 All right, can all the speakers join us now to be honest We said lunch at 12 o'clock 5 and it's 12 o'clock 5, but we did schedule an hour and 10 minutes for lunch So let's eat into a little of our lunchtime and see how many questions you can come up with Step up to the mic if you'd like to be recorded Our esteemed colleague dr. John Farquhar is going to lead off Are you live dr. Farquhar? Just a quick question for Randy How did you Measure or or prevent cross-contamination within your Community with you know three different programs going and they're all in a big neighborhood was there a problem of One group infecting the other with a better way of doing things so first of all it's impossible to prevent cross-contamination altogether and that Contamination might occur in several different ways particular because we had the same primary care physician might have particular patients in each of the three arms in addition these are people that we live in the same neighborhood so they may see each other and of course those participating in the group sessions a group session may include those that receive only the case management component as well as those that are receiving the case management and the Home visits so some of that was unavoidable We think that some of it is at such a low level that we don't particularly think that it's going to affect the Results certainly it would have a conservative bias Reducing the the magnitude of the size of effects, but particularly for the physicians those physicians haven't been successful at fistful at hating weight loss and to somehow Shift to a more effective model where some of their patients are affecting their behavior towards the Usual care patients. I think would be unusual So it is an issue. We're not particularly worried about it affecting the final results Dr. Abby King So I unlike Jack. I don't have to bend down First thanks for a great set of talks each one was terrific my questions for bar So hi I'm interested in terms of the current and future pressures on schools Here we're seeing they're getting you know physical education is being legislated out of schools and everything How do you see your curriculum fitting into the school day? And how do you see that working given the continued academic pressures on schools these days? Yeah, it's a great question. And as you know having us a huge problem The way we have been doing it is to actually have it in health education classes and We've looked at the state guidelines for health education and said we'll take on teaching these guidelines about nutrition and so forth and Then put it in the physical activity class and but it has to be done on the computer which And that's actually worked pretty well so far. So it's the the the schools Really are quite happy to have us take over that function, but it's been both aspects of it is both providing something for healthy What regulation but doing the contents of health education? You did understand me correctly. Yes one of the ironies Well, we actually looked at the numbers because we that takes about an hour or 12 hours of they lose 12 hours of physical activity by doing this particular program and You know, we we were worried about that because you know You've seen the importance of having these kids not sedentary But of course in the program is the whole point of it is to increase physical activity or at least half of it So we monitor that and we try to really move kids outside of the school and to do in more physical activity Not I didn't show you the data But we do have some preliminary data because we really based on Tom's work and yours a lot of other people really noted the importance of reducing television time and computer time and so forth. So that is a has been a major emphasis and It's very It's a substantially difficult thing to do But we have some evidence that we succeeded in some of the schools So we try to balance that with a gain of more time outside of school Thanks, Dr. Marcia Stefanik. So I want to echo Abby's Congratulations to all of you. Those were great talks. My question is for Jerry And it's too bad I couldn't ask you right after your talk because there was a particular slide you showed that were your own data where you had the turtiles of the SSPG And you were showing the total cholesterol in the LDL and the other things and what struck me Was that actually the lines were very parallel so that increasing weight was Really equally bad for all groups. It was the where they started their baseline. That was the most important Issue which from a clinician's perspective. I think it's fine because it's at baseline that you're looking at that But my question to you is you've done a wonderful job of making everybody recognize that Being overweight is not equal for all people, but on the other end so the people who are normal weight Who are already showing those major problems? It seems to me that people aren't even thinking about the fact that they could actually continue on those beautiful parallel curves of yours and Improve if they lost weight and so I'm kind of wondering do we have the 25 is that set too high for at least certain populations? It's a complex question and I won't even try to deal with that last part about what is right for what population on the other hand as I tried to say earlier that differences in weight count for about 25% of that variability in insulin action and So it's very possible that the people with normal weight Are still have problems not only in our data But it was more