Inflammation is activation of the immune system in response to threat or injury to the body. Acute inflammation mobilizes the immune system to repair an injury or fight an infection. Once healing takes place the immune system goes back to baseline. Chronic inflammation, however, involves long term activation of the immune system caused by some ongoing stress to the body. More and more, researchers are beginning to show that chronic inflammation is the common pathway to many diseases. There are multiple causes of chronic inflammation. In this post I will write about the causes of chronic inflammation. I will also do a series of posts about the many diseases that chronic inflammation causes. These posts will be based on the structure of an excellent book: Inflamed – Deep Medicine and the Anatomy of Injustice. It is not easy to read because it is disturbing but I highly recommend it. I will also write about a test to measure chronic inflammation. I will write about things you can do to decrease chronic inflammation if you have it and how to prevent it if you don’t. There are many causes of chronic inflammation that have to do with the structure of our society. These are things an individual cannot control. These societal causes will take ongoing efforts by all of us to change some of the toxic structures of society.
The Process of Inflammation
The inflammatory process starts with damage or threat of damage to the body. That can be an infection, a wound, or perceived threat of such. The immune system mobilizes white blood cells called macrophages to the injured area or site of infection. The cells of the immune system also release a cascade of messenger molecules called cytokines that amplify inflammation. These include interleukin 1ß, interleukin- 6 and tumor necrosis factor -α. The liver also releases a protein called c-reactive protein. When the threat is neutralized the immune system helps the body start to heal by releasing anti-inflammatory cytokines including interleukin (IL)-1 receptor antagonist, IL-4, IL-10, IL-11, and IL-13.
In chronic inflammation the pro-inflammatory cytokines continue to predominate and the c-reactive protein continues to be elevated.
Causes of Chronic Inflammation
Causes an individual can do something about
Low levels of physical activity.
Having a BMI at or above 30 , especially when excess weight is deep within your belly (visceral fat). The best way to measure belly fat is to use a tape measure to measure your waist at the widest point. Increased belly fat is greater than 35 inches for women or greater than 40 inches for men
An imbalance of healthy and unhealthy bacteria in your intestine (dysbiosis). Dysbiosis can be caused by antibiotics and by eating foods low in soluble fiber.
Regularly eating foods that cause inflammation, especially highly processed foods, or foods high in sugar or salt
Inadequate sleep
Using tobacco products.
Regularly drinking too much alcohol
Periodontal disease (gum infection) and tooth decay
Perceived stress
Societal Causes
Experience of racism (structural or personal)
Poverty
Homelessness
Worry about debt
Work stress
Exposure to air pollution
Exposure to chemicals (pesticides and herbicides for farm workers, glyphosphate (RoundUp) for everyone, microplastics in our bloodstreams for everyone. Every day, we are surrounded by thousands of synthetic chemicals. They are in our food, clothes, tools, furniture, toys, cosmetics and medicines. We know the health effects of only a few of these).
All of the inflammatory cytokines can be measured but those are expensive tests. A simple inexpensive test that measures inflammation, both acute and chronic is high sensitivity CRP. It will also be high with an acute infection or injury, but will return to normal after the infection or injury have resolved. If it remains elevated when you are not sick or injured it is a sign of chronic inflammation. It may be worth asking your doctor to order this test if you have any of the individual or societal risk factors for chronic inflammation. A normal hs-CRP is less than 0.55 mg/dl in men and less than 1.0 mg/dl in women. If your hs-CRP is high in the absence of acute infection or injury, that can serve as motivation to make lifestyle changes to decrease your chronic inflammation and put you in a population that has less risk of developing any of the diseases associated with chronic inflammation.
Anti-inflammatory lifestyle
Exercise regularly. The CDC recommends 30 minutes of moderate exercise (walking briskly) for 30 minutes at least 5 days a week.
Eat mostly unprocessed or minimally processed foods and avoid sugary drinks or foods with added sugar or high fructose corn syrup. Also include foods with high soluble fiber such as beans, carrots, sweet potatoes, nuts, berries and most fruits (not fruit juice). Organic foods, while more expensive, have no residual pesticides or herbicides. If you eat meat buy grass fed beef, and pasture raised chicken and pork. Eat more plant-based foods than meat.
Avoid taking antibiotics as much as possible
Sleep. Average at least 8 hours a night
Floss your teeth daily, brush twice a day and see your dentist every 6 months
If you don’t smoke, don’t start and if you do smoke quit.
It is better not to drink alcohol at all, but if you do limit it to 1 drink a day or less.
Learn meditation or self hypnosis to manage stress. There are good books and videos, but an in person course is best if it is available.
Drink only filtered water and not bottled water in plastic bottles
Gas stoves cause significant indoor air pollution. If possible switch to an electric stove. Induction type burners actually heat more quickly than gas. If you have to use a gas stove, be sure to turn the ventilator fan on and open a window if possible.
Bottom Line
Chronic inflammation is the common pathway for many chronic diseases. There are many individual strategies that reduce or prevent chronic inflammation. Many of these strategies are not possible for people with socioeconomic problems. The stress black people experience from structural and individual racism, homelessness or inadequate housing, anxiety over debt, exposure to environmental synthetic chemicals, and exposure to air pollution are societal problems that we all have a responsibility to address.
My next post will deal with chronic inflammation and cardiovascular disease.
A recent article in the Washington Post reported on a hospital system, Steward Healthcare, that was started by a private equity firm, Cerberus, in 2010. It was based in Dallas and owned 30 hospitals across the country. It recently filed for bankruptcy, leaving patients to suffer and some to even die.
This is only the tip of an iceberg. Private equity funds have increasingly purchased healthcare organizations. According to the Lown Institute At least 386 hospitals are now owned by private equity firms, comprising 30% of for-profit hospitals in the U.S. In this post I will discuss effects of private equity ownership of hospitals on the quality and cost of care.
Private equity firms are businesses that seek large investors by having a very large minimum investment, so investors usually include both wealthy individuals and large institutional investors like pension funds, insurance companies, endowments, and sovereign wealth funds. Typical large private equity firms are Cerberus, Bain Capital, Apollo Global Management, TPG, KKR and Blackstone. Private equity firms are different from venture capitalists, who provide a cash infusion to small startups and hope they blossom into the next Facebook. Nor are they stock traders making split-second decisions to buy or sell shares in public companies. Rather, private equity funds aim to take control of a business for a relatively short time, restructure it and resell the company at a profit. Investors in private equity firms expect to make a much larger profit than typically provided by the stock market.
Private equity firms claim they are good for healthcare systems because they provide needed capital for investment in better quality care. Let’s look at the data and see if this is true. Remember that the purpose of a private equity fund is to make a large return for its investors. Its purpose is not to improve healthcare delivery.
Cost
A recent review of 55 studies of cost and quality of care in hospitals and nursing homes owned by private equity firms in the British Medical Journal found that costs to patients and insurers were increased in those institutions owned by private equity firms compared to non-equity owned institutions.
Quality of Care
The review in BMJ also found that effects on quality of care in private equity owned institutions was mixed to harmful. A recent study reported in the Journal of the American Medical Association reported higher complication rates in private equity owned hospitals. Here is a quote from the key points in the JAMA article:
“Private equity acquisition was associated with a 25.4% increase in hospital-acquired conditions, which was driven by falls and central line–associated bloodstream infections. Medicare beneficiaries at private equity hospitals were modestly younger, less likely to have dual eligibility for Medicare and Medicaid, and transferred more to other acute care hospitals relative to controls.“
Financial Engineering
Private equity firms use some money from investors and borrow the rest to purchase hospital systems. That’s why they are known as leveraged buyouts. They then saddle the hospital systems with the debt. In other words, they have very little “skin in the game.” They do well whether the hospital does or not.
Short Term Goals
Private equity firms make most of their profits when they sell the hospital or hospital system, and they look to exit within 5-8 years. Thus they look for ways to cut costs quickly like reducing staff or selling the hospital real estate.
Moral Hazard
Private equity firms can make a big profit and pay big dividends to investors even if the hospital goes bankrupt or struggles to survive and is unable to provide the services they did before. See this report about how this happened to one hospital system: Shell game. This is different from most investments where the success of the investor depends on how well the target company does.
Financialization of Hospitals
Financialization is a pattern in which profits come primarily through financial channels rather than through trade and commodity production. In healthcare that means that profits come from buying and selling hospitals rather than from the provision of medical care. This has happened for non-profit hospitals as well as for profit hospitals. For non-profits financialization has occurred by purchasing smaller hospitals, creating large medical systems that dominate the market. The acceleration of the acquisition and selling of for-profit hospitals by private equity firms started in the mid 1990’s and continues to accelerate.
