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!

Brian Klepper 

Some things are timeless. I remember watching Jack La Lanne, the TV health fitness evangelist, when I was a boy, 45 years ago. My Mom would turn him on, and would occasionally bend and stretch with his show. You couldn't help but admire his strength and vitality. It was clear he was doing something that everyone ought to do.

It turns out, of course, that his advice - exercise and diet - was solid then and is solid now. Now 93, Mr. La Lanne's life and achievements are chronicled in, of all places, the Costco Connection. If nothing else, in checking out this article you'll learn, for example, that in 1956, at age 42, he set a new world record by doing 1,033 pushups in 23 minutes on the TV show You Asked For It. Or that in 1984, at age 70, handcuffed and shackled, he swam 1.5 miles in the Long Beach, CA harbor, towing 70 boats carrying 70 people.

Stunts aside, its worth getting a glimpse of this remarkable individual, equal parts health expert, showman and true believer, who by discipline and saavy introduced the American public to the idea that everyone could be fit and healthy. Be sure to look for the photo of him exercising on a common chair, conveying that no special equipment is needed, that anybody can get down to business.

Like an even earlier fitness guru I pointed to last August, Bernarr Mcfadden, "The Father of Physical Culture," Mr. LaLanne's life is an inspiration to us all.

by Pat Salber

You want to buy organic...you believe it is better to eat fruits and veggies sans pesticides, but, wow! look at the prices on those tomatoes.  So, you slip the non-organic version into your cart and move on to the next grocery decision.  I've been there and done that. 

But there is an alternative to going 100% organic.  It is outlined in nice little blog post, "Five Easy Ways to Go Organic," on the NY Times website.  This article offers a way to go organic -  mostly -  with out going broke.  The idea is to add a small number of organic products to your shopping cart by focusing on ones that can have the biggest impact your family's diet.  This strategy is based on recommendations by pediatrician Dr. Alan Greene, author of "Raising Baby Green."  He suggests buying organic versions of the following foods:

• Milk
• Potatoes
• Peanut butter
• Ketchup (ketchup?)
• Apples

You can read the rationale in the NY Times article, but basically it boils down to these being commonly eaten foods (did you know 75% of tomatoes are eaten in the form of processed foods, such as ketchup and tomato juice? -  I can't remember the last time I ate ketchup.  I think it was when I learned it was one of Pres. Nixon's favorite foods).  These common foods also tend to be heavily contaminated with pesticides.  In the case of ketchup, you should go organic because there are more antioxidants in organic ketchup compared with plain ketchup.

I suggest you assess your usual diet in order to develop an organic strategy that makes sense for you and your family.  Make a list of the most common foods you eat .  Then check them out on the the Food News data set compiled by the Environmental Working Group (it is a pretty scary list) to determine how likely they are to be contaminated with chemicals.   That way, you can choose which foods that make most sense for you to make the organic investment.

Happy eating.

"Most heart attacks in women are preventable," is the headline of an article posted on NBC.com.  The article describes a study, published in the Archives of Internal Medicine, that was done by the researchers at the Karoinska Institute in Sweden.  Dr. Agneta Akesson and colleagues looked at the diet and lifestyle patterns of almost 25,000 postmenopausal women.  At the time of enrollment none of the women had heart disease, diabetes or cancer.

The researchers asked the women to fill out "food frequency" questionnaires to identify how often they ate 96 different foods.  The researchers analyzed the data and found four major dietary patterns:

• Healthy - vegetables, fruits, and legumes
• Western/Swedish - red meat, processed meat, poultry, rice, pasta, eggs, fried potatoes, and fish
• Alcohol - wine, beer and some snacks
• Sweets - sweet baked goods, candy, chocolate, jam, and ice cream

Other information collected included family history of heart disease, education level, physical activity, and body measurements.

The women were followed for an average of 6 years.  During that time, 308 women had heart attacks.  The investigators found that two of the dietary patterns (healthy and alcohol) were associated with a decreased risk of heart attack.  Women who drank less than a quarter ounce of alcohol daily (that is just a splash in the bottom of your glass) and ate lots of veggies, fruit, whole grains, legumes, and fish had a 57% lower risk of having a first heart attack.  That is a whopping big difference.

