Obesity

As I wrote about yesterday, new research in PLOS ONE suggests that sugar may play a stronger role in the origins of diabetes than anyone realized. Countries with more sugar in their food supplies have higher rates of diabetes, independent of sugar’s ties to obesity, other parts of the diet, and several economic and demographic factors, the researchers found.

Although the study focused on diabetes rates among adults aged 20 to 79, it got me thinking about children’s health. Type 2 diabetes, which accounts for 90 percent of adult cases and is tied to obesity, used to be unheard-of in kids. But over the last few decades, it has been showing up in many more children and teens at younger and younger ages. Meanwhile, reducing kids’ sugar intake is already the focus of several preventive-health efforts, such as campaigns to remove sugary drinks from schools and children’s hospitals.

To get some perspective on how the new findings apply to children, I turned to Thomas Robinson, MD, a Stanford pediatric obesity researcher who directs the Center for Healthy Weight at Lucile Packard Children’s Hospital. Though Robinson, also a professor of pediatrics at the School of Medicine, cautioned that the epidemiological, “10,000-foot view” given by this study doesn’t prove a cause-and-effect link between sugar and diabetes in individuals - “it does not prove that the amount of sugar an individual eats is related to his or her diabetes risk,” he said - he had lots to say about the new results.

What do you think the findings mean for children’s health?

Children’s behaviors and environmental exposures have an impact on adult health and disease. This study used sugar data for entire countries, not individuals. That means that both the children and the adults were living in countries where higher levels of sugars in the food supply were associated with higher rates of diabetes. The potential implications are even stronger for children than adults. Children are being exposed to that environment for a much longer time. This is particularly a problem in developing countries where their food supplies, diets and weights are changing so rapidly.

A number of us here at Stanford focus on what we can do in early life, and throughout the lifespan, to prevent diseases that have origins in childhood but only first become apparent in adulthood. One can consider our work on obesity, physical activity, sedentary behavior and nutrition in children as really the prevention of diabetes, heart disease, many cancers and other chronic diseases in adults.

What factors has prior research identified as the biggest contributors to the increase in diagnoses of type 2 diabetes in pediatric patients?

The biggest contributor identified has been increased weight, but the increasing rate of type 2 diabetes at younger and younger ages probably reflects obesity plus lots of different changes, including changes in our diets, such as more sugars and processed foods, and less physical activity. The CDC now projects that 1 in 3 U.S. children will have diabetes in their lifetimes, and it will be 1 in 2 among African-American and Latina girls. That is a pretty scary thought. That is why we focus so strongly on helping families improve their diets, increase activity levels, and reduce sedentary time. We want to prevent and control excessive weight gain and all the problems that go with it, of which diabetes is just one.

In light of the new findings, do you think that parents whose children are not obese should be concerned about how sugar consumption could raise their children’s diabetes risk?

This study doesn’t really address the question of what happens at the level of an individual child. However, it is still consistent with the advice we would give now, for both normal weight and overweight children. I definitely recommend that parents try to reduce sugars in their children’s diets. Most parents are not even aware how much sugar their children are eating. Sure, sodas and sweets are the obvious sources but sugars are also added to seemingly all processed foods, including even bread, pizza and French fries. The added sugars are just empty calories — providing extra calories and no additional nutritional benefit. So I recommend that all parents try at least to reduce the obvious sources of sugary drinks, sweets and desserts.

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Sugar consumption and diabetes risk may be more closely linked than anyone realized.

For years, research has supported a roundabout path from excess sugar intake to type 2 diabetes. Eat too much of anything, including sugar, and the resulting weight gain raises your diabetes risk, the theory goes. There’s lots of evidence to support this pattern, but also a big hitch: A small but noteworthy proportion of people with type 2 diabetes aren’t overweight or obese. And up to 40 percent of normal-weight people show signs of the metabolic syndrome, a constellation of metabolic disturbances that predisposes people to diabetes.

So what’s going on? New epidemiological evidence, published today in PLOS ONE, suggests that sugar intake may be directly associated with diabetes risk. This research doesn’t refute the sugar-to-obesity-to-diabetes pathway; instead, it suggests that eating too much sugar promotes diabetes in more than one way.

