Why are we getting fat?

Is it too much TV?  Too much carbonated soda?  Are our jobs too sedentary? Is it not enough “healthy whole grains” in our diet?

It may be all of the above.  A relatively new book, The Wheat Belly, written by a preventive cardiologist, William Davis, MD, asserts the culprit is the character of modern wheat.  Modern dwarf wheat, developed in the 1940’s, is not the same wheat that grandmother ate.  The newer wheat is a hybrid of previous grains, designed to be more drought-resistant and have higher yields.  It also has complex proteins, gliadins among others.

Modern wheat has large amounts of amylopectin A.  This is a complex carbohydrate, that is easily digested by our bodies.  It leads to a greater spike in blood glucose than we realize. Wheat bread leads to a higher rise in glucose (and greater spikes in insulin) that table sugar. Excessive spikes in insulin lead to greater production of fat, particularly visceral fat, or belly fat.  It’s a very complex story, but visceral fat, or belly fat, plays a different role in the body than fat stored elsewhere in the body.  For example, large amounts of belly fat appear to contribute to the risk of breast cancer, to increased risk of heart disease.

The book is a complex story.  It does present a striking argument that the introduction of the new grain (90% of all wheat now grown on the planet) contributes directly to the fattening, and worsening health, of modern America.

There has been a 2 or 3 fold increase in the diagnosis of attention deficit disorder and autism.  Are these diagnoses related in some way to food intake?  Perhaps.  Nothing will be as simple as one cause, but there are some issues here that would worth looking into, in greater detail.

We do a lousy job of estimating probability.

Daniel Kahneman won the Nobel Prize in Economics.  He is a psychologist.  He is one of the people who created the field of behavioral economics.  We make judgments of value and decisions based on those judgments, with little data.  We don’t know as much as we think we do.   Despite our ignorance, we make decisions as if we knew more than we do.  Daniel Kahneman’s work (among others) show us why we are wired to make bad decisions.  The problems / puzzles below are taken from his work.  References will be found at this link: References

For example, we judge people and situations based on their degree of “representativeness”.  We also fail to understand the role of sample size in the probability of random events.

Old white guys with gray hair, wearing a suit and tie, don’t seem “the type” to be bank robbers.  So, if we see such a person in a line up, we are not likely to assume that person is a bank robber.  He “doesn’t look like” a bank robber. (Someone wrote, “the best way to rob a bank is to own it.”)  If you have 3 teenagers, and 3 “biker dudes” in their leathers with their beer, and three guys in pin stripe suits, which group is more likely to have taken the money from your bank account? The three guys in suits are all bankers, the teenages all look like computer geeks and the dudes look like, well, dudes.  They guy (or guys) who took your money do belong to one of the three groups.  Which one?

Taking up the issue of sample size, we have hospital A and hospital B.  A is 2 times as large as B.  Assume Hospital A does twice as many deliveries, each day, as Hospital B.  At the end of the year, each hospital has almost exactly 50% boys born and 50% girls.  On any given day, however, either or both of them may have slightly more boys than girls born, or vice versa.

The questions is: Which hospital A (bigger) or B (smaller) is more likely, on any given day, to have more than 60% of babies born that day be boys?  Is one more likely than the other, or does it matter?

The answer to each of these questions will be posted in a day or so and will be at this link: Answers

 

We have met the enemy and he is us.

Medical care in the United States of America costs “too much.” That’s a Enemy is usgenerally accepted wisdom, I think. Not too many physicians believe we get paid too much, although I think one could make a good case that physician salaries or profits are somewhat out of proportion. Many physicians believe insurance companies are the cause of excessive health care costs.

Do we do too much medicine? I think so. In the mid 1990’s, I was stationed at an Air Force base in Mississppi and I suffered a broken jaw when another softball player ran into me at full speed. My jaw had to be wired for a month and I lived on Ensure and similar food. When I went to the ER for the immediate care, I had to refuse a CAT scan. I did not have a concussion; I did not lose consciousness. But it had become “standard of care” to perform a CAT scan after any injury to the head.

It is now standard of care to perform laboratory tests to monitor patients taking many medicines. Not all of the tests are unreasonable, but some of them get fairly expensive and the yield is pretty low. All of these tests drive up costs.