If women added three other healthy lifestyle habits into the mix (not smoking, being physically active, and avoiding too much weight gain), they had a 92% lower risk of heart attack.  In other words, most heart attacks in women are preventable by making healthy lifestyle choices.

Now, it is one thing to say, eat healthy, drink in moderation, exercise and maintain a healthy weight.  It is quite another thing to actually do all of those things over the course of an entire lifetime.  On the other hand, if you look at the amount of money the US (and, indeed, the entire world) spends to treat cardiovascular disease, I believe you would find there is enough there to buy each and every person a personal cook and a personal trainer (I believe this is the secret to Oprah's weight loss and maintenance).

I say this tongue in cheek, but it does make the point that we aren't spending our "health" care dollars on the right things.  We spend generously to fix disease, but we are very stingy when it comes to funding health.   It is time to get this right.  There aren't enough dollars in any treasury to treat all of the heart disease we are going to see as a result of the global epidemic of obesity and physical inactivity.  This must be  a top priority of policy makers and health reformers.  Studies, like the Karolinska study, should be used to promote changes in public policy - such as healthy school foods, ensuring that all neighborhoods have access to fresh fruits and vegetables and that they have safe places where kids and adults can move their bodies (without worrying about getting shot in the process).

Every politician, health reformer, and policy wonk ought to know about this study and others that prove that healthy lifestyles mean fewer heart (expensive) attacks - not just in women, but in men as well.  The bottom line is most heart attacks are preventable!

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

It's that time of the year to think about getting vaccinated against influenza.  I got my flu shot at work last week.  I barely felt it thanks to new needle technology and a skilled nurse.  Flu shot clinics are everywhere and, often, the price is quite reasonable.

So why doesn't everyone who should get one do it?  Fear of needles?  Laziness?  Misunderstanding of the potential seriousness of the disease?  I have also heard people say, "I got my shot but I got the flu anyway, so why bother?"

Here are some facts that may help motivate you.  Flu and complications of flu cause about 36,000 deaths and 236,000 hospitalizations per year. Also, if you have ever had the flu you know it is no fun.  Muscle aches, fatigue, malaise, dry cough, headache, and fever are common symptoms.  But you can also have a runny nose and sore throat making it hard to distinguish from a cold. 

Individuals at high risk for bad outcomes from influenza include:

• Adults over the age of 50
• Children ages 6 months to 59 months
• Adults or kids with chronic lung disease, heart disease, blood diseases, diabetes and certain other chronic conditions
• Individuals with conditions that comprise breathing (e.g., spinal cord injury), handling of secretions, or that predispose to aspiration 
• People on long-term aspirin therapy because that can place them at risk for Reye's syndrome, a serious and often fatal complication of influenza

Healthy people who are close contacts of high risk persons should also be immunized.  This includes household members (including children); health care workers and other caregivers, including day care workers. 

Vaccination currently is offered to anyone who wants it providing there is an adequate supply of vaccination and no contraindications to receiving the vaccine (see below).

There are two types of vaccination available.  One is the familiar flu shot which contains three different strains of killed influenza virus.  It must be give every year because flu strains change year to year.  There is also a shot alternative available - the live attenuated influenze vaccine which is administered by nasal spray.  It also contains three strains of virus, but the virus is a live virus that has been attenuated (weakened).

The flu shot can be administered to almost any one (over 6 months of  age).  People who should not get the flu shot include people with a history of serious allergic reactions to eggs or other components of the vaccine.  Vaccination should be posponed if the individual has a moderate or severe febrile illness, although it is ok to get it is you have an illness with a mild fever.  A history of Guillain-Barre syndrome that occured within 6 weeks after a previous flu shot generally (but not always) is a reason not to get the shot.

The intranasal vaccine is currently approved for use in healthy, nonpregnant people ages 5 to 49.  Because this is a live virus vaccine it should not be used when the person being vaccinated is or is in contact with severely immunosuppressed people.

