Science
Opinion: I'm a doctor in East L.A. and Beverly Hills. I want to treat obesity the same way in both places
As a diabetes specialist, I’ve treated thousands of patients, some in Beverly Hills and some in East Los Angeles. My Beverly Hills patients live to become healthy 80- and 90-year-olds. I can’t remember when my last patient from this community lost their vision, had an amputation or started dialysis. Almost none have heart attacks or strokes.
But in under-resourced parts of East L.A. I see people every week in their 40s and 50s who have developed life-altering, preventable diabetes complications — blindness, kidney failure, the loss of a limb. These patients rarely live to grow old.
Obesity is one of the drivers of this heartbreaking disparity. Health-conscious Beverly Hills is replete with doctors’ offices, fresh food and gyms. Most residents there can spend what they need to maintain a healthy diet and get help to control diabetes. In East Los Angeles, where for some a home refrigerator can be a luxury, diabetes and obesity afflict thousands of families who depend on fast and processed food to provide the affordable calories they need to survive.
The tale of these two neighborhoods is replicated across the country. Obesity kills 300,000 Americans annually. It is associated with increased risk of more than 200 other diseases, including heart disease, diabetes, cancer and dementia. According to modeling by my colleagues at the USC Schaeffer Institute for Public Policy & Government Service, the average American will soon have obesity. Black and Latino individuals experience higher rates of severe obesity compared to non-Latino white people, translating into higher rates of chronic diseases.
Despite decades of public health efforts, obesity increases. Some recent lifestyle interventions have shown promise; for the most part, however, simply urging people in minority neighborhoods to change their diets has proved ineffective. Although providing resources and education do help, these initiatives are often grant-funded and not routinely available. Lots of proposed solutions that might resonate in wealthier communities, such as recommending “fixed” foods, with reduced sugar, fats and preservatives, just don’t fly in East L.A. Cost and availability of healthy foods are two reasons. So is culture. Where there is food insecurity, familiar food can be a celebration not easily surrendered.
But at least one weight-loss remedy that is enormously popular in Beverly Hills also works across town: medication. New drugs such as Wegovy/Ozempic (semaglutide) and Zepbound/Mounjaro (tirzepatide), if used with proper medical supervision, can often reduce body weight by 15% or more. Several of my patients with severe obesity have lost close to 100 pounds and avoided much more burdensome metabolic surgery.
The drugs come with list prices that can top $1,200 a month, although health insurance companies often negotiate deep discounts. So far Medicare is not helping reduce patient costs because it is barred from paying for weight-loss drugs. But Medicaid, the state/federal program that covers the poor, faces no such constraint. And it has a big price advantage: By law, it automatically gets the biggest discounts negotiated by any payer.
Several states, including California, have added one or more of the obesity drugs to their Medicaid formularies. In Los Angeles County, use is still not widespread as doctors have to secure prior authorizations through Medicaid managed-care organizations and teach patients how to inject themselves at home. But among those patients who are taking the drugs, we are seeing improvements in health.
The balance between the drugs’ prices and their benefits is a fraught debate, mostly centered on what would happen to public and private sector budgets under broadened coverage. The Congressional Budget Office recently concluded that the costs of authorizing coverage in Medicare would exceed the benefits of beneficiaries’ improved health for the next 10 years.
I’m not an economist, but I know that focusing just on government ledgers can be shortsighted. I see firsthand that medications have a big role to play in the treatment of obesity and diabetes. Like many other drugs I have prescribed for other diseases, over time they will become more affordable while reducing the costs of treating associated illnesses. Research at USC Schaeffer projects that Medicare coverage of obesity treatments could generate $4 trillion in social value to Americans over three decades.
Of course we also need to keep pressing for better, broader fresh food access, healthier diets and safe places to exercise around the clinic where I work in East L.A. However, use of these newer medications in any part of town can provide true benefit even if lifestyle changes are harder to implement.
I’m in favor of whatever works for my patients, no matter where they live, as long as preventive healthcare and individualized treatment plans are part of the equation.
In addition to her medical practice, Anne L. Peters is a senior scholar at the USC Schaeffer Institute for Public Policy & Government Service.
