Signs that read, “Burn Calories, Not Electricity” posted in lobbies of New York City buildings, motivated more people to take the stairs and continue to use them even months later.

A new study, which appears online in the February issue of the American Journal of Preventive Medicine, observed and analyzed people making 18,462 trips up and down stairs at three sites. The signs immediately increased stair use between 9.2 and 34.7 percent at all locations.

“The gains in physical activity continued to be observed nine months after the signs were first placed,” noted Karen K Lee, M.D., author of the study at New York City Department of Health and Mental Hygiene. “We found that placing stair prompts at the point of decision is effective.”

The study is among the first to assess the effects of stair prompts on stair climbing as well as descent in different types of buildings over many months. Prompts were posted in a three-story health clinic, a 10-story affordable housing building, and an 8-story academic site and studied over several months.

“Human-made environments in everyday life offer numerous opportunities for maintaining health, controlling weight and preventing disease,” Lee said. “One of those health opportunities is stair climbing, a vigorous activity which can burn more calories than jogging.”

Instead of removing the signage after the study was completed, the prompts were purposely left in place. New York City continues to promote the health benefits of stair climbing by distributing free stair signs to owners and managers of public and private buildings who request them.

“So far, we’ve distributed over 26,000 signs to owners and managers of about 1,000 buildings including residential, worksites, hospitals and academic centers,” said Lee.

Remington sees opportunities for widespread use of prompts. “For example, a zoning law could be enacted that requires buildings to have stair prompts …like they require signs for exits.”

Remington added, “Overall, this is a great study, showing how for almost no investment we can improve health.”

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

By Randy Dotinga & Kelly Malcom

Health Behavior News Service 

We often give a chilly reception to the idea of going “cold turkey” when it comes to anything that has to do with changing behaviors and habits, even those that may be important for our health.

And no wonder: habits become habits because they give us something we think we need. Maybe they make us feel better (hello, chocolate!) or they bring comfort, familiarity or convenience to our lives.

Once we get used to doing things a certain way, the idea of changing a routine behavior can seem overwhelming. And we worry (with good reason) that we won’t be successful if we try to change our habits all at once.

Joan Christensen, a 57-year-old dance teacher from North Branford, Conn., understands. The recession and personal challenges sent her into a depression. She coped by eating more, ballooning her 5-foot-4 frame up to 204 pounds. “I was feeling sorry for myself and food became my solace,” she says. Yet, she wasn’t motivated to turn her life around.

Then a medical crisis hit. Suddenly, Christensen was ready to make changes, but didn’t know where to start. With the help of her physician, she began to take small but meaningful steps to reduce her weight. It worked.

“I’m a new woman,” Christensen says. Through a series of small steps over a period of six months, she lost 44 pounds.

What can I do to ensure my success in changing my behavior?

• Get help from your primary care doctor (or another professional, like a nutritionist)—they may have access to resources you don’t know about.

• Make changes you’re about 70 to 80 percent sure you can accomplish.

• Set up your environment to trigger the behavior you want to engage in (i.e. if you want to floss your teeth more frequently, put the dental floss next to your toothbrush).

• Focus on the positive impact of what you are doing, rather than how far you have to go.

• Think about finding or creating a support group.

It’s not just common sense that backs up her go-slow approach. Research supports it too, suggesting we’re more likely to improve our health if we don’t pressure ourselves into developing new routines overnight but instead take time to learn new habits.

“We talk as if willpower were the whole show,” says Christensen’s physician, David Katz, M.D., director of Yale University’s Prevention Research Center. “But that’s like thinking you can climb Mount Everest if you just want to badly enough. Nonsense. You need mountaineering skills.”

Tipping Points

“Rationally, you’d think motivation would be strong enough to get you to adopt a health behavior, but it’s not,” says BJ Fogg, Ph.D., director of the Persuasive Technology Lab at Stanford University.

Motivation, he explains, is important for developing the initial surge in energy to make a change, what he calls a motivational wave.

For Christensen, her motivational wave wasn’t voluntary. She became ill one particularly busy day after eating an unhealthy breakfast and skipping lunch.

Nausea, stomach pains and shortness of breath hit her all at once. “I sat down and cried,” she recalls. “I was spiraling out of control and had hit bottom. I then knew that it was now or never.”