So make your choice (based on the recommendations above) - shot or spray - and call your doctor or get on-line to find out where you can get your flu vaccination.  It is best if you get it now, but, if possible,  no later than the end of November.

by Pat Salber, MD

When's the last time you seriously looked at the vending machines at work?  When you looked, what did you see?  I found candy bars, cookies (including the notorious transfat-laden Oreos), and grease chips (as opposed to "sun chips"). 

The first few times that I got the mid-day munchies at my new job, I made several trips to the break room searching for something to eat from the company's vending machine.  Nope, I said to myself, you can't buy corn chips, Oreos, or snickers--a dry, stale sweet roll is just not the way to use any of those precious 1200-1300 calories per day.  Come on now, isn't there anything remotely healthy or real in this machine?? - Apparently not. 

Back and forth I go, office to vending machine; vending machine to office.  Finally, the hunger pangs make the decision for me.  I will buy the least unhealthy thing in the machine - salted, greasy, (and stale) peanuts.  The little bag of "baddies" that I purchase for 65 cents is ingested in less than 2 minutes.

So, what to do?  As the brand-spanking new Chief Medical Officer of a Health Insurance Company, I know I need to do something.  But exactly what to do gets catalyzed at a health care conference I attended recently.  I chaired a panel on the integration of disease management and disability management, sponsored by Presagia, a leader in software to support this type of integration. 

One of the speakers on the panel, Bruce Goya, Universitywide Coordinator of Employee Support Programs at the University of California - a major employer in the state -gave a presentation in which he emphasized the importance of creating a culture of health in the workplace.  The light bulb in my head went on - big time. 

This is the answer to the vending maching problem at work.  Improving the vending machine selections in my workplace is not just about messing with people's snack choices, rather it is part and parcel of CREATING A CULTURE OF HEALTH.  A Culture of Health, I love it.

So, dear readers, here is a practical question.  If you got to choose what to put in your workplace vending machines to offer your fellow employees a healthy alternative to the usual vending machine fare....what would you choose?  Sunchips?  Protein bars?  Unsalted almonds?

Send me your suggestions.  I may not be able to change your company's culture of health, but you can help me change mine.

by Pat Salber, MD

While not nearly as high profile as TV’s “The Biggest Loser,” the National Weight Control Registry has helped researchers gain a better understanding of what it takes to lose a significant amount of weight (at least 30 pounds) and keep it off (for at least a year).

The Registry was started in 1994 by Rena Wing, Ph.D. from Brown Medical School, and James O. Hill, Ph.D. from the University of Colorado. According to the NWCR website, it is the largest prospective investigation of long-term successful weight loss maintenance in the country.  Individuals who meet the criteria of “successful losers” self-report information about their dietary, exercise, and other lifestyle habits. Although not a randomized, controlled clinical study (the “gold standard” in research), there is nevertheless some valuable information to be gleaned from this weight control registry.

According to results reported by lead investigator, Suzanne Phelan, PhD, at the June 2-5, 2007 Endocrine Society meetings in Toronto, 89% of 4,200 registry participants lost weight with diet and exercise. Ten percent used diet alone and 1% exercise alone. The average age of the losers was 47 years old; 77% were female, 95% Caucasian, 64% married and 82% college-educated.

Nearly half the registrants lost weight on their own, not relying on outside help such as weight loss programs or counselors. Strategies included restricting certain foods, such as deserts (87%), portion control (44%); counting calories (43%), counting fat grams (25%), and using liquid meal-replacements (20%).

The August 2007 issues of DOC News, a publication of the American Diabetes Association, reports that Phelan and her team identified a number of other key strategies:

• Low cal, low fat. Participants reported an average energy intake of about 1,300 calories per day with about 20-30% of those calories from fat. To put this in perspective, this is about the amount of calories you get when you lunch on a Big Mac with medium fries and a Coke.
• Lots of physical activity. These losers reported burning about 2,600 calories per week (walking 5 miles or engaging in 30-90 minutes of physical activity per day).
• Limited TV viewing. More than half of the participants watched fewer than 10 hours of TV per week. Only 21% watched more than 21 hours weekly. The average American watches about 28 hours/week. [Note: Not only did these folks have more time to exercise, they also may have been able to avoid the compulsive eating associated with eating while viewing.]
• Frequent self-weighing. Seventy-five percent reported weighing at least once a week. Forty-four percent weighed daily and 31% weekly.   Click here for more information on this important weight control behavior.
• Dietary consistency. Participant tended to eat the same type and amount of food on weekends and holidays as during the work week.
• Limited dietary variety. Many participants restricted their choices within food groups.
• Don’t skip breakfast. Almost 80% of participants reported eating breakfast every day.
• Limited fast food. Participants rarely ate fast food – consuming less than one such meal per week (see bullet one to see why this is important!)

