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Tag: overall health

  • ‘Gut Health’ Has a Fatal Flaw

    ‘Gut Health’ Has a Fatal Flaw

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    In my childhood home, an often-repeated phrase was “All disease begins in the gut.” My dad, a health nut, used this mantra to justify his insistence that our family eat rice-heavy meals, at the exact same time every day, to promote regularity and thus overall health. I would roll my eyes, dubious that his enthusiasm for this practice was anything more than fussiness.

    Now, to my chagrin, his obsession has become mainstream. Social-media testimonials claim that improving your “gut health” not only helps with stomach issues such as bloating and pain but also leads to benefits beyond the gastrointestinal system (easing problems including, but not limited to, itching, puffy face, slow-growing hair, low energy, acne, weight gain, and anxiety). You can now find a staggering range of products claiming to support digestive health: Joining traditionally gut-friendly fermented foods such as yogurt and sauerkraut are “probiotic” or “prebiotic” teas, cookies, gummies, supplements, powders, and even sodas.

    The reality is less straightforward. Maintaining the health of the gastrointestinal tract, like the health of any body part, is always a good idea. But expecting certain foods and products to overhaul gut health is unrealistic, as is believing that they will guarantee greater overall well-being. Those claims are “a little bit premature,” Karen Corbin, an investigator at the Translational Research Institute of Metabolism and Diabetes, told me. Obsessing over it just isn’t worth the trouble, and can even do more harm than good. “Gut health” cookies, after all, are still cookies.

    In my dad’s defense, your gut does matter for your health. A massive microbial civilization lives mostly along the large intestine, helping the body get the most out of food. Broadly, a healthy gut is one where the different segments of this population—numerous species of bacteria, fungi, and viruses—live in harmony. An unhealthy one implies a disturbance of the peace: One group may grow too powerful, or an invading microbe may throw things off-balance, leading to problems including gastroenteritis and a compromised immune system.

    Diet in particular has a profound impact on the gut—and how it subsequently makes you feel. “Food can have effects on the microbiome, which can then secondarily affect the host,” Purna Kashyap, a gastroenterologist at the Mayo Clinic, told me. The effects of food on a person and their microbes, he added, are generally congruent; fast food, for example, is “bad for both of us.” Neglect to feed your microbiome and the balance of microbes could tip into disarray, resulting in an imbalanced gut and corresponding bloating, stomach pain, and problems with bowel movements.

    Fermented foods such as yogurt and kimchi, long considered good for digestive health, are known as “probiotics” because they contain live bacteria that take up residence in your gut. Other foods are considered “prebiotic” because they feed the microbes already in your gut—mostly fiber, because it isn’t digested in the stomach. Getting more fiber improves regularity and supports a more normal GI system, Corbin said.

    But the fundamental problem with the gut-health obsession is that “there’s no clear definition of a healthy gut microbiome,” Corbin said. The makeup and balance of people’s microbiomes vary based on numerous factors, including genes, diet, environment, and even pets. This means that a treatment that works to rebalance one gut might not work for another. It also means that a product promoting a healthy gut doesn’t mean anything concrete. The idea that achieving gut health, however it’s defined, can solve stomach-related issues is misguided; many diseases can cause abdominal distress.

    Less certain is how much gut health is responsible for benefits beyond the gastrointestinal tract. No doubt the microbiome is connected to other parts of the body; recent research has suggested that it has a role in weight gain, depression, and even cancer, supporting the idea that having a healthy gut could lead to other benefits. But the mechanisms underpinning them are largely unknown. Which microbes are involved? What are they doing? There are “a lot of tall claims based on animal studies that the microbiome influences diabetes or obesity or whatever,” and the translatability of those studies to humans is “really unlikely,” Daniel Freedberg, a gastroenterologist at Columbia University, told me. Until scientists can show definitively that microbe X leads to outcome Y, Corbin said, any relationships between the gut and overall health are “just correlations.”