Nursing Homes
In 2022 private equity firms owned 5% of nursing homes. As the purchasing trend accelerates, that number is almost certainly higher now. Studies show that private equity ownership results in an 11% increase in mortality, a 6% decrease in mobility, an 8% increase in bedsores and a 10% increase in pain. (Owner Incentives and Performance in Healthcare: Private Equity Investment in Nursing Homes)
Bottom Line
The preponderance of evidence shows that Private equity ownership of healthcare institutions results in lower quality and higher cost healthcare. It is only the worst aspect of financialization of healthcare that has occurred in the US. There are things the US could to about this if the political will were there. Here is a list of solutions from the Lown Institute:
Joint Liability. Currently PE firms can put all of their debt on the balance sheet of the firm they acquire, letting them off the hook for this debt and making it harder for the acquired company to succeed. “Requiring private equity firms to share in the responsibility of the debt…would prevent them from making huge profits while they are saddling hospitals and nursing homes with debts that ultimately impact worker pay and cut off care to patients,” write Stewart and Baker.
Regulate mergers. Private equity acquisitions often go under the radar because the acquisitions are small enough to not be reported to authorities. But the U.S. Federal Trade Commission could be more aggressive in evaluating mergers and buyouts by PE, as they have done recently in Texas, where a PE firm has been buying up numerous anesthesia practices.
Transparency of PE ownership. It can be hard to know when hospitals are bought by a PE firm. The Department of Health and Human Services could require disclosure of PE ownership for hospitals as they have done for nursing homes.
Remove tax loopholes. The carried interest loophole allows PE management fees to be taxed at as capital gains, which is a lower rate than corporate income. Closing this loophole would remove a big incentive that makes PE buyouts so attractive for firms.
If it becomes less lucrative for private equity firms to purchase and sell healthcare institutions then they will concentrate their investments elsewhere. That would be good for all of us.
We are inundated from social media and other sources about diets and how well they work. In this post I’m going to describe the current most popular diets and how safe and effective they are at producing weight loss. I’m also going to write about the physiology of appetite, what controls appetite, and the mechanisms involved in weight regain after dieting. I will also discuss the ways people have discovered to maintain their weight loss. I am not going to discuss medicines for weight loss or bariatric surgery in this post. Those are subjects for another day. I did do a previous post on GLP1 agonists for weight loss. If you are interested you can link to that post here.
Energy Balance
Neither humans nor any other animal can survive without food. Our bodies convert food into the energy we need to keep our bodies intact and to be able to move about. The measure of the available energy in food is calories. A calorie is the amount of heat energy required to raise 1 gram of water by 1 degree centigrade. This is a very small amount of energy, so the unit we usually use is 1000 calories or kilocalories. When you see the number of calories on a food label, it is always means kilocalories even though it says “calories” on the label.
If on average we eat more calories than we use, our bodies store the extra energy as fat and we gain weight. If on average we use more energy than we get from our food, our bodies use the stored energy from fat and we lose weight. If on average we eat as many calories as we use, our weight is stable. We are in energy balance. We can also gain weight by increasing our muscle mass, but in this post I’m going to write about weight gain and loss as changes in body fat. This is an immutable law. Diet claims that calories don’t matter for weight loss are simply wrong. Calories in versus calories out sounds simple, but energy balance in our bodies is not simple at all.
Our intake of calories is controlled by our appetite and the control of appetite involves multiple hormones and neurotransmitters at multiple places in the brain and in the body. Control of appetite is very complex. I will write more about this later in this post.
Energy we use is of two types. A certain amount of energy is needed just to keep our bodies functioning. This is called the basal metabolic rate. It is also called resting energy expenditure (REE). It varies with weight. The average REE is 1 kilocalorie per hour per Kg (2.2 pounds) of body weight. That means that for a person who weighs 70 Kg (154 pounds) the REE would be 1680 kilocalories per 24 hours, just sitting on the couch. To calculate your own REE, divide your body weight in pounds by 2.2 and multiply that by 24. That will give you the number of calories you use in 24 hours just sitting on the couch during the day and sleeping at night. In general it is going to be in the neighborhood of 1500 to 2000 kilocalories per day.
The other type of energy we use is the energy required to move our bodies. These are called active calories. Active calories also based on body weight. For a 154 pound person, walking briskly burns 280 calories per hour. More vigorous activity burns more calories. Here is an extensive table from the Department of Health Services of Wisconsin that shows kilocalories burned for various activities at different body weights: CALORIES BURNED PER HOUR.
So what would it take for you to be in energy balance if you weigh 70 Kg (154 pounds) and do brisk walking for 30 minutes 5 days a week? Brisk walking uses 280 kilocalories per hour, so 140 kilocalories for each exercise session. That would be 700 kilocalories per week or an average of 100 kilocalories per day. Regular household activities burn about the same amount per hour as walking, so if you do household chores for 4 hours per day including weekends, that would be another 1,120 kilocalories per day. Your REE is 1680 kilocalories per day. You would be burning on average 100 active kilocalories per day for your walking and another 1,120 kilocalories a day for household chores for a total of 2900 kilocalories per day. That number will be a little higher if you weigh more that 154 pounds and a little less if you weigh less than 154 pounds. To be in energy balance you would need to eat no more than 2900 kilocalories per day. If you exercise more, you can eat more and stay in energy balance, but you would need to add a lot more exercise.
Fortunately, you don’t have to do all these calculations. In a normal weight person your body stays in energy balance automatically. Obviously, people who are overweight or obese either are not now, or at some point have not been in energy balance. It doesn’t take being out of energy balance much per day to cause significant weight gain. Lets suppose you take in 100 more calories per day than you use. It takes about 3500 extra kilocalories to gain a pound of fat. That would equal weight gain of fat at a rate of a pound every 35 days, or 10 pounds per year.
Being overweight or obese has serious health consequences that escalate with the degree of obesity. In order for overweight or obese people to avoid these consequences, they need to make a conscious effort to lose weight. That is where diets come in. Exercise is important too, but more for maintaining weight loss than losing weight. Of course exercise is good for you whether you lose weight or not.
Diets
I will write about the most extreme diets first, and then discuss the more moderate ones.
Keto (ketogenic) Diet
The brain is the second most active organ in the body after the liver. The brain normally uses glucose for energy but when glucose is not available and all the glycogen in the liver (which can be converted to glucose) is used up, the body starts to break down fat into something called ketones. The brain can use ketones for energy although it cannot use fat directly. The purpose of the ketogenic diet is to switch the whole body to the use of ketones for energy instead of glucose. This is accomplished by a high fat, very low carbohydrate and low protein diet. Protein has to be low because it can be broken down in the liver to form glucose. Carbohydrate is reduced to less than 50 grams per day which is less than the amount in a medium bagel. Protein is restricted to less than 1 gram per pound of body weight per day.
The ketogenic diet works because it decreases appetite, so despite eating calorie dense fat, total calories consumed are markedly decreased. It does lead to significant and fairly rapid weight loss. It is, however a markedly nutrient deficient diet. People who are on this diet must take supplemental multivitamins and minerals. Doing so keeps people from getting gross vitamin deficiency, but there is also a loss of micronutrients found in complex carbohydrates and it is unclear what the effects of this deficiency are. The ketogenic diet is very low in fiber, which alters the gut microbiome adversely. It decreases triglycerides and increases HDL, which are good, but it also increases LDL, which is bad. On the other hand, it decreases hypertension and has an anti-inflammatory effect. It is not clear whether the positive effects are outweighed by the LDL increase effects. So far, there is no evidence that ketogenic diets increase the risk of heart disease.
The main drawback of the ketogenic diet besides the nutritional deficiencies is that it is virtually impossible to stick to for more than a few weeks or months. Ketogenic diets do reduce insulin secretion since there is much less glucose for insulin to carry into the cells. The ketogenic diet may be useful in type 2 diabetics to reduce insulin resistance and decrease weight, particularly for diabetics in poor control. It is not a diet that can be maintained long term.
Very Low Calorie Diets
These diets restrict calories to 800 calories per day or less using proprietary liquid formulas that contain electrolytes and high protein to prevent muscle loss. VLCD diets lead to rapid and significant weight loss and are used primarily for people with severe obesity or medical complications of obesity. Such a diet should not be used without supervision of a physician. Again, like the ketogenic diet, VLCD diets should not be maintained long term.
Intermittent Fasting
Intermittent fasting is going without food for some period. Non-caloric drinks such as water or coffee are encouraged during fasting times. The simplest is restricted time eating. This involves skipping one or two meals per day and only eating during a restricted time. Whole day fasts can be once or twice a week or even every other day. One might think that a person would eat twice as many calories on a non-fasting day and so would not experience weight loss. This rarely happens. Intermittent fasting does reduce average calorie intake, and so people on any of the intermittent fasting regimens lose weight. People who start an intermittent fasting diet get very hungry at first on fasting days, but this hunger tends to decrease over time. It takes discipline to maintain intermittent fasting over a long period, but people who have the discipline to stick to the intermittent fasting regimen can stay on it long term. If the food they eat on non-fasting days is healthy (more on this later) then this can be a successful long term eating plan to maintain energy balance at a lower weight.
Paleo Diet
This is supposedly the type of diet that humans ate in the paleolithic period prior to agriculture when all humans were hunter gatherers. Of course people on the paleo diet do not become hunter gatherers. According to the Mayo Clinic a modern paleo diet includes fruits, vegetables, lean meats -especially game meats, fish, eggs, nuts and seeds. These are foods that in the past people could get by hunting and gathering. It doesn’t include foods that became more common when small-scale farming began about 10,000 years ago. These foods include grains, legumes and dairy products.