Science
His computer simulations help communities survive disasters. Can they design a Palisades that never burns?
In what used to be a dry cleaner’s on Sunset Boulevard, Robert Lempert listened, hands clasped behind his back, as his neighbors finally took a moment to step away from recovery’s endless stream of paperwork, permits, bills and bureaucracy to, instead, envision a fire-resilient Pacific Palisades in 2035.
As a researcher at RAND, Lempert has spent decades studying how communities, corporations and governments can use computer simulations to understand complex problems with huge uncertainties — from how an Alaska town can better warn its residents about landslides to how climate change is worsening disasters and what strategies the United Nations can support to address them.
In January, one such complex problem ran straight through his neighborhood and burned down his house.
As Lempert and his wife process their own trauma forged by flames, Lempert has become fixated on capturing the flickers of insights from fellow survivors and, hopefully, eventually, transforming them into computer programs that could help the community rebuild the Palisades into a global leader in wildfire resilience.
“Otherwise, we won’t end up with a functional community that anybody wants to — or can — live in,” he said. “You can spin out all sorts of disaster scenarios” for the Pacific Palisades of 2035. If the community fails to confront them in rebuilding, “you make them a hell of a lot more likely.”
Lempert doesn’t see a mass exodus from high-fire-hazard areas as a viable solution. Out of the more than 12 million buildings the climate risk modeling company First Street studies in California, 4 in 10 have at least a 5% chance of facing a wildfire in the next 30 years. (Out of the nearly 10,000 buildings First Street studies in the Palisades, 82% carry that level of risk.) And the areas without significant fire risk have their own environmental challenges: flooding, earthquakes, landslides, hurricanes, tornadoes, droughts. Learning to live with these risks, consequently, is part of the practice of living in California — and really, in most of the places humans have settled on Earth.
After two of the most destructive fires in the state’s history, The Times takes a critical look at the past year and the steps taken — or not taken — to prevent this from happening again in all future fires.
So, Lempert has taken to the modus operandi he helped develop at RAND:
Identify the problem. In this case, living in Pacific Palisades carries a nonzero risk you lose your house or life to fire.
Define the goals. Perhaps it is that, in the next fire, the Palisades doesn’t lose any homes or lives (and, ideally, accomplishes this without spending billions).
Then, the real work: Code up a bunch of proposed solutions from all of the groups with wildly disparate views on how the system (i.e., Southern California wildfires) works.
Stress-test those solutions against a wide range of environmental conditions in the computer. Extreme winds, downed communication systems, closed evacuation routes — the list goes on.
Finally, sit back, and see what insights the computer spits out.
It’s easy enough to agree on the problem, goals and environmental factors. For the proposed solutions, Lempert set out to collect data.
Poster paper with residents’ handwritten ideas now fills the walls of the former dry cleaner’s, now the headquarters of the grassroots organization Palisades Recovery Coalition. It’s through these “visioning charrettes” that Lempert hopes his community can develop a magic solution capable of beating the computer’s trials.
Lempert holds a photo of his home as it looked before it was destroyed by the Palisades fire.
The streets could be lined with next-generation homes of concrete and steel where even the tiniest gaps are meticulously sealed up to keep embers from breaching the exterior. Each home could be equipped with rain-capture cisterns, hooked up to a neighborhood-wide system of sensors and autonomous fire hoses that intelligently target blazes in real time. One or two shiny new fire stations — maybe even serving as full-blown fire shelters for residents, equipped with food and oxygen to combat the smoke — might sit atop one of the neighborhood’s main thoroughfares, Palisades Drive. The street, formerly a bottleneck during evacuations, might now have a dedicated emergency lane.
Every year, the community could practice a Palisades-wide evacuation drill so the procedures are fresh in the mind. Community brigades might even train with the local fire departments so, during emergencies, they can effectively put out spot fires and ensure their elderly neighbors get out safely.
Lempert, who now lives in a Santa Monica apartment with his wife, doesn’t entertain speculation about whether the Palisades will ever reach this optimistic vision — even though his own decision to move back someday, in part, hinges on the answer.
