Michaela Kiernan

All of us who have struggled with our waistlines over the years know that sometimes losing weight isn’t the hardest part. Keeping it off is.

But an approach that sounds a bit odd might be the solution: Before you try shedding any pounds, learn the skills that will help you maintain your weight.

In a study published today in the Journal of Consulting and Clinical Psychology, researchers at Stanford’s medical school reported that women who spent eight weeks mastering weight-maintenance skills before embarking on a weight-loss program shed the same number of pounds as women who started a weight-loss program immediately. More importantly, the “maintenance-first” women had regained only 3 pounds on average a year later, compared to the average 7-pound gain for the immediate dieters.

“Those eight weeks were like a practice run. Women could try out different stability skills and work out the kinks without the pressure of worrying about how much weight they had lost,” lead author Michaela Kiernan, PhD, senior research scientist at the Stanford Prevention Research Center, said in our news release about the study.

Among the weight-maintenance skills the women learned were:

• Searching out low-fat or low-calorie foods that taste as good as high-fat/high-calorie options to avoid feelings of deprivation.
• Occasionally eating and savoring small amounts of favorite high-fat/high-calorie foods.
• Weighing daily to see how their body weight naturally fluctuates from day to day.
• Identifying a personalized weight-fluctuation range of about 5 pounds to account for common disruptions, such as water gain and vacations.
• Strategically losing a few pounds before a known disruption (such as a vacation) to minimize its effects.
• Eating a little more when reaching the lower limit of the personalized 5-pound range.

Kiernan said the maintenance-first approach, though sounding a bit unorthodox, could be a useful tool for those who are trying to slim down and be healthier. “This approach helps people learn how to make small, quick adjustments that can help them maintain their weight without requiring a lot of effort,” she said.

You can also listen to this podcast with Kiernan as she explains the study.

Discussions about U.S. health-care reform have largely focused on broadening insurance coverage. That’s unfortunate, says a Stanford researcher, because we should spend more time looking for ways to truly improve health.

Randall Stafford, MD, PhD, professor of medicine at the Stanford Prevention Research Center, says the health-care system needs to be re-engineered to help people stave off conditions like obesity and diabetes in the first place.

“Increasing health-care coverage has the potential to make the inefficiencies of the current system more visible and worsen the current financial stresses in the system,” Stafford says. “We need to think about more fundamental changes in the way that health care is delivered.”

Stafford lays out his position in this perspective piece published in the Sept. 6 issue of the New England Journal of Medicine. He and co-author, Farshad Marvasti, MD, MPH, an adjunct clinical instructor of medicine, write that although policy-makers have highlighted the need to develop better methods of preventing disease, “efforts to expand prevention continue to be thwarted by a system better suited to acute care.”

They point out that the current model for medical care arose 100 years ago when people didn’t live as long and infectious diseases caused large numbers of deaths. Laboratory research helped develop treatments and technologies to combat these diseases, and a payment structure evolved that compensated doctors for prescribing pills and procedures to treat the conditions.

But the picture has changed drastically today. More Americans are living longer and are dealing with the results of progressive, chronic diseases brought on by factors such as smoking and obesity. Yet the health-care payment structure hasn’t adapted. Strategies for preventing disease — such as coaching patients on how to make meaningful changes that will enhance their health — may be cost-effective, but they can’t be patented or made profitable, which gives researchers little incentive to explore the field, the authors write.

And the way doctors are trained must change as well, Stafford and Marvasti write. Medical students should be taught disease-prevention strategies, and residencies in primary care should be shifted away from hospitals (where acutely ill patients are treated) into alternative settings, such as “medical homes” where a full team of health-care professionals work with patients and their family members to get the care they need at the appropriate time.

These kinds of wholesale changes to encourage disease prevention are “the only way to thwart the emerging pandemic of chronic disease,” they write.

Previously: Does the Affordable Health Care Act address our health-cost problem?, Physician organizations offer free curriculum to educate medical students on reducing health costs
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Using aspartame or stevia instead of sugar will help you lose weight, right? Well, the answer isn’t quite so simple. A scientific statement released today by the American Heart Association and the American Diabetes Association shows that there’s inconclusive evidence that non-nutritive sweeteners will help people lose excess weight.

Stanford nutrition expert Christopher Gardner, PhD, who chaired the writing committee for the group that prepared the scientific statement, says the problem is that many people who use the sweeteners end up compensating for those calories later in the day. In short, as a reward for using stevia in their coffee, they reward themselves with a cookie.

