May 2015

VOL.88 NO.4 May 2015

SAN FRANCISCO MEDICINEJOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

OBESITYCAUSALITY, CONSEQUENCES, AND CURES

Plus: SGR Reform at Last!

Finding the Obesity X-FactorPopping Big Sodas BubblePutting Healthy Foods in ReachWeight Loss: Perfect vs. Good EnoughThe Asian BMI

IN THIS ISSUE SAN FRANCISCO MEDICINE MAY 2015 Volume 88, Number 4

OBESITY: CAUSALITY, CONSEQUENCES, AND CURES

Editorial and Advertising Offices: 1003 A OReilly Ave. San Francisco, CA 94129 Phone: (415) 561-0850Web: www.sfms.org

MONTHLY COLUMNS

4 Membership Matters

7 Presidents Message Roger S. Eng, MD, MPH, FACR9 Editorial Gordon Fung, MD, PhD, and Steve Heilig, MPH32 Medical Community News

34 Classified Ad

34 Upcoming Events

ADVOCACY UPDATES

29 San Francisco Board of Supervisors Approves First-in-Nation Legislation to Ban Tobacco Products from City Baseball Venues and Athletic Fields

31 SGR Repealed with Passage of HR 2

FEATURE ARTICLES

10 Do We Have an Obesity Epidemic? And What Are the Causes? Payal Bhandari, MD12 Putting Healthy Food in Reach: Food Access Issues and Solutions Eli Zigas16 Preventing Armageddon: Robert Lustig, MD, on the State of the Sugar Epidemic Steve Heilig, MPH18 The Open Truth Campaign: Popping Big Sodas Bubble Janna Cordeiro, MPH; Marianne Szeto, MPH; Christina Goette, MPH; Toms Aragn, MD, DrPH19 High Strung: The Link Between Stress and Obesity Mima Geere, MD21 Childhood Obesity: The Impact of Slow Medicine on the Epidemic Julia K. Getzelman, MD, and Sommer Barnes, MPH22 Weight Loss: Perfection Is the Enemy of Good Enough Erica T. Goode, MD24 The Asian BMI Is 23: Screening for Diabetes in Asian Americans Edward A. Chow, MD, and David Hawks25 Bariatric Surgery: The Sooner the Better Gregg Jossart, MD, FACS27 The War on Obesity: Conscientious Objections Michel Accad, MD

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May 2015

Editor Gordon Fung, MD, PhDManaging Editor Amanda Denz, MACopy Editor Mary VanClay

EDITORIAL BOARDEditor Gordon Fung, MD, PhD

Obituarist Erica Goode, MD, MPH

SFMS OFFICERSPresident Roger S. Eng, MD

President-Elect Richard A. Podolin, MDSecretary Kimberly L. Newell, MDTreasurer Man-Kit Leung, MD

Immediate Past President Lawrence Cheung, MD

SFMS STAFFExecutive Director and CEO Mary Lou Licwinko, JD, MHSA

Associate Executive Director, Public Health and Education Steve Heilig, MPHAssociate Executive Director, Membership and Marketing Jessica Kuo, MBADirector of Administration Posi LyonMembership Coordinator Ariel Young

CMA Trustee Shannon Udovic-Constant, MDAMA Delegate Robert J. Margolin, MDAMA Alternate Gordon L. Fung, MD, PhD

Michel Accad, MD

Stephen Askin, MD

Payal Bhandari, MD

Toni Brayer, MD

Chunbo Cai, MD

Linda Hawes Clever, MD

Erica Goode, MD, MPH

Shieva Khayam-Bashi, MD

Arthur Lyons, MD

John Maa, MD

David Pating, MD

BOARD OF DIRECTORSTerm: Jan 2015-Dec 2017Steven H. Fugaro, MD

Brian Grady, MD

John Maa, MD

Todd A. May, MD

Stephanie Oltmann, MD

William T. Prey, MD

Michael C. Schrader, MD

Term: Jan 2014-Dec 2016William J. Black, MD

Benjamin C.K. Lau, MD

Ingrid T. Lim, MD

Keith E. Loring, MD

Ryan Padrez, MD

Rachel H.C. Shu, MD

Paul J. Turek, MD

Term: Jan 2013-Dec 2015Charles E. Binkley, MD

Gary L. Chan, MD

Katherine E. Herz, MD

David R. Pating, MD

Cynthia A. Point, MD

Lisa W. Tang, MD

Joseph Woo, MD

Volume 88, Number 4CMS Issues Draft Stage 3 Rules for EHR Incentive Program The Centers for Medicare and Medicaid Services (CMS) drafted regula-tions for the third stage for Meaningful Use (MU), the EHR incentive pro-gram that provides financial incentives for the meaningful use of certified EHR technology.

Stage 3 introduces a new edition of certification criteria, proposes a new 2015 Edition Base EHR definition, requires providers to ensure pa-tient engagement, and increases computerized physician order entry. Stage 3 will further identify how health IT certification can support the develop-ment of an interoperable nationwide health information infrastructure and is meant to drive better-quality, more cost-effective, and coordinated care. Eligible physicians and professionals who do not meet the require-ments of MU Stage 3 are expected to pay $500 million in Medicare penalties between 2018 and 2020. All providers are expected to conform to the rules by 2018. The comment period for Stage 3 will end May 29, 2015.United Healthcare Opts Physicians into Core Narrow Network Product

United Healthcare (UHC) recently issued notifications to 19,000 prac-tices included in its commercially contracted provider network, advising of their inclusion in the UHC Core product. The new UHC Core plan will access a significantly narrowed network and will be marketed to employer groups seeking lower premiums for their employees. Additionally, indications are that UHC will also use the narrowed Core network for its potential future exchange products in 2016. UHC has advised that reimbursement for the Core product line will be at the commercial fee schedule rates outlined in the UHC physician agree-ment. Those providers with multiple fee schedules in their contract will be paid at the fee schedule indicated for the United Healthcare Choice/Choice Plus benefit plans.For physicians who wish to opt out of the Core product network, the only option is to terminate the underlying UHC commercial agreement. There is no ability to opt out of just the Core network.Physicians who are unsure about whether or not they are affected by this change, those who have general questions about the notice, or those who wish to dispute their participation in the Core plan network can con-tact UHC Network Management at (866) 574-6088. Identity Theft Tax Scam Targeting Physicians

SFMS has been notified of a tax scam directed at physicians after re-ceiving reports that fraudulent federal income tax returns have been filed using physician names, addresses, and social security numbers. In many cases, the fraudulent tax return includes the name of an unknown person listed as the physicians spouse. Generally, this other name is a prior patient of the physician.Affected physicians are likely to learn of the scam by receiving a 5071C letter from the IRS alerting them of possible fraud. Physicians may also have received a rejection notification when attempting to electronically file their taxes. This occurs because a return has already been filed using that social security number.SFMS members are urged to contact the CMA Center for Legal Affairs at (800) 786-4262 for assistance or visit http://bit.ly/1EecxEX for guidelines and resources.

WWW.SFMS.ORG MAY 2015 SAN FRANCISCO MEDICINE 7

Today, organized medicine basks in glow of one of its most successful years in memory, with the defeat of Proposition 46 and election of 90 percent of statewide candidates friendly to doctors, including Sacramento pediatrician Richard Pan to the State Senate. Was this easy? Of course not. It took years of work and financial investment in the political process to lay the foundation for success. And now, as I write this message, comes news of a federal fix of the SGR Medicare payment system, a longtime goal of the AMA and CMA. This was only made possible through the concerted efforts of physicians in each local district, state, and capital, arguing and demon-strating how things could be better for all concerned. It is a huge breakthrough, and long overdue.

