Fat, Added Fat, and Obesity in America

In the last post, we saw that carbohydrate and particularly sugar intake have been declining in the US since 1999, even as our obesity rate has continued to climb.

In this post, let's look at another putative driver of obesity: our fat intake, and especially our intake of added fats like seed oils, butter, and olive oil.  Like the graphs in the last post, the data underlying the following graphs come from USDA food disappearance records (not self-reported), and NHANES survey data (1, 2).  Also like the last post, the graph of total fat intake is not adjusted for waste (non-eaten food), while the graph of added fat intake is*.  As a consequence, the figures for total carbohydrate and total fat intake are higher than actual intakes, but still good for illustrating trends.

Here we go.  First, total fat:
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Appreciate We Have the Incredible Opportunity to Get Fit

I read this motivation today and I could not have penned it better myself, especially during the holiday season.  We lose sight of what an incredible opportunity we have to get fit and instead of looking at it as a burden, we should be spilling over with thankfulness.  Do you have a working body?  I do, and although I may have some medical limitations, it has taught me to appreciate what I can do with what I have.

Do we really have a right to sit and complain about how difficult getting healthy is when others can't even lift from a wheelchair?  We live in a stressed up world and most of the time self-induced with all the busy stuff that keeps us away from the important things in life.  Getting fit and healthy is a privilege just the same as growing older.  If our mindset is not screwed on right, we will make a mess of what life is all about, including how to treat our bodies.

Instead of looking at meal prep to keep you on track with your fitness goals as a pain in the butt, try looking at your healthy food with a thankful spirit of what it is going to do for your body.  There are many who only wish to have the healthy food stocking your pantry.  The same goes for exercise and having such a busy life to not fit in a 30 minute workout.  Really?! There are many who long everyday to even lift their own body weight from a wheel chair.  Try looking at your body as a beautiful gift and appreciate the awesome opportunity you have to get in shape.

It will be our mindset that carries us into the right way of thinking about getting fit.  Our bodies will not go where our mind does not push us and a thankful spirit is going to be a great place to start.  Let's celebrate the fact we can apply the effort to get fit because it is truly something to be thankful for.

I wish you all a beautiful Thanksgiving holiday and a renewed mindset and application of achieving your best healthy body. Be well and Stay Healthy!



Always updated articles on my about.com health website.  Did you know that famous burning "3500 Calories to Lose a Pound of Fat" is not accurate.  Read the article and plug in your own stats with the free weight change predictor calculator!

There is More to 3500 Calories Burns a Pound...Read the Article

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Happy Thanksgiving!

Smartphone Apps: Architecture Trumps Content

According to this The Wall Street Journal article, the prospect that "your doctor may soon prescribe you a smartphone app," has put us on the cusp of a new age of m-healthiness. 

 

Regular Population Health Blog readers are not surprised. They have an "over-the-horizon" awareness of health information technology and know that the health app ecosystem has been flourishing for quite some time. 

 

What is surprising, however, is how the news article from a prestigious news organization conflated architecture and content. 

 

The PHB explains.

 

The WSJ article describes how intrepid e-researchers from marquee academic institutions are documenting the impact of apps on medication compliance, symptom management, risk reduction and provider-patient communication. Once users open these apps, there's not only an eHealth technology platform but an accompanying library of tailored e-prompts, e-reminders, e-pop-ups, e-recommendations, e-messaging, e-images and e-videos.  Mix one app with one patient and quality goes up and costs go down.

 

Unfortunately, what the article failed to mention is that much of that content made up of information that is freely available in the public domain, and that these app developers have reconfigured and adapted it according to the interests, expertise and culture of their sponsoring institutions.

 

While policymakers and researchers would like to believe that on-line and public domain health information is a commodity, the fact is that buyer, purchaser and provider organizations have been accessing and downloading it for years.  They've take special pride of ownership in the wording, editing, formatting, presentation of that content.  That's what makes it "theirs" for both their providers and their patients.  After all, all healthcare is local.

 

This has important implications for the smartphone app indsutry.  While the academic e-researchers and business e-developers dream of having their apps adopted by delivery systems everywhere, the problem is that their apps are often tethered to their own organizations' content. 

