Senin, 24 Juni 2013

A failure of knowledge marketing: The example of obesity with physical activity

The failure of knowledge marketing: The example of obesity and activity

For the last six weeks, I've been on and off aeroplanes flying between Europe, Africa and the USA for a series of conferences on science, high performance, coaching and more science.  It's been a stimulating and challenging period, one which has entrenched a realisation about the value of sports science that I've been developing for a while now, namely that the effectiveness of science is primarily dependent on how well it is 'sold' to prospective 'end-users', be they coaches, high performance managers, policy-makers in government or athletes.

Today, reading through a few local papers, I came across a report that is the catalyst for some further thoughts on this subject, and below are some of my thoughts on it, which use the specific example of obesity and physical activity, but which are equally relevant to high performance strategies and the delivery of science to elite athletes.

The report described the recommendation of a review led by Baroness Tanni Grey-Thompson into the growing obesity problem in Wales, and its findings can be summarised into one sentence:  Give Physical Education a standing in schools that is comparable to maths and science in order to tackle the obesity problem.

First of all, I must say that I don't think any complex problem can be reduced to a single solution.  It certainly would be part of it, but I believe a similar action was taken in Australia without effect, and that's because changing people's behaviour is never a simple matter of introducing a compulsory change.  Simple solutions are desirable, but rarely effective by themselves.

Granting core status to physical education would apparently cost 5 million pounds per year, which the report argued is trivial compared to the current cost of 73 million pounds spent on obesity and related conditions (This assumes of course that the programme would save 5 million pounds per year on those costs to at least break-even - they may have done these projections, I'm not sure)

This is not a new concept - reviews have recommended prioritizing physical activity before, and I have no doubt they will do it again.  The removal of physical education from schools (as a subject, let alone a core subject) in South Africa is constantly bemoaned as one of the key moments in our own battle with obesity, yet change seems incredible slow.  Similarly, around the world, there is nothing revolutionary about the idea that growing levels of inactivity need to be addressed.  What is revolutionary is actually doing it, which few have.

A marketing challenge - why wouldn't you drink the iced tea?

The biggest challenge when attempting to change behavior and policy, be it high performance sport related, which is my primary interest, or physical activity, such as this illustration of obesity and physical activity, is bridging the gap between people's intellectual understanding and their desire to act upon it.  It is one thing to know a problem exists, and even how to solve it.  Another is making the decision to solve it, and then doing it, particularly when there is a cost attached, and that cost must be weighed up against others in terms of 'leverage', or return on investment.

Yes, one can argue for the potential financial savings when comparing the cost of promotional campaigns and policy changes compared to the cost of obesity and its associated diseases to health care.    Yes, we can provide data that shows how workplace productivity increases with increased physical activity (absenteeism and presenteeism, for instance).  Yes, we can even find relatively short-term success stories with which to inspire change.

But the fact that this debate keeps circling back on itself (the Grey-Thompson review is not the first, and nor will it be the last of its kind to promote physical education in schools) suggests that action rarely follows data or words.

Part of this is because decision-makers often have many interwoven problems to deal with, and they can't (or don't) view a solution to a particular problem in isolation.  Their decision-making process is tangled because of overlapping challenges and the conflict this creates for resource allocation.  Consider for instance the response to the Grey-Thompson report by one senior figure in Welsh education:

"Dr Philip Dixon, director of education union ATL Cymru, warned that literacy and numeracy was of most pressing concern in Wales and overloading the curriculum with core subjects could prove counterproductive"

In other words, physical activity is one of many concerns, and is a lesser problem in the larger scheme of things.  He has weighed up A vs B and decided which requires prioritisation   That is a fair concern, because adding physical activity means, in a 'zero-sum' decision-making world (which it often is), taking away from something else.  Unless an hour a day could be added to the school year, and unless more money could be found, implementation of one solution means another is overlooked or compromised.  This is, as an aside, why talent identification systems in sport are so complex - if you spend more on the selected individuals, it means less on the non-selected players, and vice-versa, making the balance and requirement for selection so important.

However, the case could still be made, and has been, for physical activity, that the benefits are not only large but essential.  With 36% of Welsh children obese (and it's even greater in other parts of the world), and with the cost of diseases associated with obesity sky-rocketing to levels that may cripple health care, you'd think the urgency would exist.

