Is obesity genetic?

While lifestyle contributes substantially more to risk of cancer (and other chronic diseases) than genetics alone, the interplay between genetics and lifestyle is a subject of increasing interest. That's what makes a new study out of the UK, published in PLoS Medicine so exciting.

The researchers took 12 genetic mutations that had previously been found to be associated with obesity risk and examined how they combined to be associated with risk of weight gain. The presence of each additional mutation increased risk of weight gain -- the more mutations, the greater the risk. The mutations significantly increased the risk of obesity by 16%. The researchers then did something quite novel, using the data the participants reported about how physically active (or not) they were, the researchers re-examined the associations. In the inactive men and women, the association was stronger than in the inactive people. What this means is that the effect of genes were stronger in the people who were inactive - or - that physical activity "erased" some of the genetic predisposition - about 40% of it.

What does this mean for those of us who have no idea how "genetically predisposed" we might be to obesity? Physical activity has benefits for everyone, but for individuals who are genetically predisposed to obesity, physical activity is especially important. It also means that a genetic predisposition to obesity isn't cause for "doom and gloom" - there ARE things you can do to counter it - notably, being physically active!

Medicare: putting their money where the evidence is

On Friday, the federal government announced that effective immediately Medicare would cover the cost of smoking cessation counseling. Anyone covered by Medicare will be able to receive tobacco cessation counseling from a qualified physician or other Medicare-recognized practitioner who can work with them to help them quit. (All people with Medicare will continue to have access to tobacco cessation prescription medication through the Medicare Prescription Drug Program.)

This is great news on several fronts:
- there is great evidence for the value of this kind of coverage so it is nice to see the goverment implementing evidence-based medicine
- other insurers typically follow what Medicare does
- it keeps tobacco in the news - an issue we've discussed before

The price we pay for obesity: diabetes drives hospital costs

The Agency for Healthcare Research and Quality reported yesterday (see full report) that 1 in 5 hospitalizations in 2008 involved a person with diabetes. This amounted to 7.7 million hospital stays at a cost of $83 billion in just the hospital costs. Diabetics had hospital stays that were longer, on average, and more likely to originate in the emergency department than stays for patients without diabetes. While diabetes was the indication for hospitalization, many of these patients were admitted with circulatory disorders or complications due to their diabetes.

Why this matters

Medicare covered almost 60% of the total hospital costs for these diabetic patients. So we all paid our share.

Second, diabetes is driven by obesity and lack of physical activity, with poor diet adding further risk. We have previously shown that the vast majority of diabetes in adults is preventable. This is supported by randomized trial evidence that weight loss reduces incidence of diabetes.

Importantly, we have discussed the role of diabetes and obesity as causes of cancer, yet another cost to society.  These disease and their costs are avoidable through prevention.

Context

So while the pattern of hospitalization for diabetes tracks the CDC maps of obesity – higher rates of hospital sat in the South, the cost to society of not acting to prevent adult weight gain and the ensuing health consequences is adding enormously to the costs of our health care system. We have the strongest evidence that weight control can avoid many of the complications of overweight and obesity, not just diabetes but also cancer and heart disease.

Action

Following the steps we outline can prevent cancer now. We need to increase our focus on weight control at the clinical level of primary cancer; at the policy level through strategies that can make activity a part of our everyday lives (and reinforce these behaviors once we all adopt them); and through our communities and schools so that we all move to a healthier lifestyle before our hospitals buckle and collapse under the weight of obese diabetic patients.

State policies drive cancer burden

Recent media reports highlight how a lack of state policy on cigarette taxes can drive a state to have high cancer rates. Missouri is a fine US example which now has the lowest tax on cigarettes in the nation (17 cents per pack).

