The Doctor Weighs In

by Pat Salber

Perhaps the folks over at Hardee's fast food haven't heard the country is in the midst of an obesity epidemic.  They have just unveiled a new breakfast offering, the Country Breakfast burrito.  It consists of a two egg omelet filled with bacon, sausage, diced ham, cheddar cheese, hash browns and sausage gravy.  Surrounding this protein load is a flour tortilla.  The burrito weighs in at 920 calories.  That's right, 920 calories, about half of what you should ingest in a day.  This little baby also has 60 grams of fat.  All those calories and all that fat will only set you back $2.69.

According to a story by the Associated Press, Brad Haley, Hardees' marketing chief, says that the burrito offers the sort of big breakfast item normally found in sit-down restaurants with an added advantage.  "It makes this big country breakfast portable," he said.

Other Hardee offerings include the Monster Thickburger, a 1,420-calorie sandwich that contains two 1/3-pound slabs of beef, four strips of bacon, three slices of cheese and mayonnaise!  Want a healthy alternative?  Try the Hardees' chicken salad --it is only 1,100 calories and 83 grams of fat.  Supposedly, the chain does offer some low-calorie options, including roast beef and chicken sandwiches.

AP reports that the Center for Science in the Public Interest, a Washington-based advocate for nutrition and health, has called the Hardee's line of Thickburgers "food porn." I love it, food porn!

Jayne Hurley, senior nutritionist at the Center, said the burrito is "another lousy invention by a fast-food company."  The "country breakfast bomb," as she called it, represents half a day's calories and a full day's worth of saturated fat and salt, to say nothing of cholesterol.  "That's all before 10 o'clock in the morning," she said.

Hardees' Haley makes no apologies:  "We don't try to hide what these are," he said. "When consumers go to other fast-food places they feel like they've got to buy two of their breakfast sandwiches or burritos to fill up. This is really designed to fill you up."

Way to go, Hardees.  Keep on fillin' us up.

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.

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 

California always seems to be ahead on things that matter. A CNN story this week highlights that state's terrific anti-obesity TV campaign. The ads have cute kids sweetly asking "Dad, could you buy me some diabetes?" and "Can I drink another cup of sugar?" The goal is to shock adults into appreciating that the cheap, tasty foods they shovel down their children's gullets will have real impact. In one of the CNN clips, Adam Sandler says the ads work so well that he and his little girl suddenly dropped their cheeseburgers. I passed along the link to folks in Florida's government, and asked, "Why aren't we doing something like this?"

It's a fair question, but as I tried to point out in my post the other day on food companies' lobbying influence, these ads, powerful as they are, are hardly a match for the food industry's virtually unlimited resources and unrestrained marketing power. A well-intentioned state agency may place a few high profile ads, but the food companies can run theirs unrelentingly and in many different media. They're all over kids’ TV programming, in children’s books, and at schools. They have product placements in the movies, and are on Internet gaming sites. It's difficult to go head-to-head and expect to win against such sophisticated techniques and on so many fronts.

We’re utterly losing the war on obesity. The disease and cost numbers make that abundantly clear. The other day, Bob Laszewski at The Health Care Policy and Marketplace Review reminded us of an important 2005 Emory University study on the topic. The team, led by prominent health services researcher Kenneth Thorpe PhD, analyzed the 20 medical conditions that accounted for most of the growth in health insurance spending between 1987 and 2002.

The conditions, in order of their influence, included:

1. Newborn and Maternity Care
2. Cancer
3. Pulmonary Conditions
4. Arthritis
5. Mental Disorders
6. Hyperlipidemia
7. Hypertension
8. Lupus
9. Back Problems
10. Upper Gasterintestinal
11. Diabetes
12. Kidney Problems
13. Infectious Disease
14. Heart Disease
15. Skin Disorders
16. Bronchitis
17. Endocrine Disorders
18. Other Gasterointestinal Diseases
19. Bone Disorders
20. Cerebrovascular Disease

During that 15-year period, the cost of treating obesity-related conditions rose tenfold, growing to two-thirds of our total health care spending. The number of people who became obese, the percentage of obese people with serious medical conditions, and the cost to treat each obese patient all skyrocketed.