All politics are local is the old saying, and that is at least partly true. Physician engagement begins in our own towns, including, of course, San Francisco. When credible candi-dates appear who seek elected office, SFMS leaders engage them to assess their interest in medical and public health is-sues, to educate them where needed, and to support them as we can. Where we decide it is worth it, we contribute to their campaigns via our SFMS PAC (Political Action Committee). Such efforts go back many decades, with more recent examples being our close work with Gavin Newsom when he was a San Francisco Supervisor, then Mayor, and now Lieutenant Governor (and perhaps more). We also forged a solid link with David Chiu during his Supervisorial campaign, while he was in office here, and then for his successful As-sembly campaign. Our relations do not stop when such lead-ers achieve higher office, as they then know the value of col-laborating with the CMA on issues of statewide interest.How does this advance SFMSs goals and vision? Lets take a look at Prop 46 again. In a city where most Democrats support dismantling MICRA, Chiu stood up for doctors and patients early on by opposing Prop 46, knowing it could be unpopular with his supporters and some voters in a bitterly contested Assembly campaign. Meanwhile his opponent, Da-vid Campos, fully sided with the trial lawyers. Had SFMS not engaged then-candidate Supervisor Chiu early in his career, most in the know feel he would not have championed the physician cause or, even worse, would have opposed us. Today, SFMS continues to engage our current and future political leaders not just on medical issues, such as access to

care and sustainable insurance systems, but on public health issues as well. Here are a couple of current examples:Drug Take Back Program: We are working with Super-

visor London Breed to create a network of fifty-five drop-in centers throughout San Francisco where patients can dispose of their unused prescription and nonprescription medica-tions. This program would be funded by pharmaceutical com-panies. SFMS is engaged in the process and testifying in City Hall, working to help its implementation with stakeholders.Smokeless tobacco ban at all athletic fields: We are working with Supervisor Mark Farrell and a coalition of com-

munity groups to make SF athletic fields safe from all tobacco products, including chewing tobacco. This legislation applies to Giants games at AT&T Park. Supervisor Farrell, CMA, and SFMS held a press conference this past February that gar-nered national attention. There are many more such efforts, but these are just two in the news of late. One common aspect of these is that our pol-icies so often originate in our elected delegation to the CMA, which has for years led the entire state with the mostand, many would say, bestslate of public health policies. From HIV to reproductive health to environmental health and end-of-life care issues, we have set the agenda many times, and such SFMS resolutions, once they are adopted by CMA (and even AMA), have had a measurable impact. Back home, they guide our actions as we work with our local elected officials, health department authorities, and community advocates.

Doctors still hold great influence in our communities when we apply ourselves and engage our legislators and com-munity partners in health care. But the garden requires con-stant tending to bear fruit. We cant do this as individuals from our offices, but we can and do through SFMS and the SFMS Political Action Committee, who are here to spread the word on the behalf of both doctors and patients.

Connect with Dr. Eng via Twitter @RogerEngMD or send him an email at [email protected]. To learn more about the SFMS PAC, visit www.sfms.org/about/related-organizations/sfms-pac.aspx.

Physician Engagement

Roger S. Eng, MD, MPH, FACR

PRESIDENTS MESSAGE

If you could get ten doctors this engaged in the political affairs of San Francisco, you could control the City.Major California health care organization executive at a recent mayoral fund-raiser

OBESITY

With more than two out of every three Americans overweight or obese, the natural question is, why do we have an obesity epidemic? There have been many articles attributing obesity to poor nutrition and lack of exer-cise. While both are significant contributors, I propose that the obesity epidemic is primarily the result of corporate innova-tions and government policies that did not intend to cause obe-sity. They were instead aimed at keeping our country well fed and to accommodate for an increasingly fast-paced American lifestyle.The resulting food innovations and eating practices have led to the following outcomes:

Meals are increasingly consumed on the go while the consumer is distracted (i.e., availability of drive-through fast-food restaurants, TV dinners; eating while surfing the Internet and using mobile phones). Distracted eating can lead to overeating. Home-cooked meals made from scratch are increasingly replaced by ready-made food options that are less nutri-tious. Longer workdays result in dinners later in the evenings. With busy workdays often requiring quick meals, dinner is valued as a time to unwind and indulge in a large meal. Late-night meals are challenging for the body to optimally digest, increasing the production of stored fat. Increasing late-night screen time is decreasing optimal sleep hygiene and melatonin production, essential compo-nents to optimal digestive system function and the overall functioning of the body and mind. Growing isolation within modern societies leads to in-creased emotional and distracted eating. Lifestyles are ever more sedentary.

The Impacts of Our Fast-Paced LifestyleAs the pace of life has accelerated, Americans have been pleased with how the transformation of modern eating allows them to focus on other tasks. Most people are now working lon-ger and spending less time at home. They do not have adequate time every day to make meals from scratch. They do not eat at home while socializing with loved ones. They are instead grab-bing something on the go and devouring it in their cars or at their desks while checking email or watching TV. Fast-paced eating habits do not align well with the bodys optimal extrac-tion and utilization of nutrients from food.As workdays have become longer, dinners are eaten later. Lifestyles are increasingly sedentary as modern conveniences have largely eliminated the necessity for people to move and dramatically lessened face-to-face socialization. By spending 10 SAN FRANCISCO MEDICINE MAY 2015 WWW.SFMS.ORG

long hours not moving, we often do not exert sufficient energy relative to the calories consumed. We do not feel sleepy enough to go to bed on time, leading to persistent sleep deprivation. The combination of late-night large meals, chronic sleep debt, and less physical activity creates a formula for food being poorly digested and a higher rate of food being converted to fat. With these patterns taking root, people gradually feel less ener-gized each morning. They may drag their feet to get out of bed and then rush out the door, having either skipped breakfast or eating it on the go. Feeling tired leads to an increased preference for caffeinated, sugary, and dense items that are often lacking in nutrients and that drain energy. Fatigue also negatively affects mood and increases stress. People have become less insightful about how their daily physical activity, sleep, and eating habits directly impact their bodies and minds. All of these factors contribute to an increased risk of gaining weight. Our Modern FoodThe transformation of breakfast foods is an example of how good intentions to feed the masses have led to a downward-spiraling impact. In the nineteenth century, Americans usually ate leftovers for breakfast. In search of an easy breakfast solution, brothers Will K. Kellogg and Dr. John Harvey Kellogg invented corn flakes in 1894. Since W.K. Kellogg wanted to make cereal more palatable, he enlivened the cereal with sugar. The corn flake company attracted millions of Americans by introducing many different types of cereals, advertising on television, and Saturday morning cartoons with Kelloggs Disney-like characters associated with its cereal lines. Housewives became liberated from cooking breakfast since they could just pour their children a bowl of Corn Flakes, leave a milk carton out, and let the kids be entranced by their favorite TV shows. Kids began eating cereal for breakfast, lunch, and bedtime snacks, setting the stage for todays eating habits. Kellogg and other competing cereal companies began domi-nating the processed food industry. Fast-food and beverage com-panies followed suit and showed up on almost every street cor-ner with cheap, tasty, ready-made food and drink options. These powerful industries now dominate how grocery and conve-nience stores are stocked, what food is being served in schools, and how people perceive what meal and snack options should be. The food and beverage industries invest heavily in advertis-ing to capture the publics attention and drive sales. By control-ling a large percentage of the U.S. food market, the major food and beverage companies have now redefined the staples of the American diet. With the challenge of facing a growing world population and

Payal Bhandari, MD

And What Are the Causes?DO WE HAVE AN OBESITY EPIDEMIC?

OBESITY

Eli Zigas

Food Access Issues and SolutionsPUTTING HEALTHY FOOD IN REACH

One in ten adults in the Bay Area struggle to consis-tently find three meals a day. More than half of all adults are overweight or obese. And residents in many of the regions communities live in neighborhoods where fast food restaurants and convenience stores abound, while grocery stores are scarce or dont exist at all. As doctors, you see how your patients health suffers from this poor access to healthy food. And as doctors, you can help your patients not only by advising them one on one but also by advocating for policy changes that make it easier for them to find, afford, and choose healthy food.

Last year, the Bay Area-based nonprofit SPUR convened an expert task force representing a variety of public health, policy, and social service organizations that explored how local gov-ernment agencies could improve access to healthy food. Some of the most powerful tools are at the state and federal levels. But our local officials can also help reduce hunger and improve public health through policy at the city and county levels.Defining Food Access

Food access, building off a definition from the United Na-tions Food and Agriculture Organization, is an individual or familys ability to obtain sufficient, safe, and nutritious food to meet their dietary needs and food preferences for an active and healthy life. There are four main barriers to food access, and we need to address all of them to promote a more wholesome diet for individuals and a healthy food economy for communities.Physical: Can you find healthy food?

Economic: Can you afford healthy food?Educational: Do you know how to make healthy choices and how to cook?Cultural: Do you want the healthy food that is available and affordable?Why Food Access MattersAccess to healthy food in the Bay Area is intimately tied to three major problems facing the region:1. Hunger and Food InsecurityEven in a wealthy region like the Bay Area, many people experience food insecurity, a category that includes both those who are chronically hungry and those who are uncertain, from one week to the next, if theyll be able to obtain enough food for an active and healthy life.

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The Bay Areas adult obesity rates have been steadily in-creasing from 2001 to 2011, from 16 percent to 20 percent, which is slightly lower than the statewide average of 25 percent. The increase has been most dramatic among the regions low-income residents.


