Fat vs. Carbohydrate Overeating: Which Causes More Fat Gain?

Two human studies, published in 1995 and 2000, tested the effect of carbohydrate vs. fat overfeeding on body fat gain in humans.  What did they find, and why is it important?

We know that daily calorie intake has increased the US, in parallel with the dramatic increase in body fatness.  These excess calories appear to have come from fat, carbohydrate, and protein all at the same time (although carbohydrate increased the most).  Since the increase in calories, carbohydrate, fat, and protein all happened at the same time, how do we know that the obesity epidemic was due to increased calorie intake and not just increased carbohydrate or fat intake?  If our calorie intake had increased solely by the addition of carbohydrate or fat, would we be in the midst of an obesity epidemic?

The best way to answer this question is to examine the controlled studies that have compared carbohydrate and fat overfeeding in humans.

Horton et al.

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Commitment Devices, Behavior Change and Population Health

A new addition to the
behavior change tool box

Whenever the Population Health Blog encountered a tobacco user in its clinic, it would gauge the patient's readiness to quit. For those patients who were ready, it then established a future "quit date" (to facilitate planning), a "contract" (a jointly signed prescription for display on the home fridge) and advice to use any money savings (tobacco is expensive) for a nice reward once seven days of success (for example, a restaurant dinner) was achieved.

The PHB didn't know it at the time, but that seven-day reward was a variation of a "commitment device."  That's what it learned after reading this just-published JAMA manuscript by Todd Rogers and colleagues.

Commitment devices are a way that "present" persons can commit their "future selves" to a sufficient level of needed behavior change.  The threat of a penalty, such as the loss of a night out on the town, imposes a limit on future choices and makes success more likely. 

Other examples of commitment devices described by the authors include applying cash to a success contract (for example, employers could link a bonus to participation in a exercise program that would otherwise be lost), "temptation" bundling that limits access to a gratifying experience in exchange for "consistent" behaviors (used with repeated success by the crafty PHB spouse), limiting bad choices to small packages (smaller portion sizes) and partnering (to avoid disappointing a buddy who shares the commitment).

In retrospect, "commitment devices" have been used in population health for decades.  As Rogers et al point out, however, despite some good research on how effective this approach is, they're generally underused by providers and patients.  One potential way to overcome that is to offer them routinely on an "opt-out" basis, 401k savings-plan style.  The authors also point out that a series of commitment devices on a longitudinal basis could be used to blunt drop outs and maintain long-term behavior change. Last but not least, leveraging social networks with or without handheld "apps" remains an area ripe for future research.

As medical homes spread and shared-risk payment reforms gain traction, the art and science of commitment devices will likely grow. Not only is it a cool piece of insider jargon ("Hey, Mary, I like this care management proposal, but have you any plans to develop commitment devices?"), but any addition to the behavior-change tool box can only help.

Image from Wikipedia

Eating Healthy When Traveling

With 10 weeks until my fitness bikini competition, I'm getting a little freaked out.  The meal plan I'm on is really tough, mainly because it's boring to eat the same thing over and over and over.  I have not been perfect, but I'm doing pretty well.  I flew to Dallas for two days on Thursday and in preparation for the trip, I brought food so I could stay on my meal plan.  My flight was only an hour, so I packed my small skillet (perfect size for my protein pancake), Pam coconut oil spray, ground oats (for the pancake), brown rice, and protein powder in my checked luggage.  My local friend Cassie brought me frozen chicken, veggies, and egg whites. 

We lucked out and landed in the penthouse suit of the hotel that was equipped with a stove and microwave, so I was able to prepare some meals.  But, nothing is easy.  The room was so high-tech that we couldn't get the stove working and the engineer had to come 3 times to get it to work.   My protein pancake had to be cooked in a special skillet designed for the stove and pretty much fell apart, but I ate it anyway.  (My pancake is just 1/2 cup of ground oats, 3/4 cup egg whites, 1/4 cup water and cinnamon).  I have been "cheating" and eating it with a trace amount of natural peanut butter spread on top. 

My chicken, rice, and veggies were easy to microwave and I had that several times during the trip.

But, I wasn't perfect.  I ate pita chips and hummus, small part of a chocolate bar, and a glass of champagne at the pool.  

Thursday night at dinner I ordered a buffalo burger with no bun and a side salad without dressing. We  ate dinner at a Mexican restaurant on Friday night, and although I ordered iced tea (when everyone had margaritas) and skipped the chips and queso, I ordered grilled chicken with onions, rice and beans and devoured it.  

Saturday morning before my flight, I didn't have time to eat breakfast before heading to the airport (besides an apple and peanut butter) so  before my plane took off I grabbed a turkey sandwich and just ate the turkey out of it since the bread was soggy.  And I had my Starbuck's iced tall 2-pump mocha on Saturday and Sunday.  Yikes.