People on a version of the paleo diet do lose weight for exactly the same reason as weight loss on other diets. The average calorie intake on the paleo diet is substantially less than the standard American diet. It is not clear that excluding grains, legumes and dairy products is a good thing. Whole grains, legumes and dairy products supply high quality nutrients that may be missing in the paleo diet. The paleo diet is also more expensive and may be out of reach for lower income people. There are no long term studies of the health effects of the paleo diet.
Whole30 Diet
This is similar to the paleo diet but is recommended for 30 days. Foods to avoid are alcohol, sugar, dairy products and legumes and grains. There is a list of foods you can eat and all of these are unprocessed foods. The idea is that you reset your metabolism, and then you gradually add back the avoided foods and see how they make you feel. There is no evidence about the claimed long term good health effects of the Whole30 Diet. Like other diets that lead to fewer calories consumed, people do lose weight on this diet.
Plant based Diet
A plant based diet is exactly what it says. It is derived entirely from plants and eliminates all animal products including dairy products and eggs. The sources of protein are legumes, nuts, seeds, soy and lentils. Sources of fat are nuts, avocados, olive oil and vegetable oils. Plant based diets tend to focus on unprocessed foods. Unlike the other diets mentioned in this post, there is a lot of evidence that plant-based diets decrease the risk of developing diabetes (and also treat type 2 diabetes), decrease the risk of high blood pressure, heart disease and autoimmune diseases. Plant based diets have an anti-inflammatory effect, which probably is responsible for many of the benefits of plant based diets.
Unprocessed plant based food is more expensive than ultra processed foods and requires substantially more preparation time. People who live in poor neighborhoods often live in a “food desert” and unprocessed plant foods may not be available or be too expensive to buy. People who have low end jobs often have neither the time nor the equipment for food preparation. Although plant based diets have multiple health benefits, they are out of reach for a substantial part of the US population.
GOLO Diet
The GOLO diet is a proprietary diet plan you have to pay for. It is essentially a Mediterranean type diet that includes a supplement. The supplement has a lot of minerals and vitamins and there is no evidence that any supplement helps with weight loss. It is currently heavily advertised on television and social media. The research cited in all of these ads is research funded by the GOLO company. I will write about the benefits of the Mediterranean type diet next, but GOLO uses a standard dietary plan and a worthless supplement to make money. Don’t waste your money on this diet.
Mediterranean Diet
The original Mediterranean diet was the traditional diet of Crete, Greece and southern Italy in the 1960’s. Italians and Greeks no longer necessarily eat like this, but their original diet had lots of whole grains, vegetables and fish and used lots of olive oil. This type of diet has been studied more than any other and has very similar benefits to the plant-based diet. It reduces the risk of high blood pressure, diabetes, heart disease and autoimmune disorders. Here is the Mediterranean diet food pyramid from Wikipedia. It was developed by Oldways Trust, Harvard and the World Health Organization.
The things at the base of the pyramid are the things you eat the most and the things at the top of the pyramid you eat the least. Notice that red meat and butter are at the top of the pyramid. You don’t eliminate any class of food entirely in this diet, you just don’t eat the things at the top very often. Once again the diet includes mostly unprocessed foods and requires considerable food preparation.
The Standard American Diet (Also called the Western pattern diet)
It is no wonder that we have an epidemic of obesity! The standard American diet is almost the exact opposite of the Mediterranean diet and plant-based diets. It is very high calorie and high in ultra-processed foods. That is why all of the diets I described above cause weight loss. Almost anything is better than the standard American diet!
Weight Regain After Weight Loss
With any diet (other than the very low calorie diets) weight loss stabilizes after a while and then there is very frequently some weight regain. Why does this happen? During the evolution of the human species, obesity was very rare. Hunter gatherers, even the few modern ones that remain in remote parts of the world are not fat. In evolutionary terms, weight loss meant that there was not enough to eat, so metabolic strategies to conserve calories during times of starvation had high survival value. The result is that when we lose a significant amount of weight, the body thinks we are starving. Several things happen to conserve energy. The first thing is that the basal metabolic rate or resting energy expenditure (REE) decreases an average of 50 kilocalories per day, but people who are obese to start with and lose a significant amount of weight can have decreases of REE as much as 700 kilocalories per day. Another body adaptation to weight loss is that the muscles become more efficient and use less fuel. This means that the calories you burn per hour with exercise decreases as you lose weight.
Appetite
As I mentioned before, the control of appetite is complex. Almost all control of appetite is unconscious. Appetite can be consciously controlled only for a short time, just as we can consciously control our breathing for a short time, but most breathing is (fortunately) unconscious. The part of the brain that controls our appetite and food intake is the hypothalamus. The hypothalamus secretes some hormones on its own and controls other hormones and/or peptides that both increase and decrease appetite. One hormone that increases appetite is Ghrelin. It is secreted by the stomach, small intestine, pancreas and brain and has multiple effects. It increases appetite and food intake and promotes fat storage. Hormones that makes you feel full or satiated are Leptin and GLP1. Control of appetite is actually a lot more complicated than this. Below is a table taken from a review article about hormonal control of appetite. Here is a link to the full article. It is not for the faint hearted. Hormonal Regulators of Appetite
The table summarizes what we know about the hormones and peptides that increase appetite and stimulate feeding and those that make us feel full and inhibit feeding. As you can see, control of hunger and satiety is very complicated. All of this takes place outside of our conscious awareness.
Hunger
Hormone
Primary location of production
Receptors
Action
Hypothalamus
NPY
Medial arcuate nucleus (also widespread in CNS
Y1, Y5
Stimulating feeding and atagonizing satiety
AgRP
Medial arcuate nucleus
MC3R and MC4R antagonist
Stimulating feeding
Peripheral Peptides
Ghrelin
Stomach
GHS-R1a
Stimulating feeding by increasing NPY/AgRP and antagonizing Leptin effects
Satiety
Hypothalamus
POMC/a–MSH
Arcuate nucleus
NC3R and MC4R
Inhibiting feeding, stimulating basal metabolic rate and altering nutrient partitioning
CART
Arcuate nucleus
Inhibiting feeding
Peripheral peptides
Cholecystokinin
Duodenum, jejunum
CCK-A
Inhibiting feeding and stimulating gall bladder contraction, intestinal motility, and inhibition of gastric motility
PYY
Ileum, colon, rectum
Y2
Inhibiting feeding by inhibition of NPY and stimulation of POMC
Glucose-dependent insulin secretion, induction of beta cell proliferation, promotion of energy storage, enhancement of bone formation
Insulin
Pancreas
Insulin receptor
Inhibiting feeding
Leptin
Fat cells
Leptin receptor, Ob-Rb
Inhibiting NPY and AgRP and stimulating POMC and CART
Adiponectin
Fat cells
Adipo R1, R2
Inhibiting feeding
With significant weight loss (10% or more) the hormones that control appetite shift toward the hormones that make us hungry. Those includes Ghrelin, NPY and AGrP. The hormones that make us feel full, including leptin and others decrease.
The result of all this is that even if we are sure we are staying on the same foods, we are unconsciously eating more of them. The result is weight regain. The bad news is that 80% of people who lose weight on diets regain a substantial portion if not all of the weight they lost within 1-5 years. The good news is that 20% of people maintain most of the weight loss they achieved even after 5 years. How do those 20% of people who lost 10% or more of their body weight keep from regaining weight? We actually know a lot about how they do it.
National Weight Control Registry
Here is the introductory paragraph from the National Weight Control Registry website:
The National Weight Control Registry (NWCR), established in 1994 by Rena Wing, Ph.D. from Brown Medical School, and James O. Hill, Ph.D.from the University of Colorado, is the largest prospective investigation of long-term successful weight loss maintenance. Given the prevailing belief that few individuals succeed at long-term weight loss, the NWCR was developed to identify and investigate the characteristics of individuals who have succeeded at long-term weight loss. The NWCR is tracking over10,000 individuals who have lost significant amounts of weight and kept it off for long periods of time. Detailed questionnaires and annual follow-up surveys are used to examine the behavioral and psychological characteristics of weight maintainers, as well as the strategies they use to maintaining their weight losses.
The extensive research on the 10,000 people in the registry who have maintained weight loss show the following things that they do. This list is again from the registry website.
98% of Registry participants report that they modified their food intake in some way to lose weight.
94% increased their physical activity, with the most frequently reported form of activity being walking.
There is variety in how NWCR members keep the weight off. Most report continuing to maintain a low calorie, low fat diet and doing high levels of activity.
What all this research means is that it is possible to maintain weight loss despite the cascade of hormonal mechanisms that kick in to conserve calories when weight loss happens that work to get us back to the weight that we were. It is possible, but not easy. It takes continual effort, although people in the registry do report that it gets somewhat easier over time.
Bottom Line
All diets when adhered to result in weight loss
Some eating plans are sustainable and are not nutrient deficient. These include intermittent fasting, plant-based diets and the Mediterranean diet.
More extreme diets such as the Keto diet, VLCD diets and Paleo diet are not sustainable and have various nutrient deficiencies.
