Obesity Game Changer?

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Obesity is a serious issue in the U.S. and around the world; type 2 diabetes, hypertension, CVD, and other diseases associated with obesity have significant health costs. That’s why a real game changer would be important to help people lose weight and maintain their weight loss. The latest candidate is semaglutide, an anti-diabetic medication used for the treatment of type 2 diabetes by increasing insulin secretion. In my opinion, the results of this study do not achieve game-changing status. Let’s take a look at the details.

There Was Limited Weight Loss

The mean weight loss was 14.9% which translated to 34 pounds in 68 weeks. That’s really not impressive; most people can lose a half pound a week by paying more attention to their diet and increasing their activity level. The rate of weight loss in the placebo group stabilized at about 20 weeks, and that’s where it stayed for the rest of the study. In the experimental group, the rate of weight loss declined twice; first at about 20 weeks and then again at 52 weeks. By 60 weeks, the experimental subjects did not appear to be losing any more weight.

The Lifestyle-Change Program Was Ineffective

With 35 years of experience in weight loss programs, my hunch is that by 20 weeks, both the placebo and the experimental group had reverted to their prior eating patterns. We don’t know for sure because no nutritional data were presented, but that would explain the lack of continued weight loss in the placebo group and slowing weight loss in the experimental group. The drug may be game-changing, but without permanent lifestyle changes, it’s just another weight loss drug.

The medication was effective in continuing weight loss in the experimental groups, but we don’t know how. Insulin is the most powerful hormone in the body, but we don’t know exactly how semaglutide helped these subjects lose weight. Did it influence appetite? Did it impact insulin levels alone?

At What Price?

The lowest price I could find with insurance coverage was $800 per month. This would be cost-prohibitive for most people. Another way of looking at: it cost $376 per pound of weight lost. I’m not sure that’s worth the price because we still don’t know if the drug will help maintain the loss for a significant period.

And besides the monetary cost, what physical cost did the drug have? Every drug has side effects. That’s why in most cases I recommend trying lifestyle changes before adding a medication; if unhealthy habits helped create the problem, changing those habits is the best place to start. Even if a healthier diet and increased activity don’t solve the problem, those changes may mean you can take a lower dose of the med, thus reducing side effects. Except in urgent cases, most doctors will give you some time to try lifestyle changes before adding a medication.

The Bottom Line

I consider the study a failure because the subjects in both groups never learned how to change their food intake and exercise behaviors. Yes, those people taking the pharmaceutical did better related to weight loss, and because of that, some metabolic factors improved. But the rate of weight loss slowed down as the study progressed and eventually appeared to stop. Maybe this drug will give some people an edge with initial weight loss and thus improve their odds of long-term success, but if they don’t permanently change their behaviors, they won’t permanently lose weight.

We have to quit thinking of a healthier diet as a temporary change. The challenge is not losing weight; the challenge is in maintaining the lost weight. If you go back to your old eating habits, you’ll go back to your old weight; if you won’t commit to changing your diet and activity, taking a pill isn’t going to help you for very long.

While interesting, this study doesn’t change the game. The game was, is, and always will be eat better, eat less, and move more. For life.

What are you prepared to do today?

        Dr. Chet

Reference: NEJM. 2021. DOI: 10.1056/NEJMoa2032183

“Game-Changing” Treatment for Obesity!

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If ever a health headline gets your attention, it’s one that proclaims there’s a better way to lose weight. “A game changer” said one of the principle authors of the study in a news release about the study. The results of any study that suggests “game-changing results” just has to be reviewed, and that’s what I’ll do in this week’s Memos.

The study was a trial of 1,961 subjects conducted at 129 sites around the world. The subjects were randomly assigned to the experimental group and placebo group in a 2:1 ratio. The experimental group received once-weekly injections of semaglutide, currently approved as a diabetes treatment, while the controls were injected with a placebo. Both groups received individual counseling sessions every four weeks to help them adhere to a reduced-calorie diet and increased physical activity. The study was 68 weeks long.

After 68 weeks, the mean change in body weight from baseline to week 68 was 14.9% or 34 pounds in the semaglutide group as compared with 2.4% in the placebo or about six pounds. Anthropometric measures, BMI, and cardiovascular and metabolic measures were better in the semaglutide group compared to the controls.

The results of the trial have already caused the manufacturer to apply for a rapid approval review as a weight loss drug. The question is this: is it really a game changer in the treatment for obesity? I’ll talk about that on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: NEJM. 2021. DOI: 10.1056/NEJMoa2032183

How the Quality of Your Diet Changes Your Mycobiome

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In the experiment I told you about on Tuesday, the researchers established that environment—exposure to light, temperature, and other environmental factors—affects the microbiome, including the fungi or mycobiome. The researchers then tested the changes in the mycobiome (the fungus part of the microbiome) after feeding the mice a highly processed diet compared with mice eating conventional mice chow. They also monitored changes in body composition, triglycerides, and other hormones related to obesity.

