The Doctor Weighs In

by Pat Salber, MD

I wonder if we will ever know how many American kids got pregnant or contracted sexually transmitted diseases (STDs) because of a decade of a failed national health policy: abstinence-only programs. Thankfully, we seem to be regaining our senses and will once again resort to science to guide public health policy related to sex education.

This positive development is discussed in some detail in the May 7, 2008 issue of JAMA  (Vol. 299, No. 17, p. 2013-15). Here is a brief summary:

In 2007, Mathematica Policy, Inc., a nonpartisan research firm (oh, how sad it is that it must be pointed out that a research firm is nonpartisan) published the results of its controlled trial of abstinence-only programs. For its study, Mathematica surveyed more than 2000 elementary and middle school students who were followed into high school. 60% of these young people were in programs identified by abstinence-only proponents as “ideal programs,” 40% were controls – in other words, a best case vs worst case scenario.

The conclusion: The abstinence-only programs “had absolutely no measurable impact on initiation rates [first time sex], age of first intercourse, number of partners, number of pregnancies, births, or STDs.” In other words, not one of the major hoped for outcomes of these programs was obtained. Hmmm. Once again, it seems hormones have trumped the best intentions of some wishful thinkers. Lest you think the “dose” of the programs was not intensive enough, the study points out that “in some of these cases, kids sat through 3 years of mandatory abstinence-only classes.

At long last, medical organizations are once again talking about the need to have REAL (science-based) sex education, as opposed to programs driven by ideology. The Society for Adolescent Medicine (http://www.adolescenthealth.org/) states that “abstinence-only as a basis for health policy and programs should be abandoned.” The American Psychological Association, the AMA, the National Association of School Psychologists, the American Academy of Pediatrics, and the American Public Health Association have all criticized abstinence-only approaches. Thank heavens. Our kids need a great big dose of reality when it comes to sex: and it is this - sexual desire is a powerful driver of young (and old) people’s behaviors. Hey, y’all, don’t you remember what it was like when you were teens? We are finally acknowledging that it is better to know what you can do to protect yourself from the life-long consequences of unprotected sex instead of muddling through ignorant of the facts of life – so to speak.

One of the most interesting aspects of the JAMA article is a comparison of US approaches to sex education compared to what happens in the Netherlands. The JAMA article states that the US has one of the highest rates of teen pregnancy in the Western world and the Netherlands has one of the lowest.

Abstinence-only programs are not part of Dutch public health policy. In the Netherlands, adolescent girls can get birth control pills confidentially and those aged 16 or older have access to government subsidized clinics where they can get abortions without parental consent. Despite, or perhaps because of, these progressive policies, the teen pregnancy and abortions rates in the Netherlands are among the lowest in the world.

In a study comparing parental attitudes about teenage sexuality in the US vs the Netherlands, researcher Amy Schalet , PhD, interviewed parents of teens in both countries. She found dramatic differences in attitudes. US parents worried about their teens getting carried away by emotions they “mistake for love.” Dutch parents believed their children could fall in love, pace their sexual development and, (lordy, lordy), use contraceptives when they (the teens) deem themselves ready for intercourse.

In the US, the government spent the last decade behaving like a strict surrogate parent to our teens: controlling information about alternatives to abstinence, making it hard for comprehensive sex education programs to get funded, and substituting religious ideology for science. Thank heavens, that we are finally moving on and that we are ready, once again, to base our public health programs on science, real, honest to goodness science. Whoopee!

by Pat Salber

I was pretty shocked when I first heard about diabulemia. This is a practice some teens and young women with Type 1 diabetes, are using in order to lose weight. They purposely underdose their insulin allowing their blood glucoses to skyrocket. The excess blood glucose is eliminated in the urine. “Traditional” bulimics purge excess calories by forcing themselves to vomit. Diabulimics purge excess calories by underdosing on insulin and peeing out unmetabolized glucose.

Girls and young women with diabulimia will tell you they feel really crummy as their glucose levels increase and they increasingly rely on metabolizing fatty acids for energy instead of glucose. The end result of underdosing insulin is a state known as diabetic ketoacidosis, that is characterized by high blood glucose and increased acidity of the blood -- a potentially fatal condition.

Here is how one young woman describes (on the internet) what it feels like to be chronically hyperglycemic and ketotic:

“…I skipped all my insulin but two units at night, sometimes only one. I would consume up to 40,000 calories a day, purge maybe half, and pee the rest out. My muscles deteriorated. My hair fell out, and many nights I couldn't breathe.

