Thoughts on the McDougall Advanced Study Weekend

For those of you who aren't familiar with him, Dr. John McDougall is a doctor and diet/health advocate who recommends a very low fat, high starch, whole food vegan diet to control weight and avoid chronic disease.  He's been at it for a long time, and he's a major figure in the "plant-based diet" community (i.e., a diet including little or no animal foods).

Dr. McDougall invited me to participate in his 3-day Advanced Study Weekend retreat in Santa Rosa, CA.  My job was to give my talk on insulin and obesity, and participate in a panel discussion/debate with Dr. McDougall in which we sorted through issues related to low-carb, Paleo, and the health implications of eating animal foods.  I was glad to receive the invitation, because I don't see myself as a diet partisan, and I believe that my evidence-based information is applicable to a variety of diet styles.  I saw the Weekend as an opportunity to extend my thoughts to a new community, challenge myself, and maybe even learn a thing or two.  It was particularly interesting to compare and contrast the Advanced Study Weekend with the Ancestral Health Symposium, which is more Paleo- and low-carb-friendly.

General Observations

The attendees were a lot older than AHS attendees.  I estimate that most of them were in their 60s, although there were some young people in attendance.

I don't place too much emphasis on peoples' personal appearance at conferences like this.  You don't know what a person's background, genetics, or personal struggles may be, you don't know how closely they adhere to the program, and you don't know to what degree a group of people might be self-selected for particular traits*.  But I will note that Dr. McDougall, his family, and many of the other starch-based/plant-based diet advocates tended to be extremely lean with low fat and muscle mass.  They also tended to have a healthy and energetic appearance and demeanor.  As I would expect, decades of exceptionally high starch intake hasn't made them obese or obviously ill.

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What about the Other Weight Loss Diet Study??

The same day the low-fat vs low-carb study by Bazzano and colleagues was published, the Journal of the American Medical Association published a meta-analysis that compared the effectiveness of "named diet programs".  Many people have interpreted this study as demonstrating that low-carbohydrate and low-fat diets are both effective for weight loss, and that we simply need to pick a diet and stick with it, but that's not really what the study showed.  Let's take a closer look.

Johnston and colleagues sifted through PubMed for studies that evaluated "named diet programs", such as Ornish, Atkins, LEARN, Weight Watchers, etc (1).  In addition, the methods state that they included any study as low-carbohydrate that recommended less than 40% of calories from carbohydrate, was funded by the Atkins foundation, or was "Atkins-like".  These criteria weren't extended to the low-fat diet: only studies of name-brand low-fat diets like the Ornish diet were included, while the meta-analysis excluded low-fat diet studies whose guidelines were based on recommendations from government and academic sources, even though the latter group represents the majority of the evidence we have for low-fat diets.  The inclusion criteria were therefore extremely asymmetrical in how they represented low-carb and low-fat diets.  This fact explains the unusual findings of the paper.

The abstract immediately activated my skeptic alarm, because it states that at the one-year mark, low-carbohydrate diets and low-fat diets both led to a sustained weight loss of about 16 pounds (7.3 kg).  Based on my understanding of the weight loss literature, that number seems far too high for the low-fat diet, and also too high for the low-carbohydrate diet.

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Underwriting vs. Care Management

Rock on, care management

In the course of learning about care management, the Population Health Blog has benefitted from sitting at the feet of high-functioning finance experts, actuaries and underwriters. Reconciling health care revenue/expense, trend, monetized risk and pricing of insurance with the savings, quality and patient experience that comes from optimized care has been a fascinating - if sometimes frustrating - intellectual exercise.

However, this report on the rise of machines and the continuing displacement of knowledge workers reminded the PHB of the divide between the science and the art in this corner of health care. 

According to David Autor, it's only a matter of time until machines begin to displace the high-end brainiacs who oversee the health insurance industry's premium, reserves, claims payments and surpluses.  Human judgment will never go away, but logarithmic jumps in processing power combined with the big data that comes from industry consolidation means the "answer" on how much to charge for coverage of a person with diabetes will be less flexible and more preordained.

The PHB, however, is of good cheer. 