After eight weeks on the highly processed diet, there were differences in the quantity of fungi. Some groups of related organisms increased while others decreased. Because not every group has known roles in digestion and metabolism, the researchers examined metabolic changes in response to the dietary change; they found an increase in body fat and triglycerides in the male mice along with concurrent changes in hormones that signified a move toward prediabetes. (For some reason, the female mice in this species are protected from those effects.)

After examining the composition of the highly processed chow, I’d like to have seen one more group of mice in the experimental group. Because the highly processed chow had no fiber, it would have been helpful to see what would happen to the entire microbiome if the amount of fiber was the same in the processed chow as the conventional chow. Maybe it wouldn’t have impacted the fungi at all, or the change could have been significant.

The Bottom Line

What lessons can we learn from this study? We’re not mice after all. I think it means that a highly processed, highly-refined carbohydrate diet may cause undesirable changes in our microbiome, including the fungal levels as well. For example, Candida albicans is a primary fungus in our digestive system, but it can cause all kinds of problems if it gets out of control. Reducing refined carbohydrates has a beneficial impact on keeping that fungus at beneficial levels.

Regardless of your current age, a better diet is part of Aging with a Vengeance. Reducing processed food, especially carbohydrates, can benefit your microbiome and all that it impacts. Time to start now.

What are you prepared to do today?

        Dr. Chet

Reference: Comm Bio (2021).4:281 https://doi.org/10.1038/s42003-021-01820-z

The Fungus Among Us

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The microbiome is made up of a variety of microbes. I tend to focus on the bacteria because that’s where the bulk of the research exists, but there are more microbes in and on us such as fungi, protozoa, and viruses. A recent paper provided some interesting insight into one category of microbes: the fungi, also called the mycobiome. I loved this research paper; the methodology is extremely complex, but the logic of the questions they lined up and answered was fantastic.

Researchers began with the most basic question: Are the microbiomes, including the fungi, the same when they purchase genetically identical mice from four different animal vendors? It turns out the answer is no. While the core fungi were similar, they each had subtle differences in types of fungal colonies. That means when used in research, although genetically identical, the growing environment was different enough to potentially influence outcomes when using some form of dietary intervention.

What does that mean for human research? Research using dietary changes could be impacted by the microbial differences. The researchers tested that concept, and I’ll talk about that on Saturday.

What are you prepared to do today?

        Dr. Chet

P.S. Members and Insiders: check out the latest Straight Talk on Health covering melatonin and memory, and a dog’s microbiome. Be sure to go to membership log in first.

Reference: Comm Bio (2021).4:281 https://doi.org/10.1038/s42003-021-01820-z

How Periodontal Disease Makes COVID-19 Worse

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Aging with a Vengeance is more than gaining muscle mass and losing fat around your waist; it also means that your immune system is robust. I think we often over-emphasize supplementation; while I think it’s necessary, it really should serve as support for other actions that are equally or even more important. For example, taking care of your teeth. By that, I mean regular checkups, brushing after meals, and flossing every day. Does that affect the immune system? You bet it does, and a recent study illustrates how significant that can be.

Researchers in Qatar conducted a study to see if people with periodontal disease had an increased risk of being in the intensive care unit (ICU), being put on a ventilator, or dying from COVID-19. Qatar Is a country of 2.3 million people with an advanced electronic medical records system; because dental records are a part of the medical records system, they were able to identify people with periodontal disease, sometimes called gum disease. In addition to the medical records on COVID-19 and how the subjects fared, they were also able to get data such as BMI, HbA1c, and CRP, among other health indicators.

As an observational study, researchers were able to find 568 people who were diagnosed with COVID-19 between February 2020 and the end of July. That number included 40 people with severe cases of COVID-19 that required hospitalization. The characteristics of those who had severe cases are similar to what we find in the U.S.: more were overweight or obese, had higher HbA1c levels, and had higher CRP levels.

Of those who had periodontal disease, 33 had severe cases of COVID-19; only seven people who had no periodontal disease had a severe outcome. When looking at the odds ratios, a person with periodontal disease had six times the risk of being admitted to the ICU, almost eight times the risk of being put on an ventilator, and a 17 times greater risk of death from COVID-19.

Why would having periodontal disease, an infection that appears to be limited to the teeth and gums, have such an overall effect? The reason is that it creates a state of higher inflammation that compromises the immune system. When exposed to the virus, the immune system is already stressed and the body does not have all the resources it needs to fight the infection.

The Bottom Line

Here’s my advice: if you’re overdue for your dental checkup, call and make the appointment, especially if your gums bleed regularly when you floss, if your gums seem inflamed, or if you have a very bad mouth odor. No excuses; gum disease should not be ignored.