The researchers, who are from Stanford, UC-Berkeley and UC-San Francisco, analyzed a decade’s worth of data on sugar availability in the food supplies and diabetes rates in the populations of 175 countries. They used new statistical methods derived from the field of econometrics to control for several factors that could provide alternate explanations for the relationship between sugar intake and diabetes, including obesity, overweight, sedentary behavior, other calorie sources, and a long list of socioeconomic measures. The statistical controls were more sophisticated than those typically used in biomedical research, the study’s lead author, Sanjay Basu, MD, PhD, explained to me when I interviewed him about the findings. (And for those who want more information about the statistics, Basu has written an interesting post on his personal blog to explain the methods in detail.)

After all the statistical crunching was done, the research showed that every 150-calorie increase in available sugar was associated with a 1 percent increase in the population’s diabetes rate. A 12-oz soda contains about 150 calories of sugar.

From our press release on the study:

Not only was sugar availability correlated to diabetes risk, but the longer a population was exposed to excess sugar, the higher its diabetes rate after controlling for obesity and other factors. In addition, diabetes rates dropped over time when sugar availability dropped, independent of changes to consumption of other calories and physical activity or obesity rates.

The findings do not prove that sugar causes diabetes, Basu emphasized, but do provide real-world support for the body of previous laboratory and experimental trials that suggest sugar affects the liver and pancreas in ways that other types of foods or obesity do not. “We really put the data through a wringer in order to test it out,” Basu said.

…

“As far as I know, this is the first paper that has had data on the relationship of sugar consumption to diabetes,” said Marion Nestle, PhD, a professor of nutrition, food studies and public health at New York University who was not involved in the study. “This has been a source of controversy forever. It’s been very, very difficult to separate sugar from the calories it provides. This work is carefully done, it’s interesting and it deserves attention.”

Previously: Nature/nurture study of type 2 diabetes risk unearths carrots as potential risk reducers and Fighting a fatalistic attitude toward diabetes
Photo by La Piazza Pizzeria

When it comes to losing weight, the current process for assessing calories is flawed. That’s the conclusion of a panel of researchers who convened at the annual meeting of the American Association for the Advancement of Science to discuss how misleading calorie counts affect the human diet.

The method, known as the Atwater system, calculates the available energy in foods. But, as a story today in Wired points out, the system doesn’t account for calories used to digest food, the possibility that bacteria in the digestive track may absorb some of the energy in foods, or the fact that foods in different forms, cooked vs. raw or ground vs. whole grain, are digested at different rates.

From the piece:

Why does all of this matter? Because we’re in the midst of an obesity epidemic and counting calories has been misleading, said David Ludwig, a pediatric endocrinologist at Children’s Hospital Boston and Harvard Medical School. How the body processes different foods in different ways matters. “The quality of calories is as important as the quantity of calories.” While others not on the panel welcome applying “the best science” to the problem of weight loss, they also provide a word of caution about getting too worried about precise calorie counts. “You can put a ton of effort into getting more accurate calorie counts,” says nutrition scientist Christopher Gardner of Stanford University in Palo Alto, California. “But why are you doing this? Will it make a real difference? If you want to lose weight, you still have to cut back on calories.” A few calories here and there may not matter to most people. But to the panel members, every little bit counts.

Previously: Cooked food, calorie counts and food labels
Photo by Jason Tester Guerrilla Futures

When you reach for a late-afternoon snack today consider halving the portion size. New research from Cornell University shows that doing so will leave you equally satisfied while reducing your daily calorie intake.

In the study (subscription required), researchers divided participants into two groups and gave each different portion sizes of snacks. One group was given 100g of chocolate, 200g of apple pie and 80g of potato chips. These portions were all slightly bigger than the recommended sizes, and the total snack equaled 1370 calories. The second group was provided with 10g, 40g, and 10g of these same foods respectively, for a total of 195 calories. Both groups were given as much time as needed to eat the snacks, and afterwards, individuals rated their hunger and craving before the snacks were presented and 15 minutes after eating the food.

As Science Daily reports, study results showed:

… smaller portion sizes are capable of providing similar feelings of satisfaction as larger ones. Those given larger portions consumed 77% more food, amounting to 103 calories more, but they did not feel any appetite enhancing or stronger feelings of satiety than the group with the smaller portions. Overall these findings reflect the importance of portion size. While larger portions result in increased food intake, smaller portions may make you feel equally satisfied. The smaller portions can lead to a decline in hunger and desire that would help people limit their food intake.