Right now, all that matters is that change is possible.
He pointed to an anecdote he heard once from the fire historian Stephen Pyne: American cities used to burn down — from within — all the time in the 19th century. Portland, Maine, burned in 1866 thanks to a Fourth of July firecracker. Chicago in 1871, after a blaze somehow broke out in a barn. Boston the following year, this time starting in a warehouse basement. Eventually, we got fed up with our cities burning down, so we created professional fire departments, stopped building downtowns out of wood and bolstered public water systems with larger water mains and standardized fire hydrants. Then, it stopped happening.
Now we face a new fire threat — this time, from the outside. Maybe we’re fed up enough to do something about it.
“Cities shouldn’t burn down,” Lempert said with a chuckle, amused by the simplicity of his own words. “So let’s just design them so they don’t.”
Science
China’s Clean Energy Push is Powering Flying Taxis, Food Delivery Drones and Bullet Trains
As an American reporter living in Beijing, I’ve watched both China and the rest of the world flirt with cutting-edge technologies involving robots, drones and self-driving vehicles.
But China has now raced far beyond the flirtation stage. It’s rolling out fleets of autonomous delivery trucks, experimenting with flying cars and installing parking lot robots that can swap out your E.V.’s dying battery in just minutes. There are drones that deliver lunch by lowering it from the sky on a cable.
If all that sounds futuristic and perhaps bizarre, it also shows China’s ambition to dominate clean energy technologies of all kinds, not just solar panels or battery-powered cars, then sell them to the rest of the world. China has incurred huge debts to put trillions of dollars into efforts like these, along with the full force of its state-planned economy.
These ideas, while ambitious, don’t always work smoothly, as I learned after taking a bullet train to Hefei, a city the size of Chicago, to see what it’s like to live in this vision of tomorrow. Hefei is one of many cities where technologies like these are getting prototyped in real time.
I checked them all out. The battery-swapping robots, the self-driving delivery trucks, the lunches from the sky. Starting with flying taxis, no pilot on board.
Battery-swapping robots for cars
Of course, far more people get around by car. And navigating Hefei’s city streets shows how China has radically transformed the driving experience.
Electric vehicles (including models with a tiny gasoline engine for extra range) have accounted for more than half of new-car sales in China every month since March. A subcompact can cost as little as $9,000.
They are quite advanced. New models can charge in as little as five minutes. China has installed 18.6 million public charging stations, making them abundant even in rural areas and all but eliminating the range anxiety holding back E.V. sales in the United States.
Essentially, China has turned cars into sophisticated rolling smartphones. Some have built-in karaoke apps so you can entertain yourself while your car does the driving.
You still need to charge, though.
Lunch from the sky
China’s goal with ideas like these is to power more of its economy on clean electricity, instead of costly imported fossil fuels. Beijing has spent vast sums of money, much of it borrowed, on efforts to combine its prowess in manufacturing, artificial intelligence and clean energy to develop entirely new products to sell to the rest of the world.
Drone delivery has a serious side. Hospitals in Hefei now use drones to move emergency supplies, including blood, swiftly around the city. Retailers have visions of fewer packages stuck in traffic.
But does the world need drone-delivered fast food? And how fast would it really be? As afternoon approached, we decided to put flying lunches to the test.
We decided to eat in a city park where a billboard advertised drone delivery of pork cutlets, duck wings and milk tea from local restaurants, or hamburgers from Burger King. Someone had scrawled in Chinese characters on the sign, “Don’t order, it won’t deliver.” A park worker offered us free advice: Get someone to deliver it on a scooter.
Undeterred, we used a drone-delivery app to order a fried pork cutlet and a small omelet on fried rice. Then, rather than wait in the park, we went to the restaurant to see how the system worked.
Very rapid transit
China’s bullet trains are famous for a reason. Many can go nearly 220 miles per hour — so fast that when you blast past a highway in one of these trains, cars look like they’re barely moving.
In less than two decades China has built a high-speed rail network some 30,000 miles long, two-thirds the length of the U.S. Interstate highway system. As many as 100 trains a day connect China’s biggest cities.
