The Doctor Weighs In

Brian Klepper

Here's one of today's entries in The Writers' Almanac, the wonderful daily newsletter sent out by Garrison Keillor on NPR. Parents of boomers like me were big fans of Dr. Spock, treating him with an almost cult-like reverence for his sensible wisdom about child care. He later parted ways with some of his more conservative followers, when he became an iconic protester against America's war in Viet Nam.

Be sure to note the last line of the blurb below. This is the same message Jane Sarasohn-Kahn related recently in The Wisdom of Patients. We stand on the shoulders of giants.

It's the birthday of Dr. Benjamin Spock, (books by this author) born in New Haven, Connecticut (1903). His Common Sense Book of Baby and Child Care (1946) was a best seller during the period after World War II, when parents across America were raising the Baby Boom generation. Spock opened his first pediatric practice in 1933. After 10 years of observing children and their health, Spock decided to write a book about taking care of them. Instead of writing it out himself, he dictated the book to his wife, to give it a conversational tone. Previous parenting guidebooks had encouraged parents to be stern with their children, and they were written as a list of commands. Dr. John B. Watson had written in his guidebook, "Never, never kiss your child. Never hold it in your lap. Never rock its carriage." Dr. Spock encouraged parents to be affectionate, and he also encouraged them to follow their own instincts. The first sentence of his book was, "You know more than you think you do."

Brian Klepper 

I was on the phone with my good friend, fellow TDWI columnist Bill Bestermann MD yesterday.  Dr. B, a preventive cardiologist who is passionate about the underlying mechanics of cardiovascular disease and the horrific toll the American diet and lack of exercise is taking on everyday people, lives in spectacularly beautiful, rural Kingsport TN. He told me he was driving through town, channel surfing on his radio, and he happened upon the station that broadcasts information for the local schools. They were announcing the menu in the school cafeterias. He said it was appalling. "Honeybuns and processed foods. It was all the stuff I tell my patients to avoid."

Never one to shrink from suggesting that other people embark on courageous courses of action, I urged him to ask for a meeting with the School Board to lay out what the long term effects of this diet are on the children of the region. "Think in terms of leveraging your credibility as a trusted authority," I advised.

Many school boards have defaulted to whatever's most financially expedient in their school cafeterias. They take money from junk food companies and, in exchange, give the firms free access to the kids with vending machines and ads. They ignore the rising tide of obesity and chronic disease that threatens the kids and their future.

Imagine if a doctor or, better yet, a small army of local doctors, waltzed in and explained the impacts of the school menu to the Board and, if possible, the community, through the local newspapers, TV and radio stations. Then they could make recommendations for a diet that would be acceptable to kids while providing actual nutrition. (And while they're at it maybe they could explain why getting rid of gym and other physical activities is moronically penny-wise and dollar foolish.)

Physicians shouldn't underestimate their power in this. While physician credibility has waned in recent years as the health care crisis has intensified, a 2003 study found that Americans still trust their physicians more than any other relationship outside of family.

It's not like this is a small problem. In my talks I flash my favorite obesity slide, an image generated by the gifted illustrator Wellington Grey. (When it comes up on the screen and the audience begins to absorb it, you can always hear embarrassed laughter ripple through the crowd.) It shows the percentage of adults over age 15 in a variety of developed countries with a body mass index over 30 (that is, who are obese). Americans, at 31%, are far and away the fattest people, with Mexico and the UK trailing distantly at 24% and 23%, respectively. The French, Austrians and Italians are at 9%, and the ridiculously trim Koreans and Japanese are at 3%.

This slide tells us everything we need to know about America's future competitiveness. If obesity is a general predictor of health, health is related to productivity and productivity to competitiveness, we're toast.

To turn this around, we need leadership. If not from doctors, our most trusted professionals, then from whom? This is really a problem that local medical societies ought to wave the flag on. It might create the impetus for real change, and remind people that their doctors do really want what's best for us all.

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 Pat Salber

It is always unbearably sad to learn about a child's death.  But for families with children living with complex chronic conditions, such as progressive neuromuscular diseases or cancer, it is something they must be prepared to deal with.   The miracles of modern medicine simply cannot cure every serious childhood illness. 

