The talks were semi interesting today; apparently I made a bad pick by missing one on gastric band surgery arguing that whatever section of the stomach you band off – insulin sensitivity goes up. However, only banding off the top part cuases weight loss; the bottom part has no effect. The talks on increasing the accuracy with which we measure energy intake and expenditure were less psychologically informed than I had hoped, and the talks on cardiovascular disease (CVD) risk factors pretty much all contained within the their abstracts – all though all talks were of course very good. The best part of the day for me, was a roundtable discussion on ‘’Genetics and Genomics” – I went thinking that I would be listening to one, but found that the format was to participate in one. I tried to run away, but my friend / colleague Ryan convinced me it would “be OK”. It was an hour long discussion, and there was one strand of conversation that really interested me and is a particular passion of mine, and I would like to share my thoughts on. It is something very dear to my heart, and probably underpinning my interest in obesity research:
How do we get individuals to respond to genetic risk information and alter their lifestyles?
NB: As before, I do not wish to claim that all people currently have the tools (whatever they may be) to reduce their risk of future disease; the question of how to effect pubic health change is a huge puzzle for many professionals to solve: epidemiologists, bench Scientists, policy makers, economists, psychologists, sociologists… to name but a few. This topic, again, is my thoughts on just one tiny thread that may help contribute in a huge tapestry of human health, and I would in no way judge anyone for the lifestyle choices they make.
Some of the participants were clinicians and spoke movingly of patients with a history of CVD heading right down the path themselves, in fact, being clinicians they usually saw them after a cardiac event and still these individuals were smoking, eating a high-fat and high-refined carbohydrate diet and doing little to no exercise. They had treated these people’s fathers, brothers and uncles, yet still saw it passing down the generations. I empathised. Someone very near to me own heart turned his father’s life support machine off ~5 years ago after a cardiac event. He saw the family left behind, he talks movingly about how his niece and nephew found it so hard to lose their grandpa, and now my friend is getting married, has witnessed the disappointment of not being able to at least tell his father in person. Yet, my friend will eat calorically dense (beyond their requirement), and high salt fast food up to three times a day, has more sugar than anyone I have ever met, chews tobacco, has a current BMI classification of ‘clinically obese’ (31; although he is very broad so it is perhaps slightly overstated) and does no regular vigorous exercise. He admits that his father’s untimely death was in no way unusual for the family: indicating a potentially very high genetic risk.
Why? Why do people ignore these signs? My suspicions are:
(1) Misunderstanding genetic risk. In terms of the spectrum of the potential impact of genetic risk perhaps people fall too far at the tail ends of the distribution. Their attitude is either “it doesn’t really have any effect” or “it is a fait accompli”. Of course, neither is accurate and despite how Science prevaricates and evolves, I would say we are pretty sure, that genetic risk exists but for a large portion of the population, can be mediated by environmental and lifestyle interventions. Put it this way: you can have all the genes to be the greatest chess player ever, but if no one teaches you chess, they aren’t going to show. Or you can have obesity risk allele there is, but if you don’t get any food… you’re not going to be overweight. Genes are rarely a prescription set in stone, rather they are another increased risk factor. Rather like driving a car: driving a car puts you at increased risk for mortality. But, some people feel they have / want / need to do it – putting themselves at this increased risk. But, they work out ways to minimise this risk: use of traffic signals, driving carefully and with awareness, seatbelts, not talking on the ‘phone. For the majority of people, this will have an effect and prevent mortality, but it won’t be foolproof. We need to get the message to people that if they are at genetic risk, but they can substantially lower their risk.
(2) People don’t want to decrease their obesity / risk of CVD. This is something I struggle with; I came to UAB with an attitude that we must make people reduce their BMI / CVD risk, almost by any means necessary. If that meant making sugar sweetened beverages an unviable option through taxation: so be it! But I think my attitude was very biased towards my own inclinations. I assumed that everyone wanted to be healthy – they just didn’t know how, or have the psychological tools to be able to. My friend David strongly disagrees. He says some people don’t want to be slimmer, they don’t want to reduce their risk of later disease and that is utterly up to them: surely it is their choice? I raised the issue of socialized medicine, where the rest of society is paying for these choices, but that is not the case here in the US, and possibly not a great argument anyway. But then I raised the issue of familial responsibility. By dramatically increasing your risk of future mortality – Don’t you have a responsibility to your family?
Possibly not to your parents, because you did not choose them. So despite the fact that they may have raised you, provided for you and given their life to you, you do perhaps have moral justification to look them in the eye and say
“I’m sorry Mum. Despite everything you have given me, material and non, and despite all my love for you, I am not going to return that gesture and be there when you most need me, because, literally, eating the majority of my meals, to caloric excess, is more important than helping you through your latter years”
Possibly you don’t have a moral obligation to your partner, because he / she had some say in choosing you. So, I guess, you are also justified in saying:
“Thank you for making a lifelong commitment to me, I am afraid I cannot do the same to you, and now, I must leave you to nurse me through ill health, and then face life alone, without the man you built you life around, because, again, lying on the sofa was just way more important to me than doing some regular exercise”.
OK, but what about children (and I know not everyone has children. Nor life partners or parents anymore, so perhaps they do indeed get a free pass). Once you bring a child into the world, is it not your responsibility to do the best by them? Is it morally acceptable to look into your daughter’s eyes and say:
“I am afraid I won’t be there to walk you down the aisle on your wedding day, you must find a surrogate – that tobacco was just too tasty”
I am not entirely sure people should have the right to make those decisions. Yes – nanny state and all, but if we don’t have the right to decide to take other’s material things, to intrude on their time with loud music, or take a lot of other liberties with them: I am not convinced people have the right make these decisions either.
(3) Science doesn’t know enough to quantify risk, or how mitigate it. Science is working… Science is improving our understanding, but it’s a two-way street. Science may not have quite such a hard job if people listened to, and effected, healthy lifestyle advice. We don’t know which genes cause CVD, we don’t know how each risk allele interacts with lifestyle factors, and some lifestyle factors, sure, there is debate about the efficacy of reducing CVD by changing them. But Science is pretty sure about some things:
- There are genetic risk factors that increase your risk for CVD, although they vary in the magnitude of individual effect in the population
- Tobacco for sure, vastly increases your risk
- Being overweight (BMI over 25) increased your risk, especially in the absence of regular, strenuous exercise (sorry, walking across the street to Wendy’s doesn’t count)
- High-fat, combined with high-carbohydrate, in the absence of endurance athlete training, will vastly increase your risk.
(4) A lack of understanding that change needs to happen today: not tomorrow, or after the weekend, or after school finishes, or when you have a child, or when you get sick. TODAY. And an understanding that it will be hard, and something you do have to work at all your life – although it will become easier.
So, how to move forward from this? What do we need?
-Better understanding of genetics in the general population. Perhaps it now needs to come into the high school curriculum: not the biology of genetics, but the use of genetic information and an understanding of what “genetic risk” means. And more research from Scientists to understand it themselves
-Perhaps some way of empowering people to believe they can make a difference, and to help them have the physical, economic and psychological tools they need to. And of course, more research into what those tools are, and how to give them to people
-Better education about the efficacy of lifestyle interventions, and better research on what they need to be
-Better research on individual differences in what people need to effect change in their life.
But, bottom line: although imperfect, Science has given you the tools to reduce your risk of all cause mortality: use them!!