Archive for the ‘obesity’ Category

Obesity 4

Thursday, April 11th, 2013

Other things about obesity

1.  Someone somewhere may be fit but fat, but you are not one of them.  And you’ll never be one of them either.

2.  Losing even ten or twenty pounds can have positive health benefits.

3. Set goals and evaluate how you are doing at regular intervals. Every month or so, do a self-assessment and see how you are doing. Above all avoid gaining weight.

4.  People who are overweight or obese know they are. They don’t need you to remind them or scold them. Be nice. It’s not easy to keep the weight off.

5. Obesity is not a personal moral failure, it’s a social (group) moral failure.

6. Avoid drugs and over the counter weight loss aids. They are unsafe or ineffective. Though surgery may help if you are severely obese.

7. Being too thin is a health risk as well. There are a lot of people with eating disorders and they need professional help and everyone’s deep sympathy and support.

8. There may be a sweet spot for maximum longevity around a BMI of about 26. This is just over the oversight line. But the maximum for overall good health is lower than that, squarely in the normal weight category.

9. Smoking to keep the weight off may work, but it’s extremely wrong.

10.  Weight lifting is a critical part of healthy living. Everyone who can and should do it.

11.  Buying cheap exercise equipment (and expensive equipment) so you’ll work out at home rarely works because most people don’t have the self-motivation to use it consistently.

Obesity 3

Thursday, April 4th, 2013

Physical activity

1.  It’s impossible to get enough physical activity solely by going to the gym. No one who is gainfully employed or in a relationship (or looking for one) can get to the gym consistently enough.

2.  Therefore, you are going to have to incorporate physical activity into your day to day life. This means walking a half hour a day. Every day, good weather and bad.

3. Long commutes are bad for your health. You’ll never make up the time and you’ll spend far too much time sitting and being stressed.

4.  Even a little regular physical activity is good if you are sedentary.

5. Take the stairs.  Park further from your office or the mall entrance. Every step adds up.

6. Unless you are a college athlete, too much exercise doesn’t help. After about a half hour of vigorous physical activity, the marginal benefit declines.

7. It’s hard to get to the gym every day. And that fifth straight day at the gym doesn’t get you too much. Your body needs some rest.

8. Based purely on personal observation at the gym, one mistake beginners make is to spend too much time stretching. Five minutes is enough (there is little evidence that stretching helps prevent injuries though it may be good for long term heal and flexibility). But I’ve seen people spend half an hour or more stretching. They stretch rather than exercise. Not good. You only have so much time.

9. A personal trainer can be a great way to get fit or meet fitness goals. But not all are good. Avoid those that emphasize strange exercises that require help to perform. Or trainers that have you do dangerous exercises.

10. For me at least, there really is an exercise high where I feel invigorated. Try to see if you have can get there too

11. The advantage of a gym is that it is socially acceptable to check out the good looking bodies. But be discreet. Don’t be creepy.

12. Walking to get frozen yogurt does not improve health and fitness.

13. Don’t sit. Stand up every 15-20 minutes and walk some. This is good for your weight, back muscles, and eyes.

14. Walking seems to be good for mental health and avoiding cognitive decline. Walk. Walk as much and often as you can.

Obesity 2

Thursday, March 28th, 2013

13. Unless you have a serious chronic illness, don’t bother with gluten free or other fad diets. If they appear to help, it’s most likely a placebo effect you’re experiencing. The other problem is that the more restrictive a diet is, the harder it is to keep to it.

14. If you do have a serious chronic illness, then definitely explore gluten free or other types of special diets. Though the science isn’t there yet, the anecdotal evidence is intriguing.

15. Don’t ever feed your children chicken tenders. Humanity existed for 100,000 years before they were invented. They may get you through a few picky eating years, but you’re setting your child up for a lifetime of bad eating habits and a taste for over indulging in salty processed fried food.

16. Keep adults away from the blue cheese and ranch dressings. Most salad dressings. They are all fat, salts, and sugar. You might as well put MnMs on your salad.

17. A little wine with dinner is good for you. If you have a substance abuse problem, No! Avoid any and all wine. Otherwise, have a glass at dinner. Just one glass. And maybe you shouldn’t drive after that.