The study’s authors had a simple summary statement:

"If insurers and employers are serious about reigning in health care spending, then obesity prevention should be at the top of their agenda."

There's no mystery here. Long term, the magnitude of the obesity crisis threatens our national health and economic welfare. The roots of obesity-related diseases and their costs lie in the marketing methods of the fast, prepared and junk food industries. Look for the source, and you’ll find the food industry's boardrooms and their DC lobbying offices.

California has taken the first step on this issue. We’ll soon see whether Washington takes it as seriously. On Wednesday, Dr. James Holsinger, the White House' Surgeon General nominee said that, if he gets the job, he will focus on childhood obesity. It’s one right issue for our time, but talk is cheap. The real question is what he or someone like him would be willing to do. If he carries the torch for nutrition guidelines and curbs on food company marketing, then he’ll stand with our children and America’s future. But if he refuses to actively confront how foods are sold or what the obesity data say, then he’ll be standing with the food companies and their lobbying dollars.

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

Photo by Mark Boster, LA TimesThis story, from the Los Angeles Times,  is so outrageous I have to take a few deep breaths before I tell it.

Edith Rodriguez died in the ER…not on a gurney surrounded by doctors and nurses desperately trying to save her life. She died on the floor of the lobby, lying in her own blood as a janitor mopped up around her.

Jose Prado, her partner, tried to get the attention of Los Angeles’ King-Harbor ER staff, but he was ignored even though Edith was writhing in pain and spitting up blood as she lay on the floor. He called 911 from a pay phone only to be told “Paramedics are not going to pick…his wife up, from a hospital, because she’s already at one.”

An unidentified woman, perhaps another patient, jumped in to help. She also called 911. According to the LA Times, here is what took place:

“After a short debate about whether the call was an emergency, the dispatcher scolded her and insisted that it was not. The 2-1/2 minute call ended on a hostile note. ‘May God strike you too for acting the way you just acted,’ the frustrated caller told the dispatcher, just before 2 am on May 9. ‘Negative ma’am, you’re the one,’ the dispatcher responded before disconnecting.”

Edith Isabel Rodriguez died 17 minutes later. She died of a perforated bowel.

Ms. Rodriguez had sought care at the King-Harbor emergency room three times in the days leading up to her death. A perforated bowel leads to peritonitis one of the most painful conditions known to man. Each time, after she was seen, she was discharged from the ER with a prescription for painkillers. As an emergency physician, I am appalled that this diagnosis was missed – not once, not twice, but three times.

On the day before her death, rather than leave the hospital, she lay down on one of the benches in front of the main entrance. The police found her there and helped escort her back to the Emergency Room where she was summarily dismissed:

“A triage nurse told Rodriguez that nothing could be done to help her.”

I think what the nurse was really trying to say was that nothing would be done to help her.

This story shows a failure, not just of King-Drew hospital, but of the entire health care system. This story
King Harbor Hospitalhappens to be about a hospital in Los Angeles with a troubled history: The US Centers for Medicare and Medicaid Services has repeatedly found Martin Luther King Jr.-Harbor Hospital out of compliance with its minimum standards. In September of 2006, the hospital was informed that it had failed a critical inspection and that it would lose annual funding of about $200 million (more than half of its budget).

Rather, the failures here are much larger than any one hospital. It starts with our country’s refusal to enact universal health care coverage. Although it may seem like it saves money, at least in the short run, by not providing care to poor people, it does not. An analysis by the New America Foundation, in support of Governor Schwarzenegger’s universal health care proposal, shows that costs actually increase when large numbers of people are uninsured. That is because, most of the time, we don’t let people die - untreated - on the floor. Instead, we provide the care and shift the costs onto insured people – raising costs for companies and public entities that provide health insurance.

Then, there is the callous disregard for human suffering shown by the individuals manning the phones at the 911 station. I know these jobs are stressful, but arguing with desperate callers about what is and is not an emergency is dismaying.  But, missing the diagnosis of a treatable condition on three different occasions is inexcusable. Perforated bowel and peritonitis are not subtle conditions. Even in the busy, overworked and understaffed conditions of a county hospital, surely someone could have recognized that this woman was really sick.