Substantial weight loss triggers hormonal changes in the body that conserve calories. These changes are responsible for the fact that weight loss plateaus on almost any diet and significant weight regain even often back to the original weight occurs in 80% of people who lose a substantial amount of weight.
It is possible to maintain weight loss over many years, but it is not easy. Findings from the National Weight Control Registry suggest the following strategies to maintain weight loss
Longevity is the newest health buzzword. There are an increasing number of so-called longevity experts. They say, just read my book and follow my instructions and you can live past 100 years. Some of these “experts” focus on health span. They say follow my instructions and you will stay healthy and die suddenly at an advanced age. As of 4/21/2024 there are 34 books on longevity listed on Amazon.
In this post I will do my best to distinguish the hype from the science with regard to living a long and healthy life.
Hype
Calorie restricted diets – Some people have extrapolated mouse and rat experiments that show that animals fed restricted calorie diets live a lot longer than animals fed a normal diet. There is not one shred of evidence that this works with humans, and is more likely to lead to diseases of malnourishment.
Nutrtional supplements – Recommendations range from vitamins, to protein powder, to collagen powder, to herbal preparations, to encapsulated fruits and vegetables. There is absolutely no evidence that any of these things or any other supplements including multivitamins work to extend your life. Anecdotal reports of feeling better on these supplements are almost certainly a placebo effect
Anti-aging medicines – reservetrol, metformin, rapamycin have all been shown to prolong life in some experimental animals. In humans Metformin and reservetrol decrease the ability to exercise and rapamycin suppresses the immune system. There is no evidence whatever that these compounds increase life or health span in humans.
Extensive lab tests – Other than lipid (cholesterol) tests, there is no evidence that otherwise healthy non-obese people benefit from any blood tests. More about screening tests later.
Imaging tests – One of the most popular longevity “experts” ,Dr. Peter Attia, recommends full body MRI scans for his patients. Imaging tests in people who have no symptoms are much more likely to lead to over diagnosis and unnecessary treatment than to find things that really need to be treated,
Very intense exercise regimens – The only thing very intense exercise regimens accomplish that moderate exercise regimens do not is that the intense regimens are more likely to cause injury.
Science
Genetics
Up until into the 80’s, lifestyle is the major contributor to healthy aging. There are some people, however who remain healthy well into their 90’s and a few to past 100. Genetics is the main contributor to these “super centenarians.” There is not a single or even a few aging genes. Super aging is caused by hundreds of genetic variants called SNP’s (single nucleotide polymorphisms). We cannot alter our genes (yet), so there are no lifestyle changes you can make in order to live to 100 if you don’t have the rare combination of all these genetic variants.
That is not to say that lifestyle is not important to healthy aging. In the US, the average person’s last birthday in good health is age 65! Lifestyle changes will almost certainly help you do better than that.
Exercise
Regular exercise decreases your risk of chronic disease and therefore increases your chance of living healthier longer. To accomplish the maximum health benefit the CDC recommends 150 minutes of moderate exercise per week. Brisk walking or cycling at a moderate pace on level ground would qualify. If you choose high intensity exercise like jogging or running or high intensity cycling, you only need to do 75 minutes a week according to the CDC. The CDC also recommends activity to strengthen your muscles two days a week. For a population of adults doing this exercise regimen the risk of death is decreased by 17%. This regimen decreases the risk of heart disease, diabetes, certain cancers and decreases the risk of hospitalization or death from infectious diseases like COVID, flu and pneumonia. This regimen also increases bone and muscle strength and thus decreases the risk of falls and fractures. This exercise regimen also helps maintain a healthy weight.
Any amount of walking or activity decreases risk somewhat. The CDC recommended regimen decreases risk the most.
Nutrition
Eat mostly unprocessed foods and avoid ultra-processed foods. The best way to identify ultra-processed foods is to look at the ingredients label. If there are more than four ingredients, and/or if there are some you don’t recognize, then put that food back on the shelf. It is best to keep nutrition advice simple. The most concise recommendation I know comes from author Michael Pollan. “Eat food (food is anything your grandmother would have recognized as food), not too much, mostly plants.” I can’t do much better than that. Most of the evidence about the beneficial effects of good nutrition come from studies of the Mediterranean style diet. The Mediterranean diet adheres to Michal Pollan’s advice. It has lots of fruits, vegetables, fish, olive oil and very little meat. Adherence to this type of diet showed a 46% increase in living healthfully until 70 or greater.
Social Connectedness
The CDC defines social connectedness as the degree to which people have and perceive a desired number, quality, and diversity of relationships that create a sense of belonging, and being cared for, valued, and supported. An analysis of multiple studies showed that high social connectedness as defined above decreases the risk of premature death by 50%! High social connectedness also decreases the risk of heart disease, stroke and dementia.
Social Determinants of Health
The main reason that the US average health span is 65 years is the tremendous inequity of resources in the US. People who live in substandard housing (or no housing at all) do not have the opportunity or resources to do all of the things above that tend to extend life. That is why life expectancy at birth is related to zip code more than any other factor. My feeling is that we should expend our resources working on improving health equity, which will increase both life and health span for everyone rather than focusing on helping wealthy people live to 100.
Screening Tests
There are a few screening tests recommended by the US Preventive Care Task Force for healthy people. These tests are meant to find disease, especially cancer early so it can be more successfully treated and thus prolong healthy life. The absolute risk reduction of death for these tests is small, most around 1%, but that ends up saving a lot of people when you apply it to the whole US population. The recommended screening tests are listed below.
Mammograms for women beginning at age 50. Recommended every two years. Absolute risk reduction about 1%.
Pap Smears beginning at age 21 every 3 years through age 29 and then every 5 years from age 30 to 65. The absolute death risk reduction is .0009%, which means your would need to do pap smears on 11140 women to prevent one death from cervical cancer.
Colorectal cancer screening. There are three different tests: colonoscopy, the most invasive (recommended every 10 years), Cologuard (a stool sent to a lab in a box recommended every 3 years) and fecal immunochemical test (done on a stool sample and either tested at home or sent to lab recommended every year). All three tests reduce deaths from colon cancer with an absolute risk reduction of around 0.6%. Only colonoscopy can prevent some cancers by removing precancerous polyps.
Vaccines
There is no question that vaccines save lives by preventing some serious life threatening diseases, or making them less severe. Vaccines are especially important for infants and children, who are most at risk from the infectious diseases prevented by vaccines. Childhood vaccines prevent diptheria, whooping cough, tetanus, measles, mumps, rubella, polio, rotavirus (which causes severe diarrhea and dehydration in infants), hemophilus influenza (which caused joint infections and meningitis), hepatitis b, RSV (which causes severe respiratory illness), pneumonia caused by strep (the most common kind of bacterial pnuemonia), COVID (also for adults), meningitis, chicken pox, and HPV (the virus that causes cervical cancer in women).
Adults can get any of these vaccines, but also a vaccine to prevent shingles.
Bottom Line
Living in good health to past 100 depends on genetics, not lifestyle. Many things recommended by so called longevity experts do nothing to prolong life and may increase risk. There are a number of lifestyle changes including exercise, good nutrition, social connectedness, certain screening tests and vaccines that increase you chances of remaining healthy well into your eighties. The main cause of early death in the US is poverty, homelessness and systemic racism. Addressing these inequities is a lot more important than helping wealthy people try to live to 100.
Television viewers in the United States watch an average of nine drug advertisements per day, or about 16 hours per year, far in excess of the time spent with their physician. That is because pharmaceutical companies spend huge amounts of money on direct to consumer advertising. In 2022 pharmaceutical companies spent 6.88 billion U.S. dollars on direct to consumer advertising! Pharmaceutical companies claim that these ads educate patients about treatment options they might not know about and foster conversations with their physicians. Pharmaceutical companies, however, are in the business of making money and these ads do a great deal to increase their revenue or they would not spend billions of dollars on them. This post will examine the claim that the ads are helpful to patients and doctors and will document the substantial harm that these ads do to both the health system and to individuals.
Almost all other countries besides the United States ban direct to consumer advertising of prescription medicines. The only other country that allows them is New Zealand.
History of Direct to Consumer Advertising
In the 1960’s congress granted the FDA the authority to regulate prescription drug labeling and advertising. The FDA was to ensure that prescription drug ads were: not false or misleading; presented a fair balance of drug risks and benefits; included facts that are material to a drug’s advertised use; included a brief summary that notes every risk described in the drug’s labeling. Because of these requirements, almost all drug advertising was directly to physicians.
In the late 90’s, the FDA changed the required risk information by stating that only major risks must be disclosed in ads and that they must provide resources that consumers can be directed to for full risk information. Because of this change, direct to consumer advertising has exploded since the late 90’s.
Compliance with FDA Requirements
Pharmaceutical companies are not required to submit ads to the FDA before they are used. They are required to submit ads to the FDA for review after they are in use, but the FDA lacks resources to review these ads in a timely manner. Many times the ad has already stopped running by the time the FDA gets around to reviewing it. A 2018 study published in the Journal of General Internal Medicine evaluated all broadcast direct to consumer pharmaceutical ads for 6 months for compliance with FDA regulations. The study found that only 26% of the ads were fully compliant with FDA regulations.