It’s quite common for a medical crisis to serve as a tipping point, Katz notes.

“Unfortunately, tipping points do tend to come in the aftermath of calamity, such as after a heart attack or stroke. Sometimes they occur when a medical crisis strikes a family member or friend,” he says. “Sometimes they are due to other kinds of events that change our perspective-such as pregnancy. What is most powerful varies with the individual.”

If you can’t quite bring yourself to begin changing your health for the better, there are things you can do to help move in that direction. Talk to your doctor, Katz suggests, and ask about the perils of the status quo and the possible benefits of changing your habits.

Simply having motivation, wherever it originates, is not enough to develop new habits. “One of the problems is when people fail at changing their behavior they blame themselves and their lack of motivation. They are blaming the wrong thing,” says Fogg.

Online Support for Health Change

You might start out with an online health assessment like this tool from Dartmouth:http://howsyourhealth.com/

Looking for ideas about small steps that could make a big difference to your health? Check these online resources:

• General health information and guidance about healthy living is available from the U.S Department of Health and Human Services at http://www.healthfinder.gov/

• The U.S. Department of Health & Human Services offers 119 ideas about small steps you can take to improve your diet and get more exercise. Examples: Grill, steam or bake instead of frying. Choose a checkout line without a candy display. Walk to a co-worker’s desk instead of emailing or calling.

• The American Dietetic Association offers a variety of small ways to shave calories off your daily diet. Examples: Don’t eat out of a box or bag because you’ll feel like you need to finish everything. Satisfy your ice cream urge by buying brands that are slow-churned and have reduced calories.

Smoking:

• http://www.smokefree.gov/ is available from the Tobacco Control Research Branch of the National Cancer Institute to offer help with quitting smoking.

Mental health and substance abuse:

• This resource guide from a California non-profit lead by Robert and Jeanne Segal with support from Rotary International could be helpful for a wide range of health concerns including mental health and substance use information: http://www.helpguide.org/index.htm

Skill-Building over Time

Katz says some people actually prefer to make a big change in one fell swoop. They might suddenly quit smoking or start following their insulin injection routine to the letter. “It’s constitutionally who they are,” he says.

But researchers have found that most people do better with a slower, step-by-step approach, Katz says. To use this approach effectively, however, you may need an education in exactly what your options can be.

People often fail at making important changes because they lack information, adds Judith H. Hibbard, Ph.D., a professor of health policy at the University of Oregon who studies the choices people make about their health. “They don’t know what their role is in the care process, and they’re overwhelmed with the task of managing their health. It’s more like being defeated and discouraged rather than being lazy.”

With her doctor’s help, Christensen learned new weight-loss techniques. She started keeping a food diary, for instance, to give her insight into her daily diet. “You don’t realize what you are putting in [your body] until you see it on paper,” she says.

She began eating six times a day instead of going from breakfast to dinner without food. She cut down on sugar by changing brands, learned to savor her food instead of wolfing it down and tried new recipes.

“It isn’t easy…in the beginning it was very hard to give up sugar,” she says. “But you soon learn that it’s not a necessity. I can now go out and watch people have dessert around me, and it doesn’t faze me. It is empowering to know that you are in control. And I have found that gaining control over my weight and eating habits has taught me to take control in the areas of my life that were causing the overeating.”

If you’re overweight, you may think Christensen’s success is unrealistic. But a landmark 2002 study published in the New England Journal of Medicine finds that a moderate amount of weight loss, the kind you can achieve through fairly minor changes in exercise and eating habits, had a bigger positive effect on overweight people at risk for diabetes than preventive medication had.

Those who exercised a half-hour a day and lost just 5 to 10 percent of their weight-10 to 20 pounds for a 200-pound person-were almost 60 percent less likely to develop diabetes.

If 30 minutes seems like too much, Fogg suggests starting shorter. “Tiny habits grow into full behaviors over time. If you get in the tiny habit of exercising for three minutes and that becomes a true habit, you will eventually just naturally end up doing 30 minutes,” he says. “Over time, you develop the physical capabilities and arrange the world around you to make it easier.”

Building Confidence

Needles don’t bother Joan Reder, a medical transcriptionist with the Scripps Health System in San Diego. That’s a good thing: She has had type 1 diabetes for 35 years and daily insulin injections have long been part of her daily routine.