And, finally, letting a woman die in a pool of blood in the lobby of an emergency department is nothing short of criminal. What did they think?…she was faking her symptoms?

If I had told you that this took place in the inner city of some third-world country, you probably would have clucked your tongue and thought to yourself: “How lucky I am to live in America.”

But, guys, this is America. This happened in Los Angeles, home to the rich and famous. This is a story that ought not to die. It should be cited repeatedly in the next months and years as we debate how we are going to -- finally --  reform health care in this country.

Edmundo Rodriguez, Edith’s 25-year-old son is quoted as saying “We know we have the responsibility to make sure justice is done for our mother. We just don’t want this to happen again.”

I say, the responsibility should not rest solely with Edith’s loved ones. It needs to belong to all of us. We all helped create the environment that led to this tragedy. And, so we all need to tell this story to our politicians and policy makers, over and over again.  We should not -- must not -- stop talking about Edith Isabel Rodriguez until we have fixed this terribly broken “system.”

Pat Salber, MD

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The President has indicated that he will veto the bill on Monday when he returns to Washington, DC. Please tell the President to uphold his duty to the 70% of Americans who support embryonic stem cell research and not to veto S. 5....send a fax to the White House and ask President Bush not to veto hope!"

Here is how you can help:  Send a simple email to President Bush today at comments@whitehouse.gov or fax (202-456-1111).  Your message doesn't need to be long (he probably won't read it anyway) or complicated.  Just be clear about what you want. 

Here is some sample language:

"President Bush,

Don't veto hope.  Americans want sensible, sensitive stem cell research.  S-5 provides for that.  This legislation is life-affirming.  Let it stand.

Sincerely,"

Please help.

Pat Salber, MD

Ok, so I am tooting my own horn, but I want to share with you the latest review of the book I c0-authored together with Dr. Ellen Taliaferro, The Physician's Guide to Intimate Partner Violence and Abuse.  The book is published by Volcano Press, the leading publisher of books on family violence. 

The review appeared in the Permanente Journal's Spring 2007 issue.  It is written by Ruth Shaber, MD, an OB/Gyn at Kaiser Permanente's Daly City Medical Office in Northern California.  She is also the Director of Women's Health Services and Director of the Women's Health Research Institute for Kaiser Permanente Northern California. 

Here is her review:

"The facts are overwhelming. The Centers for Disease Control and Prevention (CDC) predicts that 5.3 million incidents of intimate partner violence (IPV) occur each year among US adult women and 3.2 million occur among men. Recent data from Group Health Cooperative demonstrates that about 46% of the female members have experienced physical, sexual, or emotional IPV in their lifetime, and data from the Kaiser Permanente Northern California Prevention Program estimates that in the previous year, at least 4% of women patients have experienced physical injury from an intimate partner--that is about 46,000 members in Northern California alone. The social and financial impact is enormous. The CDC estimates that the direct health care costs of IPV are over $4 billion a year. And, evidence has shown that IPV, along with its many comorbidities, is the number one cause of premature death, injury, and illness in women ages 15-­44 years.¹

It is difficult for even the most experienced clinician to recognize which of our
Ruth Shaber, MD patients are victims of IPV. The violence cuts across all socioeconomic and demographic categories. But we do know that routine screening of all patients is an effective way to identify victims and to offer them assistance. And we know that offering support and counseling to victims can improve the quality of their lives.

Now that we understand these facts, how can clinicians begin to care for patients who are victimized by this overwhelming social problem? The first step would be to open The Physician's Guide to Intimate Partner Violence and Abuse. This book is an essential tool for both experienced and new clinicians. It will help everyone better understand the impact of IPV and to start to comprehend the complicated issues that perpetuate the violence.