Yet still, decision-makers seem stuck in second gear.  They may know a solution, and even be intellectually aware of its value, but unable to act upon it.  And when I see that, it always strikes me that the likeliest explanation, here in SA anyway, is that the people who hear the message don't fully understand a) their need, or b) its value.  That is a failure of marketing, not science.

If I staggered into your house having been stranded in the desert for 3 days without water, on the verge of death, and you offered me a bottle of iced tea, which I've never tasted, the only circumstances under which I'd refuse it are:

a)  I don't trust you not to poison me with an unfamiliar drink, or;
b)  I don't understand what you are offering.  I have no experience with iced tea, I don't know what it does, tastes like, or why it may be of value to me.  Therefore I decline, because my perception of its value is lower than my awareness of my need for it.

Now, to return to the overlapping decision analogy, imagine you offered me a choice between iced-tea and a wet sponge.  The decision is more complex, because I have to choose between two options.  If you made me pay for it, then it becomes even more complex, because my decision depends not only on the perceived product benefit, but also the cost to me (we make these cost-benefit decisions all the time - early start to your day, running late for work, you might spend $6 on a cup of coffee because it's the only available option, where normally you'd balk at $4)

So it comes down to customer-perceived value, in that people will not 'buy' unless they perceive the value to be greater than the cost.  In a "competitive" market, where they have a choice of purchases, it is even more important to communicate the value (or reduce the cost, of course).

This is, in my experience, the biggest problem facing sports science and its application to high performance teams, coaches and the public.  We can argue with data all we want, we can promote the merits of our ideas, be they scientific analysis of performance, the health benefits of physical activity, the cost savings to health care, or the scientific monitoring of athletes in Olympic competition.  But until the potential customer genuinely recognizes the value, and establishes a deeper, almost emotional connection with it, the data will have minimal impact.  Sports scientists of course have this connection - they are already converts, and cannot imagine how anyone would not see the value.  But this is a little like me not understanding how anyone would prefer BMWs to Audis just because I drive an Audi.

In a competitive market, communication swings decisions, not 'truth'

Last year in September, I attended a conference at which Kenneth Cooper presented some of his data from decades of being involved in physical activity work in the USA.  He showed data that obesity had risen steadily since he founded his Cooper Institute.  Somehow he was claiming credit for helping combat obesity, even though the line of obesity over the years was snaking its way steadily towards the top right of the graph.

Then, a few years ago, the NFL partnered with a few campaigns to promote physical activity in children.  They made use of some recognizable NFL stars and sent the message out to get active, eat better.  The result was the first dent in the obesity growth rate.  And while causation is difficult to infer, Cooper himself acknowledged the impact made by this marketing campaign.  The message I took from that is that all our science, data, knowledge and educational campaigns can be matched by a creative campaign using a method of communication that children really value.

This is the power of marketing.  It is the reason that the 10,000 hour concept is so powerful even among coaches and high performance managers - Gladwell and Syed spun a story around data, not letting the facts get in the way of that story, and it was more effective than published research that said the opposite.  It's the reason Power Balance bracelets catch on like wildfire despite our best attempts as scientists to explain the fallacy in theory and practice behind them.  Conversely, the failure to creatively and accurately market sports science is the reason that so many coaches and high performance managers reject scientific support - they simply do not perceive its value relative to its cost.

My point is this:  As scientists, whether we are involved in sports performance, health and physical activity, education, even conservation of the environment and other scientific pursuits, if we cannot also market the knowledge, then we will be ineffective.  And we will always be vulnerable to decisions and people who do it better, even when their "product" is inferior and their truth, well, untrue.

So the challenge is not merely to know the truth, it is to sell the truth.  That is a difficult balance because salesmanship almost always compromises integrity, which is why I hate advocacy and extremism - it is often the sale mentality that drives it.  But if there is one thing that each individual can change, it is the method of communication of science and its value.

