lumps and reducing false positives on its own, though early results suggest it might be helpful at doing that when used at the same time as the 2D digital mammogram.  (Please see the linked article for a very interesting history on how the 2D mammogram replaced the Screen Film Mammography before research indicated that it should. spoiler: it never really did)

At this time, it makes more sense for women to continue with the usual, insurance covered (actually free because there is no copay for this covered preventative service) 2D digital mammogram.  At least one large clinical trial is currently underway to determine if the 3D scan, actually called Digital Breast Tomosynthesis or DBT is better than the 2D alone and whether or not the improvement is worth the extra radiation. The DBT is similar to a CT scan, which I have discussed in past posts. 

The reason I wanted to look into the 3D evidence is because for the last two years when I went in for my screening, I was asked by the imaging center staff - not my doctor - if I wanted the 3D scan.  It is not covered by insurance - its not free anyways.  The first year I asked why? Why would I want this type of imaging? I am pretty certain that the radiology tech told me that the 3D exam gives a clearer image and may reduce false positives (which appears to be true).  I then asked, "is there more radiation?"  The answer was yes so I declined this 'better' test.  This year, a few weeks ago, the image center receptionist asked me if I wanted the 3D scan and when I said NO without hesitation, I was told to read and sign a WAIVER form.  I was documenting that I was offered the 3D scan and declined it.  That was odd, so I asked, "Do you make people who agree to the exam sign a form too?"   She said yes, and I should have asked to see it, because the feeling I had at the time, as the patient, was that they were trying to scare me into getting an exam - without clinical indication and at extra cost to me.  Why would they do that?  I expect because the imaging center makes a profit from it.

I would like to see the results of a randomized clinical trial that compares the 2 types of mammograms. Based on my strong concern over radiation, I expect that even if the 3D comes out ahead, I will skip it... remember radiation is itself a cause of cancer.  That is my PERSONAL informed decision; you must make your own informed decision.

Click here to see a document listing what is known and unknown about this type of imaging to date.  It includes information on the large clinical trial that is still under way - The Oslo Screening Trial.