Previously: Can edible “stop signs” revive portion control and curb overeating?, Stanford nutritionist offers guidelines for eating healthy on the go, Is frequent snacking to blame for Americans’ growing waistlines? and The dark side of “light” snacks: study shows substitutes may contribute to weight gain
Photo by Melissa Wiese

I’m a few days late to this, but a writer with the Columbia Journalism Review has some great things to say about ChopChop, a new children’s magazine that is “beautiful and engaging” and “empowers kids to cook and eat healthy foods, offers recipes even adult foodies will love, and aims to help reduce childhood obesity…” (Indeed, curtailing obesity is part of the publication’s mission statement.) Trudy Lieberman writes:

ChopChop is the brainchild of cookbook author Sally Sampson who was casting about for ways to use her skills to do something about obesity. She approached Dr. Barry Zuckerman, chief of pediatrics at Boston Medical Center, who loved her idea and suggested it was a natural for pediatricians’ offices. And so ChopChop was born three years ago with an initial print run of 150,000. (The Boston Globe ran a business page story soon after the magazine debuted). Today its circulation is half a million with a new distribution strategy. “We changed the model to be where kids are,” Sampson said. That means schools, community centers, Boys and Girls Clubs, and other groups that serve low-income children. Half the magazines go to doctors’ offices and organizations and the rest are bulk sales. Of course, the public can buy a subscription too.

Sampson wants to “change eating habits one bite at a time” and encourage families to eat together. She believes people don’t cook anymore, but if kids can bring the magazine home and ask “can we roast carrots,” that’s a step in the right direction. The fall issue featured a family dinner and showed a family dining on roast chicken with roasted root vegetables like onions, carrots and sweet potatoes. There was a recipe for basic chicken soup that encourages the kids to use left over chicken and offers riffs on the soup—curried chicken soup, tortilla soup, tortellini soup.

Lieberman also points out how important this type of thing is from a policy perspective:

…In America, where more than one-third of adults and 17 percent of children are obese, stopping obesity in kids long before they become young adults with health problems is crucial. Efforts like ChopChop’s are significant. Illness and death resulting from too much of the wrong foods contribute mightily to the growing US health care bill threatening the stability of government programs like Medicare and Medicaid and contributing to the high insurance premiums the rest of us must pay.

Previously: Can cooking classes help curb childhood obesity?, Children and obesity: What can parents do to help?, Smaller plates may be a tool to curtail childhood obesity and Obesity in kids: A growing and dangerous epidemic
Via @TEDMED
Photo by andrewmalone

Teenagers get an average of 3,339 texts a month, according to data from Nielsen consumer research group. In light of this data, researchers investigating how to best leverage this technology to educate kids on nutrition and fitness.

To better understand how healthy text messages could help improve teens’ eating and exercise habits, University of Arizona researchers conducted a yearlong trial involving 177 teens to identify their preferences for content, format, style, origin, frequency and mode of delivery. Study results revealed that telling teens what to do, using phrases such as “you should” and “never,” and texts introduced by the words “did you know” were unpopular. Age-relevant information, fun facts and trivia were well received. Futurity reports:

Texts the teens liked best included those that specifically referenced their age group, such as, “American girls aged 12-19 years old drink an average of 650 cans of soda a year!”

They also liked messages that were interactive, like fun quizzes; messages that were actionable, like simple recipes; and messages that included links to websites where they could learn more about a topic if desired.

The teens also appreciated the occasional fun fact not necessarily related to health – some bit of trivia they could share with their friends, like the fact that carrots were originally purple or that ears of corn have an even number of rows.

Beyond such content preferences the study showed teens didn’t want to be inundated with information and said about two texts a day was sufficient. Researchers say the findings could pave the way for the development of text message-based health prevention programs geared toward teens.

Previously: Study says nearly 40 percent of American children’s diet consists of empty calories and Are sports drinks healthier than sodas? Study shows teens think so
Photo by Karin Vlietstra

Past research has shown that primary care physicians feel under qualified and unprepared to provide weight-related counseling. The need to better educate doctors on how to advise patients about making healthy lifestyle changes could be a key factor in why few physicians offer weight counseling, despite an uptick in the number of overweight and obese Americans, according to findings recently published in Medical Care.