Sometimes, the value is purely financial, in which case the decision will be made based on income, expenses and profit - show the decision-maker how much money they will save by implementing athlete monitoring or physical activity.  On that note, be aware of who makes the decision because your compelling argument may be borderline irrelevant to the person you're talking to.  One of the problems for the advocacy of physical activity in schools is that one of the common arguments is the financial saving because it will reduce the cost of health care.  But education decision-makers are not obliged to care about this, it's not their incentive.  It's a health department issue, so the right message is being given to the wrong people!

Other times, the decision is emotive, bordering on folly, or its the high performance managers' desire to use technology, to do what nobody else can, and the level of evidence is less important than the 'glamour' and innovation behind it.  The challenge for all those reading this who are trying to find a foothold in sport and health as a scientist is to recognize the specific need of the person you are talking to, and offer the right thing to the right person at the right time.  We simply have to do better at marketing our own value.

Hopefully, the decision-makers recognize the value of physical activity.  It'll take a lot more than statistics, however compelling, about cost and benefit, however.  Forgive me if you are already a 'convert' and think all these concepts are self-evident.  I suspect that many reading this are, because it's why you're here!  But in South Africa, and dare I say it in many other places, the value is undersold and sports science scratches its collective head wondering why others don't see the world the way it does!

Ross

Senin, 17 Juni 2013

What is your optimal weight? Maybe it is the one that minimizes your waist-to-weight ratio


There is a significant amount of empirical evidence suggesting that, for a given individual and under normal circumstances, the optimal weight is the one that maximizes the ratio below, where: L = lean body mass, and T = total mass.

L / T

L is difficult and often costly to measure. T can be measured easily, as one’s total weight.

Through some simple algebraic manipulations, you can see below that the ratio above can be rewritten in terms of one’s body fat mass (F).

L / T = (T – F) / T = 1 – F / T

Therefore, in order to maximize L / T, one should maximize 1 – F / T. This essentially means that one should minimize the second term, or the ratio below, which is one’s body fat mass (F) divided by one’s weight (T).

F / T

So, you may say, all I have to do is to minimize my body fat percentage. The problem with this is that body fat percentage is very difficult to measure with precision, and, perhaps more importantly, body fat percentage is associated with lean body mass (and also weight) in a nonlinear way.

In English, it becomes increasingly difficult to retain lean body mass as one's body fat percentage goes down. Mathematically, body fat percentage (F / T) is a nonlinear function of T, where this function has the shape of a J curve.

This is what complicates matters, making the issue somewhat counterintuitive. Six-pack abs may look good, but many people would have to sacrifice too much lean body mass for their own good to get there. Genetics definitely plays a role here, as well as other factors such as age.

Keep in mind that this (i.e., F / T) is a ratio, not an absolute measure. Given this, and to facilitate measurement, we can replace F with a variable that is highly correlated with it, and that captures one or more important dimensions particularly well. This new variable would be a proxy for F. One the most widely used proxies in this type of context is waist circumference. We’ll refer to it as W.

W may well be a very good proxy, because it is a measure that is particularly sensitive to visceral body fat mass, an important dimension of body fat mass. W likely captures variations in visceral body fat mass at the levels where this type of body fat accumulation seems to cause health problems.

Therefore, the ratio that most of us would probably want to minimize is the following, where W is one’s waist circumference, and T is one’s weight.

W / T = waist / weight


Based on the experience of HCE () users, variations in this ratio are likely to be small and require 4-decimals or more to be captured. If you want to avoid having so many decimals, you can multiply the ratio by 1000. This will have no effect on the use of the ratio to find your optimal weight; it is analogous to multiplying a ratio by 100 to express it as a percentage.

Also based on the experience of HCE users, there are fluctuations that make the ratio look like it is changing direction when it is not actually doing that. Many of these fluctuations may be due to measurement error.

If you are obese, as you lose weight through dieting, the waist / weight ratio should go down, because you will be losing more body fat mass than lean body mass, in proportion to your total body mass.

It would arguably be wise to stop losing weight when the waist / weight ratio starts going up, because at that point you will be losing more lean body mass than body fat mass, in proportion to your total body mass.

One’s lowest waist / weight ratio at a given point in time should vary depending on a number of factors, including: diet, exercise, general lifestyle, and age. This lowest ratio will also be dependent on one’s height and genetic makeup.