impressive and what in Wildman's data where you know quarter of those three populations pretty much a normal weight Already were unhealthy quote-unquote then I think you're talking about differences in genetic makeup Differences level activity none of which were controlled for so I'm not so sure How much benefit would occur in the insulin resistant person at normal weight by Losing more weight. It's a good question. I'm not sure every get it by an IRB, but it's really a good point to make I'm not sure it follows that they would but who knows Go ahead Jennifer Robinson This question is actually for almost all of you Several of you mentioned measuring waist circumference in various studies And I'm just curious to know if you all measured the waist circumference in the same location I know that there's some different information about different places to measure and then also Just your thoughts on waist circumference versus waist to hip ratio Who wants it? Well, I'm the most skeptical. I think it's a waste that yeah, first of all I think we measure the same way like the NIH tells you to measure it I think the very interesting thing in that slide I showed you from the Emerging risk factors blah blah blah what they found that whether you measure waist circumference or waist hip ratio or BMI None of them were independent predictors of heart disease for example And what they also show which I did not necessarily get into was that Looking at the different centers the least Some of them had actually done reproduced had done Successive measurements that the least reproducible was waist hip ratio the most reproducible is BMI But certainly in our data we measure it the same way and I don't know what you know what anybody else does is their own business Dr. Kiran, and didn't you publish a paper called measuring waist is a waste? Guidelines where they had set up this very elaborate and what looked very official algorithm to measure both BMI and waist circumference and risk factors and it was this enormous 25-step thing and we went and looked at the The Additional predictive value or exactly and we looked at it in a large national data set and basically added nothing to Actual BMI in part because their cutoff was driven from a study that had been coming from BMI So it was sort of this gigantic circular kind of thing in our particular study We started to measure it and was in the grants and we had just a horrendous time trying to Get reliable measures and I made a really Calculated decision that the sort of our study wasn't going to add anything to the Physiology around the waist circumference and we I dropped the measure on purpose given We were trying to get the women sort of in and out of the clinic visits at that point And I spent a fair amount of time with a lot of different investigators trying to get a really good Protocol and was stunned at how poor they were so We worked hard to try and do it and didn't sell just a quick added any dough one of the hardest things I Difficulties we're having I had to do or try to do with our various studies Was to insist that we measure waist circumference because so many of my colleagues felt that I've had to stupid Non reproducible thing to do that they didn't want to do it anymore But I knew we would have a couple game published if we didn't have waist circumference measurements That's anecdotal not scientific, but I've had a somewhat interesting insight from the clinical viewpoint which is that in a busy clinic where Assistants are weighing people it's extremely unreliable people get weighed with or without their shoes with clothing and various types So although there's a lot of focus on how unreliable waist circumference is in clinical use I think the two may not be so different just because we have failed to standardize weight Measurement in a in a busy clinic. I think there's also a potential and again This is a bit anecdotal that some patients who are extremely frustrated that they have been Behaviourally adherent to physical activity and dietary restriction often don't see early success with weight But frequently do with small changes in waist circumference So I think that the waist circumference we shouldn't give up hope on it but this whole issue of measurement and Difficulty training people to do it properly is a huge issue Just caution that just to say however when you bring so I agree with you on all that People hate getting it done and it's just an incredibly Invasive thing to have done and incredibly difficult for people who are really overweight It's very hard to do and you put it inside or outside the roles and stuff So it it's it becomes a very psychologically difficult thing to navigate So I think you have to go in maybe with a subset of patients or a very very good reason why to do it Given that added aspect well at the risk So I kind of classic why do you care? I mean I just got through pointing out the emerging risk factor group showed that these measures Were it not independent a matter which when you did there was an earlier paper using in Haines data They showed the same thing that they took all the so-called risk factors from from the quote-unquote metabolic syndrome That the only one that had nothing to do with predicting anything Was the measurements of adiposity would predict this stuff Where the metabolic outcomes not the measures of adiposity? So why gets to hung up on which one you're gonna do Miss Whale nevermind because we present I think it's important because we presume that Weight gain is going