In February (2003) I had a heart attack after taking up to 80 laxatives a day for three months, so I knew I had to quit that. Even Standford [sic] didn't know what to do. They sent me home and told my Mom to expect to find me dead in my bed one day soon.

My days became consumed with EKGs, getting labs taken, and doctor visits. I was so dehydrated that if I did venture to take my insulin I would gain so much as fifteen pounds of water overnight, so I quit trying.

I became too weak to go anywhere. I would cry for no reason, low cries, because I could barely breathe from all the acid in my lungs. My heart constantly raced, I developed G.E.R.D. [reflux], my labs were always off, and I was very weak. I would sleep 20 hours a day, the other 4 hours I spent between the kitchen and the bathroom, eating , drinking, peeing and sometimes puking. My speech became slower, and it was an effort to even think.

The scariest day was when I lay awake in bed, too weak to move, and I heard my Mom whisper to my brother, "go make sure your sister is breathing".

I didn't know it at the time, but they were planning my funeral.”

Overtime, continual underdosing of insulin also contributes to the development of complications of diabetes, such as retinopathy (diabetic eye disease), nephropathy (diabetic kidney disease), and neuropathy (diabetic nerve damage). It is no laughing matter. Diabulimia is as serious as other, more “traditional” eating disorders such as anorexia and bulimia.

Here is an internet quote from “Jennie,”a women who has “practiced” diabulimia for more than 10 years:

“ I have been suffering for diabulimia for 10 years now.I became diabetic when I was 17 and quickly found out on how to keep my weight down by not taking my shots. 2 years ago I went into diabetic coma for 3 days. The doctors made my family come in and say goodbye because I was not suppose to make it. I thought that would wake me up but it hasn’t. I am 6 feet 1 inch and weighted 130 pounds for the past 10 years. I see the pain in my family eyes but for some reason I just cant get my diabetes under control. I have so much damage to my body that I feel more like a 90 year old instead of a 27 year old. I have completely ruined my chances of ever having children and I have to take a pill everytime I eat in order to digest my food. I have tried many times to get my diabetes under control but everytime I start taking my insulin regularly I gain about 20 pounds of water weight. This gets so frustrating that I just give up. If any one knows a solution to the water weight gain, PLEASE let me know. I take water pills that my doctor gave me but it does not help.”

Like anorexia and bulimia, diabulimia is a body image disorder. Girls and women with this disorder need specialized help to overcome this serious, and potentially fatal, condition. Not all doctors, diabetes educators, or behavioral therapists are adequately equipped to help individuals with diabulimia. If you are suffering from this disorder or if you have a loved one or friend with this disorder, you need to seek help from experts.

The National Eating Disorders Association (NEDA) has an information and referral hotline (800-931-2237). You can also find therapists by using the referral form on their website. Parents, family, and friends can a learn how to support their loved one with an eating disorder through the Parents, Family, and Friends Network.

I did not find any specific reference to diabulimia on the National Eating Disorder Association website, so I suggest interviewing the therapists to find out if they have expertise in this disorder prior to making an appointment. In addition, it is crucial to involve your treating endocrinologist so that he/she can help provide support for management of diabetes and any complications.

Readers, if you have other ideas please post them in the comments section.   Your suggestion could save a life.

by Pat Salber

Today is the first ever UN-observed World Diabetes Day led by the International Diabetes Federation. It was established as a result of a resolution passed last December by the General Assembly of the UN. The idea behind the Day is to increase visibility of diabetes world-wide.  Hopefully this will lead to better funding, more research, public education, and other resources being applied to the condition.

The focus of this year’s World Diabetes Day campaign is diabetes in children and adolescents. Diabetes is one of the most common chronic disease of childhood. Children and teens can develop Type 1 diabetes – an autoimmune disorder in which the insulin producing cells in the pancreas are destroyed – or they can develop Type 2 diabetes – a condition caused by the development of resistance to the hormone, insulin.

Type 2 diabetes used to be rare in kids, but with the advent of the childhood obesity epidemic, Type 2 diabetes is now seen in even very young children. Both Type 1 and Type 2 diabetes are associated with serious complications, such as kidney, nerve and eye damage, as well as atherosclerotic vascular diseases, such as coronary artery disease.