Mathematically, this lowest ratio is the ratio at which d(W / T) / dT = 0 and d(d(W / T) / dT) / dT > 0. That is, the first derivative of W / T with respect to T equals zero, and the second derivative is greater than zero.

The lowest waist / weight ratio is unique to each individual, and can go up and down over time (e.g., resistance exercise will push it down). Here I am talking about one's lowest waist / weight ratio at a given point in time, not one's waist / weight ratio at a given point in time.

This optimal waist / weight ratio theory is one of the most compatible with evidence regarding the lowest mortality body mass index (, ). Nevertheless, it is another ratio that gets a lot of attention in the health-related literature. I am talking about the waist / hip ratio (). In this literature, waist circumference is often used alone, not as part of a ratio.

Senin, 03 Juni 2013

Dr. Jekyll dieted and became Mr. Hyde


One of the most fascinating topics for an independent health researcher is the dichotomy between short- and long-term responses in successful dieters. In the short term, dieters that manage to lose a significant amount of fat mass, tend to feel quite well. Many report that their energy levels go through the roof.

A significant loss of fat mass could be considered one of 30 lbs, or 13.6 kg. This is the threshold for weight loss used in the National Weight Control Registry. Ideally you want to lose body fat, not lean mass, both of which contribute to weight loss.

So, in the short term, significant body fat loss feels pretty good for the dieters. In the long term, however, successful dieters tend to experience the symptoms of chronic stress. This should be no surprise because some of the same hormones that induce a sense of elation and high energy are the ones associated with chronic stress. These are generally referred to as “stress hormones”, of which the most prominent seem to be cortisol, epinephrine (adrenaline), and norepinephrine (noradrenaline).

Stress hormones display acute elevations during intense exercise as well ().

This is all consistent with evolution, and with the idea that our hominid ancestors would not go hungry for too long, at least not on a regular basis. High energy levels, combined with hunger, would make them succeed at hunting-gathering activities, leading to a period of feast before a certain threshold of sustained caloric restriction (with or without full fasting) would be reached. This would translate into a regular and cyclical hunger-feast process, with certain caloric costs having to be met for successful hunting-gathering.

After a certain period of time under sustained caloric restriction, it would probably be adaptive among our ancestors to experience significant mental and physical discomfort. That would compel our hominid ancestors to more urgently engaged in hunting-gathering activities.

And here is a big difference between those ancestors and modern urbanites: our ancestors would actually be working towards getting food for a feast, not restraining themselves from eating what they have easily available at home or from a grocery store nearby. There are major psychological differences here. Dieting, in the sense of not eating when food is easily available, is as unnatural as obesity, if not more.

So what are some of the mechanisms by which the body dials up stress, leading to the resulting mental and physical discomfort? Here is one that seems to play a key role: hypoglycemia.

Of the different types of hypoglycemia, there is one that is quite interesting in this type of context, because it refers to hypoglycemia in response to intake of any food item that raises insulin levels; that is, food that contains protein and/or carbohydrates. More specifically, we are referring here to reactive hypoglycemia, of the same general type as that experienced by those on their way to type II diabetes.

But reactive hypoglycemia in successful dieters is often different from that of prediabetics, as it is caused by something that would sound surprising to many: successful dieters appear to become too insulin sensitive for their own good!

There is ongoing debate as to what is considered a blood glucose level that is low enough to characterize hypoglycemia. Several factors influence that, including measurement method and age. One important factor related to measurement method is this: commercial fingerstick glucose meters tend to grossly underestimate low glucose levels (e.g., 50 mg/dl shows as 30 mg/dl).

Having said that, glucose levels below 60 mg/dl are generally considered low.

Luyckx and Lefebvre selected 47 cases of reactive hypoglycemia for a study, from a total of 663 standard four-hour oral glucose tolerance tests (OGTT). They classified these 47 cases as follows, with the number of cases in each class within parentheses: obesity (11), obesity with chemical diabetes (9), postgastrectomy syndrome (3), chemical diabetes without obesity (1), renal glycosuria (7), and isolated reactive hypoglycemia (16).

Postgastrectomy is the period following a gastrectomy, which is removal of part of one’s stomach. The modern term for this stomach amputation procedure is “bariatric surgery”; admittedly a broader term, which many people say they would do as if they were referring to a walk in the park!