At our school Gala on Saturday night, I had two glasses of champagne and on Sunday I had a piece of pizza!

I know that strictly sticking to the meal plan is key, so I'm going to be on it this week.  Tomorrow is a new day!  Last Friday I got my body fat tested again by my trainer and it went down from 25% to 21% in just a couple weeks, which is good progress.  I've found the best way to get through sticking to the meal plan is to just put it on auto-pilot.  Don't think about it, just do it.  The good results I'm seeing keep me motivated to continue.

I'll post a progress pic soon!

LOVE THE HATERS

Yes I do.  I love my haters and I will share that typically those who are “hating” or critical of others really do desire to be loved.  There is something down deep inside of each of us that longs to be accepted and  feel good enough, and when hate comes to the surface it usually defines deep insecurities or unresolved issues within a person.  The ability to be motivated or happy by or for another is replaced with bitterness, jealousy, and to the point of “hating” a person for their accomplishments.  Because I realize that there are underlying factors involved with “hating”, I can look past comments and know that it is not about me when my haters come to calling.  Lately, I have received lots of negative comments, and especially when I share motivational posters that feature me in fitness wear or bathing suits.  If I allowed the negative posts I receive to negatively impair me as a person, I really do not have any business being an internet personality.  I have been in this industry for thirty years, and have read and heard my share of negative as well as the positive.

The only thing in this life I can control is me, and I let go of all the rest.  What I share with you comes with pure intention to motivate you to live a healthy life, and if that is not well received that is the chance I take, and the positive will always outweigh the negative in my opinion.  The recent “hating” on my body and boobs with a post focus/motivation  to live a healthy lifestyle, exercise, eat healthy,  or be happy with self is a clear demonstration of people that are not happy with “self” and feel the need to project and vent their frustrations.  The sad part about hating on the internet is the people acting out the behavior do not know the circumstances or life journey of the person they are criticizing.  Let’s use breast augmentation as an example in general and the possibility that the woman making this choice is doing so for cancer reconstructive purposes, or has been involved in an auto accident which has disfigured her breast, or to feel better about herself by gaining a more proportionate figure, or to regain fuller breasts post pregnancy of one or more births and breast feeding her blessings in life, and the list of reasons can go on and on.  I had a girlfriend who was out for a jog and an unleashed dog attacked her, leaped at her breast and pulled it off her chest, which took months of reconstructive repair.  We all need to realize, accept, and appreciate that personal choices belong to each person and that it does not make that person fake or a “bad” example.  In fact, it could be this person’s life story that can reach out and help others in similar situations.  It really comes down to if you do not have anything nice to say, do not say anything at all. 

Wouldn’t life be grand if all of us were pro-positive of each other, supportive, motivating and complimentary?  The sad truth is that life is not that way, and within this imperfect world we are imperfect people trying the best we can to deal with unfair issues in this life.  That is the point of it all to be happy, and become a better person each day through our journey.  That is not accomplished riding in the “hate” wagon of life.  So whether it is a new house, car, clothes, body, face or your life in general, haters will hate because you possess something they don’t.  Their inability to figure out how to obtain happiness within their own self and life can create a very upset and angry person who copes with frustration through “hating”.  They deal with personal feelings of inadequacy after comparing themselves with others by turning themselves on what they think is making them feel upset…Me, You, Us.

Understanding the psychology of people has helped me a great deal in my journey of life, and has enabled me to develop a “turtle shell” skin that shields me from the negative drama in life.  Also, knowing that there is a lot to be said and appreciated with that old saying “sticks and stones may break my bones, but words will never hurt me”.  I think it also comes down to maturity and realizing that life is too short and precious to not be surrounded by positive and to choose to be positive in life.  Loving my haters is a decision to persevere through adversity, and a choice to continue motivating no matter what the cost.  Also, I do wish for their health and happiness deep down and regardless of the negative, I get people talking and learning through the process.  That is a great thing! 

Thanks for stopping by my Blog, hope you enjoy the content, and if you have not become a follower yet, I would love to see your face on my friend's list.  If you are inspired, LIKE my entry, leave a comment and I look forward to responding!

StayHealthy!

Darla

The Latest Health Wonk Review Is Up

Louise Norris hosts a wide ranging Health Wonk Review at her smartly-written Colorado Health Insurance Insider. Like prior HWRs, Louise summarizes and links the best health policy bloggers on topics like the high price of Hepatitis C treatment (follow the money), Medicaid (does it really save lives), how the competition in Mexico is taking a bite out dentists' fees... and so much more.

Enjoy!