In this just-published Q&A, Gardner talks about why non-nutritive sweeteners aren’t more effective in the effort to cut sugar intake. His advice? Stick to eating “real” food and cut down on the sodas and snack food. “There’s no aspartame in broccoli,” he notes.

Photo by Steve Snodgrass

You might want to ask your doctor a few questions the next time he or she hands you a prescription. An interesting commentary in this week’s Journal of the American Medical Association points out that many physicians prescribe treatments for which there is little or no evidence to support their use. Instead, the doctors are simply following long-established prescribing patterns and haven’t checked to see whether there is solid evidence suggesting that the treatment will achieve the desired effect.

John Ioannidis, MD, director of the Stanford Prevention Research Center, is the senior author of the commentary. Check out my Q&A with him, and read why he thinks doctors should “abandon ship” on treatments that aren’t supported by strong evidence. He points out that “trust is likely to be strengthened when patients are more knowledgeable, when they question their physicians about the evidence pertaining to their condition and when physicians give them the full, unbiased picture about this evidence.”

Previously: Convincing physicians to change their prescribing patterns

Stanford nutrition researcher Jennifer Otten and some of the promotional items given away with children's meals.

Do ordinances that restrict the ability of restaurants to give away toys with unhealthy kids’ meals have an impact? A new Stanford study looks at what happened in Santa Clara County in the months after the nation’s first such policy was enacted.

The study, published today in the American Journal of Preventive Medicine, examines the actions taken by a small number restaurants immediately after Santa Clara’s ordinance took effect in August 2010.

Although none of the restaurants in the study added healthier offerings for children, two of the restaurants removed toy marketing posters and two offered toys separately at an additional cost. One restaurant singled out the children’s meals that met the ordinance criteria as “promoting good nutrition” on its menu boards.

“Before, parents had no idea which meals met the nutritional criteria. After the law was implemented, one restaurant made it clear which ones did,” said lead researcher Jennifer Otten. “In addition, there was a clear decrease in toy marketing and advertising at some of the affected restaurants.”

With an increasing number of communities looking at ways to curb the rising rates of childhood obesity, Otten and her team want to gather objective data on the effects of policies like the one in Santa Clara County. “This ordinance gave us the opportunity to study a real-world example of a private-sector response to a public health policy,” she said.

But the effort won’t end there. The researchers surveyed almost 900 families before and after the ordinance took effect to determine whether it affected their fast-food purchases. The team is also collecting data from families and fast-food restaurants in San Francisco, where a similar law took effect on Dec. 1. They plan to publish the findings related to the family surveys and the longer-term restaurant responses in future papers.

Previously: Toying with Happy Meals and Are Happy Meals illegal? A public health lawyer says, yes
Photo by Norbert von der Groeben

As you may have heard, a new San Francisco law forbids fast-food restaurants from giving away toys with children’s meals that don’t meet specific nutritional standards. And, as reported in today’s San Francisco Chronicle, some McDonald’s franchisees have opted to charge customers 10 cents if they want a toy with their Happy Meal. They said they would give the money to a charity.

Judging from the comments on the Chronicle story, many people believe McDonald’s is circumventing the law, which was aimed at making children’s fast-food meals healthier. But while some are calling the law a failure, Jennifer Otten, PhD, doesn’t see it that way. Otten, a postdoctoral scholar at the Stanford Prevention Research Center, has been tracking the legislation in San Francisco as well as a similar 2010 law in Santa Clara County.

“This particular legislation has gotten the conversation going about what we as a society are marketing and feeding to our children,” Otten told me today. “The way McDonald’s is responding invites more conversation.”

Otten’s interest is in evaluating policies aimed at helping families make choices that improve their health in order to see which approaches actually work. “We want to gather data on legislation with the potential to move the public health needle in the right direction,” she said.

Otten has already interviewed more than 500 San Francisco families prior to the implementation of the new law, and she’ll conduct later interviews to determine whether it affected the awareness and choices of parents in buying fast-food meals for their children. She’s already analyzing similar survey data from almost 900 families in Santa Clara County.

As for Otten’s view of McDonald’s actions, she said it appears the franchisees are “complying with the law, but not necessarily the spirit of the law.” But regardless of what the fast-food outlets do, she said these types of policies are part of a bigger movement to identify the best levers for addressing childhood obesity.

Previously: Are Happy Meals illegal? A public health lawyer says, yes
Photo by Pengrin

I still smile when I remember talking with a friend who told me he had quit smoking a few years back. “But I saw you smoking on Saturday,” I reminded him.

After a pause, he murmured that he had given up his daily habit and now only smoked an occasional cigarette when he was feeling stressed. “But you’re still smoking, right?” I said. After another pause, he said, “Well, if you want to look at it that way, I guess I am.”