Given that, what do we know about where these children die?  A recent study, led by Chris Feudtner, MD, PhD, MPH and colleagues, published in JAMA (June 27, 2007) documented that increasingly these children are dying at home instead of in the hospital - and I believe that is a good thing, allowing both the child and loved ones the comfort and privacy we all want to have at the end of life.  Advances in technology (home ventilators, tube feeding) and greater availability of services to support families at home (pediatric home care and hospice services) have made it easier for children and families to choose to die at home.

Comparing where these very sick children died in 2003 to what happened in 1989, the researchers found that the percent of infants dying at home increased significantly from 4.9% to 7.3%; 1-9 year olds from 17.9% to 30.7%, and 10-19 years olds from 18.4% to 32.2%.

White children were twice as likely to die at home as black or hispanic children - even after adjusting for a variety of factors, such as medical condition or geographic location.  The researchers speculate that differences in access to health care services or technology, cultural attitudes toward palliative and end-of-life carte, and different levels of financial and social support may contribute to this finding.

Dying at home should be an option for all who choose it.  If and when health care reform and universal health insurance become a reality in this country, it is important that palliative care and end-of-life services be a part of the coverage - and not just for children.

by Pat Salber

Earlier this year, I wrote about the Food Industry Playing Games with our Children.  Now, thank heavens, HMO giant, Kaiser Permanente (KP), is countering with a food game of its own - a good food game. 

The Incredible Adventures of the Amazing Food Detective was developed by KP to teach youngsters (9-10 years old) about healthy eating and exercise.  Unlike other video games that have inducements to keep kids on the site, exercising only a few fingers at a time, Incredible Adventures only allows 20 minutes of play and then locks the young'uns out, encouraging them to stop playing computer games and go outside for fresh air and exercise instead.  Once locked out, they can't get back into the site for an hour. 

While playing the game, kids learn how to read food labels, how to measure the amount of sugar in drinks and other health skills.   Now that may sound pretty dull, but the site has woven this information into adventures that engage junior food detectives (from the site):

"There has been a mysterious outbreak of unhealthy habits hitting too many boys and girls. If we don't solve these cases, and fast, kids might not make the right food and exercise choices as they grow, and that could be trouble!

All junior food detectives will get secret training on how to eat right and exercise. You can investigate fun games like Whack A Snack, Soccer, and Zap the TV. Plus you can print out classified clues on ways to be healthy, then share them with your parents, teachers, and pals."

Now, as you know, I am not 9 or 10, so I am probably not the best person to evaluate whether the site can engage kids of this age -- and teach them healthy habits to boot.  If you have kids, know kids, or can get kids on the site, write us, let us know.  Can the Incredible Adventures website trump www.Tonythetiger.com" or www.bubbletape.com?  Let me know...

by Pat Salber, MD

A small story in the business section of USA Today is good news (I hope). It says eleven major food companies, including giants Coca-Cola, Pepsi, and McDonalds will announce changes in how they advertise their products to kids. The Council of Better Business Bureaus (CBBB), in an effort to respond to the epidemic of childhood obesity, has organized the Childrens Food and Beverage Advertising Initiative to get food companies to “pledge” to stop advertising unhealthy products to children. These voluntary measures are supposed to go into effect by the end of 2008.

Evidently each company is making its own pledge. McDonalds, the article notes, will only promote meals with “no more than 600 calories, no more than 35% of calories from fat, 10% of calories from saturated fat and 35% total sugar by weight.” Is that dinner they are talking about? Or a mid-afternoon snack. When it comes to healthy eating, the devil is always in the details.  Products in Kraft Foods' Sensible Solutions line, which has less fat and calories than their other foods, will be the only types of products advertised to kids.

Although, the USA article was pretty positive about the Initiative, it did close with a quote from Kelly Brownell, director of the Rudd Center for Food Policy and Obesity at Yale University. Brownell says that the food companies’ voluntary guidelines for advertising to kids “are a good move in the right direction, the risk is that it stops here.” We’ve all seen that happen before, right? It is the rare industry that voluntarily reigns in bad practices that are highly profitable.

Digging Deeper

This article motivated me to dig a bit deeper. According to a press release found on the CBBB’s website, the eleven companies* participating in its Childrens Food and Beverage Advertising Initiative, have

“pledged to focus essentially all of their advertising primarily directed to children under 12 on products meeting better-for-you standards or refrain from advertising to that age group.” (Better-for you, compared to what?? … the high sugar, high fat they were advertising to kids before?). Steven J Cole, President and CEO of the CBBB goes on to day, “These expansive commitments significantly exceed the Initiative’s baseline requirements.”