18. Needing 8 glasses of water a day is a myth. But why not drink water instead if a soda or sweetened fruit drink.

19. Avoid sodas and most fruit drinks. They are bad whether sugar free or not.

20. Fasting may be good for spiritual health, but not for physical health. Do not fast.

21. A cleanse is pure pseudo-science. Avoid taking any advice from anyone who tells you it’s a good thing.

22. If it’s on the Internet, chances are it’s pure bunk.

23. Telling someone to talk to their doctor is the medical equivalent of the fine print in your cell phone contract. Your doctor doesn’t know because they weren’t trained in nutrition. The person giving you the advice is just covering their butt so they won’t get sued.

24. At any given meal, half your plate should be fruits and vegetables. Then some starch, preferably whole grain, then just a tiny amount of neat, if any. Eat your vegetables and fruits first.

25. Some things have to be eliminated from your daily life. Sorry, but no mochas, smoothies, cupcakes, etc.  You grew up without a daily dose of these things, be a child and go without them again.

26. But limited your food intake does not mean a life of deprivation. Go for better quality food and savor what you do eat. And if it doesn’t taste great, don’t eat it.

28. Don’t grocery shop when you are hungry. You’ll be more likely to buy things that are bad for you.

29. Develop a repertoire of healthy, easy and quick to make meals. Then make them.

Obesity 1

Thursday, March 21st, 2013

Obesity 1

Having spent fifteen years researching obesity related topics, here is my take on how to achieve a healthy weight.

1.  Some scientists say that to lose a pound you must eat 3500 calories less than you burn, this is based on simple thermodynamics models. But because the human body can adjust its efficiency at using calories, the reality might be higher and the deficit may be over 4000 calories per pound. It’s not going to be easy to avoid weight gain or to lose weight

2. In general, each individual’s body does establish its own equilibrium point between calorie consumption and energy expenditure. Some scientists say that it is very difficult to change this point. Unfortunately, it is easy to adjust it up so that the body requires more food and tries to maintain itself at a higher weight. That’s one reason it’s so hard to lose weight and one reason that your first goal should be to not gain weight.

3. No one knows how many calories are in anything by just looking at it. No one knows what a portion size is.  So you have to drastically overestimate your portion sizes and underestimate calories per portion to be on the safe side.  Better still, check product information when you can.

4. Plan ahead. Check restaurant web sites for menus and calorie information if you can.

5.  Use small plates. They seem to trick the eye into believing you are eating more and the result is that you will eat fewer calories.

6. Avoid processed foods. They tend to have too many calories and too much salt. Sugar too.

7.  Eat as many vegetables and fruits as you can. But fried, salted, sugared, and buttered ones must be avoided.

8. Never finish a meal. Share or save for later. Never join the clean plate club

9. Never eat until you are groggy full. Well on Christmas, Thanksgiving, and your birthday you may. No other times.

10.  Those healthy alternatives at fast food restaurants?  Don’t believe it. They lie.  “Healthy items” often contain fats, processed chemicals, sugars, and who knows what else.

11. Meatless Mondays?  How about going the opposite and only eat meat once a week. Or only on special occasions? Or not at all?

12. Unless you are a woman of childbearing age, eat more fish. Women of childbearing age should also eat fish, but be careful to eat only fish from low on the food chain.

The Built Environment and Obesity: What We Know and What We Need to Know

Thursday, February 28th, 2013



  1. Summarize current research and evaluate state of knowledge on the built environment/obesity link.


2.         Outline gaps in current knowledge and suggest additional needed research.





A number of studies have been published exploring the relationship between the built environment and obesity.  The vast majority of these studies have been suburban and cross sectional, comparing current outcomes to current conditions.  A very limited number have studied obesity before and after an environmental amenity has been built and none have been longitudinal with obesity as an outcome.  Few have focused on inner city and minority populations.  This is an appropriate time to assess the current state of the evidence.


While the some of the literature suggests that there may be a relationship between the built environment and obesity, there are a number of important research needs including:


Statistical/Epidemiological issues:  Are multilevel studies appropriate models for studying built environment/obesity relationships?  Does the evidence meet conventional standards of causality?


Longitudinal studies.  Do people move to automobile focused neighborhoods because they are already overweigh? Or does weight rise after moving to sprawled communities?


Interventions.  A limited number of neighborhoods might benefit from the installation of sidewalks or other pedestrian amenities.  But many other communities might not be so easily retrofitted.  What can be done to address obesity in the vast majority of already built neighborhoods?

Special Populations.  Most studies to date have focused on predominately suburban neighborhoods.  What can be done to improve the built environment in inner cities and communities of color? How does this research apply to people with disabilities?


Addressing these issues are critical if the current obesity epidemic is to be reduced.