 

In other words, you can have any breast cancer, heart failure or post-hospital discharge smartphone-based solution that you want, just so long as you also import their prompts, reminders, pop-ups, recommendations, messages, images and videos. 

 

The Population Health Blog believes the secret sauce for competitive success for app developers is accordingly three-fold:

 

1) Architecture Trumps Content: Smart app developers understand that the value proposition of the underlying technology architecture is separate from the value proposition of the content.  The app itself needs to be independently stable, secure and snappy with minimal branching logic, an easy-to-use interface and freedom from annoying bugs, whether it's heart failure in for a hundred patients in Halifax or a dozen persons with diabetes in Des Moines. 

 

2) Architecture Supports Content: Very smart app developers also understand that the architecture should be able to accommodate any content that is preferred by their customers. If ABC Regional Health System wants their in-house policies, procedures, pamphlets, web-pages, in-house guidelines and electronic record prompts to be reflected in a smartphone app, then the app's framework should be able to import it.  Think plug and play.

 

3) Architecture Has Content: That being said, not every buyer, purchaser or provider will have all the content needed to manage a target population. That means app developers will need to have generic content ready to go to fill in the gaps. 

 

The business case for apps may be similar to selling a house.  First off, make sure the foundation is solid and the roof is intact.  Be prepared to move walls and windows, if that's what the buyer wants.  And, if the house needs to be furnished with some furniture, do it; if the buyer wants some or all of their furniture to furnish the house, do it.

 

Image from Wikipedia

Carbohydrate, Sugar, and Obesity in America

We like explanations that are simple, easy to understand, and explain everything.  One example of this is the idea that eating carbohydrate, or sugar, is the primary cause of obesity.  This lets us point our finger at something concrete and change our behavior accordingly.  And it's true enough that it has practical value.  But the world around us often turns out to be more complex than we'd like it to be.

The CDC recently released its latest data on the prevalence of obesity in the US, spanning the years 2013-2014 (1).  These data come from its periodic National Health and Nutrition Examination Surveys (NHANES).  Contrary to what many of us had hoped for after a slight decline in obesity in the last survey, the prevalence has once again increased.  Today, roughly 38 percent of US adults have obesity.  As a nation, we're continuing to gain fat, which is extremely concerning.

I decided to examine the relationship between obesity prevalence and our intake of carbohydrate and sugar over the years.  The food intake data come from the USDA's Economic Research Service (2).  For some reason, the data on carbohydrate don't extend beyond 2010.  This probably relates to funding cuts at the USDA*.

Let's have a look at the data for carbohydrate:

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Fitness is Not About Having All the Answers

Fitness is a process and an ongoing journey of learning what works and what doesn't.  There will be ups, downs, frustrations and victories fine tuning our daily choices.  The point is to continue the uphill climb to becoming our best healthy self.  It's not about having all the answers because we never will.  During our life, our bodies will change, circumstances will happen and the pursuit of health and happiness will need to continue no matter what.  Quitting is never an option for us.

Fitness comes at a price and we do not get a free pass to good health.  Life is not that easy although many of us search around for things believing it possible and spend too much money on wasted gimmicks and unregulated supplements.  It is really OK to take things slow and enjoy the fitness ride along the way.  We are all works in progress in search of being better than yesterday.  Mistakes are not seen as failure but opportunities of learning and not repeating.  The mastery of adopting a healthy lifestyle stems from our mistakes and shows us the areas we need to change to reach our fitness goals.

We learn how to do that each day through what we eat and drink, how we exercise, time spent resting, and even the balance of work vs. play.  The opportunity is there for us and without excuse and what it comes down to is priorities. Is your fitness taking a backseat to the busy going on in your life, or negative self talk that keeps you from even trying?  As I shared, it is not about having all the answers, but it does require you to not want to stay in an unhealthy life situation. Something for you to think about.  Be well and Stay Healthy!

I have published some informative articles on the about.com network that will help with your journey of health and fitness.  My newest article titled "Holidays Call For Us to Become Food Snobs" is an entertaining read full of fitness tips on how to maintain your shred through the holidays.