2. Public HealthWhile numerous factors such as physical activity and ge-netics contribute to a persons weight, studies continue to show that what we eat has a strong influence on our weight and our likelihood of developing a diet-related disease such as diabetes. 3. Quality of LifeResidents in some Bay Area neighborhoodsespecially low-income and rural oneshave to travel significantly farther than their counterparts in other neighborhoods just to find a grocery store or market that offers fresh fruit, vegetables, and other healthy items. A longer trip is not just an inconvenience and frustration for many residents; its also an equity issue, because the transportation costs (in both money and time) to get basic groceries pose a greater burden for lower-income residents.Recommendations

To address these barriers, elected officials and agency staff should adopt policies that increase the affordability, availability, and appeal of healthy food. Below are some of the priority rec-ommendations developed by SPURs task force. Maximize enrollment in federally funded food-assistance programs.In the nine-county Bay Area, 6 percent of all residents re-ceived CalFresh benefits (previously known as food stamps) in 2013. Strikingly, only 56 percent of those who are estimated to be eligible for the program are enrolled, which means that an additional 350,000 Bay Area residents could be receiving assis-tance through the program.In terms of bang for the buck, the CalFresh program is very

cost effective for local governments. The federal government provides funding for 100 percent of the costs of CalFresh ben-efits and, along with support from the state government, covers 85 percent of a countys administrative costs. In San Francisco, for example, this means that the citys General Fund only pays for $3.6 million of the citys $121 million CalFresh budget nearly $100 million of which is used by residents to purchase food. Stated another way, every dollar the San Francisco gov-ernment spends on CalFresh brings in $25 that low-income San Franciscans can spend on food. Support long-term funding for healthy food incen-tive programs.

In the past few years, nonprofit organizations, government agencies, and farmers markets across the country have collabo-rated to create another model to increase low-income residents economic access to healthy food. Known as Market Match in California, these programs provide a subsidy, in the form of cou-pons or matching dollars, to low-income families who shop at farmers markets. For example, at some participating farmers markets in the Bay Area, the Market Match program provides customers with an extra $10 if they spend $10 of their CalFresh benefits on fresh produce at the market. These programs have been shown to boost low-income customers purchase of fresh, healthy food while also increas-ing revenue for local farmers. The biggest obstacle to the expan-sion of these programs is a steady stream of funding. Currently, nearly all of the programs are funded by public or private grants.

Continued on page 15 . . .



FOR $3 A DAY, SFMS/CMA MEMBERS RECEIVE MORE THAN $6,000 A YEAR IN SAVINGS AND SERVICES, INCLUDING:

SFMS/CMA Member Benefit Value

Patient referral service via SFMS phone referral line and online physician finder tool . . . . . . . . . . . . . . . . . . . . . . . . . $200

Access to exclusive physician networking events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150

Personal physician webpage for practice promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100

Subscriptions to San Francisco Medicine and SFMS Membership Directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100

One-on-one assistance with practice management experts from Center for Economic Services on . . . . . . . . . . . . . *$150reimbursement and practice operation issues . *value hourly rate with a practice management consultant

Access to objective written analyses of major health plan contracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200

Discounted employment contract review service with a contract attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500

Special member rate for AAPCs ICD-10 training seminars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200/session

Discounted registration for the Western Leadership Academy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300

CME tracking and credentialing service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20

HIPAA-compliant communication via DocBookMD, enabling physicians to instantly exchange patient information . . . . $100with other physicians at the point of care

15% off temper-resistant security prescription pads and printer paper with Rx Security . . . . . . . . . . . . . . . . . . . . $162 .75

30% off your current bill for medical waste management and disposal services through EnviroMerica . . . . . . . . . .*$1,000*based on average savings

30% off on Epocrates products, including Epocrates Essentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50

Up to 10% discount on life insurance through Mercer Health & Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100

Member-only savings on office supplies and magazine subscriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500

Access to webinars and seminars ranging from business essentials for physicians, EHR adoption best practices, . . . $400and effective coding/billing strategies, including our exclusive value-based payment model workshop with CMS Region IX Administrator in May 2015 .

For a list of full member benefits, visit http://www.sfms.org/membership/membership-benefits/full-member-benefits.aspx.

SFMS_3DollarsADay_FlyerAd_2015.indd 1 4/27/15 12:35 PM

Make healthy food available in all neighborhoods.Attracting grocery stores to neighborhoods without them is one way to improve the availability of healthy food in a com-munity. Converting the product mix of corner stores to include healthier options is another way to improve an areas food re-tail options in dense neighborhoods that dont have vacant sites suitable for a large grocery store. The Good. To Go. initiative in San Jose is one example of corner store conversion efforts that are currently underway in the Bay Area. Health departments, economic development agencies, and any other department that provides assistance to a grocery store or corner store should condition that assistance on ensuring that a minimum level of healthy products are offered and that the store accepts, or has applied to accept, CalFresh and other food assistance benefits.

Ensure that people know how to cook and make healthy food choices.Beyond improving economic and physical access, policy makers must also work to ensure that residents have the knowl-edge and skills to identify and prepare healthy food. This type of education can include the basic elements of nutrition for a balanced diet, lessons on cooking from scratch (such as those taught by 18 Reasons Cooking Matters courses) or workshops on how to grow and make the most of fresh food. School districts should integrate nutrition education more comprehensively into their curricula, and nonprofits can also play a role in pro-moting food literacy.Reduce demand for unhealthy food while increas-ing demand for healthier options.In addition to supporting the strategies outlined above to help residents find, afford, and choose nutritious food, policy makers should complement these efforts with policies that re-duce demand for unhealthy options. This includes: Limiting or prohibiting the sales and marketing of un-healthy food in environments frequented by children, especially at facilities that receive government funding. Taxing sugar-sweetened beverages to decrease consump-tion and generate revenue for initiatives addressing diet-related disease and food access. In November 2014, Berkeley became the first city in America to pass a soda tax when 76 percent of voters approved Measure D, a one-cent-per-ounce tax on sugar-sweetened beverages.Some observers argue that the role of government in im-proving Americans diets should be focused solely on education and encouraging people to eat more healthfully. While nutrition education and food literacy programs can, and should, be ex-panded, they do not address the availability and affordability of healthy food. For that we need additional governmental policy. And with the support of doctors, nurses, and other health pro-fessionals, we have a much greater chance of passing effective policies that result in greater access to healthy food and fewer patients with diet-related disease.

Putting Healthy Food in ReachContinued from page 13 . . .

Ways to Get Involved

Attend a meeting of the San Francisco Food Security Task Force and support their advocacy efforts. Work within your professional associations and encourage them to officially endorse city, county, and state legislation that makes it easier for patients to find, afford, and choose healthy food and reduces de-mand for unhealthy options. Encourage the hospitals and clinics where you work to participate in Physicians for Social Responsibil-itys Healthy Food in Health Care program so that their cafeterias serve food that promotes health.Make sure your low-income patients know about CalFresh, free school meals, WIC, and other food assistance programs. Eli Zigas is the Food and Agriculture Policy Director at

SPUR, a nonprofit urban planning organization in the Bay Area. For more detailed information about the findings and recom-mendations highlighted in this article, see SPURs recent report Healthy Food Within Reach (http://www.spur.org/foodac-cess). All images and figures courtesy of SPUR.


OBESITY

Dr. Robert Lustig might be the sugar industrys Public Enemy No. 1. A professor of pediatrics in the divi-sion of endocrinology at UCSF, he is widely published in the medical literature and published his book Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease in 2012. A New York Times article on his work asked, Is Sugar Toxic? His 2009 online talk Sugar: The Bitter Truth has been viewed 5.5 million times; his 2013 TED talk Sugar: The Ele-phant in the Kitchen more than 150,000 times.

In your book, you gave a dark diagnosis regarding the obe-sity epidemic, calling it a medical and financial Armaged-don. Since then, is there any reason for more optimism?We see some progress at several levels now. First, the FDA has now proposed that we put added sugars on product nutri-tion facts labels, and the dietary guidelines advisory committee has recommended to the FDA that we actually have a limit on allowable added sugars to 10 percent of calories. I dont think either of those would have been remotely possible just five years ago. The fact that two government agencies are suddenly taking their ostrich-like heads out of the sand to see theres a problem has to be taken as progress. But having said that, the soda industry is fighting these moves tooth and nail. And, if anything, that aspect has gotten worseas they lose market share they are doubling down, as Coke just said. This is in-sane, and its become a war.There seem to be many parallels with the tobacco wars here.Absolutely. This is tobacco all over again. But sugar, from a marketing and hepatic metabolic perspective, is more like al-cohol. Ive often said sugar is the alcohol of the child, and thats why children are now showing alcohol-related diseases like type 2 diabetes and fatty liver disease, which were seen in alco-holic adults until 1980. You can get sick from overconsumption of both alcohol and sugar. The difference is that with alcohol, youre not allowed to put it into food! So from a biochemical perspective sugar is like alcohol, but from a political or busi-ness standpoint, the sugar companies are acting just like the tobacco industry did thirty years ago.Youve used the term toxic with respect to sugar, with some controversy. Is this really a case of the dose making the poison?

Exactly, it depends on how much. A little sugar is fine, just like a little alcohol is OK. But with alcohol we know that, and regulate it, and try to stop it, for example when bartenders must stop serving a person whos had too much. But we dont have that for sugar. We are triple over our dose, as the sugar industry has added it to everything to make us buy and consume more.