Online Direct to Consumer Advertising
Pharmaceutical companies have markedly increased online advertising through social media including FaceBook, Twitter (now X), YouTube and blog posts. This advertising reaches consumers in English speaking countries who ban direct to consumer prescription drug advertising. The FDA can only review a small portion of these. Here is a link to an article from an international policy journal about online direct to consumer ads by pharmaceutical companies: The Tip of the Iceberg of Misleading Online Advertising.
What the FDA does not require in direct to consumer advertising
Here is a list of important things that pharmaceutical companies are not required by the FDA to include in direct to consumer advertising.
Cost – Many of the medicines advertised are very expensive, especially cancer drugs. Pharmaceutical companies are not required to tell you anything about cost in their ads
If there is a generic version of the drug (a drug with the same active ingredient that might be cheaper) -Many times there is a generic version of the brand name drug that will do exactly the same thing as the drug advertised
If there is a similar drug with fewer or different risks that can treat the condition – There may also be a similar drug with fewer risks that could treat the condition advertised. The pharmaceutical companies are not required to tell you that in their ads
If changes in your behavior could help your condition (such as diet and exercise) – Eighty percent of chronic disease could be treated with life style changes. Ads are not required to tell you that
How many people have the condition the drug treats – The percentage of people who have the condition the drug treats may be very small. They don’t have to tell you that either
How the drug works (its “mechanism of action”)
How quickly the drug works
How many people who take the drug will be helped by it – It could be that only a small percentage of people who take the advertised drug will improve. Ads are not required to tell you that.
Evidence that direct to consumer drug advertising is helpful
There is evidence that direct to consumer drug advertising is beneficial for patients and their doctors. Here are the claims that have at least some evidence. This list come from a paper in the journal Pharmacy and Therapeutics: Direct-to-Consumer Pharmaceutical Advertising – Therapeutic or Toxic? The paper also summarizes the evidence for each of these claims
Informs, educates, and empowers patients.
Encourages patients to contact a clinician.
Strengthens a patient’s relationship with a clinician
Encourages patient compliance.
Reduces underdiagnosis and undertreatment of conditions.
I don’t find the evidence for any of these particularly convincing. None of the papers cited in the article disclose whether any of the authors have financial relationships with pharmaceutical companies.
Evidence that direct to consumer drug advertising is harmful
Despite pharmaceutical companies touting the educational benefits of direct to consumer advertising, remember that the main purpose of these ads is to sell a product, not to educate consumers. Here is a list of well documented harms of direct to consumer drug advertising:
Present incomplete or biased information – Most ads either leave out risk of the disease the advertised drug treats or use vague terms (like millions) Ads for drugs for which lifestyle modification is a viable alternative did not mention lifestyle changes. Over half of ads presented the advertised drug as a scientific breakthrough. See this paper from the Annals of Family Medicine: Creating Demand for Prescription Drugs: A Content Analysis of Television Direct-to-Consumer Advertising
Spur people to ask for medications they don’t need - A study published in the Journal of the American Medical Association found that “Fewer than one-third of the most common drugs featured in direct-to-consumer television advertising were rated as having high therapeutic value, defined as providing at least moderate improvement in clinical outcomes compared with existing therapies” (Therapeutic Value of Drugs Frequently Marketed Using Direct-to-Consumer Television Advertising, 2015 to 2021)
Promote medications before long-term safety is known. In the case of Vioxx, a new pain relief drug, it was pulled from the market due to an unexpected rise in heart attacks and strokes — but not before millions of people saw the ad and began taking it. (Merck to pay $950 million for illegal marketing of Vioxx)
Create conflicts between patients asking for a drug and doctors who don’t recommend it – An article in Consumer reports reported that 78% of doctors report that patients at least occasionally ask them for medicines they saw in drug ads. 54% of those doctors said they often decline these requests (Consumer Reports Survey: Patients and Doctors Disagree on Some Essential Issues)
Drive up healthcare costs without adding health benefits – New drugs are much more expensive than generic drugs that may do the same job. Also, unfortunately doctors are much more likely to prescribe the medicines that patient’s ask for rather than an alternative less expensive and/or more effective treatment. This is the biggest societal harm of direct to consumer prescription drug advertising. See this paper: Effects of Patient Medication Requests on Physician Prescribing Behavior.
Bottom Line
The FDA simply does not have the resources to adequately regulate pharmaceutical company direct to consumer advertising. Even if they did, it is unlikely that the FDA could even partially mitigate the well documented harms of the tremendous spending by pharmaceutical companies on these ads. I agree with my friend and mentor Dr. Kurt Stange that the only viable recourse is to ban direct to consumer drug advertising as almost every other country in the world has done. Here is his editorial in the Annals of Family Medicine: Time to Ban Direct-to-Consumer Prescription Drug Marketing.
We have all been told for years that the main dietary risk factor for heart disease and stroke is how much saturated fat we eat. We have also been told that eating foods high in cholesterol also increases risk of heart disease and stroke. Evidence is accumulating that consumption of saturated fat increases risk of heart disease and stroke little if at all. Since your body makes cholesterol itself, eating cholesterol rich foods has almost no effect on serum cholesterol. Other aspects of diet have a much greater effect on increasing the risk of heart disease and stroke. In this post I will summarize the evidence and spend some time discussing things we eat and drink that do substantially increase the risk of heart disease, stroke and other chronic diseases.
The Seven Country Study
The most famous study that led to the saturated fat hypothesis was carried out by Ancel Keys. The study started in 1956 and was published in 1978. He looked at the dietary patterns of 7 different countries. The countries included Finland, Greece, US, Italy, Yugoslavia, Netherlands and Japan. He found that saturated fat intake was correlated with increased risk of heart attack and stroke. The country with the lowest saturated fat intake was Crete in Italy, which also had the lowest incidence of heart disease and stroke of the 7 countries. The diet of Crete is the basis for the famous Mediterranean Diet.
Diets of free living humans are notoriously difficult to measure. Keys did his best to accurately determine diet. He had a subset of his subjects in each country weigh their food for a number of days, which is considered the gold standard for dietary studies. The problem with any population study like this is that populations in different countries differ in lots of other ways besides diet. Also diets are complex, so some other factor or factors in diet could account for the low heart disease incidence in Crete. Another problem was that diet was measured in Crete during Lent, when most people did not eat meat. All Keys could really say was that saturated fat intake was associated with heart disease, but he could not say that saturated fat caused heart disease.
People who adhered to the Mediterranean Diet did reduce their population risk of heart disease, but there is a lot more to the Mediterranean Diet than reduced saturated fats. It also includes little added sugar, lots of vegetables and fruit and mostly unprocessed foods. It is not clear that reduction in saturated fat is responsible for the health benefits of the Mediterranean Diet.
The Framingham Study
The next big population study was the Framingham Study. A large group of people in Framingham Massachusetts was followed over many years with surveys about diet, activity, smoking and laboratory measurements of total cholesterol, LDL, HDL and triglyerides among other measurements. Heart attacks, strokes, death from either of these things and death from any cause were recorded in the study group. This was the first large study that implicated cigarette smoking as a cause of cardiovascular disease and cancer. It was also found that the higher the total cholesterol and especially the higher the LDL (low density lipoprotein) the higher the risk of cardiovascular disease. It was also one of the first studies that showed that the higher the blood pressure, the greater the risk of cardiovascular disease. This was a tremendously important and well done study.
The Diet-Heart Hypothesis
The diet-heart hypothesis is that saturated fat is the main dietary cause of cardiovascular disease. It has been very influential over 60 years and is still promoted by the American Heart Association and many cardiologists. Here is the train of thought. The 7 country study implicated saturated fat as associated with cardiovascular disease. It has been found through multiple studies that saturated fat intake raises LDL (so called bad cholesterol). The Framingham study showed that increased LDL was a major risk factor for cardiovascular disease. Since saturated fat raises LDL, therefore saturated fat must cause cardiovascular disease.
That makes perfect sense, so many randomized trials were carried out to nail down the diet-heart hypothesis. Unfortunately, as is often the case with beautiful theories, further randomized trials did not consistently show the expected increase in heart disease from eating saturated fat. The other part of the hypothesis was that eating polyunsaturated fats would decrease the population risk of heart disease. That was based on the observation that consuming polyunsaturated fats decreased LDL levels. Randomized trials have generally failed to consistently show that eating polyunsaturated fats reduces the risk of cardiovascular disease.
Reduced Risk of Cardiovascular Disease in US
Heart disease was epidemic in the US, peaking in the 60’s. Since then, the incidence of heart disease in the US and most other developed countries has decreased by 60%! Scientists debate the cause for this decline. Although saturated fat consumption decreased some, Americans still eat much more saturated fat than the 5% of fat recommended by the American Heart Association. So the fact that we eat somewhat less saturated fat does not explain the remarkable decline in heart disease over the last 60 years. What else changed?
Cigarette Smoking
In the 1940’s half of all Americans said they smoked cigarettes. Smoking began to decline in the US in the 60’s and today only 11.5% of Americans smoke tobacco! This has to be a major factor in the decline of cardiovascular disease (and lung cancer).