    None of this is to say that paying more attention to your digestive health is a bad idea. Especially for people diagnosed with gastrointestinal problems like IBS or Crohn’s disease, it can be essential. For everyone else, pursuing a healthy gut with food and supplements can be a nonspecific process with poorly defined goals. The food industry has capitalized on interest in probiotics and prebiotics—as well as lesser-known postbiotics and synbiotics—making products such as “insanely probiotic” yogurt, probiotic-fortified chocolate and spaghetti, and prebiotic sodas. Particularly with probiotics, the specifics are lacking. Which bacteria, and how many of them, actually make it past the stomach into the colon isn’t well understood. “A lot of probiotics are unlikely to contain viable bacteria, and probably very few of them are really making it through to the colon,” Freedberg said.

    Prebiotics are generally more important, although the source matters. Prebiotic fiber is “one of the most important things that determines what bacteria are there,” Freedberg told me, but getting small amounts from fiber-fortified products isn’t going to make a huge difference. The soda brands Poppi and Olipop largely contain inulin, a type of fiber that’s common in food manufacturing for its slightly sweet taste, Freedberg explained, though it probably doesn’t contain a lot, otherwise it would become “sludgy.” Olipop contains about nine grams of fiber per can, roughly the same amount as one cup of cooked lima beans.

    Of course, any product that is inherently unhealthy won’t magically become good for you the moment fiber or live bacteria are added to it. With desserts and salty snacks, no amount of fiber “is going to overcome the issue” that they are full of sugar or salt, Corbin said. Concerns about medium aside, though, gut-health products elicited a shrug from her: Buying foods containing additional prebiotic fiber is a “reasonable approach,” so long as they’re healthy to begin with. If probiotics make a patient feel “fantastic,” Freedberg said, “I’m not going to rock the boat.” Prebiotic and probiotic products may help to a degree, but don’t expect them to overhaul an unhealthy gut one soda at a time. All of the experts I spoke with said that people concerned about their gut health should eat a lot of fruits, vegetables, whole grains, and legumes, and cut out junk that won’t feed their microbiome. In other words, a basic healthy diet is more than enough to achieve good gut health.

    My dad’s gut-health mantra was apparently borrowed from Hippocrates, suggesting that people have been obsessing over the digestive system for thousands of years with the belief that it is the key to overall health. The draw of this idea is its simplicity: Proposing that the body’s many ills can be collapsed into a single mega-ailment makes treatment seem refreshingly uncomplicated compared with the medical interventions needed to address individual problems. That the proposed treatments are easy and self-administrable—sipping fibrous soda, popping bacteria-packed pills—adds to the appeal.

    But perhaps what is most compelling about the idea is that there is some truth to it. Lately, research on the microbiome has seen some promising advances. A large study published in 2022 showed significantly elevated levels of certain bacteria in people with depressive symptoms. Another study, co-authored by Corbin in 2023, was one of the first to show, in a human clinical trial, that a high-fiber diet shifts the microbiome in a way that could promote weight loss. This moment is especially confusing because we are finally beginning to understand the gut’s connections to the rest of the body, and how eating certain foods can soothe it. Much more is known about the gut than in the days of Hippocrates, but still far less than the gut influencers on social media would have you believe.

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    Yasmin Tayag

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  • BMI Won’t Die

    BMI Won’t Die

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    If anything defines America’s current obesity-drug boom, it’s this: Many more people want these injections than can actually get them. The roadblocks include exorbitant costs that can stretch beyond $1,000 a month, limited insurance coverage, and constant supply shortages. But before all of those issues come into play, anyone attempting to get a prescription will inevitably confront the same obstacle: their body mass index, or BMI.

    So much depends on the simple calculation of dividing one’s weight by the square of their height. According to the FDA, people qualify for prescriptions of Wegovy and Zepbound—the obesity-drug versions of the diabetes medications Ozempic and Mounjaro—only if their BMI is 3o or higher, or 27 or higher with a weight-related health issue such as hypertension. Many who do get on the medication use BMI to track their progress. That BMI is the single biggest factor determining who gets prescribed these drugs, and who doesn’t, is the result of how deeply entrenched this metric has become in how both doctors and regular people approach health: Low BMI is good and high BMI is bad, or so most of us have come to think.