In the study (subscription required), Penn State researchers examined data from the National Ambulatory Medical Care Survey for the years 1995-1996 and 2007-2008. The survey collects information about the provision and use of outpatient medical care services in the United States. The 2007-08 data was the most recent available at the time of the study. Researchers selected the two time periods because the survey structure was similar for better comparisons. Futurity reports:

More than 145 million adult Americans are overweight or obese. Despite the current obesity epidemic, patients seen in 2007-2008 had 46 percent lower odds of receiving weight counseling, with counseling occurring in only 6.2 percent of visits in that year. At the same time, the percentage of adults who were overweight or obese increased from 52.1 percent in 1995 to 63.3 percent in 2008.

“It is striking that the odds of weight loss counseling declined by 41 percent, with only 29.9 percent of obese patients receiving counseling in 2007-2008, given the substantial increases in the rates of overweight and obesity during that time,” says Jennifer Kraschnewski, assistant professor of medicine at Penn State.

Patients with high blood pressure were 46 percent less likely to receive counseling, and diabetes patients were 59 percent less likely. “People with these conditions stand the most to gain from the weight counseling,” Kraschnewski says.

Researchers say that beyond doctors’ perceptions that their training for lifestyle counseling is inadequate the barriers for physicians to offer weight counseling also include pessimism that patients can change and time limitations during appointments.

Previously: Stanford forum on how food policies affect our nation’s obesity rates posted online, A call to support, not shame, obese people and Four states examine their cultural environment to reduce obesity rates
Photo by USACE Europe District

Two weeks ago, the Stanford Health Policy Forum hosted an event examining the reasons why we get fat and how different diet trends and food policies affect our nation’s obesity rates. The forum featured a conversation between science writer Gary Taubes and Christopher Gardner, PhD, director of Nutrition Studies at the Stanford Prevention Research Center. During the discussion, Paul Costello, the medical school’s chief communications officer, talked to Taubes and Gardner about Americans’ misconceptions about food, diet and nutrition, the driving forces behind the obesity surge of the late-80s and the path to a healthier, leaner lifestyle.

Previously: Forum to focus on how food policies affect our nation’s obesity rates, Four states examine their cultural environment to reduce obesity rates and Examining why instilling healthy eating and exercise habits in children may not prevent obesity later in life

A recent Peninsula Press story highlights the success of Stanford GOALS and other East Palo Alto, Calif.-based programs in helping promote healthier lifestyles and reduce childhood obesity rates in the low-income community. Kristina Krohn writes:

A team of researchers including Dr. Dana Weintraub, a clinical assistant professor in pediatrics at Lucile Packard Children’s Hospital, has enrolled more than 100 kids [in the Stanford GOALS program] since September and is still recruiting. The seven-year study, which accepts only children whose BMI is greater than the 85th percentile, combines after-school team sports with home visits to promote a healthy diet.

Information collected by area school districts shows that nearly 42 percent of East Palo Alto fifth-graders were overweight or obese during the 2010-11 school year, compared with 24 percent of their peers throughout San Mateo County. Physicians and community leaders, however, point to evidence that a pattern of rising weight gain in the city appears to be leveling off.

Elizabeth Baca, MD, a clinical instructor at Lucile Packard Children’s Hospital, emphasized that reducing childhood obesity in East Palo Alto will involve a comprehensive approach that addresses nutrition, exercise and safety, saying, “Its not just one magic thing or we would have done that by now.”

The above video produced by Stanford student Adelaide Oneal captures the efforts of another nonprofit, Collective Roots, which operates at the East Palo Alto Farmer’s Market and offers community-based cooking, gardening and nutrition classes.

Previously: Doctors tackling child hunger during the summer and Seniors help build a blueprint for a healthier city

Encourage people to be healthier, while not shaming them for their weight? Seems pretty un-provocative (and reasonable) to me, but as CommonHealth’s Carey Goldberg writes today, an essay from Stanford Medicine X presenter Esther Dyson seems to have “touched a nerve” with readers. Take a look at the Slate piece and see what you think.

Previously: Forum to focus on how food policies affect our nation’s obesity rates, Examining why instilling healthy eating and exercise habits in children may not prevent obesity later in life and Four states examine their cultural environment to reduce obesity rates