High Blood Pressure
High blood pressure is a major risk factor for heart disease. The number of people with high blood pressure successfully controlled on medicine has more than doubled since 1960. This is clearly another major factor in the decline of cardiovascular disease
Trans Fats
The rise of trans fat consumption was an unintended consequence of the heart-diet hypothesis. Because animal fat (mostly saturated fat) was postulated to cause heart disease, the food industry started figuring out how to use vegetable oil to replace lard and butter, which were high in saturated fats. They needed something that would be solid, not liquid at room temperature. They discovered that if they partially hydrogenated vegetable oil, then it would be solid at room temperature and could substitute for lard and butter. They marketed these products as healthier because they were only partially saturated fats, not saturated fats. The medical establishment bought this story and recommended margarine as a substitute for butter and Crisco (the most successfully marketed shortening substitute) as healthier alternatives. I have been unable to find statistics on trans fat consumption in the US, but it was very large.
It turns out that consumption of trans fats markedly increased the risk of cardiovascular disease. For every 2% increase in the consumption of trans fats, heart disease increased by 23%. This is a shocking number! The consumption of trans fats certainly contributed to the epidemic of heart disease in the 50’s and 60’s. The FDA essentially banned the addition of trans fats to food in June of 1978. The elimination of trans fats is almost certainly another major factor in the decline of heart disease.
Interesterification
Since trans fats have been banned, food companies have come up with a new way to make vegetable oil solid and spreadable. It is called interesterification. It is complicated, but the simplest explanation is that it involves changing the arrangement of fatty acids on a glycerol backbone. These are fully hydrogenated fats, so are not trans fats. We know very little about how these new industrial fats affect human health, but the information we do have suggests that these new products may be just as bad for you as trans fats. You would do best to avoid them until we know more. More about how to do this later in this post.
Do we need to limit red meat consumption?
The main risk of consumption of any food is eating too much of it. It is total calorie intake that makes us fat, and being fat increases the risk of cardiovascular disease, diabetes and some cancers. Eating red meat by itself is very unlikely to increase your risk of heart disease as long as your total calorie intake is equal to the calories you burn up. So there is very little health risk to you in eating red meat, but there is a big risk to the environment. Cattle raising worldwide contributes about 16% of greenhouse gas emissions. Here is a link to a balanced discussion of greenhouse gas emissions from cattle raising: Livestock Don’t Contribute 14.5% of Global Greenhouse Gas Emissions.
The other thing to think about when consuming any meat product, including chicken is that almost all the meat you buy in the grocery store comes from giant factory farms, where animals are treated very inhumanely. That in itself is bad enough, but raising all those animals together increases risk of spreading disease to the people who eat them. Antibiotics are used in many factory farms to keep animals from getting sick. This contributes to the evolution of bacteria that are resistant to most antibiotics.
If you are not willing to give up eating meat entirely, try to find locally raised beef, pork and poultry. Farmer’s Markets are a good place to find meat from locally raised animals. It may be a little more expensive, but likely a lot safer.
What about eating fish?
If you are at high risk of cardiovascular disease or have cardiovascular disease then eating oily fish (salmon, sardines, anchovies, herring, mackerel, tuna, swordfish) twice a week reduces your risk of a heart attack by 50%. If you are at average risk, these fish don’t have unusual health benefits but if you like them, it’s fine to eat them. Because most of these fish contain some mercury they should probably be avoided by pregnant women and children. If you get canned tuna, get Pacific Island Tuna at Walmart. It is sustainably caught. Here is a link to an article from the Nature Conservancy about it: The Nature Conservancy. By the way taking fish oil is not nearly as good for you as eating fish.
Highly Processed Foods
There are convincing data that consumption of lots of highly processed foods leads to health concerns ranging from increased risk of obesity, high blood pressure, breast and colorectal cancer, to dying prematurely from all causes.These foods all also contain additives whose health effects have never been adequately tested. How do you recognize them? Just look at the label where the ingredients are listed. If there are more than two things you don’t recognize, put it back on the shelf. Here is an example of an ingredients list from a loaf of bread!
This is not bread you would want to eat! If you mostly stay out of the central aisles of the grocery store you will avoid most highly processed foods. Just be sure to look at the ingredients label before you buy anything.
It is all well and good for me to make these recommendations, but highly processed foods and factory farmed meat are cheap. People who are poor cannot afford to buy anything else. This is only one of the things that have led to the major health inequities that are present in this richest country in the world.
Foods that decrease risk of cardiovascular disease
Fiber
Increased dietary fiber has been shown to decrease risk of cardiovascular disease. This may well have to do with promoting a healthy microbiome in the intestine. Sources of fiber that promote growth of healthy gut bacteria are ones that contain inulin. The highest sources of inulin are leeks, asparagus, onions, wheat, garlic, chicory, oats, soybeans, and Jerusalem artichoke. Sourdough bread (no added sugar, honey, or high fructose corn syrup) is also a good source of fiber. Whole grains, fruits, nuts and vegetables are also good sources of fiber.
Fresh Fruits
Fresh fruits are a good source of fiber and also contain many beneficial nutrients including vitamins and antioxidants. Data from multiple studies show that eating fresh fruit daily reduces risk of cardiovascular disease.
Nuts
Eating a handful of nuts per day reduces your risk of heart disease by 20%. Peanuts are technically of legume, not a nut, but legumes reduce the risk of cardiovascular disease as well. Unsalted nuts are better for you than salted.
Whole grains
Whole grains are also a good source of fiber and other beneficial nutrients. Eating whole grains most days is associated with decreased obesity, diabetes and heart disease. Examples of whole grains are
Barley.
Bulgur, also called cracked wheat.
Farro.
Millet.
Quinoa.
Black rice.
Brown rice.
Red rice.
Wild rice.
Oatmeal.
Popcorn.
Whole-wheat flour.
Whole-grain breakfast cereals.
Whole-wheat bread, pasta or crackers.
Make sure to read the ingredients label for cereals and crackers. Don’t buy anything that has more than two ingredients you don’t recognize.
Fresh Vegetables
Fresh vegetables are also a good source of fiber. Sorry folks, but potato chips and french fries do not count as fresh vegetables! Once again eating fresh vegetables daily significantly lowers your risk of cardiovascular disease.
Bottom Line
Eating red meat and saturated fats does very little to increase your risk of heart disease, but it also does not reduce your risk. Raising livestock on factory farms causes significant harm to the environment and puts people at risk of infectious disease. Eating meat from locally raised animals is safer.
Eating high fiber foods, whole grains, nuts, fruits and vegetable does substantially reduce your risk of cardiovascular disease as well as cancer.
Eating highly processed foods, and this includes the new industrial fats made by interesterfication increases your risk of cardiovascular disease and cancer. The biggest risk of these is probably because they encourage people to eat more calories than they need and have almost certainly led to the epidemic of obesity.
The most concise recommendation for a healthy diet comes from author Michael Poulin: “Eat food (food is anything your grandmother would have recognized as food), mostly plants, not too much.”
All mammals, including humans have an innate response to perceived threat or stress. The more common name for it is the “flight or fight” response. Our remote ancestors faced many real threats. Let’s say for example one encountered a saber tooth tiger. As soon as he (or she) saw the tiger, several things happened. Epinephrine and norepinephrine were released, speeding up the heart rate in preparation for running away. A surge of cortisol was also released, which increased glucose in the bloodstream for fuel for muscles and the brain. Cortisol also increases mental alertness. Inflammatory molecules were released to promote wound healing should that be needed.
This kind of acute stress response is a good thing. People or animals with this kind of response were more likely to survive and reproduce. Once the acute threat was over, all the hormones and neurotransmitters quickly returned to their baseline levels.
In today’s world, threats from predators are not a problem for the vast majority of people. The threats we perceive are things like poor work conditions; experiencing discrimination, hate, or abuse; poverty; homelessness; divorce or other family discord; having little control over outcomes; feeling overwhelmed.
These are all things that produce the stress response, but unlike our remote ancestors, these threats are chronic. They are either lifelong or at least last a long time. Instead of returning to normal, the stress hormones and neurotransmitters stay elevated for long periods of time. A chronic stress response is definitely not a good thing!
Allostatic Load
The medical term for the acute stress response is called allostasis. Here is the definition of allostasis from Wikipedia: “Allostasis is the efficient regulation required to prepare the body to satisfy its needs before they arise by budgeting those needed resources such as oxygen, insulin etc., as opposed to homeostasis, in which the goal is a steady state.” Allostasis is an adaptive response to acute stress. Allostatic load on the other hand is the long-term result of failed allostasis, resulting in dysregulation (abnormal function) of multiple systems including the neuroendocrine, cardiovascular, immune, and metabolic systems.
Allostatic load is measured traditionally by 10 indicators of chronic stress. Primary indicators are the hormones and neurotransmitters released by stress. Secondary outcomes are measurements of the systemic effects of the primary indicators. All of these indicators are associated with the perception of stress. Below is a table showing the 10 indicators, how they are measured, and which body systems are affected. Here is a link to the full article from which this table comes: Allostatic Load: Importance, Markers, and Score Determination in Minority and Disparity Populations
Category
Marker
Functional purpose
Primary mediators
Dehydroepiandrosterone sulfate (DHEA), serum
Secreted by the adrenal glands. When high with stress it tends to lower cortisol and be protective in the stress response.