Become a Fitness Food Snob for the Holidays

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Darla Leal, Fit over 50

Service Guarantees in Healthcare: Not So Easy

From time to time, the bad behavior of airlines will prompt the awarding of frequent-flyer mile credits or partial refunds to aggrieved customers.  Given that that industry has been used to portray everything that's wrong with U.S. healthcare, why hasn't this virtuous example of customer service been used by hospitals and other medical providers?

According to this news article, it will be.  As the PHB understands it, once patients have completed their treatment, they will be able to access an app to register their displeasure and access a "money-back guarantee" in the form of a partial refund.

PHB readers know that there is always more to stories like this. Despite its familiarity with the population health service industry's many years of money-back guarantees, the PHB decided to help its readers stay ahead of the competition with a quick look at the topic of provider guarantees.

It's not a slam dunk.

For starters, "service guarantees" can be divided into two categories: specific and unconditional.  The former is tied to one or more measurable elements of the service, such as the on-time delivery of a pizza or the HCG + implantation of a fertilized embryo. The unconditional category is typically tied to a global assessment of the consumer, who can access the guarantee for any reason, such as the disappointing frothiness of a cappuccino or the unfriendly persona of a nightshift nurse. 

The service guarantee described above appears to be unconditional.  

Service guarantees have long-known upsides and downsides.  In the healthcare industry, the upsides include motivating patient-centric behaviors, minimizing the use of the dreaded complaint line and undermining the competition. The downsides are that they can be used by many more patients than anticipated, once unleashed it's hard to pull it back and refunds could be driven less by satisfaction than by economic self-interest.  The PHB also worries that it's one more step toward the commoditization of healthcare and that a refund for an otherwise unavoidably bad outcome could be misinterpreted as agreement that the physician is at fault.

Service guarantees are not unheard-of in healthcare settings.  A quick Google search will reveal that they're common in in-vitro fertilization (IVF) and LASIK clinics. That's because these services are typically not covered by insurance and the fees are paid directly by the consumer.

Which raises the role of health insurance.  The PHB is no expert in this field, but it suspects that the historical absence of guarantees for services covered by insurance has to do with two broad principles:

1) if the insurer is ultimately bearing the cost of the service, the insurer should benefit from a refund.  The consumer arguably paid a premium to transfer the cost of the service to the insurer. Like it or not, the insurer, and not the patient, "owns" the cost, which is why we have insurance in the first place.

2) since the consumer is often responsible for out-of-pocket expenses "before" the insurance "kicks in," it could be argued that the aggrieved patient owns some of that service risk/cost and that the patient should also benefit from a service guarantee.  Good point, but there are decades of thorny anti-kickback laws that are designed to prevent service providers from using rebates of any kind to secure referrals or market share. Partially "waiving" or "refunding" co-pays or co-insurance as been a big regulatory no-no, and unconditional service guarantees are perilously close to crossing the line.

Bottom line:

Whether this latest foray into healthcare service guarantees remains a sideshow, or is the start of a trend remains to be seen. Much will depend on how any refunds are legally "immunized" against the insurance issues. 

Image from Wikipedia

Five Reasons to be Bullish About Theranos

Pushing back

When the Population Health Blog watched Theranos CEO Elizabeth Holmes push back during a CNBC broadcast against a Wall Street Journal report about her diagnostics testing company, it began to pay attention.

 

As the PHB understands it, Theranos is a privately held and fabulously priced biotech company built on two value propositions:

 

1) proprietary technology that enables parallel testing to be done on a weenie blood sample obtained from a single finger-prick.  

 

2) direct-to-consumer availability of blood testing outside of the dreary hassle of doctor ordering, laboratory queuing, expert interpreting and insurance reimbursing. Instead, customers can stop by their corner pharmacy, scan the menu, select some tests, use VISA or Mastercard and use the results as they see fit.

 

According to the Journal, Theranos' technology isn't necessarily ready for prime time.  It appears that while the company obtained the Food and Drug Administration approval for its proprietary technology, it's limited to testing for herpes. There are allegations that for all the other bloodwork, the results can be inaccurate and that the company is relying on the standard vein-puncture blood draws to service its consumers. 