    This roughly 200-year-old metric has never been more relevant—or maligned—than it is in the obesity-drug era. BMI has become like the decrepit car you keep driving because it still sort of works and is too much of a hassle to replace. Its numerous shortcomings have been called out for many years now: For starters, it accounts for only height and weight, not other, more pertinent measures such as body-fat percentage. In June, the American Medical Association formally recognized that BMI should not be used alone as a health measure. Last year, some doctors called for BMI to be retired altogether, echoing previous assertions.

    The thing is, BMI can be an insightful health metric, but only when used judiciously with other factors. The problem is that it often hasn’t been. Just as obesity drugs are taking off, however, professional views are changing. People are so accustomed to seeing BMI as the “be-all, end-all” of health indicators, Kate Bauer, a nutritional-sciences professor at the University of Michigan, told me. “But that’s increasingly not the way it’s being used in clinical practice.” A shift in the medical field is a good start, but the bigger challenge will be getting everyone else to catch up.

    BMI got its start in the 1830s, when a Belgian astronomer named Adolphe Quetelet attempted to determine the properties of the “average” man. Using data on primarily white people, he observed that weight tended to vary as the square of height—a calculation that came to be known as Quetelet’s index.

    Over the next 150 years, what began as a descriptive tool transformed into a prescriptive one. Quetelet’s index (and other metrics like it) informed height-weight tables used by life-insurance companies to estimate risk. These sorts of tables formed “recommendations for the general population going from ‘average’ to ‘ideal’ weights,” the epidemiologist Katherine Flegal wrote in her history of BMI; eventually, nonideal weights were classified as “overweight” and “obese.” In 1972, the American physiologist Ancel Keys proposed using Quetelet’s index—which he renamed BMI—to roughly measure obesity. We’ve been stuck with BMI ever since. The metric became embedded not only in research and doctor’s visits but also in the very definitions of obesity. According to the World Health Organization, a BMI starting at 25 and less than 30 is considered overweight; anything above that range is obese.

    But using BMI to categorize a person’s health was controversial from the start. Even Keys called it “scientifically indefensible” to use BMI to judge someone as overweight. BMI doesn’t account for where fat is distributed on the body; fat that builds up around organs and tissues, called visceral fat, is linked to serious medical issues, while fat under the skin—the kind you can pinch—is usually less of a problem. Muscularity is also overlooked: LeBron James, for example, would be considered overweight. Both fat distribution and muscularity can vary widely across sex, age, and ethnicity. People with high BMIs can be perfectly healthy, and “there are people with normal BMIs that are actually sick because they have too much body fat,” Angela Fitch, an assistant professor at Harvard Medical School and the president of the Obesity Medicine Association, told me.

    For all its flaws, BMI is actually useful at the population level, Fitch said, and doctors can measure it quickly and cheaply. But BMI becomes troubling when it is all that doctors see. In some cases, the moment when a patient’s BMI is calculated by their doctor may shape the rest of the appointment and relationship going forward. “The default is to hyper-focus on the weight number, and I just don’t think that that’s helpful,” Tracy Richmond, a pediatrics professor at Harvard Medical School, told me. Anti-obesity bias is well documented among physicians—even some obesity specialists—and can lead them to dismiss the legitimate medical needs of people with a high BMI. In one tragic example, a patient died from cancer that went undiagnosed because her doctors attributed her health issues to her high BMI.

    But after many decades, the medical community has begun to use BMI in a different way. “More and more clinicians are realizing that there are people who can be quite healthy with a high BMI,” Kate Bauer said. The shift has been gradual, though it was given a boost by the AMA policy update earlier this year: “Hopefully that will help clinicians make a change to supplement BMI with other measures,” Aayush Visaria, an internal-medicine resident at Rutgers Robert Wood Johnson Medical School who researches BMI’s shortcomings, told me.