While underwriting risk will be all about the numbers, managing conditions within those numbers will remain a very individual enterprise. Human needs, preferences, tolerances and culture will continue to shape highly variable decision-making within the care system for years to come. The need for highly skilled knowledge workers who can help patients co-manage their care will grow, not diminish. 

Factory farms may be churning out ingredients on an massive scale, but someone has to plate the finished meal. 

The music industry may be selling Beyonce at $0.99 a pop, but nothing will replace seeing her live in concert.

Payers and buyers may commoditize cataract care, but someone has to make sure patients take their eye drops.

Underwriting on one side.  Care management on the other.  The PHB likes where it's at.  

Image from Wikipedia

LIFE CAN SUCK … WORKOUT ANYWAY!

Life is not meant to be easy-peasy and all wrapped in a pretty bow all the time.  The truth about life is that it can suck and be filled with very difficult emotional and even physical hardships.  I want to target the emotional junk in this blog that can weigh down our brains and bodies and cause us to retreat into a shell of self defeat.  When life hands us hard in the form of emotional upset stemming from relationship issues, problems with co-workers, or mistreatment from friends and even family just to name a few, it is important to not give up on you. Even the day-to-day emotional junk can feel overwhelming, and sometimes we can be our own worst enemy of creating needless emotional upset over something that was simply miscommunication. Emotional upset can hit us in the face every day and we can choose to handle it in a healthy or unhealthy way. What it comes down to is that we are responsible for our own mental health and happiness.

It seems the emotional crap that hurts the most is when it occurs in our very personal relationships with our spouses, significant others, dearest friends and family. That can be a very difficult thing as we struggle to maintain happy in a storm of anger, resentment, bitterness, and even vengeful feelings that can consume us to the point of not taking care of the skin we are living in.  Often times we walk around with unrealistic expectations of how things and life are supposed to be, or even how our spouses for example are supposed to act, and when things do not happen according to our own thought processes, the emotional upset begins to fester.  Before we know it, a full blown internal eruption of drama has taken over our being and created an unhealthy person that we ourselves find hard to recognize.  I understand it is difficult when we feel hurt, but it is also important to be able to recognize if the hurt is “real” or self-induced unrealistic expectations.  Further, in the midst of life sucking emotionally, it is still important to exercise anyway and not get lost in some victim pity party.  Studies have shown exercise to be one of the top contributors for stress reduction, decreased depression, and overall positive well-being. 

It would be wonderful if life had an “easy button” and all the things that created emotional yuck could be clicked away, but the closest thing we possess to make that happen is our response to what causes the upset.  We can choose to walk around with the “cold war” bitter attitude in our homes or get off our butts, choose to be positive and take out the feelings on a great workout.  We all have had our emotional buttons pushed in this life and it is truly about how we respond to the circumstance that makes us healthy or unhealthy. Having a healthy response to unhealthy situations takes learning and practice, but the reward is a healthier happier you and me. There is nothing worse than stewing inside and growing an emotional pimple until it bursts into ugliness when there are so many positive avenues to take care of the problem in a healthy way.  As I mentioned, a great workout, meditation, going for a walk, talking to God, or even looking into a counselor if necessary are all fabulous ways to deal with the emotional downs in life. 

Life can be looked at like a classroom and we are students learning through each experience, and hopefully gaining the ability through guidance and practice to respond to the lesson in a positive way.  There is no doubt that some days and nights will be filled with emotional hurt and it will be during those moments that our “mental strong” will be the motivator that keeps us moving in the right direction of health.  It does not matter what the issue is and how bad life sucks … WORK OUT ANYWAY!

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DARLA LEAL, FIT AT 50
Orange Photography 2014

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Stay Healthy ~ Darla 

The Growing Parallels Between Health Care and Power Utilities

In some of its past musings, the Population Health Blog drew parallels between the airline industry and health care. While it knows nothing about aviation, who cares? It figures all those pundit MBAs and lawyers know nothing about medicine either: such is the standard of today's commentariat.