It just goes to show how strong nicotine’s grip can be, and how hard it can be to truly kick the habit. And it’s toward that goal that researchers at the School of Medicine are launching a study that explores the effectiveness of long-term, one-on-one counseling in helping smokers quit.

For the study, all participants will undergo six months of one-on-one therapy, and will receive smoking-cessation medications. At the end of the six months, the participants will be randomly assigned to one of two groups. The first will continue to receive individual counseling sessions for another six months, while the second will receive monthly follow-up phone calls for the same period of time. My news release gives more details about those who are eligible to participate in the study.

Principal investigator Sean David, MD, DPhil, says most people who try to quit on their own end up failing, and so he and his colleagues are looking for better approaches to help people stay off cigarettes for good.

And the study comes along at an opportune time, since the Great American Smokeout will take place on Nov. 17.

Previously: Can daily texts help smokers kick their nicotine addiction?
Photo by Qfamily

Previous research has shown that menthol cigarettes are more popular among minorities, teenagers and low-income populations. And now a new study from Stanford scientists explores some of the reasons why.

A study published today in Nicotine & Tobacco Research found that tobacco companies increased the advertising and lowered the sale price of menthol cigarettes in stores near California high schools with larger populations of African-American students.

Although cigarette makers have denied using race or ethnicity to target customers, the Stanford researchers say the data shows a “predatory” marketing pattern geared toward enticing young African Americans into becoming smokers.

For instance, lead researcher Lisa Henriksen, PhD, pointed out that for every 10 percentage point increase in the proportion of African-American students at a school, the per-pack price of Newport (the leading brand of menthol cigarettes) was 12 cents lower. However, the prices for the leading non-menthol brand weren’t affected by school demographics.

“That’s important because lower prices tend to lead to increased cigarette use,” Henriksen said.

The new study comes as the U.S. Food & Drug Administration is gathering information on whether to ban menthol as a flavoring agent in cigarettes. The committee preparing a report on the subject for the FDA will meet in July to consider final changes to its report. There’s no word yet on when the FDA will make a decision on whether to ban menthol.

Previously: Pediatrics group calls for stricter limits on tobacco advertising and Cigarette ads turn teens on to smoking
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I was speaking recently with a friend who, concerned about his father’s health, accompanied his dad to the doctor’s office. The doctor asked his dad how he felt, and the dad replied that everything was fine. That seemed to satisfy the doctor until my friend spoke up, pointing out the weakness in one of his father’s arms as well as increased memory problems. Why wasn’t the doctor better able to spot the father’s problems during multiple visits in recent months, my friend wondered?

Poor patient-physician communication is a problem that many people experience. Philip Pizzo, MD, dean of Stanford’s School of Medicine, has co-authored a commentary on the need for improvements in this area in the Journal of the American Medical Association.

In a Q&A in today’s issue of Inside Stanford Medicine, he talks about the problem, noting that, “Listening to the patient is not the same as simply asking questions and getting answers. It begins with allowing patients to tell their stories - and to have the time to do so.”

Pizzo also addresses the ways that academic medical centers like Stanford can help solve this problem.

What happens when physicians latch onto a “wonder” drug for uses that are distinctly different from its original purpose? Stanford School of Medicine researchers today showcase a clear example of the harm that can potentially be done to patients.

In a pair of studies published in the Annals of Internal Medicine, the Stanford team documents the use of recombinant factor 7a - a powerful clotting drug that was intended for a subgroup of hemophilia patients. However, the researchers estimate that in U.S. hospitals from 2000 through 2008, only 4 percent of the drug’s use was for treating hemophilia patients. A staggering 96 percent of the drug’s use involved cases of heart surgery, trauma, brain hemorrhages and a host of other surgical and medical problems.

The team also found that the use of RF7a increased the risk of blood clots without improving the mortality rates. What’s more, RF7a is pricey - it costs an estimated $10,000 for an average dose.

As first author Veronica Yank, MD, notes in our news release, “The stakes are high with this one. Because it’s such a powerful clotting agent, it has the potential when used off-label to damage the lives of patients without providing any real benefit.”

An accompanying editorial by Harvard researchers commends the Stanford team for providing “compelling data about the runaway use, uselessness and risk for this expensive treatment.”

Yank says she hopes the two studies will prompt physicians and surgeons to be more cautious about the off-label use of RF7a. “Despite the miraculous ability of this drug to stop bleeding, we have an obligation to ‘first do no harm,’” she says.

Photo by Steve Fisch