Cortisol, urinary
Integrated measure of 12-hour hypothalamic–pituitary–adrenal axis activity. Secreted by the adrenal glands. Has multiple effects in stress response.
Epinephrine, urinary
Integrated indices of 12-hour sympathetic nervous system activity. Sympathetic nervous system activation increases heart rate and blood pressure.
Norepinephrine, urinary
Secondary outcomes
Systolic blood pressure
Indices of cardiovascular activity and major risk factor for vascular disease
Index of long-term levels of metabolism and adipose (fat) tissue deposition. High value means fat around internal organs which increases inflammation and increases LDL (bad cholesterol) and triglycerides.
High-density lipoprotein cholesterol
Index of atherosclerotic risk protection. Low value increases risk of heart disease.
Total cholesterol
Index of long-term atherosclerotic risk
Hemoglobin A1C
Integrated measure of high blood sugar over 2–3 months
Each indicator that is a certain distance out of the normal range counts as one point. The score can range from zero to ten. The higher the score, the greater the risk of illness or death.
Other Indicators
Although the ten indicators were the ones described in the original papers about allostatic load, other indicators have been used as well.
Heart rate variability is the normal beat to beat variability in the heart rate. In a healthy heart there is slight variation in the timing of one heartbeat to the next. Chronic stress reduces or even eliminates this beat to beat variation.
High sensitivity C-reactive protein (CRP). This is a measure of systemic inflammation that can result from chronic stress.
How is the stress reaction triggered?
The stress reaction begins in the brain. Something in the environment is perceived in a part of the front of the brain called the prefrontal cortex. This is the executive decision maker in the brain. If the prefrontal cortex perceives something in the environment as a threat, then it sends messages to the limbic system (the part of the brain that is involved with emotions). It also sends messages to centers lower in the brain, especially the hypothalamus. The hypothalamus sends messages to the adrenal glands which secrete cortisone, norepinephrine and epinephrine. The hypothalamus secretes DHEA. Messages from the hypothalamus are also sent to the white blood cells which secrete inflammatory chemicals called cytokines. All of this prepares the body to deal with the perceived threat. Different people may perceive different things as a threat. It is the reaction to perceived threats that causes allostatic load. If another person experiences the same thing in the environment as not a threat, then there is no stress reaction.
Diseases associated with high allostatic load (high chronic stress)
A high allostatic load score is not disease in itself, but if chronic stress continues then disease in the cardiac, metabolic, neuroendocrine and immune system can occur. Here is a list of diseases associated with persistent high allostatic load.
Heart disease, primarily progressive blockage of the coronary arteries. This can lead to angina and/or heart attack. Congestive heart failure and arrhythmia like atrial fibrillation can also occur
Peripheral arterial disease. That is blockage in arteries in the legs and sometime fingers.
High blood pressure
Stroke
Autoimmune diseases like rheumatoid arthritis or lupus
Diabetes
Fibromyalgia
Chronic Fatigue Syndrome
Dementia or decreased cognitive function
Depression
PTSD
Cancer, particularly breast and ovarian cancer. The increase in cancer is probably related to decreased immune system function
Allostatic Load and Mortality
Many studies have shown that people with persistently hight allostatic load have about a 25% higher premature death rate than people with low allostatic load.
Disparities in Health Outcomes
The response to chronic stress (allostatic load) may explain some of the disparities we see in health outcomes. We know, for example that Adverse Childhood Events (ACE), which include things like abandonment and abuse, increase the risk of many chronic diseases in adulthood. Studies have shown that adults with a history of ACE have high allostatic load scores.
African Americans have higher incidence of many cancers, as well as poorer outcomes from those cancers. They also have worse outcomes from heart disease, high blood pressure and diabetes. While a good portion of these poorer outcomes are related to lack of access to health care, these disparities persist to some degree even in middle class and upper middle class African Americans. Almost all African Americans have experienced or still experience racism on a chronic basis. African Americans of all social classes have higher allostatic load scores than caucasians. Chronic stress and response to it may be the common denominator for these disparities as well as for health outcome disparities in other marginalized populations.
How to reduce allostatic load
There is typically a long time between the presence of indicators of allostatic load and illness and death caused by diseases associated with these indicators. That presents an opportunity to reduce allostatic load before the chronic stress response leads to illness and death. So how do we reduce allostatic load?
Some of the things that cause allostatic load can only be reduced by societal changes. Things like poverty, structural racism and homelessness cannot be decreased by individual effort. Even these causes, though, can respond to the mind body methods discussed below. On the other hand, if you don’t have enough to eat, have no home, or have a job that gives you no control of your life, it is not likely that you will have the energy or the will, or the financial means to do many of the mind body methods discussed below. We should not be distracted from working to decrease the inequities that are responsible for societal causes of chronic stress.
Mind-Body Medicine
Remember that an external threat is first received by the peripheral nervous system and transmitted to the pre-frontal cortex. In order to reduce allostatic load we can either reduce the threat perception in the prefrontal cortex (top down) or reduce the transmission of threat in the peripheral nerves (bottom up).
Top Down Treatments
Top down treatments start with intentional activity in the prefrontal cortex. The idea is to decrease activation of the limbic system and the hypothalamus. This can be accomplished by mindfulness meditation, hypnosis (including self hypnosis), mental imagery and progressive muscle relaxation. All of these techniques when done regularly have been found to decrease allostatic load indicators and to reduce the risk of stress related illnesses.
Bottom Up Treatments
Bottom up treatments decrease the threat transmission to the prefrontal cortex. They include yoga, Tai Chi, massage and biofeedback. These treatments have also been shown to decrease allostatic load and to reduce stress related illness.
Bottom up and top down are somewhat of an oversimplification. All of these treatments have some aspects of both top down and bottom up. Yoga, for example includes aspects of meditation. The same goes for Tai Chi. Biofeedback involves some attention from the prefrontal cortex. Massage also includes progressive muscle relaxation.
Bottom Line
The body’s reaction to a perceived threat includes a complex cascade of messages from the executive center in the prefrontal cortex to multiple body systems including the nervous system, the endocrine system, the cardiovascular system and the immune system. All of these things prepare the body to deal with the threat. As long as the threat is short term the stress response is very useful to the organism.
Perception of chronic stress leads to continuous secretion of all the stress hormones and inflammatory cytokines and this leads to dysfunction of multiple body systems and eventually to illness and death.
Mind body treatments, both top down and bottom up can reduce the allostatic load (chronic stress response) and reduce the risk of stress induced illness and death.
Many causes of chronic stress have to do with the structure of our society, such as poverty, homelessness and structural racism. Individual effort is not likely to ameliorate the effect of these causes of chronic stress. All of us should be working toward societal change to reduce chronic stress response in marginalized populations.
As I pointed out in a previous post: Cost and Quality of Healthcare in the US, we have the highest health care costs in the world, and yet have much worse outcomes than other industrialized countries. In this post I will write about why our costs are so high and what we might do to fix that.
Cost Drivers
Use of imaging
The US uses more sophisticated imaging technologies such as CT scans, MRI scans and PET scans per capita than any other industrialized country. The cost per scan is also much higher. For example an MRI in the US averages $1145, while the average cost in Switzerland is $138. Note that more imaging per person does not translate into better health.
Use of Prescription Drugs
The US is “addicted” to prescription drugs. The average person over 18 in the US is on 2.2 regular prescription drugs. That is the highest among industrialized countries. In the Netherlands, for example that number is 1.2; half as much. Prescription drugs in the US also cost more than twice as much for the same drugs from the same manufacturers as in other industrialized countries.
Costs of procedures
Routine surgical procedures cost much more in the US than in other industrialized countries. The average cost of an appendectomy in the US is $13,910. Contrast that with $4995, which is the average price in the Netherlands. The average cost of coronary bypass surgery in the US is $75,345. The average price in the Netherlands is $15,742 – 80% less!
Administrative costs
Administrative costs represent 30% of the cost of US health care. That is much greater than other western countries. Canada, for example has health care administrative costs of about 16%. Medicare administrative costs are about 2%. That means 98 cents of every dollar Medicare spends actually pays for medical care. Pretty good for an “inefficient” government program.
Specialist to Generalist ratio
Generalist physicians are considered to be in family medicine, general pediatrics or general internal medicine. In the US, the ratio of specialists to these generalist physicians is 2:1 (two specialists for every generalist). In the rest of the developed world, the ratio is exactly the opposite: 1:2 (two generalists for every specialist). Specialists in the US make an average annual salary of $350,300 while generalists make an average salary of $242,400. Those are the highest physician incomes in the world except for the tiny country of Luxembourg. In the Netherlands, average annual specialist income is $200,300 and average generalist income is $137,500. As you can see from these figures, the high specialist to generalist ratio in the US is a major driver of US health care costs. More specialists does not mean better care. In fact, the higher the specialist to generalist ratio, the worse the health outcomes. Here is a link to an article by Barbara Starfield describing how more specialists = worse health outcomes: The Effect of Specialist Supply on Population Health.