I see many comments in social media about “all the talk being about vaccinations, masks, and social distancing.” “No one ever talks about diet and exercise, etc.” The reason, at least in my humble opinion, is that the last 50 years have clearly demonstrated that most people in the U.S. don’t eat well, don’t move enough, and eat more than they should.

Instead of criticizing people for their poor dietary and exercise habits, the current medical approach seems to be to meet people where they are. My hope is that by addressing some of the other issues related to health, such as periodontal disease and overall healthcare in our quest to age with a vengeance, all readers will see ways to make their immune system much more robust so it can do a better job of protecting them.

And if it has the side benefit of shutting up the naysayers that talk about long-term solutions only at the exclusion of the things that we know are working right now—such as vaccinations, masks, etc.—I’m good with that. As I said in May, not fear; respect.

What are you prepared to do today?

        Dr. Chet

Reference: J Clin Periodontol. 2021. DOI: 10.1111/jcpe.13435.

How Exercise Improves Sleep

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To become the best version of yourself, it takes more than just eating better and moving more. One factor that gets overlooked is sleep.

Sleep patterns change over a lifetime; in addition, isolation during the COVID pandemic can also impact sleep patterns. Moderate to strenuous exercise has long been known to have a positive impact on sleep, but what about people who can’t exercise at a high level? Using a technology called actigraphy, researchers in Hong Kong attempted to find out whether mild exercise can help people with insomnia.

Actigraphy is a noninvasive technique that measures physical activity levels of a subject by means of a wristwatch-like motion-sensing device that can be worn for prolonged periods of time. Researchers recruited 320 participants with a mean age of 67 with most subjects being female. There were 110 in the control group, 105 subjects in the conventional exercise group, and 105 subjects in the tai chi group. Subjects in both exercise groups exercised for one hour, three days per week. The conventional exercise was a combination of brisk walking and weight training for 12 weeks, while the tai chi group attended a 12-week Yang-style, 24-form tai chi training program.

When compared to controls, both the exercise and tai chi groups showed improved sleep efficiency, reductions of wake time after falling asleep, and reduced number of awakenings. The actigraphy and sleep diary reports were consistent; there were no differences between exercise groups in benefits.

There’s good reason to believe that if mild to moderate exercise works for people with insomnia, it will work for anyone who wants more and better sleep. Seems like a good deal to me: invest three hours a week to help your entire body and get better sleep as a plus.

What are you prepared to do today?

        Dr. Chet

Reference: JAMA Network Open. 2021;4(2):e2037199.

Vitamin C, Zinc, and COVID-19: Ask the Right Questions

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As we left off Tuesday’s memo, I suggested that both the researchers in the study that was halted as well as the physicians who used dietary supplements as part of their treatment were wrong in their conclusions. At this point we don’t know for certain whether vitamin C and/or zinc can help with COVID-19.

Let’s define which questions we’re asking. Are we trying to prevent people from catching COVID-19? Are we trying to help them recover from a COVID-19 infection? Are we trying to prevent hospitalization? Are we trying to prevent death? Those are all different questions.

The Videos

Let’s stick with helping people recover once they’ve been infected with COVID-19. At this point, we don’t have solid data as to how long the patients were infected before they sought treatment, how many days it took them to fully recover, or if they recovered without any further treatment of any type. We also get no data on the people who needed further treatment in the hospital.

It’s not reasonable to suggest that every patient seen in these physicians’ videos all recover and no one ever gets worse, but that’s never discussed.

The Research

As for the researchers, they didn’t ask two very valuable questions: what were the subjects’ vitamin C and zinc levels before the treatment began? Without that measure, they couldn’t know whether they needed supplements; maybe their levels were as high as needed, and they didn’t need any more.

Second, how did they administer the vitamin C? If they were familiar with the research, they’d know vitamin C is more effective when given intravenously. The subjects could have been given vitamin C on an outpatient basis to begin, and then used supplements for the rest.

The Bottom Line

Neither group really provides us with much information about vitamin C and zinc to help people recover from COVID-19. When it comes to the use of dietary supplements and COVID-19, there’s a difference between preventing a person from catching the infection at all, reducing the number of days that they’re infected with the virus, and reducing the risk of having the infection progressing to hospitalization and potentially death.

Where does that leave us? Now more than ever, we should support our immune system. Vitamins D, C, and the mineral zinc can help us do that, and at the first hint of illness I’d recommend the Immune Boost supplements. I’d also like to recommend getting tested for C and zinc as we do for D, but it’s not practical at present.

Most multivitamin-multiminerals can provide a baseline to get you started. Don’t forget food has nutrients as well, so a healthy diet may help you stay COVID free.

What are you prepared to do today?