    Physicians I spoke with acknowledged BMI’s flaws but didn’t seem too concerned about its continued use in medicine—even as obesity drugs make this metric even more consequential. BMI isn’t a problem, they said, as long as physicians consider other factors when diagnosing obesity or prescribing drugs to treat it. If you go to a doctor with the intention of getting on an obesity drug, you should be subject to a comprehensive evaluation including metrics such as blood sugar, cholesterol levels, and body composition that go “way beyond BMI,” Katherine Saunders, a clinical-medicine professor at Weill Cornell Medicine, said. Because Wegovy and other drugs come with side effects, she told me, doctors must be absolutely sure that a patient actually needs them, she added.

    But BMI isn’t like most other health metrics. Because of its simplicity, it has seeped out of doctor’s offices and into the mainstream, where this more nuanced view still isn’t common. Whether we realize it or not, BMI is central to our basic idea of health, affecting nearly every aspect of daily life. Insurance companies are notorious for charging higher rates to people with high BMI and lowering premiums for people who commit to long-term weight loss. Fertility treatments and orthopedic and gender-affirming surgery can be withheld from patients until they hit BMI targets. Workplace wellness programs based on BMI are designed to help employees manage their weight. BMI has even been used to prevent prospective parents from adopting a child.

    The rise of obesity drugs may make these kinds of usages of BMI even harder to shake. Determining drug eligibility by high BMI supports the notion that a number is synonymous with illness. Certainly many people using obesity drugs take a holistic view of their health, as doctors are learning to do. But focusing on BMI is still common. Some members of the r/Ozempic Subreddit, for example, share their BMI to show their progress on the drug. Again, high BMI can be used to predict who has obesity, but it isn’t itself an obesity diagnosis. The problem with BMI’s continued dominance is that it makes it even harder to move away from simply associating a number on a scale with overall health, with all the downstream consequences that come along with a weight-obsessed culture. As obesity drugs are becoming mainstream, “there needs to be public education explaining that BMI by itself may not be a good indicator of health,” Visaria said.

    In another 200 years, surely BMI will finally be supplanted by something else. If not much sooner: A large effort to establish hard biological criteria for obesity is under way; the goal is to eliminate BMI-based definitions once and for all. Caroline Apovian, a professor at Harvard Medical School, gives it “at least 10 years” before a comparably cheap or convenient replacement arises—though any changes would take longer to filter into public consciousness.” Until that happens, we’re stuck with BMI, and the mess it has wrought.

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    Yasmin Tayag

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  • ‘It Just Seems Like My Patients Are Sicker’

    ‘It Just Seems Like My Patients Are Sicker’

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    The most haunting memory of the pandemic for Laura, a doctor who practices internal medicine in New York, is a patient who never got COVID at all. A middle-aged man diagnosed with Stage 3 colon cancer in 2019, he underwent surgery and a round of successful chemotherapy and was due for regular checkups to make sure the tumor wasn’t growing. Then the pandemic hit, and he decided that going to the hospital wasn’t worth the risk of getting COVID. So he put it off … and put it off. “The next time I saw him, in early 2022, he required hospice care,” Laura told me. He died shortly after. With proper care, Laura said, “he could have stayed alive indefinitely.” (The Atlantic agreed to withhold Laura’s last name, because she isn’t authorized to speak publicly about her patients.)

    Early in the pandemic, when much of the country was in lockdown, forgoing nonemergency health care as Laura’s patient did seemed like the right thing to do. But the health-care delays didn’t just end when America began to reopen in the summer of 2020. Patients were putting off health care through the end of the first pandemic year, when vaccines weren’t yet widely available. And they were still doing so well into 2021, at which point much of the country seemed to be moving on from COVID.

    By this point, the coronavirus has killed more than 1 million Americans and debilitated many more. One estimate shows that life expectancy in the U.S. fell 2.41 years from 2019 to 2021. But the delays in health care over the past two and a half years have allowed ailments to unduly worsen, wearing down people with non-COVID medical problems too. “It just seems like my patients are sicker,” Laura said. Compared with before the pandemic, she is seeing more people further along with AIDS, more people with irreversible heart failure, and more people with end-stage kidney failure. Mental-health issues are more severe, and her patients struggling with addiction have been more likely to relapse.