The Pledges

Here are some of the pledges:

McDonalds:

All advertising primarily directed to children under 12 will be for meals that meet “specified calorie, fat, saturated fat, and sugar limitations consistent with the Dietary Guidelines for Americans 2005 and other government standards. They will restrict their advertising to the “Advertised Meal” that must provide no more than 600 calories; and no more than 35% of calories from fat, 10% of calories from saturated fat, and 35% total sugar by weight

The “Advertised Meal” will either be a 4 piece Chicken McNuggets® Happy Meal with low fat white milk and apple dippers with low-fat caramel dip or a Hamburger Happy Meal with low fat white milk and apple dippers with low-fat caramel dip. Scroll down to Appendix A of the pledge to see the details of what’s actually in the “Advertised Meals”

Kraft Foods

Kraft has pledged to only advertise products to children that meet its Sensible Solution nutrition criteria. Cool Whip Lite, Honey Maid Bees, Oscar Mayer Fat Free Wieners, and Lunchables Pizza are some of Kraft’s Sensible Solution products.  (Want to see the rest?  Here's the link to Krafts' Sensible Solutions products.)

General Mills

General Mills will no longer advertise to children foods with more than 12 grams per serving. (Be careful with this one, serving sizes are usually a fraction of what actually gets poured into the bowl or put on the plate). They also pledge to advertise only Healthy Dietary Choices to children under 12.

In fact, according to information on the CBBB website, General Mills has partnered with Nickelodeon (scroll down to page 4 of the pledge) to bring the popular Nickelodeon characters SpongeBob SquarePants, Dora the Explorer and Diego to frozen and canned vegetables. The goal is to make eating vegetables fun for kids. Each package of frozen vegetables will also include stickers featuring the characters that parents can use to reward children for eating their vegetables.

Note, these are frozen and canned vegetables – not the fresh kind that you can get for a fraction of the cost in the veggie section of your local market. And, it is of interest, that the brands touted in the pledge are frozen beans and frozen broccoli with butter sauce!

Never good enough.

I could go on and on, but you are probably thinking. What a crab…nothing is ever good enough. Well, in the midst of an obesity epidemic that threatens the world’s children with early onset chronic diseases and a shortened lifespan, then, heck yeah, promoting frozen buttered broccoli instead of the fresh kind and “apple dippers with low-fat caramel dip” instead of real low fat, fresh apples is not really good enough.

Let’s keep on pushing and pushing until the industry really gets it right. But, we have to do more than blab about it. We have to buy better, cook better, eat better and, in this way, fundamentally change the market for food.

Big job? You bet? But it can be done. Just the fact that these eleven companies are now trying to figure out how to market healthier foods indicates that they will respond to consumer demand (and regulatory threats). When more and more of us choose to shop in the outer perimeters of supermarkets (where the fresh foods are) or in local farmers’ markets, you can bet that industry will be watching.

Pat Salber, MD

by Brian Klepper

I routinely hear well-intentioned people say that, if Americans, and most particularly kids, would just become more responsible for their own health and start eating right, then our obesity and diabetes epidemics would turn around.

I don't think this is going to happen, at least not anytime soon. The blunt truth is that, to a large degree, we have an obesity epidemic because Congress ensures that the food industry has free rein with their marketing practices.

Late last year, Pat Salber wrote a post – she had a corresponding video commentary on Medscape – on advergaming. An important study had been released on the Kaiser Family Foundation website that detailed how food companies were using the Web to influence kids' eating behaviors, building on their TV advertising tactics. Here's a quote from the press release:

The report, “It’s Child’s Play: Advergaming and the Online Marketing of Food to Children,” found that more than eight out of ten (85%) of the top food brands that target children through TV advertising also use branded websites to market to children online. Unlike traditional TV advertising, these corporate-sponsored websites offer extensive opportunities for visitors to spend an unlimited amount of time interacting with specific food brands in more personal and detailed ways. For instance, the study documents the broad use of “advergames” (online games in which a company’s product or brand characters are featured, found on 73% of the websites) and viral marketing (encouraging children to contact their peers about a specific product or brand, found on 64% of sites). In addition, a variety of other advertising and marketing tactics are employed on these sites, including sweepstakes and promotions (65%), memberships (25%), on-demand access to TV ads (53%), and incentives for product purchase (38%).