It knows nothing about power utilities either, but the gullible PHB sees parallels there too.  According to this Dummies chapter, utilities sell a heavily regulated commodity that requires a lot of debt-financed infrastructure. Since their customers have no where else to go, poor/low cost service can translate into it being considered a safe investment. Yet, do-it-yourself renewable energy is a growing threat. As companies go, they are not known for growth; rather they preserve capital and return profits to their investors in the form of dividends. And regulators are forcing these companies to reward customers for using less of what they're selling.

And what's the growing resemblance to health care? 

In their attack on variation, many services are being commoditized into a race to the bottom by payers and government.  Regulation is increasing. Poor/low cost service for "captive" patients can also mean greater profits.  The importance of access to capital, servicing debt and achieving savings are eclipsing top line revenue. Instead of dividends, they're "returning" surplus to the community in the form of more services. Do-it-yourself health care in the form of medical tourism, concierge physicians is a growing threat. And the system is starting to see incentives that help its customers to use less of what it's selling.

Is the PHB being naïve? You be the judge.

Spiced Up Rawnola

I know I haven't been updating much as of late, but school has just started and is really keeping me busy as well as keeping me from blogging. I thought it'd be nice to get away from the schoolwork though (i. e. desperately looking for distractions) so yesterday I made a batch of -believe it or not- rawnola! Yup, you heard it right, this rawnola is in fact RAW, meaning it's packed with nutrients and vitamins otherwise lost when you bake your granola, meaning it's the perfect "healthier" alternative to your regular "ALL NATURAL SUPER-GOOD-FOR-YOU GRANOLA" (pff, they put so much crap in breakfast cereal nowadays I wouldn't know where to begin). If you really can't live without that extra crunchiness you get from baking the granola, I suggest you go check out this post instead. There I've shared my favourite granola recipe, one that is actually healthy for real, gluten-free AND refined sugar free. Either way you're in for a treat. Here we go.

Spiced Up Rawnola 

50g (1/2 cup) raw oats (most oats have been steamed for longer shelf life, the fully raw ones are almost impossible to find though, so any oats you have will work just fine for this recipe)

140g (about 1 cup packed) pitted medjool dates

40g (2 big) dried figs

20g (3 tbsp) whole flax seeds

1/2 tsp ground cardamom

1/2 tsp ground cinnamon

Or any spices/superfood powders you have at home!

Optional: A handful of shredded coconut/chopped nuts/cacao nibs

1. Place all ingredients except for the flax seeds (this is very important that you don't, flaxseed oil goes rancid very quickly!) and pulse until you have a chunky mixture that holds together in smaller clumps, like real granola does. Transfer to a jar or bowl, stir in the flax seeds (or incorporate them using your hands) and store in the fridge or freezer.

Low-carbohydrate vs. Low-fat diets for Weight Loss: New Evidence

A new high-profile study compared the weight loss and cardiovascular effects of a low-carbohydrate diet vs. a low-fat diet.  Although many studies have done this before, this one is novel enough to add to our current understanding of diet and health.  Unlike most other studies of this nature, diet adherence was fairly good, and carbohydrate restriction produced greater weight loss and cardiovascular risk factor improvements than fat restriction at the one-year mark.  Yet like previous studies, neither diet produced very impressive results.

The Study

Lydia A. Bazzano and colleagues at Tulane University randomly assigned 148 obese men and women without cardiovascular disease into two groups (1):

1. Received instructions to eat less than 40 grams of carbohydrate per day, plus one low-carbohydrate meal replacement per day.  No specific advice to alter calorie intake.  Met regularly with dietitians to explain the dietary changes and maintain motivation.
2. Received instructions to eat less than 30 percent of calories from fat, less than 7 percent of calories as saturated fat, and 55 percent of calories from carbohydrate, plus one low-fat meal replacement per day.  No specific advice to alter calorie intake.  This is based on NCEP guidelines, which are actually designed for cardiovascular risk reduction and not weight loss.  Met regularly with dietitians to explain the dietary changes and maintain motivation.

Participants were followed up for one year, with data reported for 3 month, 6 month, and 12 month timepoints.  This study actually measured body fat percentage, but unfortunately did so using bioelectrical impedance (like on some bathroom scales), which is essentially meaningless in this context.

Results

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