In your book you discuss the mass misdiagnosis of how we got into this mess, with erroneous dietary culprits and diets aimed at obesity and heart disease.Yes, and the data keep getting stronger on that front. We just completed a study called SUCRE, the French word for sugar, and that stands for Sugar Comorbidities Race and Ethnicity. We took forty-three children with metabolic syndromeobe-sity plus at least one comorbidityand looked at them ten days apart, the second time after we had catered their meals with no added sugar at all; we substituted the sugars with complex carbohydrates. In other words, we took out the sodas and gave them bagels, popcorn, bean burritos insteadnot good food, but kid food, with the same calories. We sent them home with a scale to weigh themselves every day, and if they were losing weight, wed tell them to eat more, so there was no weight loss. So, no change other than substitution for sugar. And every aspect of their metabolic health improvedtheir lipids got better, their insulin resistance got better, their liver fat went down by 30 per-cent, visceral fat decreased 10 percent, their ALT and BLT went down, pancreatic fat went downall with no weight change. It sounds like you isolated the x-factor there, the smoking gun.We did. And its not calories. Is that why you maintain that prescribing diet and exercise doesnt work for almost anybody?Right, and theres a reason for that, as obesity is leptin re-sistanceleptin is the hormone that goes from your fat cells to your brain to tell you youve had enough, and when leptin cant signal, your brain thinks youre starving. When you start trying to lose weight via caloric restriction, your leptin goes down, and your brain really sees starvation and you eat it back. Recidivism of obesity is not because of weakness or a character flaw, but because we havent fixed your biochemistry. When you fix leptin resistance, you can lose weight of your own volition and dont have to go on some diet.Do you see parallels with addiction medicine here?Absolutely, weve learned this is addiction medicine. There are basically three reasons to eat: hunger, reward, and stress. In our clinic we parse those and see which is the main driver for pa-tients. The only way to help is to get the brain to see leptin, and to do that we have to get their insulin down, as that is the blocker of leptin. The question is why is their insulin high. Often we have to help their parents, as they are sugar addicts too, and its just too hard to get a kid off sugar when the parents still are [on]. And stress is by far the hardest one to deal with, as it is response to stress thats the issue, and we cant take that away very easily.

Steve Heilig, MPH

Robert Lustig, MD, on the State of the Sugar EpidemicPREVENTING ARMAGEDDON


In your book you noted that stressed is desserts spelled back-wards. For a clinician who is not specialized in this but is seeing obesity, what are you teaching regarding effective interventions?

The first thing that we are trying to impart is that the be-havior is the result of the biochemistry. Three examples: If you see a kid who drinks and urinates ten gallons of water a day, the kids got diabetes insipidus. Now, he could have a psychogenic issue that causes him to drink that water, but there are 200 cas-es of DI for each of those. Or you see a twenty-five-year-old who falls asleep in his soup, and you think narcolepsy, which we now know is a hormonal issueagain, you infer the biochemis-try. Schizophrenia was for a century seen as a behavioral disor-der, but we now know it to be a defect in dopamine neurotrans-mission. So three distinct diseases manifesting as behavioral, but every one is biochemical. Sometimes were smart enough to know the biochemistry underlying the behavior, sometimes not. Were just learning the biochemistry of obesity now, but its there, and in our clinic we are translating that into treatment, and thats why our patients are doing well.You wrote about the holy grail of the antiobesity pill, but that such medications have been elusive. Any promising changes?There are three new obesity medications on the market since the book came out. Each is designed to hit a different as-pect of the energy balance pathways. The results are mixed, to say the least. I think that obesity is so complex that its going to be very difficult to find any magic bullet.

You are skeptical about specific dietspaleo, Atkins, Ornish, etc.The real question is, Who are you and what is the actual prob-

lem? What are your insulin dynamics? Most doctors dont know how to assess that, and getting things into clinical practice takes twenty-five years from discovery to practice. And we have some outdated guidelines now. The American Diabetes Association says fasting insulin is not useful, but it tells you insulin resistance, which we need to know. And yes, people were recommending the low-fat diet for decades, but some people gain weight on low-fat diets, as it really means a high-carbohydrate diet, which means lots of glucose and thus lots of insulin. In order to see that in patients, you have to look for it, to do an oral glucose tolerance test, with insulin levels; and you have to draw blood early, and do baseline, 15 minutes, 30 minutes, and nobody does glucose tolerance levels that way. But these things are out there, accessible, and potentially remediable and treatable. But I have to say, doctors just dont get it, and its been really hard to teach this.Why do you think that isthe old docs, new tricks dynamic?Yeah, weve all been told for our entire ca-reers that a calorie is a calorie, but in the SU-CRE study weve got a slam-dunk showing thats not true. There are still scientists out there who say a calorie is a caloriebut you have to look at who funds them. There are a lot of re-searchers and doctors paid off by the food industry, just as there were with tobacco.

In your book you run through all the interventions that are needed but say each is necessary but insufficient.Rightyou need both personal and societal action. The point is the societal interventions are opposed as being anti-Americana knee-jerk, libertarian, Dont tell me what to eat or smoke or drink. Which is just bull, as weve already been told what to eat and drink by the food and drink industries. The basic argument in my TED talk is, Where were the libertarians over the last forty years when the whole system was being changed under their noses? They also say, I dont want government in my kitchen and I agreeunless there is a more destructive force there, which is what we have now.And again, as with tobacco, we have a war to fightyou half-seriously refer to a needed Occupy Nabisco battle, but it seems a huge struggle against so much money and power.We need to change the lines of engagement. Obamacare puts 32 million sick people on the rolls and says we can pay for that with preventative services, but there are no proven preventative services hereother than getting rid of the sugar. The data are so robust on this now. In our new study we were flabbergasted by itits all right there. It is amazing, and the best thing Ive been associated with.Regarding the failed San Francisco soda tax . . . We did great. We got 56 percent approvalthat was phe-nomenal, with the beverage industry spending $10 million to defeat that. I dont consider that a failure. It will be back. The one thing I have learned is you cant be impatient.

You seem to be fundamentally optimistic. How do you retain your hope and commitment?Well, I have to remain optimistic or I might just give up on life itself. And again, we are starting to see the ground shift. The FDA and USDA and WHO are making new recommendations that are very big. Mexico and Berkeley got a soda tax. Big businesses and insurers are starting to see obesity as a problem for their bottom lines. People are start-ing to get the picture. And I went into medicine to try to help people, and this seems to me to be the best way I can help the most people all at the same time.


OBESITY

Popping Big Sodas BubbleTHE OPEN TRUTH CAMPAIGN

The science is clearsugary drinks are making us sick. From the documentary film Fed Up to the groundbreaking scientific work by the Sugar Science team at UCSF and by many other research institutions, the strong evidence of the harmful effects of sugary drinks cannot be ignored. Consider these facts: Just one 12-ounce soda has about 10 teaspoons of sug-armore than the recommended daily maximum for adults and more than three times the recommended daily maximum for kids. Numerous studies link sugary drinks to chronic diseases, including obesity, type 2 diabetes, tooth decay, heart disease, and some cancers. If current trends continue, 40 percent of all Americans will get type 2 diabetes in their lifetimes, and half of Latino and African Americans will get type 2 diabetes. Whats also trueand just as distressingis that Big Soda companies are targeting youth and communities of color as their primary growth markets for the twenty-first century. In the words of Joe Tripodi, chief marketing and commercial of-ficer for the Coca-Cola Company, Vision 2020 is Cokes plan to double its business by 2020. . . . This aggressive plan is focused on dramatically increasing consumption of sugary beverages by young people using precision marketing that targets young people, mostly in Latino and African American communities in the United States and developing countries abroad. . . . As medical providers and community leaders, we under-stand the importance not only of the health impacts of sugary drinks but also of the role the environment plays to make un-healthy choices desirable and affordable, especially to low-in-come communities. When patients continue to consume sugary drinks despite a doctors recommendation, we also recognize that our patientsespecially youth, those in low-income com-munities, and people of colorare in the crosshairs of the bev-erage industry that promotes these harmful and cheap drinks. The communities aggressively targeted by the sugary drinks are also those hardest hit by chronic diseases fueled by those very same drinks. Big Soda spends hundreds of millions of dollars to lure youth and adults into purchasing their harmful products. They use celebrities like LeBron James, Beyonc, and Katy Per-ry to market their drinks, online games, and contests to engage consumers, and they use sponsorships to associate their brands with kids sports and other feel-good causes. And their tactics are working. Its no coincidence that in San Francisco, the data show that the communities that Big Soda targets are the ones spending the greatest proportion of