Promoting Active Environments: A Public Health Approach to Large-Scale Behavioral Change

Thursday, February 21st, 2013


The public health profession has developed theories and methodologies to promote behavior change on both the individual and population level. From reducing tobacco use to encouraging seat belt acceptance, many behavioral change campaigns have been successful.  This paper suggests ways these theories and methodologies could be used to create large-scale, nationwide change to promote active living.

Active living environments is used here to mean communities that foster walking, biking, and public transportation through mixed use, compact and dense development forms, and transportation systems that reduce car use. The alternative is conventional development: large lot zoning, strict separation of land uses, and streets heavily engineered for cars.

Evidence suggests that active environments promote physical activity, reduce obesity, improve mental health, and strengthen social capital.  These may increase health and reduce morbidity and mortality.



This analysis aims to provide the beginning of a discussion of what a broad public health campaign to promote the creation and use of active living environments might look like.  Objectives include:

  • Identify models of behavioral change that might assist policy makers and advocates to promote active living environments with an emphasis on families with children and communities of color.
  • Encourage efforts to change social norms that prioritize active communities.
  • Propose strategies for advancing the preference for active living.

Two outcomes were prioritized:

  • Increase demand.  How might we encourage individuals and families to choose to live in active environments?
  • Increase supply. How might we encourage governments to implement changes to codes and development guidelines that would result in more active communities?



This analysis included a scan of the public health literature on promoting behavior change.  In addition to broad theoretical models of change, it drew on experiences including reducing tobacco use as models for promoting change at both the individual and community level.



Traditionally, public health has focused on promoting behavioral change on the intrapersonal, interpersonal, and population level.  All these levels must be addressed if we are to increase both the supply of and demand for active environments.  Specific examples include:

Intrapersonal Level. Health belief models of change suggest that public health efforts include working with individuals and families to help them understand that by living in active environments, they can increase physical activity and reduce obesity risk. Thus they should be educated regarding the ways that conventional environments can pose barriers to health, particularly for children, and that health may improve by living in active environments. These campaigns should utilize planned behavior theory and encourage changes in attitudes toward living in active environments, increase perceptions that moving to these environments would mean adopting new social norms that prioritize active living, demonstrate that families with children have the ability to live in these communities in ways that would enhance their health and well being, and identify specific neighborhood attribute choices that would promote health.  Stages of change theory suggest encouraging families to the point where they contemplate moving to an active environment and then help them make that move (a priority target would be people of color most at risk for obesity).  It also suggests that strategies to help those who already live in active environments not to leave (perhaps targeting inner-city residents considering moves to the suburbs).

Intrapersonal Level. Social cognitive theory suggests that campaigns to promote active living environments should aim to change expectations regarding the kinds of neighborhoods people should live in (for example, currently many families believe that conventional neighborhoods are the only appropriate place for children).  It would communicate the idea that individuals and families have the ability to demand and choose healthy neighborhood designs. Social network theory suggests changing norms of behavior so that conventional environments are seen as less desirable.  At the same time, living in active communities would be promoted as more healthy.

Population Level.  Communication theory suggests that information campaigns are necessary so that the public understands the health consequences of conventional development with special outreach to linguistic minorities.  Diffusion of innovation models would imply the targeting of key individuals (particularly in minority communities) as the starting point in changing social norms and behavior.  Community mobilization experience demonstrates the need for planning, coalition building, and action.



If we are to move towards having a sizable portion of the US (and other countries) living in active environments, then there is a need to initiate large scale attitude and behavioral change strategies. These initiatives should include working with individuals to increase the number of people who desire to live in active environments and to develop a constituency that supports changes in zoning and development guidelines. On the community level, these strategies would have the ultimate goal of creating more opportunities for active living.  Together, they may move societies toward better health.

Graphic Health Post

Monday, November 5th, 2012

Allison Morris sent this to me.  I found it profoundly important. The graphic comes from Insurance Quotes.

Inactivity Pandemic

Don’t be surprised (or insulted) if the next prescription your doctor hands you is for nothing but an exercise regimen. Globally, 20% of early deaths are preventable with moderate exercise. And for the first time last year, sitting killed 5.3 million people worldwide, more than smoking. Inactivity is now considered as a full-on pandemic by health officials. Many U.S. doctors are pushing to make a “lack of exercise” a mainstream medical diagnosis.