Patricia Salber, MD, and Ellen Taliaferro, MD, have compiled the definitive handbook for health care professionals. Their chapters, along with those of their expert contributors, help us navigate through the complicated web of social, psychological, and medical issues that lie underneath the surface of IPV. Many clinicians are intimidated by the thought of dealing with IPV: they are unfamiliar with the proper language to use to screen their patients and they dread the time when a patient will acknowledge the violence in their lives--for fear that they won't have the expertise or enough time to support them effectively. Fortunately, the authors help us realize the therapeutic value of simply asking the questions--even if our patients aren't able to make immediate changes in their lives. And they help clinicians better understand why immediate changes may be difficult and even dangerous. They provide simple tips for offering support and referral to identified victims. And they help explain the social dynamics and practical realities that limit the speed with which change will happen. The book also outlines effective strategies to set up IPV screening programs in our clinics.

A particularly interesting chapter entitled "What Do We Know About the Perpetrators of Intimate Partner Violence and Abuse" helps us understand the prevalence of alcoholism and personality disorders among perpetrators. There is also inspiring information about the effectiveness of batterer intervention programs--with some data suggesting a re-arrest rate as low as 8% among batterers who completed an intervention program. Some of the chapters will help you better understand information that you already knew or suspected about IPV. But some of the chapters--such as the one on Adverse Childhood Experiences and IPV--will turn everything you thought you knew about medicine upside down.

The book is an extremely well-organized resource. With its easy references, clear bullet points and excellent summary tables, it makes for fascinating reading all the way through--or an easy reference book to take off the shelf for a quick review. Wherever you are in your journey of understanding IPV, I highly recommend this book to take you further down the road.

Reference

1. Victoria Department of Human Services. The health costs of violence: measuring the burden of disease caused by intimate partner violence--A summary of findings (monograph on the Internet). Victorian Health Promotion Foundation 2004 Jun [cited 2006 Nov 13]. Available from: www.togetherwedobetter.vic.gov.au/resources/pdf/FinalReport_HealthCostsOfViolence.pdf.

The results of the 2007  Food and Health Survey* are in and they show…guess what? Most people want to lose weight. Seventy-five percent of individuals surveyed said they are concerned with their weight. This is up from 66% in 2006. 70% said their reason for making dietary changes is “to lose weight,” and 56% said they are actively trying to lose weight. This is interesting as it seems to reflect reality.  According to the latest scientific evidence, 66% of Americans are overweight or obese.

Where there is a disconnect, however, is people’s knowledge of the relationship between "calories in" and "fat on."  Although 60% of Americans who are trying to lose weight say they are doing so by reducing the number of calories they consume, only 11 percent were able to correctly estimate the number of calories they should consume in order to accomplish that goal. Interestingly, most people underestimated the number of calories they thought they should consume, but that was offset by the 34% of Americans who admitted they actually consume more than they estimated they needed.

It was heartening to learn that most people (69%) say they use food and beverage packaging elements when deciding whether or not to buy and eat food products. However, the most commonly used element was the expiration date. Sixty-six percent said they used the Nutrition Facts Panel (aka the Nutrition Label) and most used the calorie information and the information about fats, particularly Trans fats. The problem is they are not paying attention to serving size – only 49% did so, down from 63% in 2006. Knowing the calories per serving does not translate into decreased caloric consumption if you do not understand serving size.  And, as I have pointed out before, serving size is not intuitive or even easy to understand (how many of us can estimate 1 oz of cashews or 30 grams of Bran Buds?).

Of the 56% of people surveyed who said they were trying to lose weight, 79% said they had increased or began to engage in physical activity; 69% had reduced portion sizes of meals and/or snacks, and 60% had reduced the number of calories. But snacking remains a national pastime with about half of those surveyed saying snacks are an important part of an overall healthful diet. Almost all Americans (93%) eat at least one snack per day with the mean number of snacks being 2.5 per day. Ten percent of those surveyed said they ate 4-5 snacks per day and 7% ate 6-7 per day. Two percent admitted to eating 8 or more snacks per day (how do they have time for anything else??).