Type 1 diabetes is rapidly fatal if not treated with insulin. Type 2 diabetes has a longer course, but if untreated or inadequately treated, lifespan is usually shortened significantly. In developing countries, access to early diagnosis and appropriate treatment of diabetes may be limited resulting in many children dying from a treatable disease. In countries with good access to health care, failure of family members, teachers, and others who care for children to recognize symptoms of diabetes can lead to delays in diagnosis that can occasionally be fatal.

The World Diabetes Day 2007 and 2008 campaigns are focused on changing the status quo with the stated goal that “no child should die of diabetes.”

Here are some statistics that highlight the magnitude of the problem:

• Type 1 diabetes is increasing by 3% per year in children and adolescents and by 5% in pre-school children - that translates into almost 200 children per day developing the disease.
• Of the approximately 440,000 cases of Type 1 diabetes in children worldwide, more than a quarter live in South East Asia and more than a fifth in Europe.
• Type 2 diabetes, previously rare in children, now constitutes between 8 to 45% of new childhood cases depending on geographic location.
• Over the past 20 years, type 2 diabetes has doubled in Japanese children. It is now more common than Type 1 diabetes.
• In native and aboriginal children in North America and Australia, type 2 diabetes range from 1.3% to 5.3%

Diabetes can be very difficult for adults to manage. It involves checking blood glucose levels, taking multiple medications, and in the case of Type 1 diabetes, multiple daily doses of insulin by injection. Imagine how hard it is for children who are also trying to do well at school, make and keep friends, and deal with the emotional issues related to growing up – particularly during adolescence. Families with diabetic children often find themselves overwhelmed by all there is to know and do. Add to that the socioeconomic challenges that people with limited resources face on a daily basis, for example, those living in poverty and the ability to manage diabetes must seem insurmountable. These families and other caregivers need help – to access needed health care and health education and support.

World Diabetes Day highlights these formidible challenges, but we must all respond by supporting this campaign with our time…and yes, with our money. To learn more, go to the World Diabetes Day website, http://www.worlddiabetesday.org.

By Dov Michaeli MD, Ph.D

Just returned from a dinner gala put on by the American Diabetes Association, to honor people and organizations who passionately work day in and day out in the cause of diabetes prevention and cure. I must say, this was truly an eye-opening experience.

But first, some statistics on the extent of the problem we are having, and the disastrous trajectory in which the disease is progressing:

• 21 million Americans have diabetes, and 54 million have pre-diabetes, or metabolic syndrome. Add the two figures, and we have 75 million Americans, or about 25% of the population suffering from the disease or its precursor.
• 1 in 3 children born this year will suffer from diabetes during their lifetime. Think of it, in a few short years one third of the population will have diabetes. I recall reading somewhere that physicians and advocates are overstating the problem; that  the appellation of “epidemic” is alarmist. I must say, to me a jump from a relativly minor disease about 30 years ago to 25% today, to 33% in a few short years meets all the criteria of an epidemic. And if you consider the spread of diabetes in Europe , China , India , and even Africa —this is a true pandemic.
• Diabetes is not an equal opportunity disease: 1 in 2 Latino, African American, and Asian American children will develop the disease.
• African Americans are 1.5 times more likely to develop diabetes than their Caucasian counterparts. Hispanic/Latino Americans have 1.8 times the risk. Asian Americans/Pacific Islanders have 2.0 times the risk. Native Americans have 2.2 times the risk. And these are the populations that suffer the most from our broken health care system.
• For the fiscally-inclined among us: the annual cost of diabetes in the U.S. is $132 billion. Consider that a proposed budget of $35 billion to cover all poor children (1 in 2 of them will develop diabetes), was just vetoed because it was “too expensive”. Were our ‘decider’ and his cohorts left behind when they taught arithmetic at school?
• 1 in 10 health care dollars spent in the U.S. are for diabetes and its complications.
• 1 in 6 Americans between the ages of 12-19 have pre-diabetes. So brace yourselves: a wave of young adults is threatening to “mature” into full fledged diabetics. If this is not an epidemic, I don’t know what is.

A ray of light

It was truly heartwarming to realize that there are heroes who are fighting the bleak reality. They don’t whine, complain or just disengage in disgust: they fight. They are there in the proverbial trenches, day in and day out, at great financial and personal sacrifice. Am I talking about doctors, or nurses? No, although I am sure there are plenty of them who deserve accolades. Believe it or not, I am talking about lawyers. Yes, lawyers! The ADA gala was to honor six lawyers of the Reed Smith law firm, who worked thousands of hours pro bono to mitigate the harsh reality our diabetics have to face.