U.S. adults end up sitting for an average of 8-10 hours everyday. This makes the American lifestyle one of the most sedentary in the world. After long commutes and hours at our desks, we can hardly blame ourselves for posting up on the couch right when we get home. Luckily, getting enough exercise is a lot easier than most of us think. The American Medical Association says that just 150 minutes of moderate exercise is all it takes to drastically reduce the risk of lifestyle diseases like obesity, diabetes and heart diseases for most adults.

Inactivity Infographic

Obesity – Maps

Monday, May 21st, 2012

Many of us first got into the field of the built environment and health because of the a series of maps that the CDC put together using data from the BRFSS.  Dr. Richard Jackson used these maps as he went around the country to incrdase awareness of the issue.

The maps can be viewed here:

CDC obesity maps

Why health and the built environment now?

Thursday, December 2nd, 2010

One interesting, yet unanswered, question is why did health and urban planning reconnect at the end of the 20th century after decades of their traveling on separate pathways?  There are several potential, overlapping reasons for this reconnection.

It could be that as the United States and other societies became more prosperous over the 1990s, their sense of environmental consciousness and demand for healthier living increased.  In a sense, this would represents movement along the Kuznets curve, the theory that as incomes grow, environmental degradation first increases as consumers demand products that address their basic needs and then decreases as consumers begin to demand cleaner environments.  Incomes in the US may have finally reached the point where the public demanded the health amenities associated with better built environments.  Evidence for this might be that New Urbanist developments and more compact metro areas command higher price premiums.

It could have been the rising tide of obesity that sparked health researchers to look at the environmental causes of increasing weight.  The increase happened far to rapidly to be the result of genetic change.  So there must have been a change in the environment, perhaps beginning in the 1970s or 1980s, that resulted in changes to the health of the US population.  While no one has documented any profound change that occurred at the time, it could have been that the nature of post war suburbia began to change somewhere at the moment.  Other alternatives, such as changes in diet (high fructose corn syrup) or changes in chemical burden (PCBEs etc.) don’t appear biologically plausible or do not explain the epidemiology of the disease.

Whatever was the initial spark, the movement gained momentum by other events including the SARS epidemic and the destruction of the World Trade Towers.  Architecture became pushed back into the consciousness of the research public.

Even though I was part of this awakening,  don’t really recall what was its impetus.  It should e documented before it becomes lost to history.

New Urbanism and Health

Thursday, November 4th, 2010

Last night as I was teaching my Built Environment class, I recounted the history of New Urbanism and its relationship to health.  The association between the two is very interesting. But it is important to note that health did not help drive the development of New Urbanism.  In fact, it was the opposite, New Urbanism helped public health return to the study of the built environment.  While there may now  be evidence to suggest that New Urbanist developments and principles are health promoting, this came after the fact.

 New Urbanism began in the 1980s as a reaction against conventional development and the concerns that the vast majority of development in the US post World War II was ugly, bad for the environment and failing the needs of communities.  It was heavily influenced by the theories of Jane Jacobs and it consciously modeled its institutions and texts after the great Modernist organization, CIAM. 

But a reading of the Charter for the New Urbanism, key early texts such as The new urbanism: Toward an architecture of community by Peter Katz, and Andres Duany’s (and other’s) model New Urbanism code, finds no mention of health except in the most perfunctory and old fashioned way.  In the Charter, the one mention of a healthy environment is clearly aimed at ecosystem health.  The model code mentions health three times in ways that suggests it is still focused on sunlight and ventilation – not different than how health and the built environment was characterized over 100 years before by Thomas Southwood Smith.  Some of the essays in Peter Katz’s book do talk about walking and pedestrian circulation, but these are not tied to health.

When the obesity hit in the mid 1980s, public health researchers searched for ideas that led them back to the study of the built environment.  At that point, it seems as if they adopted the principles of New Urbanism more or less as a whole.  But these had not yet been tested by epidemiological studies.  That came later.  In a sense, first urban planning and architecture influenced health, then health influenced urban planning.  It is an important distinction.

Built Environment Text Book

Thursday, October 7th, 2010

If all goes to plan, in the Summer of 2011, I will have a textbook published on the built environment and public health by Wiley/Jossey-Bass.  This book surveys the broad field of the built environment. It takes as its premise that there are profound health impacts on how buildings, neighborhoods, cities, and societies are built; and it uses historical analysis, epidemiology and public health research, and urban planning examples and public policy analysis, as well as case studies highlighting successful efforts to mitigate the health impacts of the built environment to analyze issues and develop provide the basis for programmatic responses. The goal is to empower students and readers to understand conditions around them and begin to address these health and environmental impacts. The book emphasizes science and solutions. The book was developed through my experience in teaching courses on the built environment and urban environmental health at the Boston University School of Public Health. It is based on the model curriculum suggested by Botchway and colleagues (of which I was a contributor).