Building anything this enormous creates pollution in its initial construction, of course, using lots of concrete and steel. Construction was expensive and the system has racked up nearly $900 billion in debt, partly because it’s politically hard to raise ticket prices.
But the trains themselves are far less polluting than cars, trucks or planes. And they make day trips fast and easy. So we decided to hop over to Wuhan, more than 200 miles away.
Taxis that drive themselves
We rolled into Wuhan looking forward to catching a robot taxi. While a few U.S. cities have experimented with driverless cars, China leads in the number on the road and where they can operate.
Wuhan is one of a dozen or more Chinese cities with driverless taxis. Hundreds now roam most of the city, serving the airport and other major sites.
But train stations are a special problem. In big cities, some stations are so popular that the streets nearby are gridlocked for blocks in every direction.
That was the case in Wuhan. Autonomous cars have not been approved in the chronically gridlocked streets next to the train stations, which meant that, to meet our robot taxi at its pickup spot, we either needed to walk 20 minutes or hop on a subway. (We walked.)
Of course if you want your own personal self-driving car, dozens of automakers in China sell models with some autonomous features. However, you are required to keep your hands on the wheel and eyes on the road. Just this month, regulators told automakers to do more testing before offering hands-free driving on mass production cars.
We wanted the full robot chauffeur experience.
Robot trucks don’t need windows
After a meal at one of Wuhan’s famous crawfish restaurants, we headed back to Hefei.
We had enjoyed Hefei’s airborne lunches, but there’s a lot more autonomous delivery in that city than just food. China still has many intercity truck drivers, but is starting to replace them with robot trucks for the last mile to stores and homes.
The trucks look strangely faceless. With no driver compartment in front, they resemble steel boxes on wheels.
The smaller ones in Hefei carry 300 to 500 packages. The trucks go to neighborhood street corners where packages are distributed to apartments by delivery people on electric scooters or a committee of local residents. Larger trucks serve stores.
Robot delivery trucks now operate even in rural areas. I recently spotted one deep in the countryside as it waited for 13 water buffalo to cross a road.
Subways get a makeover
Cities across the country are rapidly building subways. So many, in fact, that China has become the world’s main manufacturer of automated tunnel-boring machines.
It has also pioneered the manufacture of prefab subway stations. They’re lowered in sections into holes in the ground. Building a new station can take as little as two months.
Nearly 50 cities in China have subway networks, compared with about a dozen in the U.S., and they tend to be popular and heavily used.
As in many Chinese cities, people in Hefei live in clusters of high-rises, and many live or work close to stations. The trains cut down on traffic jams and air pollution.
And like so many things, new ones are usually driverless.
The changes are spreading across the country.
Many Chinese cities have not only replaced diesel buses with electric ones but are also experimenting with hydrogen-powered buses. And driverless buses. And driverless garbage trucks. And driverless vending machines.
One such vending machine was operating in the Hefei park where we ordered our drone lunches. According to a nearby hot dog vendor, the brightly lit four-wheeler drove into the park every morning, though always accompanied by a person on a bike who made sure nothing went wrong.
A robotic snack machine that needs a chaperone — how practical is that? But the fact that they are rolling around the streets of Hefei at all says something about China’s willingness to test the boundaries of transportation technologies.
Some ideas may not work out, and others might suit China but not travel well. For example, Beijing can essentially order arrow-straight rail lines to be built almost to the heart of urban areas with little concern for what’s in the way. Other countries can’t replicate that. Chinese-built bullet trains in Nigeria and Indonesia, which travel from one city’s suburbs to the next, haven’t proven nearly as popular.
Still, China shows a willingness to take risks that other countries may not. In San Francisco the death of a bodega cat, killed by a self-driving taxi, has hurt the industry’s image. But in China, fleets of similar cars are operating widely and censors delete reports of accidents. The cars are improving their software and gaining experience.
As for me, after several days putting Hefei’s idea of the future to the test, it was time to head for my next reporting assignment, in Nanjing. By bullet train, of course.