 Here are but two examples of their work. They forced the city of Philadelphia to reverse their hiring ban on police officers with diabetes. Young children with diabetes in public schools in California had to call 911 if they needed insulin. Nobody was authorized to administer it to them. Can you imagine a 5 year old afraid that she might need insulin at school and would have to wait for an ambulance to come to her aid? And what if the ambulance arrives a few minutes late? The lawyers of Reed Smith, working on behalf of the ADA and parents of children with diabetes, won the arduous legal fight for the children; School personnel will be trained to administer insulin to the children if the school nurse is unavailable. To the Nurses Association’s shame, it is now suing the ADA to reverse the settlement. I used to believe their pious propaganda about their concerns for patients, first and foremost.

I never thought that I’d find myself praising lawyers when it comes to Medicine. But my hat is off to these lawyers—they are true heroes .

Dov Michaeli MD, Ph.D is in the biotech industry

By Dov Michaeli MD, Ph.D

Neurobiological research has discovered that our brain is an arena for fierce competition: primitive reactions such as fear and aggression competing with cooperation and altruism, risk-seeking competing with risk aversion, male testosterone competing with your inner female—all competing for attention. Whose attention? – your brain’s prefrontal cortex, the executive that gets all the inputs, weighs them one against the other and then makes a decision which one should prevail—and the outcome of this process is your behavior.

Adolescent behavior

Research on the neurobiology of children’s and adolescents’ behavior revealed that the prefrontal cortex is still immature and performs its executive functions in an incomplete, and sometimes in an haphazard way. Sometimes the loud volume of a risk-seeking voice would drown out the more cautious whisper, and the poorly functioning prefrontal cortex, still lacking Solomonic wisdom, does not exert its judgment; the result is ‘adolescent behavior’.

Is it solely a function of the prefrontal cortex?

If all judgment resided in this cortex, one would expect that once all the neurons are programmed, correctly connected, and fully functioning all adults would behave in a, well, adult way. But consider these statistical finding about the behavior of adults age 35-54, published in a New York Times op-ed by Mike Males:

• 18,249 deaths from overdoses of illicit drugs in 2004, up 550 percent per capita since 1975, according to data from the National Center for Health Statistics.
• 46,925 fatal accidents and suicides in 2004, leaving today’s middle-agers 30 percent more at risk for such deaths than people aged 15 to 19, according to the national center.
• More than four million arrests in 2005, including one million for violent crimes, 500,000 for drugs and 650,000 for drinking-related offenses, according to the F.B.I. All told, this represented a 200 percent leap per capita in major index felonies since 1975.
• 630,000 middle-agers in prison in 2005, up 600 percent since 1977, according to the Bureau of Justice Statistics.
• 21 million binge drinkers (those downing five or more drinks on one occasion in the previous month), double the number among teenagers and college students combined, according to the government’s National Household Survey on Drug Use and Health.
• 370,000 people treated in hospital emergency rooms for abusing illegal drugs in 2005, with overdose rates for heroin, cocaine, pharmaceuticals and drugs mixed with alcohol far higher than among teenagers.
• More than half of all new H.I.V./AIDS diagnoses in 2005 were given to middle-aged Americans, up from less than one-third a decade ago, according to the Centers for Disease Control

In Conclusion

To ascribe all behavior, good or bad, to the structure and function of the brain is not only simplistic and incorrect biologically, it is socially dangerous; “The devil made me do it” as an excuse for sociopathic behavior is simply not compatible with a functioning civil society. Unfortunately, defense attorneys are already recruiting expert witnesses who make this deterministic argument in court.

 Males concludes his article thus: “ In reality, human brains are highly adaptive. Both teenagers and adults display a wide variety of attitudes and behaviors derived from individual conditions and choices, not harsh biological determinism. There’s no “typical teenager” any more than there’s a “typical” 45-year-old.

Commentators slandering teenagers, scientists misrepresenting shaky claims about the brain as hard facts, 47-year-olds displaying far riskier behaviors than 17-year-olds, politicians refusing to face growing middle-aged crises ... if grown-ups really have superior brains, why don’t we act as if we do?”

To which I can only add: amen!

Dov Michaeli MD Ph.D is in the biotech industry, and frquently has his doubts about his own prefrontal cortex.