Many people perceived foods and beverages to have health benefits, often beyond what medical evidence supports. Specifically, the following percentages of the surveyed population strongly or somewhat agree with the following statements:

• Specific foods improve heart health – 80%
• Specific foods improve physical energy or stamina – 76%
• Specific foods improve immune system function – 71%
• Specific foods improve mental performance – 66%
• Specific foods improve the risk of getting specific diseases – 65%

Can’t you just see the glint in the food manufacturers’ eyes (and the banners proclaiming health benefits plastered all over our food packages)? Food lies masquerading as food science – but, you will have to wait for that is the subject of a post yet to come.

The last item from this survey that I want to mention is that American’s perceived their health to be better in 2007 than in 2006. Thirty-nine percent of those surveyed said their health was “excellent” or “very good” compared to only 33% in 2006. And even more people (58%) said they were “extremely satisfied” or “somewhat satisfied” with their health status – this is somewhat puzzling since that means some people are satisfied with health that is less than “very good.”

So there you have it – a glimpse into how we perceive food, fat, and facts.

*The Survey, sponsored by the International Food Information Council (IFIC) Foundation and organization affiliated and supported by “the broad-based food, beverage, and agricultural industries.” The first survey was produced in 2006 based on a telephone survey of Americans performed in November 2006. The 2007 Survey is based on a telephone survey in March of 07.

Pat Salber, MD

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

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

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

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

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

Here’s a link to the full report:  Report

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

Pat Salber, MD

Given the drawbacks of the current commonly used diabetes screening methodology – fasting blood glucose – and the fact that more than 20 million people are thought to have undiagnosed diabetes in the US alone, an easier and more convenient screening test would be a very welcome addition to the diabetes testing armamentarium.

Fasting Plasma Glucose

The limitations of using fasting plasma glucose (FPG) as a screening test for diabetes include the following factors:

• You have to fast overnight before having the test – that means you have to get yourself to a clinic or laboratory in the morning before going to work. Hmmm. Not such an easy thing to do when you have to get the kids to school and yourself to work. So, if you are like me you keep putting it off and putting it off – it doesn’t mean you are ignoring the need to have the test – it is just a fact that today’s crowded lives don’t mesh well with yesterday’s screening technologies.

• You need to have blood drawn. Again, no big deal for some people, but a dreaded experience for others. I have seen great big guys faint on the spot when they see their blood sucked up into that little tube. So, again, it can be one more reason to put “diabetes screening” on the bottom of the “to do” list.

• The test misses quite a few cases of diabetes. It only detects elevated glucose when a person is fasting. It does not detect abnormal elevations of glucose after a meal. An even more inconvenient Oral Glucose Tolerance Test (OGTT) is needed for that. This test involves having blood drawn, drinking a standardized glucose-containing solution and then having blood drawn again 30, 60 and 120 and, sometimes, 180 minutes later.

So, you may be thinking, what’s the big deal if you put off screening for diabetes. It is because diabetes complications mount up as diabetes remains undiagnosed year after year. That is the reason that many diabetic patients will have one or more irreversible complications at the time they are diagnosed (Harris MI, Diabetes Metab Res Rev 16:230-236, 2001).

Enter SAGE

SAGE is a new diabetes screening technology. It is short for “Spectroscopic measurement of dermal AGEs.” AGEs are “advanced glycation end products” that form when glucose levels, over time, are elevated. AGEs serve as biomarkers for diabetes.  Their levels correlate with existing complications of diabetes and have been shown to predict future complications, such as diabetic kidney or eye disease

Like A1C (a blood test that measures glycosylation of hemoglobin), but unlike a spot glucose blood test, AGEs are not affected by acute increases in glucose. Therefore, a test that measures skin AGE levels can be performed regardless of whether the individual has fasted or just eaten. This fact, combined with the fact that there is no need to draw blood, makes this technology highly attractive.

AGEs are measured using a spectroscope that measures skin fluorescence. AGE accumulation impacts flourescense. Since skin naturally accumulates AGEs over a person’s lifetime, it is necessary to apply an algorithm to correct for age.

How does SAGE compare with FPG and A1C testing?