Science
After the L.A. fires, heart attacks and strange blood test results spiked
In the first 90 days after the Palisades and Eaton fires erupted in January, the caseload at Cedars-Sinai Medical Center’s emergency room looked different from the norm.
There were 46% more visits for heart attacks than typically occured during the same time period over the previous seven years. Visits for respiratory illnesses increased 24%. And unusual blood test results increased 118%.
These findings were reported in a new study published Wednesday in the Journal of the American College of Cardiology. The study, part of a research project documenting the fires’ long-term health effects, joins several recent papers documenting the disasters’ physical toll.
While other U.S. wildfires have consumed more acres or cost more lives, the Palisades and Eaton fires were uniquely dangerous to human health because they burned an unusual mix of materials: the trees, brush and organic material of a typical wildfire, along with a toxic stew of cars, batteries, plastics, electronics and other man-made materials.
There’s no precedent for a situation that exposed this many people to this kind of smoke, the paper’s authors said.
“Los Angeles has seen wildfires before, it will see wildfires again, but the Eaton fire and the Palisades fire were unique, both in their size, their scale and the sheer volume of material that burned,” said Dr. Joseph Ebinger, a Cedars-Sinai cardiologist and the paper’s first author.
The team did not find a significant increase in the overall number of visits to the medical center’s emergency room between Jan. 7, the day the fires began, and April 7. The department recorded fewer in-person visits for mental health emergencies and chronic conditions during that time compared to the same time period in earlier years, said Dr. Susan Cheng, director of public health research at Cedars-Sinai and the study’s senior author.
The increase in visits for acute cardiovascular problems and other serious sudden illnesses made up the difference.
The study team also looked at results from blood tests drawn from patients visiting the ER for serious physical symptoms without immediate explanation — dizziness without dehydration, for example, or chest pains not caused by heart attacks.
Their blood tests returned unusual results at a rate more than double that seen in previous years. These atypical numbers cut across the spectrum of the blood panel, Cheng said. “It could be electrolyte disorder, change in protein levels, change in markers of kidney or liver function.”
The rate of unusual test results held steady through the three-month period, leading the team to conclude that exposure to the fires’ smoke “has led to some kind of biochemical metabolic stress in the body that likely affected not just one but many organ systems,” Cheng said. “That’s what led to a range of different types of symptoms affecting different people.”
Joan Casey, an environmental epidemiologist at the University of Washington who was not part of the Cedars-Sinai team, noted that the study found health effects lasting over a longer period than similar studies have.
Three months “is a substantial length of time to observe elevated visits, as most studies focused on acute care utilization following wildfire smoke exposure find increased visit counts over about a weeklong period,” Casey said. Her own research found a 27% increase in outpatient respiratory visits among Kaiser Permanente Southern California members living within 12.4 miles of the burn zones in the week following the fires.
“The L.A. fires were such a severe event, including not only smoke, but also evacuation and substantial stress in the population, that effects may have lingered longer,” Casey said.
Thirty-one people are known to have died as a direct result of injuries sustained in the fires. But researchers believe that when taking into account deaths from health conditions worsened by the smoke, the true toll is significantly higher.
A research letter published earlier this year in the Journal of the American Medical Assn. calculated that there were 440 excess deaths in L.A. County between Jan. 5 and Feb. 1. That paper looked at deaths caused by a variety of factors, from exposure to air pollution to disrupted healthcare as a result of closures and evacuations.
On Tuesday, a team from Stanford University published itsprojection that exposure to the fires’ smoke, specifically, led to 14 deaths otherwise unaccounted for.
Wildfire is a major source of fine particulate pollution, bits measuring 2.5 microns or less in diameter that are small enough to cross the barriers that separate blood from the brain and the lungs’ outer branches.
Compared with other sources, wildfire smoke contains a higher proportion of ultrafine particles miniscule enough to penetrate the brain after inhalation, Casey told The Times earlier this year. The smoke has been linked to a range of health problems, including dementia, cancer and cardiovascular failure.
In the last decade, increasing numbers of wildfires in Western states have released enough fine particulate pollution to reverse years’ worth of improvements under the Clean Air Act and other antipollution measures.
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