By Dov Michaeli , MD, Ph.D

One of the plays we saw last Sunday in Ashland was “Distracted”, describing a mother whose nine year old child was diagnosed with Attention Deficit Hyperactivity disorder, or ADHD. The kid was a lively, curious, imaginative, highly intelligent child who was bored with his school, couldn’t keep his mind concentrated on the dumb and further dumbed down assignments-and was labeled by his teacher as “challenged”. It was all downhill from there. The child was seen by all kinds of healers (school nurse, psychologist, neuropsychologist, homeopathic psychiatrist), loaded up with drugs designed to “control” his behavior which in turn led to a new diagnosis: bipolar disorder. I had been vaguely aware of the problems of over- diagnosis and misdiagnosis in child psychiatry, but no idea of its alarming extent.

The problem quantified

In a study published in the September 2007 issue of the "Archives of General Psychiatry" the researchers examined 10 years of data from the National Ambulatory Medical Care Survey (NAMCS), an annual, nationwide survey of visits to doctors' offices over a one-week period, conducted by the National Center for Health Statistics. Their finding was astounding.

· The researchers estimated that in the United States from 1994-1995, the number of office visits resulting in a diagnosis of bipolar disorder for youths ages 19 and younger was 25 out of every 100,000 people. By 2002-2003, the number had jumped to 1,003 office visits resulting in bipolar diagnoses per 100,000 people. This is a 40 fold increase in 8 years! In contrast, for adults ages 20 and older, 905 office visits per 100,000 people resulted in a bipolar disorder diagnosis in 1994-1995; a decade later the number had risen to 1,679 per 100,000 people, a “mere” two fold increase.

· About half of all children and adolescents who received a diagnosis of bipolar disorder also received a diagnosis of ADHD.

What could account for this increase?

There could be several factors accounting for this “epidemic”.

· Increased awareness of the disorder. This may be true to a limited extent, but a sudden awareness by child psychiatrists (90% of the diagnoses were made by them, only 10% by pediatricians)is simply not credible. What were they teaching in medical schools and psychiatry training programs in the decades up to 1995?

· Was there a sea change in our knowledge of childhood bipolar disorder since 1995? There has been great progress made in understanding the neurobiology and genetics of the disease. Great progress has been made in drug treatments of psychiatric disorders. But such advances do not affect the diagnosis. The latter is based on observation of behavior, not on objective criteria such as fMRI scans of the brain, or biochemical markers of the disease.

· The classical manifestation of bipolar disorder is a period of euphoria alternating with deep depression. Yet in children and adolescents euphoria is almost never present. The children are depressed, angry and given to tantrums. But isn’t it reasonable to expect a child who is more or less ignored by his harried parents, or is chauffeured from one activity to another, or is subjected to the constant anxiety of Little League and pressure to get the top grades in school, will be angry and depressed? Animal experiments have demonstrated that chronic anxiety, or lack of parental attention, lead to profound depression and aggressive behavior. What makes us think that we are somehow different?

· I think that the most credible, and most cynical reason for the huge increase in the diagnoses of bipolar disorder and ADHD is money. The diagnosis is made on subjective criteria, and this is an invitation to abuse. I suspect that when this issue will get investigated in depth, it will turn out that psychiatric overdiagnoses are first cousins of excessive cardiac caths, excessive imaging studies, excessive bypass surgeries, excessive prescription of medications, and so on and so on.

I am not a policy wonk, but I sense that this corruption of medicine cannot continue without dire consequences for our society.

Dov Michaeli MD, Ph.D is in the biotech industry, researching the development of new drugs.

When I wrote about the food industry marketing sweetened, energy dense foods to kids in my post titled: "Is the food industry playing games with your children:  You bet it is," I got the usual spate of email comments telling me that it is not industry, rather it is parents, that should be faulted. After all, these folks argue, parents, not kids buy and serve the food. (Yeah, but I contend the industry wouldn’t market this stuff to kids if it didn't pay off…but that is another story.)

Now, the NY Times tells the story of an angry mom taking on junk food in her kids’ schools. The story, titled Child Nutrition: Two Mothers, a Camera and a Look at School Lunches, was emailed to me by Karen, my husband’s daughter and the mother of our lovely 3-1/2 year old granddaughter, Rebecca (nicknamed Tupy). Karen is also an angry mom…angry about the food being served at Tupy’s preschool. Read what she has to say:

“It’s gratifying to read about pissed-off parents in other places. I’ve been battling her daycare on the food issue for months. I’ve hated to be a hothead there because, after all, Tupy still has to go there. I don’t want her to be treated poorly because of her outspoken mother, but the menu is truly appalling. She used to love vegetables and beans and fish, and the day she came home asking “why can’t we have donuts and hot dogs like at school?” is the day I went to war.” 

