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Thursday, October 25, 2012

Human survival and the battle of the SExS

If all of us were simply to make better use of our feet, our forks, and our fingers; if we were to be physically active every day, eat a nearly optimal diet, and avoid tobacco; fully 80% of the chronic disease burden that plagues modern society could be eliminated. Really.

Better use of feet, forks, and fingers, and just that, could reduce our personal lifetime risk for heart disease, cancer, stroke, serious respiratory disease, or diabetes by roughly 80%. The same behaviors could slash both the human and financial costs of chronic disease, which are putting our children's futures and the fate of our nation in jeopardy. Feet, forks, and fingers don't just represent behaviors we have the means to control; they represent control we have the means to exert over the behavior of our genes themselves.

Feet, forks, and fingers could reshape our personal medical destinies, and modern public health, dramatically, for the better. We have known this for decades. So why doesn't it happen?

Because a lot stands in the way. For starters, there's 6 million years of evolutionary biology. Throughout all of human history and before, calories were relatively scarce and hard to get, and physical activity in the form of survival was unavoidable. Only in the modern era have we devised a world in which physical activity is scarce and hard to get and calories are unavoidable. We are adapted to the former, and have no native defenses against the latter.

Then, there's roughly 12,000 years of human civilization. Since the dawn of agriculture, we have been applying our large Homo sapien brains and ingenuity to the challenges of making our food supply ever more bountiful, stable, and palatable; and the demands on our muscles ever less. With the advent of modern agricultural methods and labor-saving technologies of every conception, we have succeeded beyond our wildest imaginings.

So now, we are victims of our own success. Obesity and related chronic diseases might well be called "SExS,," the "syndrome of excessive successes."

The problem with this beyond its obvious consequences is its profound cultural inertia. Having worked for 12,000 years to reduce physical exertion and increase available calories, it's rather a challenge to suddenly reduce available calories and increase exertion. Everything in modern society is inclined the other way.

And, of course, the so-called "military industrial establishment" stands in the way as well. Many of our modern institutions, from big food, to big pharma, profit from the obesogenic status quo. Although, of note, the military per se certainly does not, quite the contrary. Ever more concern is being expressed about the potential for rampant obesity to interfere with our military preparedness. So it's just the "industrial establishment" in this case.

But those institutions that do profit have deep pockets, and use them to oppose sudden change. Over time, food companies can reformulate and sell better products that preserve profit margins, but they are not inclined just to sell less of what they make right away. Over time, drug companies can become health promotion specialists; but they are not going to sit back and watch their stock values plummet.

What all this means, quite simply, is that progress toward the public health prizes that beckon will tend to be incremental, at times slow, and almost never perfect. Perfect tends to be the enemy of good in the real world.

That point was apparently lost on a certain David Lazarus, who wrote an opinion piece in the Los Angeles Times that was highly critical of Anthem Blue Cross for operating a program that provides clients with discount coupons for better, but often quite imperfect, foods.

The program is provided by a company called LinkWell, which links food companies to insurance companies in just this way. The insurance companies provide access to their clients, and the food companies pay to discount their better-for-you offerings. The idea is that people can be "nudged" this way toward better choices; the food companies can sell their products; and the insurance companies can potentially reduce their costs. In principle, everyone can win.

I find that principle quite sound, and for that very reason, and the fact that I have long been an avowed public health pragmatist, I serve on Linkwell Health's Board of Advisors.

Mr. Lazarus ridiculed the fact that Anthem provided coupons for deodorant. This, of course, has nothing to do with health but everything to do with building bridges. By sending out coupons for some products unrelated to health, Linkwell, Anthem, and the other insurance companies using the program gain traction to address the choices that do influence health.

Mr. Lazarus also beat up on those, noting that better-for-you ice cream is still ice cream. He suggested that the coupons be limited to vegetables and fruits, or maybe meats and fish.

Leaving aside an apparent willingness to attribute the same health effects to meats and vegetables, Mr. Lazarus' suggestion has intrinsic merit. The best foods generally do come direct from nature, and switching from one ice cream to another may not do much for health, personal or public.

But there is one important problem with Mr. Lazarus' suggestion. It doesn't work.

We have been encouraging Americans to eat more fruits and vegetables for literal decades, and yet only 1.5% of us (yes, 1.5%!) get the recommended daily intake of both. We have goaded and harangued, given produce out for free, and financially incentivized it. These things do make a difference, but a very small difference. That is in part because there are important barriers to more produce intake other than price, and in part because people are simply accustomed to choosing many foods that come in bags, boxes, bottles, jars, and cans.

This is not likely to change overnight, and arguments to the contrary make perfect the enemy of good.

I have been subject to such arguments myself. I led the development of a nutritional guidance system intended to guide people to more nutritious choices within any given food category. Yes, in fact, if you are inclined to eat ice cream, there truly are more and less nutritious choices. Yes, if you are inclined to eat chips, there are better chips. And frankly, it just isn't relevant, when you are inclined to eat chips, that broccoli is better for you.

The purists among my colleagues criticize such guidance because it does not advocate for consumption of pure foods only, although those, of course, do score highest of all. But I am not aware of any scientific evidence that encouraging people to eat pure foods
In contrast, I am aware of real-world evidence that guidance for trading up every food choice to a slightly better one can make an enormous difference. And that it actually has done so, repeatedly. And that simply by making slightly better choices often, the net nutritional benefit can add up to
lower rates of both chronic disease and premature death.

If only perfect would do, then calorie counts, nutrition fact panels, and ingredient lists would be moot. We could simply tell everyone to eat more spinach, and leave it at that. If only perfect would do, then modest doses of daily physical activity would be pointless. Either make the Olympic Team, or enjoy your couch.

But just recently came evidence that a mere 20 minutes of daily physical activity can be the difference between a child succumbing to type 2 diabetes or not. That matters. As do the actual choices made among foods in packages. So the public health can, in fact, be advanced with programming to empower modest amounts of daily physical activity in adults and children alike, and by programming in , supermarkets, or that is sent in the mail to help people trade up their food choices.

I quite agree that Linkwell's program is not perfect, and I am confident the company executives would say the same. No doubt Anthem would agree as well. But the reason the program isn't perfect is, quite simply, because those involved in it are committed to doing some good in the real world, where perfect tends not to be a viable option.

In the real world, often the best you can do is insert the thin edge of the wedge, and then keep pushing. You can be candid about ideals and objectives, but often must be compromising about opportunities so something gets done while waiting on the world to change.

For better health, people really should eat more wholesome foods direct from nature, mostly plants. But between here and there, choosing better cereals, breads, chips, crackers, sauces, spreads, dressings, and, yes, even ice cream can add up to dramatic improvements in overall diet quality. And that, in turn, could result in meaningful improvements in health. And it's actually feasible.

That's what Anthem, and Linkwell, are working on: progress, imperfect though it may be. In my view, that's good.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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