State level policy impacting cancer is not limited to just cigarettes and increased burden from smoking-related cancers, however. With reductions in resources available to the state, Missouri cut back funding for the Breast and Cervical Cancer Screening Program (in Missouri called Show Me Healthy Women). This added t to the existing language in qualifying for treatment after diagnosis among women without health insurance leads poor rural areas to have low breast cancer incidence (lack of screening) and high mortality. This morality is driven by late stage at diagnosis and limited access to current standard quality of care for breast cancer.  Maps at the county level show rural Missouri dominates the state with high cancer mortality.

If we are to overcome disparities in access to detection and care for cancer patients, then state policies must foster access for all. Access has to be not only for detection methods (breast, cervix, and colon cancer screening) but also to effective programs to aid cessation from smoking.  Programs must also seamlessly link those diagnosed with cancer to effective care.

Superbad? The Problem with "Superfood" Lists

Today I hopped over to Forbes.com to review their "most stressful cities" list (and was relieved that St Louis wasn't topping another "bad" place to live list -- I think topping the syphilis list is enough). While I was there, a link to a list of "10 foods you should be eating" caught my eye. I'm always wary of such lists, and this one provided a nice reminder of why:

The list starts out with three great foods - cherries, blueberries and kiwi. All three are great choices because they are fruit and eating a lot of fruits and vegetables have been shown to decrease risk of several diseases, including cancer. The problem, to me, is that most Americans don't come anywhere near to eating enough fruit, regardless of the type. Also, the three fruits are in season for a pretty short period of time, making their cost pretty high the rest of the year. Add to that, the fact that berries tend to top lists of fruits that absorb the most pesticides, so other lists are telling you to only buy organic and you've got a major cost issue on your hands. For most people, just starting to eat 2-3 servings of fruit a day, of ANY fruit, is going to be a big step.

The list then moves on to proteins -- grass-fed beef, wild salmon, flax seed and whey protein powder. While I certainly see the merit of choosing grass-fed beef over industrial beef for the reasons listed (omega-3 content being a big one, environmental impact being another), the context is missing here. Grass-fed beef is expensive and most Americans eat too much red meat of all kinds and certainly don't need beef appearing on a list of things they need more of. If you want to up your omega-3 intake, replace your meat intake with other sources of protein rich in omega-3, like fish and flax seed and aim to reduce your meat intake in general.

The list ends with dark chocolate. With overweight and obesity rates topping 60% in the US, I don't think anyone needs encouragement to eat more chocolate. Granted, the fine print suggests looking for chocolate with at least 60% cocoa content (ruling out most candy bars in the checkout aisle), but portion size and frequency of intake are big issues here and neither is mentioned.

Also overlooked in the discussion is that much of the data supporting the "superfood" concept don't come from studies of people eating those foods. The data come from studies of human cell lines or of extracts of a single component/nutrient that the food is high in. The problem with these studies is 1) that flesh and blood humans are very different from a collection of cells in a petri dish and 2) that the volume of intake needed to reach the dose given to the cells or extracted and given to humans is difficult to achieve through consumption of the food itself.

So, the cold reality is that there are no real "superfoods," just like there are no magic bullets.  It's simply a title dreamed up by magazine editors or folks who don't have a good understanding of the science linking diet and human health.

Of course, overall diet can have a large impact on chronic disease, and making simple, largely inexpensive, changes to what we eat can have big benefits.  Eating a diet rich in fruits, vegetables, whole grains, and healthy fats (like poly and monounsaturated fats); and low in red meat and unhealthy fats (like saturated and trans) will trump any collection of "superfoods" when it comes to health benefits, and it'll likely save you a lot of money along the way.

I wonder if by suggesting that people need to go spend $30 on organic blueberries and eat chocolate to be healthy we actually encourage the status quo as so few people have the ability to spend at this level and so few read the fine print of the message? What do you think? Do these lists help you make healthy choices or confirm that you are/aren't healthy already?

Carrots, Sticks, and the Potential Benefits of Health Incentives

It's a common theme here at Cancer News in Context - the important role our social and physical surroundings play in our health choices (previous posts).  The current issue of CDC's journal, Preventing Chronic Disease, is devoted almost solely to one aspect of this: creating incentives for individuals or communities to make positive health choices.  Because as we all know, sometimes it takes a little push - a view of that carrot on the stick - to actually take the steps we know we should.  