National Weight Control Registry participants did not take their weight loss and maintenance for granted. They had to work at it. But they did report that the perception of the effort required decreased over time. It becomes a way of life.

If you are interested in learning more about the National Weight Control Registry visit www.nwcr.ws/ . If you are a successful loser, consider becoming a registrant - help contribute to our national knowledgebase of what it takes to take it off and keep it off.

by Pat Salber

Here is a check list of health check-ups recommended to keep you healthy from youth to old age. I grabbed it from CNN.com. They, in turn, got it from the National Institutes of Health and the University of California, Berkeley.

There may be some differences of opinion about the details of some of these recommendations from preventive health experts, but by and large, this checklist offers good guidelines that you can discuss with your primary care physician.  Future posts will explore the scientific basis of these recommendations, but for now, regard these as a a reliable source of "general advice."

In your 20s:

• You should have two physical exams in your 20s. During the first exam, ask to have your cholesterol checked. Other blood tests are not needed in healthy people.

• Go to the dentist every year for an exam and cleaning

• If you have vision problems, have an eye exam every two years

• Have your blood pressure checked every year

• Men should perform a monthly self-exam to check for testicular cancer, the most common cause of cancer in males between the ages of 15 and 34

• Women should perform a monthly breast self-exam

• Women should have a yearly pelvic exam and Pap smear to check for cervical cancer. If your Pap smears are negative for three years in a row, the frequency may drop to every two or three years

• You should have a tetanus-diphtheria booster every 10 years.

In your 30s to 40s:

• Continue yearly visits to the dentist for cleaning

• Whether you’ve had vision problems or not, you should begin eye exams every two years. After the age of 45, start testing for glaucoma

• Continue keeping track of your blood pressure every year

• If your cholesterol remains normal, check it every five years

• Have a physical exam every one to five years

• Men should perform monthly testicular self-exams and women should perform monthly breast self-exams

• Women should have a yearly pelvic exam and Pap smear to check for cervical cancer. If your Pap smears are negative for three years in a row, the frequency may drop to every two or three years

• Women should have a yearly pelvic exam

• Women over the age of 40 should have a mammogram done every year to check for breast cancer. Earlier mammograms may be recommended for women at high risk for breast cancer

• Around age 45, everyone should be screened for diabetes every three years, or earlier if you are at high risk.

• You should have a tetanus-diphtheria booster every 10 years.

In your 50s:

• Continue yearly dental and blood pressure checkups as well as vision testing every two years

• If you cholesterol remains normal, check it every five years

• Have a physical exam every one to five years

• After age 50 men should have a yearly rectal exam to check for colorectal cancer and prostate cancer

• Have a stool guaiac test done every year and flexible sigmoidoscopy every three to five years to check for colorectal cancer. Periodic colonoscopies may be needed for those at high risk for colon cancer.

• You should receive a flu vaccine every year after the age of 50

• You should have a tetanus-diphtheria booster every 10 years • Men should perform a monthly testicular self-exam and women a monthly breast self-exam

• For women, a mammogram continues to be needed every year to check for breast cancer

• Continue to be screened for diabetes every three years

For 60s and above:

• Continue yearly dental and blood pressure checkups as well as vision testing every two years

• Have your hearing tested every year

• Check your cholesterol every three to five years, if it’s normal

• Begin yearly physical exams

• To check for cancer, every three to five years, everyone should have a sigmoidoscopy exam or every 10 years a colonoscopy

• Men should have a yearly rectal exam to check for colorectal cancer and prostate cancer

• Women should continue to perform monthly breast self-exams and have yearly mammograms, pelvic exams and Pap smears

• Men should perform a monthly testicular self-exam

• Get a flu shot every year

• After 65, get a pneumonia vaccine (good for 5 to 10 years).