But something does make the 59-year-old Reder nervous: technology.

Recently, she was intrigued by the idea of converting to using an insulin pump that would allow greater control of her insulin levels. But it worried her, too.

For one thing, the idea of using new technology didn’t thrill her. “I’m not a techie person. I know what I need to know to use my computer, and the rest…well, I don’t want to know,” she says.

She had also heard a secondhand horror story about the pump and didn’t want to shell out money for a pump that she might not want to keep using. “So having a pump was really scary to me,” she recalls.

Then she discovered that she could enroll in a study that allowed her to get extra support from medical staff and try the pump without making a major financial commitment. It also helped that she was able to turn to other diabetics in a support group and learn tips about how to use the pump.

“They know things that your doctor can’t tell you unless your doctor has diabetes, like how to eat pizza or M&Ms with the pump,” she says.

Christensen tried the pump and loved it. Instead of giving herself insulin injections throughout the day, she programs the pump’s computer to deliver the amount she needs based on what she eats.

That’s much easier than going through the multiple injections that she used to endure to be able to safely eat certain foods.

She now regularly wears the pump, which weighs about half a pound and delivers the insulin through a tube that goes under the skin in her stomach. “There’s a lab test that I take every time before I see my endocrinologist. The ideal measurement is 7 or below. The day I started on the pump, it was 8.4. Three months later, it was a 6.7.”

That improvement wouldn’t have happened without the support that helped her gain the confidence to take the small step of simply trying the pump, she says.

Taking It Home

Confidence, it turns out, is crucial to improving health through small steps. To take advantage of the powers of confidence, it’s a good idea to make changes that you’re about 70 to 80 percent sure you can accomplish, says David Sobel, M.D., medical director of patient education and health promotion for Kaiser Permanente’s Northern California system.

Judith Hibbard said she’s heard of dieters whose first step was to eat nine donuts a day instead of 12.

Katz and Hibbard say there are many other small steps you can take if your goal is to lose weight. Don’t shop while you’re hungry, for instance, and prepare a shopping list to guide healthier choices. At work, take the stairs a few days a week instead of the elevator.

You further your chance at success if you set up your environment to help trigger the behavior you want, according to Fogg. “If you want to floss more, put the floss next to your toothbrush.

When developing habits, you should try to make something you already do become the trigger for the next thing.”

Success, if you reach it, will build your sense of confidence, but don’t stop early in the process. “The thing about small steps is that you need to keep moving forward and take the next step after that,” Hibbard says.

Luckily, Fogg points out, “In general, the more you do a behavior, the easier it is to do.”

As you move forward, remember the lessons of Christensen and Reder: it’s easier to change your life when supportive people are behind you. Friends and family can make a big difference, as can the staff at your medical office. Some people also seek out support groups.

“Social support can be helpful if the people around you already have the habit you want,” says Fogg.

If you can’t find the help you need, consider creating support systems yourself, as Reder did. She co-founded a group at Scripps Health’s Behavioral Diabetes Institute that matches diabetic patients with other similar patients who serve as mentors. The program is called Diabetes TLC, with the initials standing for “talk, listen, connect.

The idea is to give the kind of insight and support that doctors can’t provide because they don’t suffer from the condition themselves, Reder says.

“The small steps our clients have taken with support from one of our teammates have assisted many of them in making huge changes, including better lab results, weight loss, testing their glucose more often and more balanced lives,” she says. “If you give people a list of 22 things they have to do, they’ll say forget it. If you do things one or two steps at a time, you’ll experience success and get ready to do more.”

It’s a small steps-big change success story. And there’s not a cold turkey in sight.

Randy Dotinga is a Contributing Writer, and Kelly Malcom is an Editor for Health Behavior News Service.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

Uncovering the Mechanisms Linking Obesity and Cancer Risk

By Sharon Reynolds
NCI Cancer Bulletin Staff Writer 

Being overweight or obese is associated with an increased risk for many types of cancer, including postmenopausal breast cancer; endometrial cancer; and colorectal, esophageal, gallbladder, kidney, pancreatic, and thyroid cancer.