 

The FDA is asking for more information, Walgreens has paused and super-litigator David Boies has joined the company's board.  Connect the dots and this Silicon Valley start-up is starting to look a bit tarnished.

 

Rather than join in the schadenfreude, the Population Health Blog has five reasons to be contrarily optimistic about Theranos:

 

1. All medical advances follow the Hype Curve of innovation, euphoria, disillusionment and equilibrium:

 

 



Thernos' travails in the trough are not only part of the natural life cycle of a health tech company, it's also a good reminder to only go public after the disillusionment has passed.  A plateau of cash flow productivity lies ahead.

 

2. The second value proposition still stands. While the notion of letting an unsophisticated lay-person interpret the meaning of an (for example) elevated adrenocorticotropin hormone level, Ms. Holmes seems to be unwittingly arguing that this another step toward "actionable" shared decision making. While the market sorts that out, a) there is considerable consumer interest and b) educational consumer-friendly resources are becoming increasingly available. While self-testing can complicate the doctor-patient relationship, it can also help it.  And if it drives consumers to Walgreen's Healthcare Clinics, so much the better

 

3. Speaking of the second value proposition, consider an unpalatable alternative: Regional health system monopolies, where consumers can get any test they want, just so long as it's through their doctors, at their labs - and done the old fashioned way.   

 

4. In looking at its ten best practices for the boards of health care companies, the PHB is going to give these heavy-hitters the benefit of the doubt. It figures that in their interactions with the C-suite and especially with their interactions with the FDA, the directors have all the resources they need to bring skepticism, rely on dual data reporting, know about human research, perform audits and access research expertise. They should know about maintaining the right tone at the top and understand how incentives can help and hinder corporate integrity. Assuming business reporters can drop the nattering negativity (like this) and instead confirm that those key governance principles  are in place, Theranos should do OK.

 

5. And one of the Theranos board members is a physician.  While time away from hands-on practice may have blunted Dr. Frist's clinical acumen, the PHB has heard him talk in conferences: he still knows of what he speaks.  As noted by the PHB here, physicians bring a unique perspective to the boardroom, including understanding patient-centric outcomes, helping the CEO navigate the clinical side of the industry, bringing a diverse viewpoint, giving insight to the competition's strengths and weakness and helping fellow board members further their healthcare education.

 

The PHB's assessment of Theranos:

 

Hype Cycle image from Wikipedia

Wildebeest image from Wikipedia
Wall Street bull image from Wikipedia

Food is Not the Enemy

It would be easy to blame food for being overweight and unhealthy, but the truth is food is not the enemy.  In fact, our survival is based on our need for food and water to run our body.  If we are honest about our lives, it is about taking responsibility for our fitness and making choices to keep us healthy.  Quality of food could be part of the issue, but then again who is making the decision to eat the frozen pizzas, burgers and fries in super size portions.  Actually, getting down to the chemistry and caloric needs of our body, eating too much is the biggest factor of not being fit.  Even if we ate the crap food and kept it within the calorie portion to run our body, we could be labeled 'skinny fat people'.  On the outside we may give an appearance of being an appropriate weight, but inside we are a hot mess and feeling like it.  There is nothing good that exists in processed fake food and the damage it does to our body through inflammation and disease is alarming.

Food is our friend and turning the crap into quality is what will change our bodies into fit, healthy people.  You have heard "no-one ever got fat eating too much kale"  and not that I would sit around eating kale all day but you get the point of the statement.  If we start eating to live instead of the other way around, a huge change in the obesity epidemic would happen as the shift toward eating the right stuff would finally be taking place.  How our bodies look and feel are our responsibility and we can absolutely use healthy food to control much of that.  We are hit in the face all day long with fast food commercials, peer pressure, and even sabotage by our own hands or significant other to turn to the dark side of food.  You have the power to see food as your friend and control what you put in your face.  The donut may look appealing but that apple is going to supply the best nutrients to fuel your body and push you closer to your fitness goals.

As the sports nutrition expert on the about.com network, I am always providing fresh exciting content for you.  Check out my recent articles on white rice, eating full-fats, how salt recommendations have been challenged and so much more.  You are guaranteed to find several subjects that interest you and may even have questions about.

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Be well and Stay Healthy!