• Get a tetanus diphtheria booster every 10 years

• Continue to be screened for diabetes every three years.

Brian Klepper 

Here's news to warm the heart of every fast food executive, but that, if the world were a sensible place, should jolt parents, school administrators and non-food industry business leaders out of their nutritional malaise. The New York Times reported this morning on a small sample taste test with 63 children ages 3-5. When presented with different foods - hamburgers, chicken nuggets, french fries, carrots - the kids invariably thought the ones in McDonald's packaging tasted better.

Naturally, the McDonald's people were thrilled, and at the ready with corporate spin. The goal, you see, is to have kids associate good tasting foods with McDonald's, and then McDonald's will gradually introduce foods that aren't so terrible  for them.  Clever, huh? From the article:

Walt Riker, a McDonald’s vice president, said in an e-mail message that “this is an important study and McDonald’s has been actively addressing it for quite some time.

“In fact,” he said, “McDonald’s own ‘branding’ of milk, apples, salads, and other fruits and vegetables has directly resulted in major increases in the purchases of these menu items by moms, families and children.”

This seems like a good time to address people who insist that, if kids are raised right, then they'll make responsible choices. I hope its doesn't rain on your philosophical parade, but so far, it looks like the safe bet is on the people with advertising dollars and the sophisticated techniques for persuasion. McDonald's is winning. Our children are losing.

by Pat Salber, MD

The cabbie who drove me from the airport to the hotel on my last business trip probably weighed 400 pounds.  We made small talk during the trip.  He told me he was hoping to leave Nevada soon and move to Oregon.  But, he said, it was tough getting the time and resources to make the move.

He works 12 hours days, six days a week.  The cab company deducts chunks of his pay  for their share of his revenues and to cover his health insurance premium and a tax on his tips.  His take home pay is $500 every two week pay period.

As we started talking about his health insurance, the conversation naturally drifted to health.  He is prediabetic, he told me, and his brother is a type 2 diabetic who has already had some toes amputated.  He knows he is facing the same future if he doesn't lose weight, but how can he do it?

When you drive a cab 12 hours a day, you often eat on the run.  That means fast food, high fat, and lots of calories.  Also, how do you fit in exercise?  Should he try to walk before the 12 hour shift or, perhaps, go out in the middle of the night when his shift is over? 

I found myself wondering what I would do if I were his doctor.  Of course, I would recommend he lose weight, alot of it.  And, I would tell him to get moderate to vigorous exercise 30 to 60 minutes a day.  I would prescribe any needed medications.  And, I would tell him to join WeightWatchers, or better yet an on-line weight loss support program, like PEERtrainer (www.peertrainer.com).

Chances are, in my 15 minute office visit, I wouldn't have learned about the challenges presented by his daily schedule.  I wouldn't understand that my recommendations were unlikely to be followed -- not because he wouldn't, but rather because he couldn't.

If something doesn't change, his prediabetes will most likely become diabetes.  He will probably have a heart attack or stroke or maybe, like his brother, he will end up with toes or feet amputated -- all potentially preventable if he could change his lifestyle.

At the end of the ride, all I could think of to say was that he needed to get a new job -- one that is less stressful and would allow him to exercise and eat better.  But I knew this too would be a daunting task given the long hours he already works and the meagerness of his financial resources.

I keep mulling over his story and wondering, how could you help this man?  I haven't come up with an answer.  Can you?

This is an oldie, but goodie, first published on TDWI September 15, 2006

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

Brian Klepper

OK, I'll admit it. I love reading the obituaries. They recount the marvelous achievements as well as, occasionally, the equally glaring flaws, of people we knew or, more often, didn't know.  I can't help being astonished, shocked, delighted, repulsed. Who knew all that was lurking under there?

There's a good one in Saturday's New York Times that's relevant to this blog.  Epidemiologist Ralph S. Paffenbarger Jr., MD, DrPH, ScD died at 84, ironically of heart failure. Dr. Paffenbarger became nationally influential for his work describing the relationship between exercise and longevity and for promoting vigorous activity to prevent heart disease. He was a professor at both Harvard and Stanford, and in 1987 he became President of the American Epidemiological Society. He helped write the exercise recommendations for the US Surgeon General's Report on Physical Activity and Health, published in 1996.