    Even as Americans are treating the pandemic like an afterthought, a disturbing possibility remains: COVID aside, is the country simply going to be in worse health than before the pandemic? According to health-care workers, administrations, and researchers I talked with from across the country, patients are still dealing with a suite of problems from delaying care during the pandemic, problems that in some cases they will be facing for the rest of their lives. The scope of this damage isn’t yet clear—and likely won’t come into focus for several years—but there are troubling signs of a looming chronic health crisis the country has yet to reckon with. At some point, the emergency phase of COVID will end, but the physical toll of the pandemic may linger in the bodies of Americans for decades to come.

    During those bleak pre-vaccine dark ages, going to the doctor could feel like a disaster in waiting. Many of the country’s hospitals were overwhelmed with COVID patients, and outpatient clinics had closed. As a result, in every week through July 2020, roughly 45 percent of American adults said that over the preceding month, they either put off medical care or didn’t get it at all because of the pandemic. Once they did come in, they were sicker—a trend observed for all sorts of ailments, including childhood diabetes, appendicitis, and cancer. A recent study analyzed the 8.4 million non-COVID Medicare hospitalizations from April 2020 to September 2021 and found not only that hospital admissions plummeted, but also that those admitted to hospitals were up to 20 percent more likely to die—an astonishing effect that lasted through the length of the study.

    Partly, that result came about because only those who were sicker made it to the hospital, James Goodwin, one of the study’s authors and a professor at the University of Texas Medical Branch, in Galveston, told me. It was also partly because overwhelmed hospitals were giving worse care. But Goodwin estimates that “more than half the cause was people delaying medical care early in their illness and therefore being more likely to die. Instead of coming in with a urinary tract infection, they’re already getting septic. I mean, people were having heart attacks and not showing up at the hospital.”

    Read: America is sliding into the long pandemic defeat

    For some conditions, skipping a checkup or two may not matter all that much in the long run. But for other conditions, every doctor’s visit can count. Take the tens of millions of Americans with vascular issues in their feet and legs due to diabetes or peripheral artery disease. Their problems might lead to, say, ulcers on the foot that can be treated with regular medical care, but delays of even a few months can increase the risk of amputation. When patients came in later in 2020, it was sometimes too late to save the limb. An Ohio trauma center found that the odds of undergoing a diabetes-related amputation in 2020 were almost 11 times higher once the pandemic hit versus earlier in the year.

    Although only a small percentage of Americans lost a limb, the lack of care early in the pandemic helped fuel a dangerous spike in substance-abuse disorders. In a matter of weeks or months, people’s support systems collapsed, and for some, years of work overcoming an addiction unraveled. “My patients took a huge step back, probably more than many of us realize,” Aarti Patel, a physician assistant at a Lower Manhattan community hospital, told me. One of her patients, a man in his late 50s who was five years sober, started drinking again during the pandemic and eventually landed in the hospital for withdrawal. Patients like this man, she said, “would have really difficult, long hospital stays, because they were at really high risk of DTs, alcohol seizures. Some of them even had to go to the ICU because [the withdrawal] was so severe.”

    Later in the year, when doctors’ offices were up and running, “a lot of patients expressed that they didn’t want to go back for care right away,” says Kim Muellers, a graduate student at Pace University who is studying the effects of COVID on medical care in New York City, North Carolina, and Florida. Indeed, through the spring of 2021, the top reason Medicare recipients failed to seek care was they didn’t want to be at a medical facility. Other people were avoiding the doctor because they’d lost their job and health insurance and couldn’t afford the bills.

    The problem, doctors told me, is that all of those missed appointments start to add up. Patients with high blood pressure or blood sugar, for example, may now be less likely to have their conditions under control—which after enough time can lead to all sorts of other ailments. Losing a limb can pose challenges for patients that will last for the rest of their lives. Relapses can put people at a higher risk for lifelong medical complications. Cancer screenings plummeted, and even a few weeks without treatment can increase the chance of dying from the disease. In other words, even short-term delays can cause long-term havoc.

    Read: How long can the coronavirus keep reinfecting us?

