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Personalized Prevention, Part IV

July 8, 2012

Earlier this year, I wrote a series of posts on the topic of Personalized Prevention.  This is a term I coined to apply to the intersection between genomics and connected health.  In Part 3, I talked about growing evidence that weight control is not as simple as calories in minus calories out.  Indeed, it seems as if there are genetic types that predispose to obesity.  My thought was that if we could screen for those genotypes early in life (or in utero), we could create connected health feedback programs for individuals who are prone to, say, energy storage, giving them the insights and tools via activity programs and monitoring to develop habits early in life to increase the calories out component.  I conjectured that we might avoid some cases of obesity this way.

Right now we’re doing a very preliminary trial to look at this in collaboration with the Personal Genome Project (led by George Church).  It’s much to early to say what we’ve learned, but this is a very exciting first step.

I confess that I believed my thinking on this topic was enlightened in considering that there may be genetic tendencies to store energy differently. But I missed a very interesting third dimension to this puzzle and that has to do with dietary composition.

My daughter Julie is a vegan.  She’s done a nice job of convincing my wife to adopt this dietary lifestyle.  I crave a good steak every now and then, but I’ve gotten used to eating more of a plant-based diet lately.  The reasons are compelling whether it is because of the inefficiency in raising animals to be used as food, the out and out cruelty in mass meat production or the well-demonstrated health benefits of a plant based diet.  Most people lose weight when the go on a plant-based diet, and I found that curious as well.  I thought it must be due to the fact that animal-based diets have much higher caloric density per unit volume. That probably accounts for part of it.  This past week,  however, a paper was published in JAMA (Ebbeling et al.) that shed more interesting light on this subject.

This was a diet study and you can read about it either first hand in JAMA, or in a well-written editorial from The New York Times.  Briefly, subjects were entered into a standard weight loss program and then broken into three groups to test the efficacy of different dieting strategies to keep weight off.  One was the standard low fat diet, a second was a low carbohydrate diet (Atkins-like) and the third was a diet rich in complex carbohydrates.

According to Ebbeling et al’s research, it takes very little effort to digest a diet of simple carbohydrates (low fat diet) and that this diet is most prone to lead to weight gain.  This is probably because simple carbs increase insulin secretion and insulin, among other things turns on fat production.

The high protein, low carbohydrate diet takes, on average, 300 calories more of work per day to digest (equivalent to a long walk or a brief stint of moderate exercise).  The downside of this one is that these individuals had higher levels of stress hormones in their urine, which may portend other untoward health effects of this diet.

The diet rich in complex carbohydrates required about 125 calories more per day to digest.  The authors make the case that this type of diet is a ‘happy medium’ for weight control.

This is fascinating. I had not considered the work required to digest food as part of this whole calories in/calories out equation.  But there you have it.

By the way, all of the participants in the study had a connected health intervention (accelerometer) as a measurement tool and their activity levels did not explain the additional calories burned.

As we look at the obesity problem, it just gets more and more interesting.  I have argued in the past we could really use a calorie intake sensor, but I’d have to modify that now and say we need a calorie intake sensor and a way to differentiate what types of calories that are eaten.  These days some folks are using pictures of their plate as a start.

My vision of how we will help those who are genetically predisposed to obesity has a new variable in it – the right diet and a way to measure dietary intake.

What do you think?

3 Comments leave one →
  1. Paul Sonnier permalink
    July 8, 2012 8:39 pm

    Fantastic, Joe! This aligns with a poll I started in my Digital Health group on LinkedIn asking members what they feel is the biggest benefit of digital health (I use a similar definition to the one you are using for connected health, since you now include genomics). Of 250+ votes, most felt disease management was the biggest near-term opportunity for digital tools to help us with our health. However, I think disease prevention will become more prominent in a very short period of time.

    Here’s the poll, with the current results (still accruing). Please do vote if you haven’t already!

    What is the biggest human health benefit derived from using digital health solutions?

    Disease management – 138 (54%)
    Disease prevention – 73 (28%)
    Disease diagnosis – 26 (10%)
    Disease prediction (especially genomics) – 14 (5%)
    Reduced radiation exposure (imaging) – 2 (0%)



    Founder, 11,000+ member Digital Health group on LinkedIn

  2. July 9, 2012 9:20 pm

    thanks for sharing this with my readers, Paul. Disease management is a near term problem to solve, no doubt. in time, the value of solving prevention will be more clear.

  3. July 15, 2012 10:11 am

    Good article and comments.

    Obesity can be viewed in two ways:
    – the chronically obese who need special diagnosis and complex treatment
    – the normally obese – some 30-50% of the population with an apparently simple treatment via diet and exercise.

    What worries me most is the chronically obese. They have tried diets and exercise without success. They have low-self esteem, Maybe it is genetically caused, but it is a major problem.

    I am not so worried about the normally obese. They have plenty of education and possibilities to reduce via diet and exercise – although more info is always valuable. Given the scale of the problem we can consider social interventions like taxing fast food.

    The chronically obese are being demonized and this makes their problem worse. Low self-esteem simply amplifies wrong behavior. Perhaps it helps when the medical establishment recognize a medical/genetic problem instead of broadcasting appeals for better discipline. In some jurisdictions the chronically obese are even denied preventative treatments – BMI too high.

    With the normally obese the psychology is important, Nobody actually wants to be fat. So instead of pointing fingers we should become more understanding?

    The current fingerpointing is not really helping. Maybe it even drives more people towards obesity. I think we need to be a lot more accepting of chronic obesity and sympathetic to the “fatties”. A recent expert study in Boston identified diet and exercise as a solution – do we seriously think that overweight people do not know this?

    I think the treatment of obesity starts by recognizing that obesity can be “normal’. Include people rather than make them feel odd or incompetent.

    Joe speculates about monitors to feedback on diet. I don’t see this happening for a long time; the technology is not there. Giving a chronically obese person a pedometer is asking them to stick it where the sun don’t shine.

    More understanding via studies is the way forward. When we start to understand how we can really help fat people then we know the use case for CH devices. We don’t need to worry too much about people who are already studying their diet and going to the gym. We need to involve the chronically obese more in our studies – they know what they are talking about. Meanwhile we should stop telling fat people that they are incompetent.

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