These risks are not minor. In 2002, the International Agency for Research on Cancer, using European data, estimated that obesity contributed to more than one-third of endometrial and esophageal cancer cases and a quarter of kidney cancer cases. (See the table below.)

Being overweight or obese also raises the risk of dying of cancer. In an often-cited paper published in 2003 in the New England Journal of Medicine, researchers from the American Cancer Society estimated that 14 percent of all cancer deaths in men and 20 percent in women could be blamed on excess weight.

The obvious question is: Why? What biological processes mediate the relationship between excess body fat and increased cancer risk? Researchers are only beginning to tease out the answers, but almost all the factors under study are rooted in the fact that adipose (fat storage) tissue is highly metabolically active.

Once thought to be just a passive storage depot for fuel, adipose tissue is now known to pump out an astounding array of hormones, growth factors, and signaling molecules, all of which can influence the behavior of other cells in the body.

Excess Hormones, Extra Risk

Most, if not all, of the molecules being studied as potential mediators between obesity and cancer are not cancer-causing but cancer-promoting. That is, they do not cause the mutations that turn a normal cell into a cancerous cell, but instead feed the growth and proliferation of malignant cells.

One of the best understood of the pathways that may lead from obesity to cancer involves the hormone estrogen, which fuels a large number of breast and endometrial cancers. In postmenopausal women, the levels of estrogen circulating in the bloodstream normally drop drastically, as the ovaries stop producing the hormone.

But fat tissue also produces estrogen, through a cellular pathway involving the enzyme aromatase, the target of several breast cancer therapies called aromatase inhibitors.

In obese women, “the body fat just becomes an estrogen-producing machine,” explained Dr. Leslie Bernstein, director of the Division of Cancer Etiology at City of Hope Comprehensive Cancer Center, who has studied the relationship between estrogen and cancer risk for years through the California Teachers Study.

This excess estrogen produced by fat can feed cancer cells that express the estrogen receptor. But estrogen alone does not account for all of the extra risk for these cancers in obese postmenopausal women.

Another likely player in many types of cancer, including breast, colorectal, and pancreatic cancer, is insulin, the hormone that triggers cells in the body to take up glucose (sugar) from the bloodstream.

Adipose Tissue

Obesity often goes hand in hand with metabolic syndrome and type II diabetes. In type II diabetes, the body’s cells stop responding to insulin, causing a buildup of glucose in the blood, which in turn stimulates the body to produce even more insulin.

And in some cancers, “insulin acts as a mitogen—it makes cancers grow faster,” said Dr. Michael Pollak, director of the Division of Cancer Prevention at McGill University in Montreal.

Interestingly, a diabetes drug called metformin, which lowers the levels of blood glucose, has shown some anticancer activity. Several studies have suggested that people with diabetes who took metformin had a lower risk of developing cancer ordying from the disease compared with diabetics who did not take metformin.

Currently, several clinical trials, including one in breast cancer, are testing the addition of metformin to standard treatment.

It will be important, stressed Dr. Pollak, to continue basic science research on metformin, given the many unanswered questions about who should take the drug.

“I think this is an extremely promising area of cancer research, but we need to do more basic science research before we’ll be able to design the best clinical trials” to figure out which patients are most likely to benefit from the drug, he said.

For example, other diabetes drugs lower insulin levels but don’t show a similar anticancer effect, suggesting that metformin may affect more than just the insulin pathway.

Also, some patients’ tumors have mutations in the insulin signaling pathway that make the cells act as if extra insulin is always present, even when it’s not. In these cases, reducing insulin would be futile in terms of cancer control. “So maybe those patients shouldn’t be on clinical trials of metformin,” said Dr. Pollak.

Digging Deeper

A myriad of other molecules are being studied to see if they contribute to the relationship between obesity and cancer. Some of these molecules, such as certain interleukins, are part of the body’s natural inflammatory response, which is often chronically overstimulated in people who are obese.

Others are signaling molecules called adipokines (cytokines produced by fat tissue), levels of which can be affected by weight gain.

Within NCI, researchers in the Division of Cancer Epidemiology and Genetics (DCEG) are using several multimarker panels to study molecular pathways that may link obesity to cancer risk in humans. Two panels—one that assesses 15 different estrogens and estrogen metabolites, and one that assesses 79 molecular markers of inflammation—are already being used to examine these mechanisms.