Discussed in the articles, which were penned by researchers and scientists involved in Robert Wood Johnson's MATCH (Mobilizing Action Toward Community Health) program, are incentives that range from financial (like, pay-for-performance) to reputational (like, community health rankings) to legal.  

By developing such incentives and studying them closely to determine which ones work and which ones are best left on the shelf, the ultimate hope is to not only effect a broad, positive change in populations but also ultimately shift the balance of the health care focus in the US much more towards prevention than it is right now.  

It's a tall order, but the benefits (apart from the carrots) could be huge.

Full issue

Summary podcast

Preventing Cancer: It's this easy...and this tasty.

In previous posts, we’ve talked about implementing the weekday vegetarian plan or moving from your farm share box to a meal plan. For those who don’t have a big pile of recipes in the kitchen (or who are at work trying to figure out what to make for dinner that night), the internet is a GREAT resource for just this type of meal planning.

Last week I realized I had a bunch of eggplant from my farm share that I needed to use up. I was at the office, so on my lunch break (of course), I went to a few of my favorite websites for recipes using eggplant. On Smitten Kitchen, I found a recipe for an eggplant and barley salad. I looked through the ingredient list to see how it aligned with my recipe goals:

- Whole grains? Yes – the recipe base is barley, a tasty whole grain. I think you could also substitute brown rice if that’s what you have, but we always have barley in the freezer (which helps keep it from going rancid in the sweltering swampy summer heat of St. Louis).

- Vegetables? YES! In addition to eggplant, the recipe calls for zucchini and tomatoes. Both are in season and were looking fantastic at the Washington University School of Medicine Farmer’s Market last Thursday so I grabbed both.

- Color? Lots of it! Nothing makes a healthy dish less appetizing than a sea of drab brown colors. But Deb’s recipe is full of color – green (zucchini and lots of fresh herbs), red (tomato), purple (red onion, eggplant and olives)

And of course, the ultimate test was the taste – which was delicious. I scaled back the oil, salt and sugar by about half and skipped the cheese and thought the result was fantastic.

Knowing that I was going to make this on the weekend and that my husband would appreciate some meat after a week of delicious meatless meals, I headed over to another favorite website, One Hungry Mama, for some ideas. I’ve found that one of the keys to keeping my sanity when cooking family dinners is to focus on one dish and keep everything else simple. Since the barley salad had a good amount of chopping involved, I was looking for a main course dish that involved little to no effort. As usually happens, Stacie had the perfect option – slow cooker ribs. While ribs aren’t appearing on any “healthy living” list anytime soon, they are a fine “occasional” food, particularly if that is your only red meat for the week! I’d never thought to do ribs in the slow cooker before but the ability to drop them in and forget them was hugely appealing. And, as Stacie notes, the slow cooker is a great resource for hot summer days when you don't want to turn on the oven (see above). My family’s favorite barbeque sauce isn’t sold in stores around here (hint hint Dinosaur guys), but thankfully, they have a cookbook that includes the recipe for their Mutha sauce. I like to cook up a batch at the beginning of summer and freeze it in 2 cup portions. Since I still have a bit left, I decided to use that instead of Stacie’s Asian BBQ sauce recipe (that I’m hoping to try another day). I knew I’d want to throw the ribs on the grill at the end as Stacie suggests to get that nice crisp edge so I scaled back the sauce I put in the slow cooker to about one cup (the sugars in barbeque sauce will burn on the grill and you’ll get too much char). When the ribs were done in the slow cooker (perfectly cooked, falling off the bone), I slathered a tad more sauce on them (about ¼ cup) and put them on the grill for about 3 minutes. When I took them off, I slathered on another 1/3 cup of sauce and served the rest on the side.

Last, I took some gorgeous sweet corn I picked up at the farmer’s market and cooked that. It was a great summer meal – full of flavor, whole grains and vegetables.