In 2005, Consumers Union issued a report on the food industry's advertising campaigns. That press release headline read:

Certainly, the data say we're losing the war on obesity. Data from two National Health and Nutrition Examination Surveys show that the prevalence of obesity in adults (aged 20–74) more than doubled between the end of the 1970s to the early 2000s (from 15.0% in the 1976–1980 survey to 32.9% in the 2003–2004 survey).

Children and teens also grew significantly plumper. The prevalence of obesity in children 2–5 years rose 2.5 times, from 5.0% to 13.9%; for those aged 6–11 years it nearly tripled, from 6.5% to 18.8%; and for the 12–19 year olds, it more than tripled, from 5.0% to 17.4%.

It's worth noting that, while obesity has intensified throughout the country over the last several decades, certain areas, like the South, are consistently worse than elsewhere. This is traceable in part to regional dietary habits that, of course, long predate the food industry's influence, as well as to the role of poverty.

Percentage of Obese Americans - 2005

BMI > 30, or ~ 30 lbs. overweight for 5'4" person

Source: Centers for Disease Control, Behavioral Risk Factor Surveillance System, 20006 

(If you're interested in seeing the CDC's 20 year (1985-2005) annual trend data on overweight by state, go to http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm, and look for the link that says "Download the Obesity Trends Map." Play the slides in quick sequence. It's very alarming to watch as the entire country lights up, reflecting how quickly we're getting fatter.)

The reality is that most of us are susceptible to the marketing, and can't withstand the barrage of enticements. And they're everywhere. Every day, Americans are bombarded by come-ons for fast, prepared and junk foods. This diet has become part of many people's regular routine. The industry now vies to subsidize school districts in exchange for the unrestricted ability to advertise, put in vending machines and have their products available in cafeterias. They have developed books for very young children with appealing characters to create brand loyalty early on,

And except for the unhealthy part, what's not to like? These foods are cheap, readily available and, lets face it, all that salt and fat taste really good. Only the most optimistic among us can imagine that, unless something dramatic changes, we'll be able to reverse our love affair with bad food. Nor will any of the other developed and developing countries that all have the same problem.

The food industry has virtually unrestrained promotional access because Congress has willfully ignored their role in the obesity problem, preferring instead to argue that if people were just more responsible as individuals, they'd get this under control. (A quick glimpse of our Congressional representatives shows that, when they preach restraint and self-control, they're talking about us, not themselves.)

 The threats are to the national health and the national pocketbook. At the moment, for example, diabetes and related conditions alone cost Americans about $165 billion a year, about 8 percent of the national health care spend. And we're just getting going. As the population gets fatter, this is going to be a blockbuster national health care problem. Nobody will be able to afford what, in today's terms, we'll be expected to pay to keep all these people alive, semi-well, and consuming.

Congress has good reason to advocate for the food industry, in the form of millions of dollars in lobbying funds that go to buy influence. Skeptical? Go to www.opensecrets.org, the site of the Center for Responsive Politics, a non-partisan group dedicated to accountability in government, and do some checking yourself. Big dollars from the food, beverage, candy and restaurant industries to Congress, part of the larger $2,5 billion dollars that were distributed in 2006 to our 535 representatives. This is the way it is with virtually all special interests. Most effective groups lobby. Why? Because it works!

There are, of course, precedents for change. Congress decided that the tobacco and alcohol industries would be limited in where and how they could advertise, actions that have had profound impacts on America.

It's absolutely in the national interest to turn this problem around. But unless we have dramatic change from elsewhere – chemical concoctions that make junk food taste as good but have no ill effects, or some miraculous national consciousness-raising (Not impossible. Check out the teen fitness program Dance Dance Revolution or consider how the green movement is sweeping across the globe.) – we won't change our obesity and chronic disease problem. To fix that, we'll need a change in how the food industry behaves. And to get that, we'll have to change how our government works.

(The same is true, by the way, for health care reform, but that's another post.)

Brian Klepper is a health care analyst based in Atlantic Beach, Florida. You can reach him at bklepper@gmail.com.