their income on sugary drinks and experiencing the greatest hospitalizations due to type 2 diabetes. Thats why the Shape Up San Francisco Coalition (project of the Population Health Division of the SF Department of Public Health), in partnership with The Bigger Picture (Youth Speaks and the Center for Vulnerable Populations at UCSF), the Alam-eda County Department of Public Health, the Sonoma County Department of Health Services, the American Heart Association Greater Bay Area Division, and the Community Engagement and Health Policy Program of the Clinical & Translational Science In-stitute (CTSI) at UCSF, have launched the Open Truth campaign.The goals of this counteradvertising campaign are to in-crease awareness about how sugary drinks are making us sick; expose the tactics of the beverage industry and its efforts to tar-get youth and communities of color; and inspire policy changes that will increase access to healthy drinks, limit marketing to kids, educate consumers, and provide funds for sugary drink education. The campaign launched in San Francisco (with funds from Bayview HEAL Zone/Kaiser Permanente) is placing ads in the Bayview neighborhood on billboards and buses and at tran-sit stops. Thanks to a partnership with the San Francisco Mu-nicipal Transportation Agency, the Open Truth campaign is also roaming the streets citywide on MUNI buses. At the heart of the Open Truth campaign are works by The Bigger Picture poets, youth-created, spoken-word poems that have been made into short videos. The youth poets brilliantly expose the predatory tactics of the beverage industry, giving a strong voice of resistance to what they see happening in their families and communities. These videos can be easily shared through social media, during educational presentations with groups, or even in waiting rooms. Combined with the powerful imagery of the Open Truth campaign, we are working to reveal the truth behind the tac-tics of the beverage industry and inspire change. Help us spread the word! People everywhere deserve to be told the truth about whats being marketed to them. Join the Truth Movement!

SHARE www.opentruthnow.org and The Bigger Picture vid-eos on the site.FOLLOW US on Facebook, Instagram, and Twitter @Open-TruthNow.PARTICIPATE in the conversation. When you see an ad, snap a photo and post it to your favorite social media venue with the #OpenTruth. If you would like an Open Truth poster at your office, con-tact the campaign at [email protected].

Janna Cordeiro, MPH; Marianne Szeto, MPH; Christina Goette, MPH; Toms Aragn, MD, DrPH


OBESITY

Obesity is a disease. It is defined as an abnormal increase in body fat often caused by nutritional imbalances and due to multiple underlying patho-genic and physiologic forces. The metabolic pathology is either due to fat mass or adiposopathy (sick fat). As obesity and obesity-related metabolic disease rates rise in our nation as well as in other parts of the world, like China and Saudi Arabia, the quick approach to advise a patient toward a life-style diet and exercise program does not get to the root of the problem and is often not effective. Yet the rising cost of health care is a testament to why prevention and proper treatment are so important. Investment in an understanding of the un-derlying physiology at play in weight and obesity can assist in approaching this problem as we do many others in medicine, by looking at the root cause and identifying solutions based on the molecular mechanisms defining the disease. In many people, weight gain and disordered eating can be attributed to the stress response. And interestingly, the pro-pensity of the body to keep the weight on is perpetuated by the same stress response but compounded by being overweight itself. Stress has differing effects on your body, depending on whether the stress is acute or sudden in nature or whether the stress is chronic or occurring over a longer period of time. An acute stress response can result in potential analgesia, whereas a prolonged one can result in chronic pain. The former occurs as the bodys natural reaction to danger, where epinephrine dominates the physiologic response. Prolonged stress results in the release of cortisol, which has more detrimental effects on your bodys overall health. Cortisols natural role in fat me-tabolism is to induce lipogenesis, or fat storage, and visceral adiposity along with the suppression of the immune system. It results in an increase in blood glucose levels and further in-creases insulin resistance and hepatic gluconeogenesis. Longer-term mental stressors such as those at home or work can lead to chronic activation of the neuroendocrine sys-tems and chronically elevated cortisol. Cortisol favors central fat deposition. Recent literature points towards chronic stress and the role of pituitary inflammation in obesity. Additionally there is a paradoxical increase in the hormone leptin, and a de-crease in ghrelin that induces a state of increased appetite and food intake. In practice we find that the more stressed someone is at work or home, the harder it is for them to lose weight even with a good, healthy weight-loss diet and exercise program. Oxidative damage to adipocytes occurs over the time of prolonged stress states as well as through obesity itself. This oxidative damage can be measured by looking at direct mea-sures of free radicals and reactive oxygen species, as shown in the latest research studies. Additionally, adipocytes contain the

enzyme that activates cortisol and can independently control and enhance the amount of cortisol available to the bodyand therefore perpetuate obesity once it begins. Advising patients on types of exercise and nutrition can be important. High-intensity exercise has been shown to induce an increased amount of free radicals, whereas lower intensity exercise does not. Also, the specific macronutrient distribution of the nutrition program in this type of cortisol-induced weight response can be important, and a diet focused on lowering total carbohydrates and introducing healthy anti-inflammatory fatty acids is most effective.Combating such deep-seated responses to stress with ad-vising on lifestyle change can be very challenging and often re-quires a holistic and multidisciplinary approach to weight loss. The focus on just what you eat or how much you exercise can be ineffective. Instead, a well-rounded approach drawing on psychology, exercise, and nutrition, in conjunction with mindful-ness training, would be most effective in promoting long-lasting changes in weight and the resulting well-being.

Mima Geere, MD, completed her masters training in nutrition science from Columbia University and residency training from UCSF in clinical pathology. Mima Geere combines a deep scientific knowledge base with a holistic and practical approach to health and wellness. She is currently the medical director at Jumpstart-MD, a San Francisco Bay Area Medical weight-loss and wellness clinic. She is a member of the SFMS.

Mima Geere, MD

The Link Between Stress and ObesityHIGH STRUNG

New Calif. Bill Would Add Two-Cent Fee on Sugary Drinks

California Health Care Foundation, May 6, 2015A new California bill (AB 1357) aims to add a 2-cent-per-ounce fee on sugary drinks that would generate about $3 billion annually to launch a program to prevent and treat dental disease, diabetes, heart disease and obesity. The bill was announced by Assembly member Richard Bloom (D-Santa Monica), the American Heart Association and the Latino Co-alition for a Health California.


OBESITY

Erica T. Goode, MD

Perfection Is the Enemy of Good EnoughWEIGHT LOSS

You, as a physician in a room with a (relatively new to your practice) overweight adult, have limited time, but, knowing about the obesification of America, you need to make weight a priority. In general, all physicians need to bring weight into the conversation early. If you tie it to whatever health factor(s) will likely affect quality of life for that individual, it lends legitimacy. Please ask about his or her history of weight ups and downs; this allows you to understand roadblocks and challenges for that individual. Be sure to take the time to listen to his/her concerns about the current weight. You may hear about foot pain, joint pain interfering with mobility, sleep issues, itch-ing, palpitations with exertion. Be sensitive; the word overweight is better received than the term obese. Many patients will know BMI values; if you state that number rather than scale weight, it can be less jarring.

First: Acknowledge that sustained behavior change is very difficult and requires daily planning, hourly vigilance. State that you are sure that he or she has tried to lose weight sev-eral times before and may be feeling discouraged about gearing up yet again. This is when you can say that your main goal is to improve blood pressure, cholesterol, blood sugar, back or degenerative knee painand that modest weight maneuvers can help greatly.

Second: Set an initial weight-loss goal of 10 pounds or of 5 percent of total weight. These small increments often yield significant, positive blood pressure, blood sugar, and perhaps cholesterol changes. State, when appropriate, that orthopedists usually dont work on knees unless weight is more manageable. You are a key change agent (Saul Alinskys term); recent studies report that with limited time and excessive pressures, physicians very likely skip this weighty topic and simply provide a medica-tion for hypertension, hyperlipidemia, or hyperglycemia and ask the patient to come back next month to follow up.1 This is not enough. Please tell your patient that the problem will only worsen if neglected. By incorporating the essential components into your practice, you can assist many people with long-term weight loss. Given the ideas below and multiple community resources avail-able to help your patient, he or she can reach and maintain that healthier weight. But you must initiate the process.

Third: Know your own biases regarding weight. In 1977, an AMCAS study reported that less than 3 percent of entering medical students were overweight (BMI over 25). A well-report-ed study done in the 1960s involved six-year-old boys shown six photos of different boys. One had no issues while others had rela-tively more serious disabilities; the subjects invariably chose the obese boy as the last one he would wish to play with. (This may have changed given the increased weight seen among Americans of all ages).