The NY Times tells the story of Susan P. Rubin, a woman on a mission to improve the quality of food in schools:

“She has emptied a bag of vending machine items onto a principal’s desk; she has delivered impassioned testimony to members of the Institute of Medicine of the National Academies in Washington while holding up potato chips and lollipops; and she has sneaked cafeteria food out of her children’s school after being barred from showing up without an appointment.” (Barred from her kids’ school? Come on now.)

Susan Rubin and another angry mom, Amy Kalafa, a filmmaker from Weston, Connecticut have made a film on the topic. “Two Angry Moms” is a 90-minute documentary that…

“…presents the good (a schoolyard in Katonah where students grow their own vegetables), the bad (chips and soda for lunch), and the ugly (what it is really like inside a school cafeteria kitchen).”

The Katonah-Lewisboro School District that is featured in “Two Angry Moms” paid attention to Susan Rubin. According to the NY Times article, “the district changed its lunch policy, even hiring an outside chef to train food service staff. ‘We went from refrying processed chicken nuggets to grilling fresh chicken breasts and making homemade apple crisp,” said Donna D. Walsh, a member of the Katonah-Lewisboro Board of Education.’”

Rubin has formed a better school food advocacy organization, named, obviously “Better School Food.” There is a lot of good information on the site. If you are a parent, aunt, uncle, teacher, friend or neighbor of a school kid (remember the concept: “it takes a village” -- then check out their website.)

Rubin and Kalafa plan to spend the summer trying to raise money for the film’s national distribution in the fall. If you want to learn more (or write a check), there is a link on the Better School Food website that will help you do that. You can also view clips from the film.

Here’s to all of the angry moms and dads and grandparents out there who believe we can do better and then roll up their shirtsleeves and get to work. Thanks, Karen, for sending me this article.

Pat Salber, MD

A survey, reported on the Kaiser Family Foundation list serve, finds that eighty-nine percent of California parents, regardless of political or religious persuasion, support comprehensive sex education programs in school. That means teaching kids about all of the choices related to sexual activity ranging from contraception to abstinence. How about that?…let’s arm our children with good solid information and then guide them to make the best choices for themselves.

Even self-identifying evangelical Christians said they supported comprehensive sex education. The lowest support came from the “very conservative” subset of the population and even then 71% supported comprehensive programs.

The study’s lead author, Norman Constantine of the Public Health Institute’s Center for Research on Adolescent Health and Development said:

"We were astonished by how universal this support is for comprehensive sex education. We expected these high levels of support in liberal urban areas but did not anticipate the equally high levels of support in California's more conservative, rural settings -- especially among self-identified evangelical Christian parents."

He went on to say, "What this shows is that the vast majority of parents put the health and safety of their children above politics and ideology." How refreshing.

Here’s a link to the full report:  Report

The study's complete results will be published in the September issue of the journal Perspectives on Sexual and Reproductive Health.

Pat Salber, MD

Genes

In 1993 scientists reported on a Dutch family, 14 members of whom were sociopaths, involved in aggressive crimes such as bullying, physical violence, rape, and arson. They all had in common a mutation in a gene that makes an enzyme called MAOA. The function of this enzyme is break down neurotransmitters such as serotonin and noradrenaline (or norepinephrine, a chemical first cousin of adrenaline). The ready conclusion was: defective enzyme caused elevated level of serotonin and noradrenaline, resulting in overactive brain circuits that serve aggressive behavior.

Case closed? Not so fast…

In a wonderful summary of the topic in Newsweek magazine ( April 30, 2007 ) one of my favorite writers on the subject, Sharon Begley) describes a 2002 study in New Zealand of 442 men who were followed since their birth. Indeed, men with low MAOA were more likely to engage in persistent fighting, bullying, cruelty and violent crime. But not all of them; only men who had been neglected or abused as children fit the bill. Men who grew up in a normal environment exhibited none of the violent traits.