The chapters of the book are:

1.         Introduction

2.         History

3.         Planning and urban design

4.         Transportation

5.         Healthy housing and housing assistance programs

6.         Infrastructure and natural disasters

7.         Assessment tools and data sources

8.         Indoor and outdoor air quality

9.         Water

10.       Food, nutrition and food security

11.       Vulnerable populations

12.       Mental health, stressors, and health care environments

13.       Social capital

14.       Environmental justice

15.       Health policies

16.       Sustainability

The cost of controlling obesity

Thursday, September 30th, 2010

Well over 60 million US adults are obese and the numbers are growing.  Other tens of millions are overweight and this is an increasing population as well.  Given these numbers, it is easy to see why pharmaceutical companies are rushing to develop drugs to treat obesity, their profits from a pharmaceutical approach to solving the obesity problem are going to be enormous.  Unfortunately, this is going to be way too big for the US economy to handle.

No new drug comes on the market today that costs less than $10,000 per person per year, it may well be that the cost will be even larger.  Suppose 40 million adults qualify and are prescribed these drugs.  That would work out to $400 billion a year.  Or $4 trillion over a decade.  Some of this would be offset by reduced expenditures on diabetes, heart disease, knee replacements, etc., but much of it would represent new costs and a new burden on insurance providers (which of course means a burden on people who pay for health insurance – employees and employers) and government funding of health care.  How are we going to pay for this?  What if these numbers underestimate the cost?  We could bankrupt ourselves paying for obesity drugs.

Suppose we started building and subsidizing transit and walkable communities instead of treating obesity after it strikes.  Maybe a cost effective alternative would be to spend even 10% of these coming health care costs on improving neighborhoods, buying out far flung suburbs,  building and maintaining sidewalks, subsidizing supermarkets in inner city communities and all the other things we know can reduce obesity.  The population would be healthier, the burden on the environment would be less and we might keep ourselves from bankruptcy.  Unfortunately, this is not how our medical/insurance system is set up.  Our we running full speed towards a cliff?

So people lie about their height and weight. What’s the problem?

Thursday, May 27th, 2010

Public health  researchers and epidemiologists have little tolerance for inaccurate data.  Their fear is that these inaccuracies could potentially impact the outcomes of research.  They could lead to inaccurate point estimates of effect or somehow produce results whose inaccuracies are impossible to detect.  An example of this potential issue is the ongoing concern regarding problems with self reported height and weight.  This issue illustrates how modern epidemiology analyzes data.

Height and weight are used to compute a person’s body mass index.  BMI , in turn is used to determine whether a person is overweight or obese – a measure that has problems of its own.  Inaccurate height and weight can produce inaccurate measures of BMI.

The easiest and cheapest way to determine height and weight is to ask him or her how tall they are and what they weigh.  No special equipment is needed, no personnel are needed, etc.  What could be easier?

But when researchers compared self reported height and weight to  measured values from data in the National Health and Nutrition Examination Study (NHANES), they found that these self reports were not accurate.  Overall, men said they were taller than they were measured, women self reported lower weights.  Furthermore, the inaccuracies were greater for whites than blacks, black women were the most accurate, Black men were actually more likely to say they were shorter than they were measured and weigh less.

Note that from this data we cannot know the reasons behind these inaccuracies.  People could truly believe they are being accurate or they could be lying.  Who knows?

The problem is that not everyone is inaccurate in the same way.  Overall, the inaccuraciess skew the data in a certain way, but this says nothing about the accuracy of any one individual’s self report.

What should researchers do?  Some suggest that self-reported height/weight data be adjusted to account for these group inaccuracies.  But that makes many researchers uneasy.  How do you know your adjustments would b e appropriate for this particular dataset?

The unknown effects on research outcomes keep researchers (or some of them) up all night.  Are the errors irrelevant?  Are they causing results to appear to be statistically significant when they are really not?    Are  they masking statistically significant associations?  Are they making the point estimates of effect inaccurate?  No one can say at this time.  Also frightening, is this problem going to lead to some skeptic to call for the wholesale rejection of all studies that use self reported height/weight data?   This is not paranoia,  this is a problem that has affected climate change research.

So we watch and we worry and we hedge our findings when we report them.