You need to be cognizant of numerous factors: Many people have tried repeatedly to lose weight. Some have families among whom obesity is the norm for one of an array of reasons. A black, Hispanic, Pacific Islander, or Native American patient will be sta-tistically more likely to be obese, and those women more than the men; lower income or time-pressured individuals food choices are likely to be limited in terms of fresh vegetables, fruits, nuts, etc., relative to the choices of their Caucasian counterparts. The microbiome of a significantly overweight person may generate more absorbable calories than that of the thinner patient. Antibi-otics taken by small children may lead to increased risk for obesity in adulthood. Over the decades since the 1960s, serving sizes of foods in restaurants and at home have become multiples of those eaten in the mid-twentieth century. This can beget larger intake, gastroparesis, and increases in ghrelin.2Finally, you as a physician may have unrecognized biases re-garding people of other socioeconomic groups, or those who are racially different or have limited English skills. This can translate into your seeing them as less able to motivate themselves toward sustained changes in behavior, unbiased as you may think you are.3 It is key for you to know some late-breaking news about why it is difficult to maintain lower weight despite fairly consistent lower intake.4

The following narrative was my first successful experience in really helping people with weight change. This example contains the basic elements that must be present for change to occur. In 1972, as a public health nutritionist, I helped sixteen very over-weight African-American women lose weight long term. They and their children were seen by me, the RNs, physicians, social work-ers, and outreach workers in a low-income neighborhood health center in Washington, D.C., where I worked for four years. All six-teen met initially with me, agreeing to participate in free weekly classes at the YMCA. All had signed up beforehand, having made plans for childcare on those Thursdays. They all came weekly.This was a reasonably close group; all were residents of three housing project buildings (no longer there). Each had experi-mented with recipes from a basic cookbook I had developed two years earlier, the recipes incorporating many of the supplemental foods they received each month if they had small children. (This later morphed into the WIC program.) I was always in the clinic in the mornings, providing foods made from this cookbook. I had befriended Julius Jones, the first African-American director of the Central Washington, D.C., YMCA, across the street from the Ex-ecutive Office Building/White House complex. He agreed to have these women join the exercise class, once they had been screened by the clinic internist.I enrolled them in the Y class, delivered them there in a Red Cross bus, and later drove them back to the neighborhood. I par-ticipated in the class as well.


Each lost about 20 pounds in 25 weeks. I gave them a new recipe a week, using foods they liked, cooked in new ways. (Greens were no longer gray; fat meat, alias salt pork, was limited; vinegar, spices, and onions were used.) As I got ready to leave for medi-cal school at UCSF, I asked what they would do to keep losing or to maintain the weight loss. They took up a collection, bought an Exercycle, and took turns using it. They chose to place it in the apartment of a blind woman with several children, who found these women to be fun and good neighbors. When I returned over Christmas vacation to see their progress, they were doing just fine. Nobody had gained weight. One year later, one of them wrote me that they were keeping it up, using weights once per month, and forming extra walking groups among themselves.You may not do this. But this is what is needed: The individual in front of you must be ready to change, having moved beyond skepticism or a sense of hopelessness. This is the get-ting ready to think about when to be starting to change phase. The person must be able to collaborate with someone elsea walking partner, a work friend, a group.The changes required must be seen, initially or later, as do-able over the long term, not just for a special occasion such as a sons wedding. This requires that the person analyze periods of setbacks, and problem solve to resume the better behavior pat-terns. They must find activities and food changes pleasant enough, realistic, and not based on some illicit ephedra-like OTC supple-ment or other harmless but ineffective herb du jour. For people struggling to initiate weight loss, phentermine, in 37.5 mg tablets taken early in the day to avoid sleep issues, can be helpful. I often suggest using it only five days per week, to avoid tachyphylaxis. It can raise systolic blood pressure about 4 mm hg in the suscep-tible individual, but this is generally offset by the initial 10 pound weight loss. (I have prescribed each of the new weight-loss drugs over the past two decades, starting with Meridia. None have last-ed, primarily due to unacceptable side effects).There must, in almost all cases, be a social structure sup-porting the change(s). One person who defied this requirement for success was a stock broker, who felt he could not adhere to classes, walks with friends, etc., due to his early morning sched-ule. His plan worked. Beginning on January 1, he wrote a self-contract. He agreed that he would put away $25 per week while taking off 25 pounds by September 1. With that goal of thirty-one weeks and $775, he decided that if he had not lost the weight the money would all go to the Skinheads. If he met his goal, the fund would go toward part of a weeks vacation. His wife had a copy of the agreement. (They vacationed, and he made various adjustments to maintain the lower weight).For most people it means saying to waiters, Dont bring bread to me before dinner or to friends, Please take the box of candy you brought; although I love candy, I am asking you to take it home (or it can be taken to work or otherwise dispatched out of harms way).Accommodative issues must be addressed (how to exercise with bad knees, for example).Methods for supporting the change must be learned and incorporated for life, with time and practice. If there is a slip in behavior, there needs to be a way for the person to self-correct.Reiterate that perfection is never the goal; this is critical.You are the initial change agent and must have resource

and referral information that you know personally, to overcome referrals that dont work. (No time, I cant cook, situational eating, etc., are in the purview of the nutritionist or registered dietitian; you need to know that this patient will do well with that medical personnel.)If obese since early childhood, or if serious psychological is-sues are at play, alternate approaches may be needed. You must screen for people with entrenched issues with weightthose with problems with unrealistic expectations, depression, PTSD, and serious addictive issues. Some people will need referral to a psychiatrist or psychologist for cognitive behavioral therapy, or lengthier work with a psychiatrist who may prescribe small amounts of topiramate or other agents that can help in both realms, before you can expect significant weight changes.6 Rather than trying to deal with all these areas of enquiry immediately, provide the patient with the quality of life ques-tionnaire, urging a paragraph for each question. Ask him or her to return in two to three weeks for a last-patient-of-the-day ap-pointment, if possible. (Develop a system with the front office to alert you if the patient cancels.) At that follow-up visit, you will recheck weight and vitals; often the individual will have begun to lose a pound or two. Discuss his or her questionnaire responses, which will help you with the appropriate referrals. Discuss the im-portance of getting to that new program (Weight Watchers, Jump-start, etc.), and be sure to schedule monthly visits with you each month. Some patients will slip off the plan and cancel; be sure to say that even if things arent going well, you really need to see them monthly to keep weight from interfering with quality of life.You need to be an upbeat coach. Help the patient at least succeed in maintaining weight, if that is the only option under the circumstances. Example: patient on steroids for asthma, recent hip fracture. Listen to the reasons for setbacks; at times problems can be solved together.7 Try to see overweight pa-tients near to Thanksgiving, reminding them that retrospective studies have shown, in someone with weight creeping up about 5 pounds over 10 years, that most of that weight accumulates over the holidays. Many RDs and nutritionists, either hospital or community based, are the experts at helping with this insidious eating and drinking. They can help with heightening awareness of holiday patterns, the national overendowment with food, and sensible yet festive alternatives.My Washington, D.C., group had all the elements of success, in a demographic that many might be thought unlikely to suc-ceed. Collaborative friendships, a shared goal, a possibility be-coming reality, some external assistance were all key. You may need to help each patient develop novel means of making chang-es that work for him or her over the long term. Next months issue of San Francisco Medicine will provide references and Bay Area referral sites for various aspects of weight management.

Erica Goode, MD, MPH, is board-certified in internal medicine. She practices general medicine with an emphasis on nutrition. Dr. Goode holds a medical degree from the UCSF, where she currently maintains an Associate Clinical Professorship and her Masters in Public Health Nutrition from UC Berkeley. Before getting her medical degree, she worked as a public-health nutritionist and wrote a week-ly nutrition column for the Washington Post. Dr. Goode is a longtime member of the SFMS and of the San Francisco Medicine editorial board. A full list of references is available online at www.sfms.org.


OBESITY

Edward A. Chow, MD, and David Lee Hawks

Screening for Diabetes in Asian AmericansTHE ASIAN BMI IS 23

Keep the number twenty-three in mind. Rather, keep the body mass index (BMI) 23 kg/m2 in mind when deciding whether to screen an Asian American for type 2 diabetes. The normal BMI cut point to screen a Caucasian patient is 25 kg/m2, but according to research there is a new baseline for recommend-ed screening guidelines for Asian Americans, adopted at the very end of last year by the American Diabetes Association (ADA).1 We say baseline, because there are always other factors to consider when screening a patient for diabetes (blood pressure, family history, diet, exercise habits). And when talking about BMI both as a cut point for screening for diabetes and other obesity-relat-ed disorders and as an indicator of what healthy weight is, we also have to acknowledge both its imperfection and the need to know more. Fortunately for screening and diagnosing Asian Americans, there is plenty that we do know about the value of using BMI 23 or, as we sometimes call it, the Asian BMI.The number isnt new. In 2004, the World Health Organiza-tion (WHO) recognized that Asians showed higher risk for de-veloping diabetes at a lower BMI, and the organization chose 23kg/m2 or greater as the cut point for screening.2 Contrary to common belief, Asian Americans have a higher incidence of dia-betes than the Caucasian population, and most patients fall into the type 2 category.Background on BMI 23In 1995, Dr. Wilfred Fujimoto of the University of Washing-ton found that rates of type 2 diabetes among second-genera-tion Japanese Americans were significantly higher than those of both the general white American population in the U.S. and of the Japanese population in Tokyo. There was evidence that genes and a unique pathophysiological response to diabetes ex-isted for Asian Americans.3 Some of the leading and ongoing research on diabetes in Asian-American populations occurs at Joslin Diabetes Centers Asian American Diabetes Initiative, headed by George King, MD, and William Hsu, MD. Much data has also been gathered via community-based participatory research conducted by re-searchers specializing in certain segments of the Asian-Ameri-can aggregate population (e.g., Dr. Alka Kanaya with South Asian Indians4 and Dr. Happy Araneta with Filipino Americans5). In late 2011, these researchers and many others came to-gether in Honolulu for a State of the Sciences Conference on Asian Americans, Native Hawaiians, and Pacific Islanders. Exist-ing and new research on this Asian BMI issue was shared, and the resulting collaborations led to two papers published in Dia-betes Care in May 2012,6,7 along with an op-ed titled Type 2 Diabetes: An Epidemic Requiring Global Attention and Urgent