It's clear from the article as well as the Wikipedia entry that he had an active, inquiring, engaged mind. One simple but important insight early in his career was that the sedentary drivers on London's double-decker buses had higher coronary risks than the more active conductors. Later, during the 1960's, he established a  study - it's still running - that looked at the effects of exercise on 17,000 male Harvard graduates, ages 30 to 70. Here's a paragraph from the obit:

By the 1970s, the study’s preliminary findings suggested that men burning 2,000 or more calories a week faced a substantially lower risk of death from heart disease than their more sedentary peers. Indeed, in 1984, Dr. Paffenbarger concluded that, among 640 men in the study who had died of cardiovascular disease, the death rate for the most sedentary was nearly twice that for the most active. By the ’90s, the study refined that figure, finding that regular exercise reduced coronary death rates by 25 percent to 33 percent.

Maybe most interestingly, Dr. Paffenbarger actively translated his work's meaning into his own life. A sedentary 45 year old, he started running and was hooked by the second week. He said, “I found it invigorating. I could consider my thoughts and conflicts, I could prepare letters, ponder problems, prepare talks.” It eventually became a 50 mile a week habit. He became a marathoner, competing in 151 marathons, as well as ultra-marathons like the grueling 100 mile mountainous Western States Endurance run.

But most importantly, he nailed down for the rest of us incontrovertible evidence of a simple life truth. Nothing's certain, but if we're active, we improve our chances to live better longer.

Here's to you and a well-lived life, Dr. Paffenbarger!

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.

By Brian Klepper

I generally make a point in my professional writing not to talk about myself, but today I make an exception.

It was 5 years ago today, July 5, 2002, 3 weeks before my 50th birthday, that I had open-heart surgery, where the blocked arteries of my heart were replaced. In medical shorthand, the procedure is called a CABGx5, which means a 5-vessel Cardio-Arterial Bypass Graft. In other words, they used pieces of vein, in my case from my leg, to reroute 5 vessels that carry the blood from my heart to feed the rest of my body. If you think about it, it’s a straightforward piece of mechanics, but of course it really is a modern miracle, the product of great advances in knowledge, skill and technology.

It surprises people when I tell them that having open heart was one of the most positive experiences of my life. But it’s true. How many of us go through an experience that takes us to the edge of death, and then, within a couple of weeks, has us back and engaged in life, physically and emotionally revitalized?

If I had lived 100 years ago, I’d almost certainly have died before my 50th birthday. Only because I had the great fortune to have resources, to live in a wealthy nation, and to live in this era, am I alive to really enjoy and be engaged in life over the last five years. That pleasure was, of course, heightened immeasurably by the just-glad-to-be-here exuberance that I still feel every day.

On this day, I think of the many people I owe great debts to:

• My physicians, Drs. Glock, Schrank and Koster, whose great skill and grave humor pulled me through.
• The Baptist Health System nursing staff, who cheerfully and capably goaded and guided me through my inpatient stay, rehab and home care.
• My great pal Steve Blumberg, who did much more than I was aware of to make sure all would run smoothly, which it did.
• My good friend George Lundberg MD, who called and calmed me with the facts when he heard about what was in store.
• My dear childhood friend Fannie Newman, gone now, who by serendipity called me the night before my surgery, and who, by the example of her own much greater courage, inspired me to face my fear directly and to understand that I could play an active role in my own recovery.
• Brooks and Helen Brown, who sat with Elaine during the entire surgery and provided unwavering support.
• Randy Kammer and my friends at Blue Cross and Blue Shield of Florida, who immediately jumped into the fray and expedited my care.
• My many friends, who came out of the woodwork and made me remember that life is about touching souls.
• And most of all, to my wife Elaine, who really brought me through, and whose presence then and now is the light of my life.
  

Here’s what I wrote in the weeks after my surgery, as I was re-emerging. I was so engrossed in the experience, I recorded it so I would never forget.

Thanks for indulging me on this day.