Doryx is a new doxycycline antibiotic. Generic doxycycline can be purchased for about $30 for a month’s supply. Doryx costs over $600 for a month supply. Olux is a sophisticated foam vehicle for clobetasol, a topical steroid we use frequently. A 100 gm can of Olux runs around $250, whereas generic clobetasol solution can be purchased for less than $50 for 100 cc. Aldara is a medicine brought out 3M ten years ago for the treatment of warts. It was too expensive in 1997 at $125 for 12 little packets of the drug (one month supply at 3 packets a week). Subsequently, it was shown to be useful for the treatment of actinic keratoses (pre-skin cancers) and for early, superficial skin cancers. 3M has sold off its pharmaceutical arm and the new manufacturer, Graceway Pharmaceuticals, sells the medicine for about $250 for twelve little packets. I refer the reader to The Truth About the Drug Companies: How They Deceive Us and What to Do About It. by Marcia Angell. The author is the former Editor-in-Chief of the New England Journal of Medicine. She documents only too well how pharmaceutical company profits have risen over the years, at all of our expense. She documents how research has been driven by pharmaceutical companies and not by NIH, the FDA, or universities.

Our prescription writing is also affected by biased publication. Please see Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy, by Turner, et al, in the New England Journal of Medicine, 2008; volume 258, page 252. From the abstract: “Among 74 FDA-registered studies, 31%, accounting for 3449 study participants, were not published. Whether and how the studies were published were associated with the study outcome. A total of 37 studies viewed by the FDA as having positive results were published; 1 study viewed as positive was not published. Studies viewed by the FDA as having negative or questionable results were, with 3 exceptions, either not published (22 studies) or published in a way that, in our opinion, conveyed a positive outcome (11 studies). According to the published literature, it appeared that 94% of the trials conducted were positive. By contrast, the FDA analysis showed that 51% were positive. Separate meta-analyses of the FDA and journal data sets showed that the increase in effect size ranged from 11 to 69% for individual drugs and was 32% overall.” To put that more simply, the published literature misrepresents the real effectiveness of antidepressant medicines. They are not as good as we think. If a careful, responsible physician were to carefully read the literature, he or she would get an overly positive view of the use of these medicines. So, we are paying for medicines that are not as good as we think they are. We are being misled. With intent? I am unable to answer that question.

What about marketing? Does it influence us? See Dr. Angell’s book for comments about marketing. The Association of American Medical Colleges (AAMC) published a symposium, The Scientific Basis of Influence and Reciprocity , which is available for free download. It is a large file in PDF format. Basically, we ae severely influenced by pharmaceutical companies. Worse, we have built-in incentives to over use and over-charge. We are also not as honest as we think we are. You should also read,“Following the Script: How Drug Reps Make Friends and Influence Doctors” from PLoS Medicine.

I will have lots of comments in this blog about this subject. For the record, I own stock in Abbott Laboratories. I don’t take drug lunches or dinners. I subscribe to the philosophy outlined in No Free Lunch. More succinctly, from Robert Heinlein’s novel, The Moon is a Harsh Mistress, he coined a phrase, TANSTAAFL (There Ain’t No Such Thing As A Free Lunch).

Finally, I remember Pogo, a cartoon character from when I was a child and young adult. He has disappeared from the newspaper comic sections, but certain of his comments live on: “We Have Met the Enemy, and He is Us”.

We all own this problem.

Yours for Cthia,

Michael

Nuclear North Korea

I have heard people comment that the North Koreans can’t believe that having one nuclear weapon, or even several, would mean that much.  “Don’t they know how many we have?  We would just nuke them out of existence!  They must be  ___________ (crazy, kidding, bluffing, doing this to fool their people, pick one).”North Korea has only the one wild card.  We don’t know what they think it’s worth.  It’s what they think it’s worth, that counts.  Our opinion is of no significance.
Having said that and written it previously at another blog site, I have an added reflection.  I have read (and heard in a briefing) that the US dropped more HE (high explosive) bombs on NK during the Korean war than were dropped on Germany in WW II.  While that seems unlikely to me, I have also heard that their subway tunnels are more than 100 meters below the surface and public bomb shelters are deeper still.  They are understandably concerned about being bombed and we never ruled out the use of nuclear weapons, in the event of a resurrgence of the Korean conflict.
Could it be that the NK leadership now thinks of things like they were in the Cold War, with Russia?  Since they also have one or more nuclear weapons, perhaps they feel safer and feel we won’t just attack them.  Unfortunately, that may increase the rhetoric and the tendency to make gambles on our behavior.