Action.8 The op-ed highlighted the fact that in addressing this grave and widespread problem of diabetes within and without the U.S., interventions needed to be tailored to specific popula-tions with pathophysiology and culture in mind. The researchers came together with community organi-zations, the American Diabetes Association (ADA), and public health advocates in 2012 to form the AANHPI Diabetes Coali-tion. One of the first priorities was to work with ADA to adopt a screening guideline that would more effectively diagnose diabe-tes among Asian-American populations. Not the Start nor the EndWhen the ADA announced the lowering of their recom-mended screening BMI for Asians, it validated many years of effort on the part of researchers and health professionals who worked with Asian American populations. Two major challeng-es, or factors, remain.

The first is the challenge of building awareness in order to increase screenings for Asian Americans at the lower cut point. The ADA announcement was important, but there are still guide-line authorities that have not adopted the lower screening point. Currently, the U.S. Preventive Services Task Force (USPSTF) rec-ommends screening for type 2 diabetes in asymptomatic adults with BMI 25. Both the CDC and CMS continue to use this guide-line to consider individuals at riskand to provide services accordinglyfor diabetes and obesity-related disorders at the standard BMI range. Those in the Asian community are disad-vantaged in being provided needed services.The second challenge is one of data, or, information itself. BMI is by no means an ideal, be-all and end-all quant for screen-ing and diagnosing Asian Americans. As Dr. Hsu et al clearly state in their position statement that formed the basis for ADAs change, more research is needed to identify better risk markers than BMI.9 BMI does not take into account the relative propor-tions of fat and lean tissue and cannot distinguish the location of fat distribution. To compound this challenge is the complexity and heterogeneity of the Asian American designation itself. South Asians and Filipino Americans develop diabetes at a significantly higher rate than other Asian Americans, in ad-dition to as compared to the general population. These two Asian-American subgroups are closer to and sometimes exceed (depending on geographic region) the rates experienced by His-panic and black communities. But Japanese and Chinese Ameri-cans, while seeming to fit the model minority stereotype of thin and therefore healthy, also experience greater risks of de-veloping type 2 diabetes. More research is needed on each Asian subpopulation in

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OBESITY

Gregg Jossart, MD, FACS

The Sooner the BetterBARIATRIC SURGERY

In 1995, surgeon Walter Pories published an article in Annals of Surgery titled, Who Would Have Thought It? An Operation Proves to Be the Most Effective Therapy for Adult-On-set Diabetes Mellitus.1 Almost two decades have passed, and we are in the middle of an obesity-related diabetes epidemic. In the United States, there are more than 100 million Americans with diabetes and prediabetes, and more than 72 million Americans with obesity. Two-thirds of adult-onset diabetes is directly associated with obe-sity. Obesity is also associated with more than forty other medical problems, including heart disease, cancer, sleep apnea, and ortho-pedic problems. All of these problems, including the obesity itself, tend only to worsen with time. The numerous medical problems can be treated to some extent with medications, CPAP devices, and physical therapy, but the core problem that remains is the obesity. Dietary and exercise weight-loss attempts are always the best start-ing point but, unfortunately, failure does occur and obesity persists. Recent commentary published in the journal Lancet Diabetes & Endocrinology claims that once people develop obesity, it is next to impossible to return to a healthy weight without bariatric surgery.2 Christopher Nolan, a clinical psychologist, noted that the average adult with sustained obesity has less than a 1 percent chance of re-turning to and maintaining a healthy body weight without surgery. Obesity surgery has the highest cure rate of obesity and its related illnesses but has been viewed as a last-resort option and thought to be dangerous. That view is changing due to newer, safer procedures and how well diabetes is cured with surgery. In April of 2013, the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American Association of Clinical Endocrinolo-gists (AACE) made recommendations that include obesity surgery as an earlier treatment option in the obesity disease process.3 Sur-gery has the highest cure rate of obesity-related diabetes when it is in the earliest stage, not when a patient has had diabetes for ten years and is approaching 400 or more pounds in weight. In the last twenty years, numerous advancements in surgical weight reduction have occurred that now make it a great option to consider earlier on in the obesity and diabetes disease process. The advancements include laparoscopic approach, safety, and lower-risk procedures. The evolution from open surgery to lapa-roscopic surgery started in 1994 and, currently, almost all weight-loss surgery is done laparoscopically. Patients have less pain, fewer complications, and require only one to two nights in the hospital. The laparoscopic approach and the increased surgeon experience have reduced complication rates to the point that bariatric surgery has been proven to be safer even than gallbladder surgery.

The most significant changes in bariatric surgery in the last ten years are related to the choice of procedures and the outcomes in diabetics. The gastric band procedure was approved by the FDA in 2001 and was placed in more than 20,000 patients in Califor-nia. It has become much less common over the past few years be-

cause of problems that develop from the device wrapped around the stomach. Essentially, the band can be effective but has a high re-moval rate. The gastric bypass and the duodenal switch have been the best operations for diabetes over the last twenty years. The in-testinal bypass that is created causes significant malabsorption of calories consumed. Malabsorption has the ability to achieve a more durable weight loss and perhaps a better cure of diabetes but also yields more long-term nutritional deficiencies and other complica-tions related directly to the intestinal bypass. Currently, all of these procedures have been proven to achieve weight loss and diabetes resolution and all are approved by insurance companies. The new-est procedure that is now selected by more than 50 percent of pa-tients is the sleeve gastrectomy (Figure 1, below). The sleeve gastrectomy (or gastric sleeve) only reduces stom-ach volume without changing the intestines (as in gastric bypass) or introducing a foreign body (as in gastric banding). This allows for a balance between portion size and range of food choices with fewer side effects. Insurance companies started approving this pro-cedure in 2010 and it has increased from 2 percent in 2008 to over 50 percent of all procedures in America in 2014. This procedure is most appealing to patients as it avoids all the potential problems of the more complex bypass operations as well as the foreign-body

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problems of the gastric band procedures. It has similar weight-loss and diabetes cure rates as the more complex gastric bypass operation, with a much lower risk profile. Historically, surgeons were slow to offer this to patients as it involves removing most of the volume of the stomach and is not reversible. They also thought weight loss would be inadequate or weight gain would occur, as it was an operation that only reduced stomach volume. Results over the last five years have proven the procedure yields durable weight loss and diabetes improvement. There is also some proof that the removal of the volume part of the stomach (greater curvature) also includes removing most of the cells that produce the hunger hor-mone, ghrelin.4 This may explain why the procedure has weight-loss results that are better than expected. Most overweight diabetic patients who choose this procedure appreciate the reduction in ap-petite, the early and lasting fullness after small portions of food, and the rapid improvement in their diabetes to the point that they do not need insulin or even oral medications.Critics of this procedure claim it has not been studied well enough yet and that without an intestinal bypass, the results will be inadequate. However, most insurance companies and Centers for Medicare and Medicaid Services have determined that it is an effective operation. The lack of an intestinal bypass may actually be what makes it so appealing to the patients themselves. Physicians and patients must realize that while this operation has proven to be effective and safe, it is most effective and most safe at at the low-est levels of obesity (BMI 35-45 kg/m2) and at the earliest onset of obesity (duration less than one year). It is difficult for many of us to accept that something as extreme as surgery should be offered so early on in the disease process. However, it may be more extreme to watch your patients weight increase at every visit and then add more and more prescriptions for diabetes, hypertension, and the numerous other weight-related conditions.