Questions That Should Be Asked in the Upcoming HHS Secretary Nomination Process

As a public service, the Population Health Blog is pleased to offer up some questions that may or should arise in the course of Senate confirmation process for HHS nominee Ms. Burwell. 

If she can address the inquiries in these key categories, the PHB suggests she'll be more than prepared for the job:

The Clinton years: Supporters of the Affordable Care Act say "it is now the law of the land."  Based on your extensive experience in the Clinton White House, how would you define "is?"

Signing up young people: Do you credit the last-minute surge in sign-ups on the individual exchanges to Mr. Obama, Mr. Galifianakis or to the Two Ferns?  How will you use that insight to increase individual enrollments in 2015?

Use of social media: Since the Population Health Blog began on-line publication more than 5 years ago, health care cost inflation has moderated significantly. Please explain how Medicare's actuaries will factor this into their future projections.

Doing your part for the 2014 mid-term elections: Will you advocate that the "essential health benefit" be broadened to include coverage for global warming?

To test your awareness of the employer mandate: If Peter Baelish hires 47 part-time seasonal service employees in KIng's Landing for more than 120 continuous days in the first quarter of 2014 without a profit sharing provision, what is the number of FTEs and what would the "4980H penalty" be if it were calculated in Gold Dragons?

And finally, tort reform:  Suppose Iva Pannus buys taxpayer subsidized insurance but also participates in a workplace weight reduction program. If Iva's girth paradoxically increases and she develops sore knees, should she sue in state court to recover her out-of-pocket "bronze" plan expenses and should HHS assert a lien if there is a jury award?

Image from Wikipedia

Discovering What We Don't' Know About Risk-Adjustment for Hospital Readmission Rates in Medicare

Something like this?

When the Population Health Blog agreed with the spouse that it was time to replace the living-room gas fireplace insert with something more sleek and modern, it then turned its attention to changing the surrounding mantle. The PHB favored something heraldic, featuring partially-garbed warrior babes, sporting shields and sandals. Cherubs too.  Preferably oak.

After some counseling from the PHB spouse, it came to realize that its wayward tastes in interior design may be a function of going sans helmet during its childhood bicycle riding, its deepening appreciation of bourbon's mysteries and pausing too frequently on Fox News' The Kelly Files. 

Naturally, the PHB wants to know the relative influence of each. Increasing exposure will help it propose some ideas for the unfinished basement.

Hospital administrators are dealing with a similar problem when it comes to readmissions.

Approximately 20% of discharged Medicare beneficiaries come back within 30 days. In response, CMS financially penalizes hospitals with high readmission rates for heart attack, heart failure and pneumonia. To reduce that penalty, hospitals have asked about the quality of their care, discharge planning and follow-up outpatient care. 

But, what is the relative impact of each? Where should administrators focus their corrective actions? 

Or, like the PHB and interior design, are readmissions ominously outside of anyone's control?

According to some interesting research, it turns out that more than half of the variation in readmissions may be outside of hospitals' control.  What's worse, CMS doesn't account for that in its calculation of the penalty that uses patient factors, such as age, gender and illness burden.

That's the conclusion of this recent article appearing in HSR Health Services Research.

Herrin and colleagues correlated CMS's Hospital Compare readmission data with each hospital county's socioeconomic data (rural vs. urban, persons living alone, employment status and educational level), access to care (the per capita density of primary care and specialist physicians as well as hospital beds) and nursing home number and quality (the number beds and the number of high-risk, long-term patients with bed sores).

Based on risk-adjusted rates from 4,079 hospitals in 2,254 counties, the authors found that more half of the variation in hospital readmissions was statistically explained by the counties' data.  That included persons living alone, low educational attainment, urban setting, a higher number of Medicare beneficiaries, fewer primary care physicians, fewer nursing home beds, higher numbers of nursing home patients with bed sores.  More beds and more specialist physicians were also independently associated with higher readmission rates.

The Population Health Blog's take?

As it noted previously, much of the vituperation around the unexplained variation in health care has been less a function of an inefficient health care system and more a function of our inability to identify the underlying drivers of utilization.

And now we're getting better. The HSR article shows that when it comes to readmissions, much of that variation is a reflection of the poverty in our neighbors' homes as well as the strength of the primary care network and the ability of nursing homes to act as a cushion.

Hopefully the mandarins at CMS will take these findings into account as they continue to financially sanction hospitals for readmissions. A more sophisticated approach to risk adjustment could help lessen the budgetary impact of county-level factors that are outside the hospital administrators' control. 

And since hospitals' bottom lines typically reflect the populations they serve, better risk adjustment could also lessen the disparate impact on the nation's poorest hospitals.

Image from Wikipedia