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

I am a big fan of the Family Violence Prevention Fund.  They have been on the cutting edge of every issue related to family violence  for years now.  These issues range from helping the criminal justice system respond better to victims to improving the health care system response to family violence.  If there is a way to try to reduce the tragedy of family violence, the Fund is there trying to figure out the best way to do it.

Now, they have a marvelous extension of their efforts -- that is a focus on helping boys learn to respect the women in their lives and to actively disavow activities and attitudes that are at the core of violence against women.  Innovative, yes.  But listen to this.  They have a program that targets coaches, that's right, sports coaches, to engage them as role models to help boys grow into nurturing, supportive boyfriends, husbands, sons, nephews, and friends of girls and women.  What a great idea!

Violence against women is not and never has been simply a "women's' issue."  It is an issue that affects men, women, children, and indeed everyone directly and indirectly related to the victim and the abuser.  Thank heavens an organization like the Family Violence Prevention Fund has taken a broader view of the problem and has begun to address the family violence as an issue that impacts just about everyone.

To learn more about Coaching Boys into Men, check out this site:  CBIM

To help support the Fund as it engages men in their programs, do what I do every year, give the best Father's Day Gift possible, a donation on behalf of your guy to the Founding Fathers program of the Family Violence Prevention Fund.  It is much better than just giving a "thing".  Just ask the men in my life -- Dov, Jason, Kevin, Gili, wouldn't you rather be gifted a Founding Father membership than get one more tie or another pair of socks.  This gift is not just for you -- it is also for your daughters, your wives, your sisters, your mothers and grandmothers and your girlfriends.

Thank you, Family Violence Prevention Fund, you are doing life-changing work.  And for that I say:  Amen.

Pat Salber, MD, MBA

I am at the Family Violence Prevention Fund’s National Conference on Health and Domestic Violence.  One of the panels that I attended examined the impact of child maltreatment on brain development.

David McCollum, MD, President of the Academy on Violence and Abuse, reviewed the medical literature on brain changes that occur after child abuse … and I am not talking about brain injury due to being hit on the head, rather I am talking about structural and functional changes in the brain that occur as a result of being exposed to the terror of family violence

Dr. McCollum briefly reviewed the biology of human brain maturation. Infants are born with an over  abundance of nerve cells, called neurons, and connections between nerve cells, called synapses. As the child gets older, there is a significant “pruning” of neurons as well as synapses.

Another process that occurs as the child’s brain matures is that the neurons become myelinated, a process that makes neuron-to-neuron transmission more efficient.

Myelination is inhibited when there are high levels of brain glucocorticoids, one class of hormone that is elevated during stress. There is no question -- being abused as a child or growing up in a home where your mother is abused is stressful…and, for many children, it is stressful over prolonged periods of time.

When the brains of children exposed to abuse are looked at anatomically, using imaging techniques, it turns out that there is a reduction in size of a number of key brain structures, including the amygdala, the hippocampus (mainly on the left side), and the cerebellar vermis. There is also a reduction in the size of the corpus callosum, the area that allows the two sides of the brain to communicate with each other. There is also an increase in the size of the putamen and the lateral ventricles (the cavities in the brain that contain cerebral spinal fluid). According to Dr. McCollum, many of these changes are explained by the inhibiting effect of glucocorticoids on myelination of neurons.

The areas of the brain impacted by glucocorticoid excess are components of the limbic system and related connections. The limbic system is involved in response to perceived danger.  It is also involved in our emotional response. The limbic system evolved to protect us from the dangers of the wild, and most likely played a role in our surviving attacks by predators. These stressful events were likely less common and less persistent than what is experienced by children trying to survive in a violent home.

Other chemical changes have been attributed to chronic stress, include overproduction of dopamine, a substance that, in excess, causes reduced attention, increased vigilance, impaired ability to learn new material, and increasing paranoid and psychotic behavior.

Serotonin levels are decreased as a result of stress. Suicidal behavior, depression, and aggression have been shown to result from low serotonin levels. Substance P, a neuropeptide that participates in pain response and inflammation, has been found at higher levels in the spinal fluid of abused, compared with non-abused individuals.

All of these findings have potentially profound implications for healthcare professionals. No longer can we say that family violence is not a health care issue. When your brain structure and function changes, for the worst, as a result of exposure to violence, I would say without a doubt that it is a healthcare issue of the highest magnitude.