    To make matters worse, the health-care delays fueling a sicker America may not be totally over yet, either. After so many backups, some health-care systems, hobbled by workforce shortages, are scrambling to address the pent-up demand for care that patients can simply no longer put off, according to administrators and doctors from several major health systems, including Cleveland Clinic, the Veterans Health Administration, and Mayo Clinic. Disruptions in the global supply chain are forcing doctors to ration basic supplies, adding to backlogs. Amy Oxentenko, a gastroenterologist at Mayo Clinic in Arizona who helps oversee clinical practice across the entire Mayo system, says that “all of these things are just adding up to a continued delay, and I think we’ll see impacts for years to come.”

    It’s still early, and not everything that providers told me is necessarily showing up in the data. Oddly enough, the CDC’s National Health Interview Survey found that most Americans were able to see a doctor at least once during the first year of the pandemic. And the same survey has not revealed any uptick in most health conditions, including asthma episodes, high blood pressure, and chronic pain—which might be expected if America were getting sicker.

    It’s even conceivable that the disturbing observations of clinicians are a statistical illusion. If for whatever reason only sicker people are now being seen by—or able to access—a doctor, then it can be true both that providers are seeing more seriously ill patients in medical facilities and that the total number of seriously ill people in the community is staying the same. The scope of the damage just isn’t yet clear: Maybe a smaller number of people will be worse off because of delayed cancer care or substance-abuse relapses, or maybe far more people—more than tens of million of Americans—will be dealing with exacerbated issues for the rest of their lives.

    None of this accounts for what COVID itself is doing to Americans, of course. The health-care system is only beginning to grapple with the ways in which a past bout with COVID is a long-term risk for overall health, or the extent to which long COVID can complicate other conditions. The pandemic may feel “over” for lots of Americans, but many who made it through the gantlet of the past two-plus years may end up living sicker, and dying sooner.

    This disturbing prospect is not only poised to further devastate communities; it’s also bad news for health-care workers already exhausted by COVID. Laura, the Manhattan internist who treated the colon-cancer patient, told me it’s disheartening to see so many people showing up at irreversible points in their disease. “As doctors,” she said, “our overall batting average is going down.” Aarti Patel, the physician assistant, put it in blunter terms: “Burnout is probably too simple a term. We’re in severe moral distress.”

    Nothing about this grim fate was inevitable. Laura told me that “going to the doctor mid-pandemic may have posed a small risk in terms of COVID, but not going was risky in terms of letting disease go unchecked. And in retrospect it seems that many people didn’t quite get that.” But there didn’t have to be such a stark trade-off between fighting a pandemic and maintaining health care for other medical conditions.

    Some hospitals—at least the better-resourced ones—figured out how to avoid the worst kind of delays. Mayo Clinic, for example, is one of a number of systems with a sophisticated triage algorithm that prioritizes patients needing acute care. In the spring of 2021, Cleveland Clinic launched a massive outreach blitz to schedule some 86,000 appointments, according to Lisa Yerian, the chief improvement officer. And the Veterans Health Administration provided iPads to thousands of veterans who lacked other means of accessing the internet in the spring of 2020, ensuring a more seamless transition to virtual care, Joe Francis, who directs health-care analytics, told me. Thanks in part to these efforts, Francis said, high-risk patients at the VHA were being seen at pre-pandemic levels a mere six months into the pandemic.

    These health-care systems also suggest a path forward. America may still be able to stave off the worst of the collateral damage by reaching the patients who have fallen through the cracks—and already the data suggest that these patients tend to be disproportionately Black, Hispanic, and low-income. Tragically, it’s too late for some Americans: People who died of cancer can’t come back to life; amputated limbs can’t regrow. Others still have plenty of time. Hypertension that’s currently uncontrolled can be tamped down before causing an early heart attack; drinking that’s gotten out of hand can be corralled before it leads to liver failure in a decade; undetected tumors can be spotted in time for treatment. An uptick in premature death and disability, summed over millions of Americans, could strain the health-care system for years. But it’s still possible to prevent an acute public-health crisis from seeding an even bigger chronic one.

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    Tim Requarth

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