Neuroanatomy

In previous postings we waxed scientific about the amygdala, two almond-shaped structures deep inside the brain, that are the seat of primitive emotions such as rage and fear; these constitute the emotional basis of the fight or flight reaction, which is mediated by noradrenaline. These waves of seemingly overwhelming emotions are checked and inhibited by another, more modern structure in the brain: the prefrontal cortex. This structure is the seat of judgment, planning, abstract thinking. It inhibits inappropriate or impulsive behavior, and is engaged in constant self-monitoring (could it be the anatomical seat of the Freudian super ego?). So in typical Ying/Yang fashion, the outcome of our behavior must then be the product of the amygdala and prefrontal interaction. Remember the then famous case of Kip Kinkel, a 15 year old who in 1998 killed his parents and two dozen schoolmates in Springfield , Oregon ? His brain scan showed a completely silent prefrontal lobe; he had nothing to check and balance his raging anger emanating from his amygdala.

Is this it? Not quite…

Hormones

Women love to point out, without much evidence I might add, that men’s aggressive behavior can be traced to their testosterone-addled brain. Only partly true. The level of testosterone is within normal limits between 20% and 200% of the mean; that’s a huge range of normal. However, if the level of testosterone exceeds 400% of the mean, then indeed women are right—men with these levels are more prone to violence. In fact, testosterone is an equal opportunity hormone; in a species of hyenas (I forget which) the first newborn in a litter, be it male or female, will eat the rest of the brood within days of birth. It turns out that this vicious sibling has inordinately high levels of testosterone in its brain, much higher then the other hapless siblings.

But to assume that we are simple automatons, following helplessly the script written by our genes, brain circuits and hormones, would deny a self evident fact—we don’t behave automatically, we do have a certain degree of free will.

Psychology

The interaction of biology and the life one leads turns out to be of paramount importance in shaping the criminal mind. The most important characteristic of the behavior of mass killers is paranoia. They have the sense that the whole world is against them, that everybody but themselves is responsible for their troubles, that the world is unfair. They are usually depressed and socially isolated.

This kind of personality, you might say, could be the product of brain circuitry gone awry. But here is a fascinating finding from animal and human studies: behavior can change brain circuitry and function-- an outstanding example of nature/nurture interaction. So what are the non-biological roots of violent behavior? We finally arrive at the inevitable:

Society and culture

It is the social environment that allows, indeed encourages, psychopathic criminal behavior. Many societies have members with genes gone awry, with malfunctioning brain circuits, with males suffering from raging hormones, with children raised in violent homes. But, sad to say, we have the dubious distinction of being the champions of gun violence in the civilized world. In 2004 there were 29,645 deaths due to gun violence in the US , or 10.08 per 100,000. For comparison, France had 4.93, Belgium 3.67,and Spain 0.75 per 100,000.

In 5 years of war in Iraq about 3200 of our soldiers got killed. Yet, we tend to see the situation in Iraq as intolerable but we dismiss  the carnage in our own streets with a helpless shrug: "It’s the culture… "

We mentioned the case of Kip Kinkel. Yes, his prefrontal lobe did not do its job. But here is rest of the story: a psychotherapist actually suggested that his dad buy him a gun so they could have something to do together.

As Pogo said: we have met the enemy, and it is us.

Dov Michaeli MD, Ph.D

Last week, Medscape posted my web video editorial about the food industry using advertising imbedded in video games as a way of marketing some of their less healthy products to children. You can watch it by clicking on this link, be sure your sound is turned on. Or you can read my post about the same topic from earlier this year (reprinted here for your convenience). This one will make your blood boil (or something like that). A recent report from the Kaiser Family Foundation, “It’s Child Play: Advergaming and the Online Marketing of Food to Children,” is a comprehensive look at this new type of advertising. Haven’t heard of it? You will. According to the report, Price Waterhouse Coopers estimates a five-fold increase in spending on this type of advertising by 2009. Advergaming (a contraction of advertising and gaming) is the use of online video games with embedded brand messages to engage your target audience. It is specifically designed to blur the boundary between advertising and entertainment. This report looks at advergaming that targets kids. Advergaming is a good deal for food marketers. It is cheap compared to TV advertising ($2 per thousand users compared with $7 to $30 per thousand viewers).

Click to read more ...

According to a front page article in the San Francisco Chronicle, a growing number of teens and twenty-somethings prefer text messaging to talking. The article describes the findings from the “Silicon Valley Cultures Project” being conducted by San Jose State University Anthropology Professors, Jan English-Lueck and Chuck Darrah. The Chronicle describes the view of 23 year old Stanford administrative assistant, Hana Xu who says,“It’s easier to say what you really want to say online because you don’t get cut off or interrupted.” Texting, it seems creates an emotional distance as well as a feeling of control that is much harder when conversing face-to-face.