Unnecessary Care
The Institute of Health estimates that unnecessary procedures and tests add 210 billion dollars to US health care costs, making it the single largest contributor to waste. Too many specialists who do procedures means more procedures get done. Here is a link to an opinion piece in Time magazine that gives some examples of egregious unnecessary care: One Patient, Too Many Doctors: The Terrible Expense of Overspecialization.
Consequences of the High Costs of Medical Care
The extraordinarily high cost of US healthcare means that the cost of health insurance is also high. Companies who provide health care insurance for their employees have moved toward high deductible plans. Many workers, especially blue collar workers cannot afford to pay several thousand dollars for health care before their insurance starts to pay. As a result, they defer needed care.
Low and middle income people do not have enough access to medical care. Rich people, on the other hand get too much medical care and are much more likely to get unnecessary care. See my recent post: Social Determinants of Health.
Can anything be done to reduce US healthcare costs?
The answer is yes, but it will require the political will to resist the giant money machine of the medical-industrial complex. In 2020 the healthcare sector spent more than 623 million dollars on lobbying. There are a few things that would make a significant difference.
If congress would allow Medicare to negotiate the price of medicines for Medicare recipients, US drug prices would be much closer to the prices paid in other western countries.
The specialist-generalist imbalance could be addressed by forgiving student loans for medical graduates who choose generalist residencies, such as family medicine and general pediatrics. Unfortunately, there are almost no general internal medicine residencies left in the US.
Most difficult of all, but also most important would be universal health insurance not tied to one’s employer. The US is the only western country that does not have universal healthcare. The Affordable Healthcare Act (sometimes called Obamacare) made some progress in this direction, but not nearly enough. Other western countries have found many different ways to provide universal health insurance. They range from a government run system like the UK to a completely private insurance system with subsidies such as Germany or Singapore.
Bottom Line
The US spends twice as much on healthcare as Switzerland, the next highest western country. US health outcomes are worse than any other rich western country. There are multiple factors responsible for our astronomical healthcare costs. Getting our healthcare costs in line with other western countries will require political solutions. The medical-industrial complex spends millions of dollars lobbying to keep things the way they are.
What do you think is the single most important predictor of life expectancy at birth in the U.S.? Genetics? Education level of parents? Single parent families?
It turns out none of these are correct. The single most important predictor of life expectancy at birth is the zip code you are born in. These differences can be tremendous for communities just a few miles apart.
In Washington, D.C., for example, a baby born in the Barry Farm neighborhood can expect to live for 63.2 years. Yet, less than 10 miles away, a baby born in Friendship Heights and Friendship Village can expect to live 96.1 years, according to CDC data. That is a 33 year difference in life expectancy between two groups of people living less than 10 miles apart!
This zip code effect on life expectancy is due to social determinants of health. The CDC defines five domains of social determinants of health. They are:
Health Care Access and Quality
Education Access and Quality
Social and Community Context
Economic Stability
Neighborhood and Built Environment
Social determinants of health account for one third of the deaths in the U.S. and 80 % of chronic disease. Lets compare Barry Farm and Friendship Heights in these domains
Barry Farm
There is only one hospital in the area and it is closing in 2023 due to economic and quality issues. Access to primary care is poor. Although there are some clinics in the area, they do not inspire confidence. Insurance coverage is mostly Medicaid. Private employer provided insurance is almost non-existent. Health literacy is low as evidenced by low high school graduation rate, high emergency department use for primary care issues and low use of existing primary care clinics. Another indicator of poor health literacy is a very high smoking rate. Barry Farm is a high density urban neighborhood where most people rent as opposed to own their homes. 92% of residents are black and median annual income is $13,750. The crime rate is high and many residents live in a deteriorating housing project that is scheduled for demolition. There is no place to buy fresh food. There is a recreation center with artificial turf for basketball and soccer. Access is mostly by car, but there is a Metro stop near the recreation center. Walking in the neighborhood is considered unsafe because of the high crime rate.
Friendship Heights
There is one private not-for profit hospital in ward 3 where Friendship Heights is. There are multiple other hospitals in Northwest DC where Friendship Heights is located. There are numerous primary care clinics nearby and access is easy. Over 80% of residents have employer sponsored health insurance. Health literacy is high. More than 85% of residents over age 25 have a bachelors degree or higher. The median annual income is $168,414. Most residents own their own homes. 67% of the residents are white and only 6% black. The crime rate is low, violent crimes only 6% higher than the national average. There are multiple grocery stores offering fresh food including Whole Foods, Rodman, and Amazon Fresh. There is a recreation center that offers multiple opportunities for outdoor exercise. Walking in the neighborhood is considered safe.
Structural Racism
Across the country, zip codes that have low life expectancy at birth have majority black or native american populations. In fact, the lowest life expectancy at birth in the country is in Stilwell, Okla., Census Tract 3769. This is a primarily Native American neighborhood with greater than fifty percent child poverty. The life expectancy at birth there is 56!
It is no accident that African Americans and Native Americans are concentrated in communities with high levels of poverty, lack of access to health care, poor access to education, high crime rates and live in deteriorating housing, most not owning their own homes. The following is a quote from an article in the New England Journal of Medicine. Here is a link to the whole article: How Structural Racism Works — Racist Policies as a Root Cause of U.S. Racial Health Inequities.
“In 1933, the federal government established the Home Owners’ Loan Corporation (HOLC) to expand homeownership as a part of recovery from the Great Depression.8 To guide determinations of mortgage-worthiness, HOLC created maps of at least 239 U.S. cities. Using racial composition as part of its assessment, HOLC staff literally drew red lines (hence “redlining”) around communities with large Black populations, flagging them as hazardous investment areas whose residents would not receive HOLC loans. Redlining made mortgages less accessible, rendering prospective Black homebuyers vulnerable to predatory terms, thereby increasing lender profits, reducing access to home ownership, and depriving these communities of an asset that is central to intergenerational wealth transfer. “
In addition to this federal policy establishing structural racism, many majority white communities instituted restrictive covenants preventing homeowners from selling their homes to African Americans. Although red lining was officially ended by the fair housing act in 1968, the damage was already done. Most African Americans and Native Americans were already too poor to live anywhere else.
Although structural racism is not listed among the CDC social determinants of health, it is obviously the largest underlying factor in zip codes or census tracts that have low life expectancy at birth.
The Blame Game
Instead of recognizing social inequities as the root cause of most ill health in the US, clinicians (as well as most of the rest of us) focus on changing individual behaviors. The person with diabetes who does not stick to the diet we prescribe gets labeled “non-compliant.” If we asked her we would learn that there are no grocery stores in her neighborhood that sell unprocessed foods, and even if there were, she could not afford them. She is taking care of her three grandchildren because their mother is in jail. She lives in substandard housing and has great difficulty getting transportation to her medical appointments. Managing her diabetes is understandably not high on her priority list!
This kind of scenario plays out again and again in our health care system. We focus on changing individual behavior and get frustrated and angry when most of the time it does not work. Non-adherent (a euphemism for non-compliant, which we don’t use anymore) is a word used all too frequently.
How can healthcare organizations address social determinants of health
The authors of the white paper identified five activities that healthcare organizations can undertake to address social determinants of health. They are: awareness, adjustment, assistance, alignment, and advocacy.
Awareness
The best way for individual clinicians to increase their awareness of the pervasive influence of the social dimensions of health is for them to make home visits. Other team members such as social workers, behavioral health professionals and pharmacists should also make home visits at least on occasion. I made home visits for all the years of my time in practice and I saw for myself how living conditions affect people’s health. Asking people about social determinants of health helps awareness too, but nothing is as powerful as a home visit.
Adjustment
Adjustment means altering the parameters of care to help people overcome barriers to care. An example might be offering telehealth visits for people who have transportation difficulties. This is another opportunity to do home visits when an in person visit is needed.
Assistance
Assistance means reducing social risk by helping people connect with existing community resources. Those could be ride sharing services, FQHC dental clinics, food banks, financial assistance programs or any other existing community resources. Assistance of course requires that members of the team know what those resources are and communicate with them regularly.
Alignment
Alignment means working with existing social resources in the community, helping coordinate their activities and supporting them financially and helping them raise funds from other sources. An example might be working with local groups to coordinate providing healthy meals to people with food insecurity (Check out this JAMA article detailing how many children in the US have food insecurity: Food Insecurity Common Among US Children).
Advocacy
Most important of all is working to change policies to promote equity. Join and support organizations that work for equity. Write or call your congressperson and/or senator to support policy changes that decrease inequity in all the social determinants of health. Health care professionals carry more weight than they realize with city councils and legislators. Use that influence! Your congressperson should know who you are!
Bottom Line
Your zip code determines your fate and how long you will live. That is caused by vast inequity in the social determinants of health. Stuctural racism is at the root of much of this inequity. We should all consider this unacceptable. It is up to every one of us to advocate for polices that reduce inequity. We all should have at least some of the things people enjoy in Friendship Heights.