We don’t yet know if these changes can be reduced with treatment. But our new understanding of the neurobiology of abuse is sure to lead to new therapies, some of which may be pharmacological and some of which may be behavioral. Hopefully, these new findings will also lead to more aggressive and more effective efforts identify kids at risk and to help families learn to live violence-free.

Finally, it is my profound wish that studies such as these will stimulate research into new ways to prevent violence in the first place. Primary prevention research in the field of family violence is woefully underfunded. It is time to get our priorities straight -- our kids brains are at risk.

If you would like to read more about this fascinating and important topic, take a look at Dr. McCollum's article on "Child Maltreatment and Brain Development" published in Minnesota Medicine in March 2006.

Pat Salber, MD

A new report by experts in fetal medicine has found that being overweight is not good for mother or baby. The report is summarized in an article by Dr. Rajesh Swaminathan that appeared on abcnews.go.com.  It is definitely worth reading.

Here are some of the important points:

• Babies born to overweight mothers have various types of birth defects, such as macrosomia (large body size) and shoulder dystocia (the baby's shoulder is injured when the baby tries to pass through the birth canal).
• Spina bifida, a serious birth defect that can cause paralysis, occurs twice as often in obese women compared to normal weight women. This may be because it is more difficult to detect neural tube defects, the abnormality that leads to spina bifida, by ultrasound because of the lower quality of ultrasound images in obese women.
• Obese moms also have a higher incidence of pregnancy-related high blood pressure, diabetes, and dangerous blood clots. They are more likely to have C-sections, post-operative infections, and spend more time recovering in the hospital after the birth.

The report recommends that women lose weight by dieting and exercise well before trying to get pregnant. Some women may want to consider weight-reduction surgery. Losing weight may help with conception because of improvements in the hormonal profile. Finally, good health habits established by moms before pregnancy may translate into good health habits for her and the whole family for years to come.

This blog was originally posted on the PEERtrainer website (www.peertrainer.com) on Febuary 4, 2006.

I grew up in a seriously dysfunctional household. My mother was battered by her partner. Both of them were alcoholics. Once, during a particularly bad fight, the police were called and, after they determined my mother did not own the house we lived in, my brother and I were hustled into my mother’s car for a pretty scary ride to a motel. In those, pre-MADD days, drunk driving was not taken as seriously as it is now.

My brother and I were sure we were the only kids in our upper middle class community of Tiburon, California who lived like that. I didn’t even know anyone else who had a divorced mother. I didn’t know that domestic violence is common. I never told any one of my classmates or their parents anything about my home life. I was too ashamed.

It wasn’t until long after I became a doctor that I started learning about domestic violence, now called intimate partner violence to acknowledge that it affects people in all kinds of relationships. I have been involved in working to increase awareness of the problem in ever since. I co-founded Physicians for a Violence-free Society (now closed) and co-authored a book for health professionals on the topic. The second edition, The Physicians Guide to Intimate Partner Violence, is available through Amazon.com or through our publisher, Volcano Press.

During the course of my advocacy work, I met Vince Felitti, MD, an internist at Kaiser Permanente’s Department of Preventive Medicine in San Diego, California. He told me about work he had been doing with Rob Anda, a doc at the Centers for Disease Control and Prevention (CDC). This body of work has become known as the Adverse Childhood Experiences (ACE) Study.

Vince and Rob and their colleagues in the CDC ACE Study Group have analyzed data from more than 17,000 men and women who were seen in Kaiser’s Department of Preventive Medicine’s Health Appraisal Clinic. They used a carefully designed survey to learn about these people’s exposure to ten categories of stressful or traumatic childhood experiences. They then looked to see if these exposures were statistically correlated with a wide range of adult health problems, including obesity, heart disease, liver disease, diabetes, substance abuse, depression, and teen and unintended pregnancy.

The experiences they studied are as follows:

Abuse

• Emotional
• Physical
• Sexual

Neglect

• Emotional
• Physical

Household dysfunction

• Battered mother
• Parental separation, divorce, or loss in childhood
• Mental illness in household
• Household alcoholism or drug abuse
• Household member in jail

The researchers learned that adverse childhood experiences are common—I wish I had known that as a kid. They also learned that they tend to occur in clusters. For example, 98% of children who experience emotional abuse also experience at least one other type of adverse childhood experience. A majority experience at least two other ACEs and between 30-60% experience 4 more.