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Here is the transcript of a recent Medscape Webcast Editorial by Dr. Harvey Fineberg, the President of the Institute of Medicine. If you want to see him deliver his talk live, click on the hyperlink. Dr. Fineberg points out in his editorial that many of the products aggressively marketed to our kids are the same foods that make us fat and lead to obesity-related chronic illnesses, such as high blood pressure, abnormal lipids, heart disease, stroke, and diabetes. He suggests that the same type of marketing strategies could be applied to promote healthier foods, beverages and meal options for children and youth. I agree. The problem is who is going to do it and who is going to pay for it? Food is big, big business in the US and globally. Public health is underfunded, too often subject to political agendas, and unfortunately, often not as effective as it should be.

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Nicholas Kristof's editorial in the today's New York Times starts off with a question:

"What vegetable do American infants and toddlers eat most?"

The answer:  A French fry?  That right, a French fry. 

A study by Gerber, the baby food company, found that a third of young children don't eat any vegetable daily, but when they do, it's the French fry they are eating.  Twenty percent of kids, 19 to 24 months old eat French fries at least once a day. 

The editorial goes on to point out that, on the day in which President Bush is going to talk about health care costs in the US in his State of the Union address, we really should be talking about health--public health.  The editorial suggests some things we could do as a nation that would reduce health care costs and at the same time improve health.  Here's a partial list:

• Ban soda, potato chips and other unhealthy snacks from schools and discourage them in workplaces
• Encourage exercise breaks (I love this one--imagine how many more people could get in their 30 minute workouts if they had time to do it at work)
• Expand PE.  And, I would add, make PE a meaningful exercise experience that will give young people skills to incorporate exercise into their daily lives once they leave school
• Promote jogging and biking and hiking and and walking and anything else that gets us up and moving.  Kristof's most creative suggestion is developing TV sets for kids that are powered by exercycles.
• Design better  stairways.  Kristof suggests making stairways open and appealing while making elevators dark, dingy and out of the way.
• Sell cigarettes only in pharmacies and raise cigarette taxes

As was pointed out in a NY Times series on diabetes , we as a nation are willing to pay many thousands of dollars to treat complications of unhealthy behaviors, but we are hesitant to add meaningful coverage for services, such as personal trainers and dietary counselors, that could prevent the development of disease in the first place.  Isn't it time to get this right?

This blog was originally posted on the PEERtrainer website (www.peertrainer.com) on January 31, 2006.

There is a wonderful story in the San Francisco Chronicle today about a boxing coach who whipped a bunch of Middle School kids into shape. Kermit Bayless, PE director of Frick Middle School in Oakland, California uses a bullhorn and boot camp techniques to get the teens moving, really moving. They do jumping jacks, push-ups, stretching and jogging, while counting in unison. Bayless paces in front of the group, shouting directions and quizzing them on the names of the muscles being targeted. "What does PE do?" shouts Bayless. "It sets the tone for the whole school," the students shout back. He is right. Frick Middle school is one of the SF Bay Area's highest-achieving middle schools on the state fitness test. 68% of Frick 7th graders achieved high marks on the fitness test last year, compared with just 16% of all Oakland 7th graders. Across the state, only 29% of 7th graders passed the fitness test. Frick Principal Calvin Criddle believes the strict fitness program has done more

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Today, the National Institutes of Health announced the results of a major study of adolescent health behavior published in the January 2006 "Archives of Pediatrics and Adolescent Medicine." The study was based on the responses by more than 14,000 young adults interviewed in 1994/5 when they ranged from 12 to 19 years old and again in 2001/2 when they were 19-26 years old. When they were young teenagers, most of the participants had fairly healthy behaviors. However, that deteriorated rapidly as time progressed. Only 5% of young white women reported no weekly physical exercise during adolescent years, but the percent not exercising weekly increased to a whopping 46% by young adulthood. The proportion of white males who were obese increased from 14% in the teen years to 19% when they became adults. Among female adults, African-Americans and Asians were the least likely to exercise (55 and 53% respectively). Among males, whites and blacks were the least likely to exercise. Other health behaviors, such as smoking and binge drinking likewise deteriorated as the teens grew up. The only good news was

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