In the cases of isolated reactive hypoglycemia, the individuals had normal weight, normal glucose tolerance, and no glycosuria (excretion of glucose in the urine). As you can see in the paragraph above, this, isolated reactive hypoglycemia, was the category with the largest number of individuals. The figure below illustrates what happened in these cases.



The cases in question are represented in the left part of the graph with dashed lines (the full lines are for normal controls). There a reasonably normal insulin response, lower in fact in terms of area under the curve (AUC) than for the controls, leads to an abnormal reduction in blood glucose levels. They are 9 out of 16, the majority of the isolated reactive hypoglycemia cases. In those 9 individuals, insulin became “more potent”, so to speak.

Reactive hypoglycemia is frequently associated with obesity, in which case it is also associated with hyperinsulinemia, and caused by an exaggerated insulin response. About 40 percent of the reactive hypoglycemia cases in the study were classified as happening in obese individuals.

This study suggests that, if you are not obese, and you are diagnosed with reactive hypoglycemia following an OGTT, chances are that the diagnosis is due to high insulin sensitivity – as opposed to low insulin sensitivity, coupled with hyperinsulinemia. A follow-up test should focus on insulin levels, to see if they are elevated; i.e., to try to detect hyperinsulinemia.

I have been blogging here long enough to hear from people who have gone the full fat2fit2fat cycle, sometimes more than once. They start dieting, go from obese to lean, feel good at first but then miserable, drop the diet, become obese or almost obese again, then start dieting again …

Quite a few are folks who do things like ditching industrial foods, regularly eating organ meats, and doing resistance exercise. How can you go wrong doing all of these, generally healthy, things? Well, they all increase your insulin sensitivity. If you don’t build in plateaus to slow down your progress, you may not give your body enough time to adapt.

You may become too lean, too fast, for your own good. The more successful the diet, the bigger is the risk. No wonder the paleo diet is being targeted lately as a “bad” diet. How can you go wrong on a diet of whole foods; “real” whole foods, not “whole wheat”? Well, here is how you can go wrong. The diet, if not managed properly, may be too successful for your own good; too much of a good thing can be a problem, you know!

See the graph below, from a previous post on a related topic (). I intend to discuss a method to identify the point at which weight loss should stop, in a future post. This method builds on the calculation of a simple index, which is unique to each individual. Let me just say now that I suspect that, with exceptions, frequently people are hurting their health by trying to have six pack abs.



But what does all this have to do with stress hormones? The connection is this. Hypoglycemia is only “felt”, as something unpleasant, due to the body’s frequent acute stress hormone response to it. Elevated levels of stress hormones also increase blood glucose levels, countering hypoglycemia. Our body’s priority is preventing hypoglycemia, not hyperglycemia ().

And here is an interesting pattern, based on anecdotal evidence from HCE () users. It seems that folks who have abnormally high insulin sensitivity, also have medium-to-high HbA1c (a measure of glycation) and fasting blood glucose levels. By medium-to-high HbA1c levels I mean 5.7 to even as high as 6.2.

Since cortisol is elevated, one would expect higher fasting blood glucose levels – the “dawn phenomenon”. But higher HbA1c, how? I am not sure, but I believe that HbA1c will be found in the future to be something a bit more complicated than what it is believed to be: a measure of average blood glucose over a period of time. I am not talking here about cases of anemia.

One indication of this complicated nature of the HbA1c is the fact that blood glucose levels in birds are high yet HbA1c levels are low, and birds live much longer than mammals of comparable size (). Some birds have extremely high glucose levels, even carnivorous birds who consume no or very small amounts of carbohydrate (e.g. hawks), with fairly low HbA1c levels.

The title of this post is inspired in the classic short novel “Strange Case of Dr. Jekyll and Mr. Hyde” by the Scottish author Robert Louis Stevenson; who also authored another famous novel, “Treasure Island”. In “Dr. Jekyll and Mr. Hyde”, gentle Dr. Jekyll becomes nasty Mr. Hyde (see poster below, from Wikipedia).



Mr. Hyde had a bad temper, impaired judgment, and was prone to criminal behavior. Hypoglycemia has long been associated with bad temper, impaired judgment, and criminal behavior (, ).