        Dr. Chet

Reference: JAMA Network Open. 2021; doi:10.1001/jamanetworkopen.2021.0369

Vitamin C, Zinc, and COVID-19

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Last week, a study was published in JAMA Online that did a randomized controlled trial using vitamin C and zinc to treat people diagnosed with COVID-19. Several longtime readers asked me to review videos posted by physicians and other healthcare professionals who’ve used vitamin C and zinc to treat COVID-19 infections. I did and I’ll comment on Saturday, but let’s look at the science.

Researchers from a well-respected healthcare organization, the Cleveland Clinic, requested volunteers from multiple locations in Ohio and Florida for a study. The purpose was to see if vitamin C (8000 mg), or zinc (50 mg), or vitamin C plus zinc would reduce symptoms associated with diagnosed COVID-19 when compared to a group taking no dietary supplements. The objective was to see if symptoms in the groups taking the supplements could be reduced by 50% within five days or less when compared with controls. They used symptom scales such as fever, cough, and shortness of breath, among others.

The researchers stopped the study early due to futility: there were no differences in any of the experimental groups compared to the controls after reaching 40% of the subjects they intended to recruit. Frontline physicians say supplements work against COVID; this research trial says they don’t. Who’s correct? I think they’re both wrong, and I’ll tell you why on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: JAMA Network Open. 2021; doi:10.1001/jamanetworkopen.2021.0369

Less Can Be More If…

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Let’s dig into the results of the National Health Interview Survey analysis to see if less really can be more: does mortality decrease even with fewer than 30 minutes per day most days of the week as long as part of the workouts was vigorous? We’re not examining other potential health benefits of exercise such as the risk of type 2 diabetes, weight loss, or gaining strength—just risk of death.

I examined the Hazard Ratios for the number of minutes spent in vigorous physical exercise per week and the total minutes of exercise per week. For those who exercised 1 to 149 minutes per week (less than the national recommendations), if 1 to 74 minutes of the total were spent in vigorous exercise, there was a 29% decrease in all-cause mortality. For CVD, there was a 20% decrease in mortality and a 24% decrease in mortality from cancer. There were additional benefits when a greater number of minutes were spent in vigorous activity, especially from CVD. Clearly, less can be more.

But…

A person must be fit enough to be able to do vigorous exercise. The survey defined vigorous exercise as hard enough to raise the heartrate and breathing rate and to increase sweating. The older you are, the less you may be able to sustain that type of effort, whether due to a lack of fitness or pre-existing CVD or orthopedic issues; the same holds true for someone who is overweight or obese. If you’re in any of those categories, you must get your physician’s approval before doing intense exercise.

You don’t have to wait, though; work up to it over a period of months with the guidance of a professional exercise specialist. Just as with any goal, you approach it in a stepwise manner. If you can walk for exercise, it may be something as simple as walking fast for 15 seconds every 3 minutes. Progress from there, increasing the fast walking by 15 seconds every week or every few days. If your body isn’t ready yet, it will let you know.

If you can get 20 to 30 minutes most days with over half of those minutes being vigorous, you may reap the benefit of lower risk of death, according to the data. Just proceed with caution and remember, this doesn’t include time working on strength, endurance, or flexibility.

What are you prepared to do today?

        Dr. Chet

References: JAMA Int Med. doi:10.1001/jamainternmed.2020.6331

Is Intense Exercise Better?

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The national recommendation for exercise is 30 to 60 minutes most days of the week. That works out to 150 to 300 minutes per week or 2.5 to 5 hours. At one point or another, I think many people have asked “What’s the least amount of exercise that I can do and still get benefits?” It’s not a simple question because it depends on the benefits you want to get. Top of the list is probably decreasing the risk of dying. It’s time to consider that question as we try to become the best version of ourselves. A recently published study may help.

Researchers analyzed the survey results from over 400,000 subjects in the National Health Interview Survey. This survey is given every year to 35,000 randomly-selected people in the U.S. Researchers focused on questions related to physical activity. They wanted to know whether people exercised, how long they exercised, and how intense the exercise was. They also asked how much time was spent in vigorous exercise within the total time people exercised.

I could have predicted the results: as the percentage of time spent in vigorous exercise increased, all-cause mortality and mortality from CVD and cancer decreased. This held true for all age groups as well as for all BMI groups. Even if you’re obese, you can still reduce your risk if part of your workout is dedicated to vigorous exercise. The question remains: how intense and how long do you have to exercise to get the life-saving benefits? I’ll finish this on Saturday.

The Insider Conference Call is tomorrow night. I’ll go into more details on this study as well as review a video making the rounds about the safety of the COVID vaccinations. If you’re not an Insider, this may be the right time to join.

What are you prepared to do today?

        Dr. Chet

References: JAMA Int Med. doi:10.1001/jamainternmed.2020.6331