A third, more experimental panel simultaneously tests 400 to 600 small molecules to give a snapshot of metabolism at the time of sample collection, said Dr. Steve Moore, a research fellow in DCEG’s Nutrition Epidemiology Branch.

With these panels, “you can look at how the markers are related to cancer risk, you can look at how obesity is related to cancer risk, and you can look at how obesity is related to cancer risk after adjusting for the marker levels,” explained Dr. Moore. “So by triangulating these three things, you can estimate which molecular mechanisms obesity is most likely to act through.”

Other researchers are examining genetic variants that might also influence how obesity and cancer risk intersect. “A lot of people have looked at biomarkers like insulin, but what are the [full] genetic and molecular pathways being affected by obesity?” asked Dr. Li Li, associate director for Prevention Research at Case Comprehensive Cancer Center, Case Western Reserve University.

His project, supported by the first tranche ofTransdisciplinary Research on Energetics and Cancer (TREC) funding, is looking at how genetic variants found naturally in the population influence whether obesity can promote colon polyp formation.

All of this research may eventually help create targeted cancer prevention measures and treatments for overweight and obese patients, based on a better understanding of the molecular events driving progression.

For now, “I would say what we know now supports the adoption of a healthier lifestyle that promotes weight control,” concluded Dr. Moore.

The NCI Cancer Bulletin is an award-winning biweekly online newsletter designed to provide useful, timely information about cancer research to the cancer community. The newsletter is published approximately 24 times per year by the National Cancer Institute (NCI), with day-to-day operational oversight conducted by federal and contract staff in the NCI Office of Communications and Education. The material is entirely in the public domain and can be repurposed or reproduced without permission. Citation of the source is appreciated.

Photo by Sue_r_b

America seems to be detrimental to the health of Hispanic immigrant populations — and the longer they are here the worse it is.

New data show that as they settle into American lifestyles, Hispanic immigrants are diagnosed with hypertension, diabetes and obesity at almost the same rate as those born in the U.S.

Hispanic immigrants who have been in the U.S. for 20 years or more are 98 percent more likely to become obese, 68 percent more likely to develop hypertension and about two and a half times more likely to become diabetic than those who have been in the U.S. for less than a decade.

Leslie Cofie, a first-year doctoral student at the University of North Carolina, and the lead researcher on this study, used data from the Centers for Disease Control and Prevention’sNational Health and Nutrition Examination Survey — a group of national studies that combines interviews and physical exams to get the numbers on health outcomes.

“A lot of the studies that have been done before on immigrants have been based on self-reported data sources,” Cofie said. But, he says, self-reported data is more error-prone since it is relying on a person’s recollection. The NHANES studies, however, provide a more comprehensive look since they use medical examination records collected by trained professionals.

At the annual American Public Health Association meeting Cofie discussed findings about Hispanic immigrants who have been in the U.S. up to 20 years and said those who were in the U.S. longer had a significantly higher percentage of hypertension, diabetes and obesity than the Hispanic immigrants who have been here for 10 or fewer years.

Female Hispanic immigrants who have lived in the U.S. for 20 or more years are more prone to obesity and hypertension, while the male Hispanic immigrants living in the U.S. for 20 or more years are more prone to diabetes.

Cofie said that his analysis shows that variables such as access to health care, social economic status or even documentation have no real effect on the number of Hispanic immigrants diagnosed with these chronic conditions. “Even after we control for all those factors, we still see higher prevalence in poor health outcomes of these immigrants.”

Dr. Emilio Carrillo, the vice president of Community Health Development at New York-Presbyterian Hospital said this data is an unfortunate, but inherent part of the Hispanic immigrant experience in the U.S.

“It’s well known that the first generation that came here had a healthier experience,” he said. “But then the next generation comes along and they tend to adapt to the American lifestyle …” which includes poor eating and exercise habits.

Jennifer Ng’andu, the deputy director of the Health Policy Project at the National Council of La Raza in Washington said Hispanic immigrants “are severely disconnected from the health care system.” Ng’andu adds that the more Hispanic immigrants are detached from the health care system, the more costly it will be to support their health care needs. “It’s going to cost us more to keep immigrants outside of the health care system.”

Photo by Sue_r_b

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.