Brian


August 25, 2002

Recently I received a big surprise, open-heart surgery. For several weeks beforehand, my chest hurt and I was short of breath whenever I mowed the lawn. I procrastinated, then called my doctor.

After some tests, he became alarmed. There was a widening in the thoracic aorta, and he worried it might be an aneurysm. It was late Friday afternoon, so he sent me over to the emergency room for a CT scan. Elaine joined me for some anxious waiting, and then the discovery that it was “just” a hiatal hernia. When my doctor joined us in the ER suite, we already had the news and were in full celebration mode. I announced we were going right home to have a steak, some Rocky Road ice cream, and then we were going to fool around.

He was unimpressed. "No," he said. "You passed the first hurdle, but we still don't have a good explanation for the chest pains. Monday you’ll see a cardiologist, and Tuesday you'll have a cardiac catheterization."

"Rats," said I. "I was counting on the Rocky Road."

Three of my grandparents died of cardiovascular disease. A heart attack killed my maternal grandfather at 48. My mother occasionally remarked that my grandmother had murdered him with chicken fat. A month shy of my 50th birthday, it didn't bode well.

The catheterization frightened me. But they put me under, it went off without a hitch and didn't hurt afterwards. That said, it typically takes 15-30 minutes, and they spent an hour and a half on me.

They called Elaine in after reviewing the images. The doctor was pointed. “Your husband has serious advanced cardiac disease.” She says she did a double-take, as in “Him? The healthy guy over there?”

They woke me and the cardiologist walked over. "You have a problem,” he said. “One vessel’s completely occluded and four are more than 75%. We need to do a multiple vessel CABG."I had an important business meeting coming up, and I protested for time. Elaine suddenly popped into my field of vision, pressed her nose next to mine, and said sweetly, firmly, filled with resolve, “Honey, you’re not going. You can put that out of your mind.” I knew I’d lost.

In recovery, the surgeon dropped by to introduce himself. He was pretty straightforward. “Look. You’ve had a load of crap dumped on you. We have to dig you out.” Charming or not, the metaphor drove the point home. I agreed.

They set me up for 3 days later, after the big holiday. As a parting shot, I asked the surgeon what would happen if I made love before the operation. He didn’t miss a beat. "You'll likely go out in blaze of glory."

I had a few days of anticipation. I read up on the procedure, how they'd saw my sternum in half, take a vein out of my leg, and sew me back together. They do nearly half a million of these procedures a year. The complication rate is less than 2%, lower than for tonsillectomies.

The Big Day, Elaine and I arrived at 5:30 AM for the 6:30 surgery. I undressed and they shaved me from stem to stern. This done, we had the chance for a little small talk. With nothing to do but wait, I wallowed in a little self-pity, whining aloud why I, who don't smoke, eat a good diet and am relatively fit, am going through this. An old black nurse sidled up and gave me a pitying look, "Sometimes," she said, "it just BE'S that way." Elaine meant it when she said, “That’s probably the smartest person in this hospital.”

When the anesthesiologist showed up, I told him I have friends who counseled me to ask for Versed. I said, "As long as I'm here, give me the good drugs." Elaine rolled her eyes. He smiled. Suddenly, I don't remember anything more.

Elaine says that after the Versed but before things got rolling, I sat up on the gurney. She told me to lie down, but I said I couldn't because I didn't have a pillow. Then I turned to the anesthesiologist and asked whether he followed protocols. Elaine said he started laughing, and said he did. I don't remember any of this, but I apologized later.

When I regained consciousness, one tube was down my throat and another stretched from my nose to my stomach. A clock on the opposite wall said 8:30. My hands were bound, a holdover from escape attempts a couple hours earlier. They woke me, but I struggled and tried to pull out my tubes. Later I apologized for this too. The nurses were good sports and said it happened all the time.

My bladder felt like it was going to explode. During the operation they stop your heart and transfer circulation and breathing to a machine, which infuses fluid into your system. I gained nearly 30 pounds during the operation. Elaine says I became very round, like a cartoon character.