to cause those other risk factors that are being measured We don't presume that people with hypertension gain weight because they're hypertensive No, but nevermind Jack yeah, I'd like to Try and put together a Marriage of the two issues of what you're doing Randy and what you're doing bar Because you could look at contamination in another way bar if you had all the schools in a and an area in a community or a region or and And and Randy if you had all of the adults under some kind of program The cross-contamination would start to get toward a total community approach Which is as you all know what I think is where we need eventually to go So I just wanted to congratulate both Randy and and bar for that Possibility of showing us what might happen if if this became more universal and then within that context every one of the things that Thomas said and Michaela etc that that if you have all of the good projects going within the context of Universality and I think we're really getting somewhere. So this was a marvelous set of presentations And yours too Jerry I got Abby go ahead You look tentative. Well, I want to ask a question to Mary In terms of the active pal What are the data for the population wide use of that because that seems like something that could solve Many of the problems we're facing with the act of graph especially in terms of 24-hour measurement And maybe your mites at some point, which I think would be the true solution will come to the fore But I know that that's going to be a while So can you speak a little bit and I know Marcia is thinking about this question too from our whi grant perspective here We have you know 45,000 women or something trying to figure out how to measure Physical activity and sedentary behavior. Can you speak a little bit about the possibilities of doing that? That active pal I think is a really interesting device There's a couple of issues with it. The first one is that you're sticking it to the thigh Which is just a little more uncomfortable than wearing an act of graph around the hip and so The rates of adherence might go down a little bit with it As far as accelerometers go, they're all sort of measuring the same thing now as far as physical activity and The different levels in that sort of thing. And so I think it can be really really useful And but there isn't as much research on its validity and that sort of thing So that's the two issues is people might not want to wear it and There's not as much validity out there on it. I think it's really promising though Okay, I'm going to take advantage of the podium here and maybe ask the last question before we head off to lunch I'm asked a loaded question Maybe of each and every one of you maybe Tom to start because you didn't get to answer yet But this could be just a one-word answer. So in everything I heard just now for the last hour or so We found different ways of identifying Targeting subsets of the population that might respond better or be at greater risk and we have innovative new Interventions that don't always work for everyone, but they they might be innovative and work in a new way for a subset so just in in terms of your your work as Interventionists and health professionals. Are you more excited or discouraged that with these methods? We have these scientific methods Are we being shackled to Interventions that get deluded and then we have to report small effects Are you excited that our tool chest is getting more and more filled with targeting Social movements or identifying sedentary behavior or finding the stability first folks Is this a really upbeat time or is it or do we have to shift our whole scientific paradigm? Simple question excited or discouraged I'm very excited and it's also in measuring outcomes. I think we're identifying a lot of new Potential outcomes other than just weight You can pass if you want Jerry. We'll just go down the line here. He's excited. He's passing Mary Yeah, I mean I'm really excited I'm the more I learn about this and the more complicated it becomes the more exciting it is You're not stressed that your effect might be deluded there's some sedentary folks and some really active folks and Measuring this it's gonna be good all around. Yeah Bar is gonna tailor his Really look great. Hey, I'm excited as well I think there are a lot of challenges in terms of trying to identify and tailor to specific populations. We don't always have the Clinical trial infrastructure to be able to do the larger trials are going to be necessary But hopefully all this excitement about technology will require The larger studies and the the more definitive studies that can take advantage of the technology Go ahead and close and I just say as a field I think we've done a terrible job at tailoring things to date and it's really Wide open against the one-size-fits-all I think we have tons of things that we can do now because I guess that's what I'm having the most fun with There's not just the low fat and the low carb diet just from the diet perspective And all I've heard this this morning was just some really great insights into targeting and improving assessment Methodology so we have a fabulous group of folks at Stanford I hope we'll collaborate with the folks in the audience and now we're gonna have a great lunch and a full hour for a Break and we'll come back for a third session. Thanks to all the panelists The preceding program is copyrighted by the board of trustees of the Leland Stanford Junior University Please visit us at med.stanford.edu