This author advises: Counsel all patients to get their BMI be-low 30 kg/m2 for optimal long-term health. Any patient with a BMI close to 35 kg/m2 should be encouraged to consider weight-loss surgery. Any patient greater than 350 pounds (BMI > 50 kg/m2) should be alerted to that fact that they may have terminal obesity and there may be no real safe or effective medical or surgical op-tion to cure their obesity. Gregg Jossart, MD, FACS, is director of bariatric surgery at Califor-

nia Pacific Medical Center and has been in practice since 1999. His spe-cialty interests include laparoscopic treatment of obesity, diaphrag-matic hernias, motility disorders, and solid tumors of the esophagus and stomach. He has written and co-authored several chapters and journal articles on the technique and outcomes of sleeve gastrectomy. He is a member of the SFMS.

References1. Pories WJ et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. Sep 1995; 222(3):339-50.2. Ochner CN et al. Treating obesity seriously: When recommenda-tions for lifestyle change confront biological adaptations. Lancet Diabe-tes Endocrinol. Apr 2015; 3(4):232-4.3. Mechanik JI et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Obesity. 2013; 21:S1-27.4. Langer FB et al. Sleeve gastrectomy and gastric banding: Effects on plasma ghrelin levels. Obes Surg. 2005; 14:1024-29.

both a broad (disaggregated data on Asians and Pacific Island-ers is always in short supply across most medical conditions) and an acute sense. In the near future, one in three diabetics in the world will be Chinese or Indian. Thus far, there have not been large-scale clinical trials done on Asian-American subgroups.Asian BMI Is 23 for Screening for DiabetesThere is enough existing research, data, and provider knowledge, however, to make the case that BMI 23 is the num-ber to use as an initial screening point for Asian Americans. A study published early in 2015 by Happy Araneta, PhD, shows that BMI 23 provides an 80 percent sensitivity with regard to Japanese, South Asian, and Filipino Americans, and that identi-fying and implementing BMI cut points for each Asian subgroup is impractical. A single BMI cut point from a public health stand-point that is simple to use is critical as we continue to face a high rate of undiagnosed diabetes in the U.S., while appreciating the need for an individualized approach on the patient level.10 Continuing to use the traditional standard of BMI 25 for Asian Americans will miss diagnoses of diabetes. Instead, BMI 23 should be used as the point for screening.

Edward A. Chow, MD, is cochair of the AANHPI Diabetes Co-alition and chair of the American Pacific American Diabetes As-sociation Action Council (APADAC), ADA. He is a longtime SFMS member. David Lee Hawks is director of communications, Nation-al Council of Asian Pacific Islander Physicians. A full list of refer-ences is available on www.sfms.org.

Bariatric Surgery Continued from previous page . . .

The Asian BMI is 23Continued from page 24 . . .

High-Fructose Heart RisksOnly two weeks of modest consumption of high-fructose corn syrup causes cholesterol and triglycerides levels to rise, and the more consumed, the greater the increases.Researchers divided 85 people chosen for their healthy lip-id profiles into four groups. One group consumed drinks sweet-ened with 25 percent high-fructose corn syrup; the second with a 17.5 percent concentration; the third 10 percent; and the last drinks sweetened only with aspartame.The results, in The American Journal of Clinical Nutrition, were consistent: The more corn syrup, the worse the lipid pro-file. While LDL (or bad cholesterol) in the aspartame group re-mained the same before and after the diet, the 10 percent group went to 102 from 95, the 17.5 percent to 102 from 93, and the 25 percent group to 107 from 91. Optimal LDL levels are under 100. Other blood tests of cardiovascular risk non-HDL cho-lesterol, triglycerides, uric acid and others moved in the same negative directions.

It was a surprise that adding as little as the equivalent of a half-can of soda at breakfast, lunch and dinner was enough to produce significant increases in risk for cardiovascular disease, said the lead author, Kimber L. Stanhope, a research scientist at the University of California, Davis. Our bodies respond to a rela-tively small increase in sugar, and thats important information.

Nicholas Bakalar | New York Times, April 28, 2015


OBESITY

Michel Accad, MD

Conscientious ObjectionsTHE WAR ON OBESITY

Truth, it has been said, is the first casualty of war.Philip Snowden (18641937)

A war on obesity has been declared. Public health au-thorities have identified excess body mass as an epidemic threat. With a great sense of urgency, they are mobilizing resources to address this preeminent health concern. To bolster the effort, the American Medical Association has recently decreed obesity a disease. Local, state, and national political powers are now engaged in its eradication and have enlisted the assistance of a number of celebrities.But does the war on obesity have clear objectives and a sound strategy? Will the campaign be conducted as a targeted strike with a well-defined exit plan, or will it turn into an open-ended conflict with limited prospects for victory? Will the offen-sive conform to just war principles, or will it be mired in moral confusion? Whatever the answers, I have reasons to object to this war.To begin with, the means by which the campaign against obesity identifies the enemy is questionable. The current defini-tion of obesitya body mass index (BMI) above an arbitrary cutoff pointdoes not amount to a compelling description of a disease. According to this definition, obesity does not entail having symptoms but only a statistical risk of future complica-tions. Individuals on either side of the cutoff point cannot be distinguished in a clinically meaningful way, yet one will be a target for intervention while the other may be falsely reassured of being safe.

Furthermore, the enemy is not identified on the basis of sound pathological science. Seen under the microscope, the fat cell from an obese individual cannot be distinguished from the fat cell of a slender person. Metabolic, hormonal, or behavioral criteria to segregate the obese from the non-obese have so far proven elusive. More important, the foe in the war on obesity cannot be separated from the friend. Unlike infectious agents or cancerous growths, fat tissue and body weight are intrinsically constitutive of the individual. An increase or a decrease in my mass is necessarilyat some levelan increase or a decrease in me. The war on obesity, then, could easily degenerate into a war on the obese.To sidestep these difficulties, commanding officers in this

conflict have targeted their action against soda drinks, corn syrup, and other carriers of empty calories. Unfortunately, the same public health authorities had also warned for many de-cades against other dietary components, namely, saturated fats and cholesterol. That advice seemed sound at the time but has

lately been called into question by the scientific community. Whats more, according to some experts, the war on dietary fat may have prompted a population-wide increase in the consump-tion of carbohydrates, setting in motion the current obesity epi-demic. The credibility of dietary guidelines is thus diminished, and a major weapon in the war on obesity is therefore seriously impaired.Finally, the threat posed by excess body mass may not be as ominous as initially calculated. For example, while the num-ber of obese Americans has increased since the early 1980s, cardiovascular mortality has decreased and, in recent years, has even plummeted. In the last ten years, cardiologists have also identified an obesity paradox: when it comes to heart failure, myocardial infarction, and recovery from bypass surgery, a BMI above what is considered healthy can actually improve survival. Proponents of the war on obesity still believe the campaign against the BMI will encourage a healthier attitude among the people. But while some individuals may respond positively, oth-ers may not. To conflate the idea of health with a single mor-phometric measurement is a gross oversimplification that can cause excessive anxiety, impair self-image, or provoke eating dis-orders. Serious collateral damage seems inevitable.My critical judgment against the war on obesity is not meant to trivialize the condition. Nor do I deny that obese persons are at risk of serious complications. But obesity is among the most intimate of diseases. It should not be addressed with propagan-da and methods of war. It calls, instead, for a language of friend-ship and genuine care.

Michel Accad, MD, FACC, is a San Francisco cardiologist and internist in solo private practice. He is founder and medical direc-tor of Athletic Heart of San Francisco, a sports cardiology clinic dedicated to serving the cardiovascular needs of athletes and physically active men and women. He is also assistant clinical pro-fessor of medicine at UCSF/SFGH, Division of Cardiology. Dr. Accad is a member of the SFMS and of the editorial board of San Fran-cisco Medicine. The views expressed in this article are his own.


ADVOCACY UPDATE

The San Francisco Board of Supervisors has unanimously approved SFMS-endorsed legislation that would ban all tobacco productsincluding smokeless tobaccofrom all baseball ven-ues and City athletic fields within the City and County of San Francisco. The ordinance, proposed by Supervisor Mark Far-rell, is expected to go into effect on January 1, 2016, and covers the players, the fans, and anyone in the venue during a base-ball game or related activity and will make any venue (such as a stadium, league field, etc.) that hosts organized baseball games completely tobacco free at all times. It will also apply to spe-cific athletic fields and events that are owned by the City. Similar penalty structures to San Franciscos already existing antitobac-co laws will also be put in place.The measure is designed to protect youth and the broader San Francisco community and, as the professional baseball sea-son gets underway, to send a simple and powerful message: To-bacco doesnt belong near San Franciscos kids or as part of our national pastime. The San Francisco Medical Society, representing 1,600 San Francisco physicians and physicians-in-training, ap-plauds Supervisor Mark Farrell for championing this ordinance to make the game of baseball safer for our kids, safer for the players, and safer for the future. We would also like to thank Supervisors Eric Mar, John Avalos, Katy Tang, Julie Christensen, Scott Wiener, and Malia Cohen, as well coalition partner Tobacco-Free Kids, for their support and efforts for a healthier San Francisco.I could not be more proud of San Francisc

May 2015

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