In the confused aftermath of the surgery, I couldn't remember whether I had a bladder catheter, even though they had told me beforehand that I'd have one. A frantic internal discussion went something like this. "WOW! I really need to go! Did they put a Foley in me? They must have. Well, I'm going to let ‘er rip!" Which I did, and guiltily felt for spreading dampness that, gratefully, never materialized. It wasn't easy, but the relief was titanic.

In the first week after the procedure, you metabolize the fluid and urinate to beat the band. Once unhooked from the catheter - a blessed moment - you start tracking the fluid, and can't help being impressed by the volume.

Drained and able to focus on the larger picture, I remember thinking, "I'm ALIVE!" I really meant this, and realized I honestly hadn't expected to be here when it was done. I was exhilarated.

I turned my head to the dimming light out the window to my left and recognized the scene. This located me in space, but more importantly, convinced me that I was aware. That was comforting.

Two nurses began to bathe me, gently, firmly, and VERY thoroughly. I felt no inhibitions, and it was utterly comforting and warm. By the time they were done, I was ready to marry them.

They told me to rest. Then another woman said it would be about a half hour before they could extubate me. I nodded. This seemed like an OK idea. I could certainly be patient for a half-hour. I kept my eyes on the clock, though. About 45 minutes later they removed the tube, which makes you gag but isn't terrible. A little after that, they withdrew the nasal-gastric tube, also an improvement but a bit of an ordeal.

In addition to the bladder catheter, I had three "fire hoses" (Elaine's term) draining my chest, a central line (a large IV half the length of a soda straw) in my neck, and an IV in my hand. I was plumbed or, to use Elaine's Human Resource term, "completely outsourced."

The nurses said Elaine had waited for me to waken, but had finally gone home. She would be back first thing in the morning. I knew she'd needed the rest. I later learned that, during surgery, several friends had sat for a long while with her. One was a pal, a VP at the hospital who "just wanted to make sure that no barriers arose." Another was a retired surgeon and his wife who knew the value of comfort. Elaine doesn’t mind being alone in circumstances like this, but I was particularly glad for these kindnesses.

Elaine arrived the next morning. Early in the afternoon, a nurse arrived with a walker and told me to get out of bed, that I was going for a walk. I looked at her and asked whether she’d been doing acid. She gave me a look that suggested she wasn’t in the mood to fool around, and that I’d better get in gear. Elaine came over and we went for a walk down the hall. Considering somebody had fiddled with my ticker the day before, we both thought this was incredible.

I remained in Cardiac ICU the next 2 days. Every half hour, the nurses took measurements, made me blow into an inspirometer, wiggle my toes, roll over. I was sore and stiff, but it wasn't bad, and they gave me drugs to keep the pain in check. Now and then there was nausea or weakness, but all in all it was a breeze.

The 3rd day, I moved to a regular room. I had a lot of visitors, calls, books and magazines. My room looked like the Ituri Forest from the plants and flowers. I'd walk around the halls, and go a little farther and faster than the day before. I watched movies or read in the quiet times. Each evening, Elaine sent out a slightly smart-alecky report on my progress to a list of friends, and the following day would bring in highlights from the emails. ("Damn! Five vessels? VERY respectable!" or “Isn’t this going a little far to study the health care system?” or “Is there no end to your histrionics?!”) It was a gratifying outpouring of support, and it meant a lot for my spirits.

They spung me in the early afternoon of the fifth day. They wheeled me down to the pick-up circle, and I eased into the back seat. You avoid airbags after this type of surgery, just in case they deploy. Elaine somehow picked the bumpiest route and I felt every jolt, but soon we were home. We placed a chair in the shower, and she gave me a luxurious shampoo and a long wash. Then we took a nap in our own bed and realized we were finally home again, together, through it.

It’s seven weeks now since the surgery, and I’ve returned to my routine. It’s oddly satisfying to noticeably feel your strength return. I began a regimen by trudging around the block. That’s progressed to a brisk 3 mile walk every morning and, sometimes, another slightly shorter one in the evenings. Now I’ve added workouts at Cardiac Rehab.

People went out of their way. A few days after arriving home I looked out the window to see my neighbor Budd – a paunchy chain smoker – cheerfully mowing my lawn. I think the irony escaped him. “So don’t expect a card,” he said.

Elaine returned to work