Because it is so common to experience multiple ACE’s, the researchers developed what they call the ACE Score. Each of the ten exposures listed above counts as 1 point. My ACE score is 3 (battered mother, divorced parents, household alcoholism). My brother’s is 5 because he was also emotionally and physically abused by my mother’s abusive partner.

Vince and Rob’s research indicates that the ACE Score likely captures the cumulative biologic consequences of these exposures. Multiple, well done analyses of the ACE data have been published in good medical journals. They demonstrate that the ACE score has a strong graded relationship to:

• Obesity, diabetes, cardiovascular disease, liver disease and other leading causes of death in the United States
• Smoking, alcohol use and abuse, as well as illicit and IV drug use
• Early initiation of sexual intercourse, promiscuity, and sexually transmitted disease (STDs)
• Teen and unintended pregnancy, stillbirths, and spontaneous abortion
• Suicide attempts, depression and poor health-related quality of life

It is important to remember that these studies are not randomized controlled studies which are considered the gold standard when trying to determine if something causes a bad health outcome. These studies, instead, looked for statistical links between ACEs and adult health. What makes these studies so compelling, however, is the fact that they found a dose related effect: as the number of exposures, or ACE Score, increases, so does the likelihood of having certain health problems as an adult.

So, what should you do if you are one of the many people in the world who have experienced one or more of these adverse childhood experiences. My friend Vince advocates autobiographical writing used in conjunction with an interested, and hopefully experienced, health professional. It may be your family doc or it may be someone in the field of behavioral health. He believes that acknowledging that you had these experiences and sharing your feelings about them with someone you trust has therapeutic value. Or you may find value in participating in support groups of people who have had the same experiences. Some folks with adverse childhood experiences may need medications for depression or anxiety. And some may benefit from formal psychotherapy.

If you want to learn more, please visit www.acestudy.org.

Pat Salber, MD, MBA

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).

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Here's a fun article about giving out healthy things for Halloween instead of candy.  Although I am often accused of being a party pooper when it comes to junk food, even I wouldn't have thought of giving the little ones a toothbrush for Halloween!

Here's the link to the article:  http://www.wikihow.com/Give-Healthy-Treats-for-Halloween

Pat Salber

Because of a deal brokered by the William J. Clinton Foundation and the American Heart Association with the American Beverage Association and major soft drink companies, Cadbury Schweppes, Coca-Cola, and PepsiCo, sodas, these companies will no longer be selling sweetened soft drinks to elementary and middle schools. They will only sell water, unsweetened juice and low-fat milds instead. High schools will only be able to buy diet sodas for purchase by their students. Diet and unsweetened teas, diet sodas, sports drinks, flavored water, seltzer and low-calorie sports drinks will be available alternatives.

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Two news stories caught my eye recently and made me wonder: "Are we creating a new norm of being fat?" One of these stories, "Heavy patients put strain on hospitals," appeared on CNN.com. The other, "Tots getting too fat to fit in car seats," appears in today's NY Post online. Both articles describe how we are outgrowing the size of our seats. In the case of hospitals, it is not only wheelchairs that are too small, but also hospital beds, diagnostic equipment (such as MRI scanners) and even doorways! The hospital article article described one hospital whose daily census of people wieghing 350 pounds or more is one-third of the 900 hospitalized patients. The article goes on to mention that, "ATF Healthcare, a union representing 70,000 nurses and other workers at hospitals in 18 states, last week called for new laws forcing hospitals to buy equipment such as portable hoists to prevent worker injuries." The story about kids getting too fat to fit into carseats is based on a study done at Johns Hopkins by lead author Lara Trifiletti.

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Want to get your little couch potatoes moving? Check out this community-based program for girls. Girls on the Run, International is a non-profit organization that is designed for pre-teen girls. It combines training for a 3.1 mile running event with self-esteem enchancing exercises. The goals of this volunteer-led organization are to encourage positive emotional, social, mental, spiritual, and physical development. Girls on the Run now operates in 198 cities in 35 states and has reached about 40,000 eight- and nine-year olds. They hope to eventually cover the globe. There are two programs: "Girls on the Run" for 3rd to 5th graders and a recently rolled out program, "Girls on Track" for 6th to 8th graders. The curriculum has been in use since 1996. It has been evaluated by a professor from Old Dominion University, Rita DiGioacchino DeBate, PhD.

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