Maynard and his New Mexico colleagues, as reported in Diabetes Care May 2007,  performed a head-to-head comparison of SAGE with both FPG and A1C testing. 351 people were tested with the SAGE technology in the fasting and fed states. They also underwent FPG , A1C and OGTT testing. The idea was to see how many of the people who had abnormal OGTT tests (the most sensitive of the diabetes diagnostic tests) also had abnormalities in the other tests. Here is what they found:

• The SAGE test identified almost 29% more individuals who were OGTT “positive” compared to FPG and 17% more than A1C testing

If these results hold up and if the testing equipment can be made to be both easily transportable and affordable, then this technology could make highly sensitive diabetes screening tests accessible to the millions of individuals who cannot or will not avail themselves of FPG testing. Early diagnosis of opens up opportunities for early intervention and prevention of diabetes complications.  This is really exciting.

As always, you must be aware that there is a caveat about this study. The lead author, John D. Maynard, MS works for VeraLight, a for-profit company that is manufacturing the SAGE instruments. Catriona Nguyen, another author on the paper is affiliated with InLight Solutions, a related company. Although VeraLight’s mission is to

“help stem the tide of the worldwide diabetes epidemic by driving early diabetes detection, thus enabling initiation of therapies that can prevent diabetes or reduce its complications”

we, nevertheless, need to be cautious about placing too much hope on technology "proven effective" by industry funded and/or affiliated publications…..we have been burned before.

Pat Salber, MD

You know that the prevention movement is gaining ground when doctors form a professional society to make “lifestyle medicine” a credentialed clinical specialty and a part of basic medical training. The American College of Lifestyle Medicine (ACLM), founded two years ago, aims to disseminate scientific research in order to encourage doctors and other health care professionals to incorporate this knowledge into their clinical practices. It also advocates appropriate reimbursement for lifestyle counseling. How about that? I say it is about time we reward docs who take the time to educate, counsel, and support patients trying to make tough lifestyle changes, such as quitting smoking or losing weight.

What I like about the ACLM is that they want to establish the scientific basis for healthy lifestyle recommendations. Right now there is a lot of noise out there with half-baked recommendations competing with those based on solid science. Dr. James Rippe, associate professor of cardiology at Tufts University School of Medicine and the editor of The American Journal of Lifestyle Medicine is quoted in an article about the College in the NY Times.  He says, “this is mainstream medicine supported by mainstream medical research”. It is not “an anti-procedure, anti-medication movement.”

In the same article, Dr. John H. Kelly, president of the ACLM, is quoted as saying,“we need to have a certification process in place with rigorous, evidence-based standards."  I wholeheartedly agree.   I believe the prevention movement will benefit greatly from having an organization, such as ACLM, work to maintain the highest standards when it comes to research and development of clinical guidelines. By sticking to the evidence, the ACLM can gain respect and adherents to prevention practice in the medical community.

So, hats off to Dr. Kelly et al for having the foresight to found this College. I, for one, am going to join.

Pat Salber, MD, MBA

"When will we ever learn?"

Every time we have a mass murder related to guns, talking heads on TV start out by saying that it is the easy accessibility of guns in this country that makes violence so deadly. [The United States has a higher rates of firearm ownership than do other developed nations, and higher rates of homicide.] Then slowly, but persistently, the "pro guns- for- everyone" folks mouth some variant of the NRA message that guns don’t kill, people do.

Yes, I agree, mass murderers can still wreak havoc even in the absence of guns. But, let’s get real…how many people could a killer kill if he only had a knife? In the case of today’s horrendous crime on the Virginia Tech campus, I would suggest that it is highly unlikely that 33 young college students would be dead tonight if the lone assailant only had a machete.

I understand the arguments for gun ownership. Some people like to hunt and some people feel better when they own a gun for self- or family protection. I have a harder time with the argument that, if everyone was armed, it would serve as a deterrent to the bad guys…do you seriously think that today’s tragedy would be averted if all of the college kids (and/or their teachers) were packing guns?

The propensity to commit violent acts is multi-faceted. Many perpetrators of violence are themselves victims of violence, particularly family violence, and in some cases, school bullying. We need to acknowledge and actively try to identify individuals with these risk factors in order to prevent future violence.   But, while we are trying to identify, counsel, and advise these folks, we must enact interventions that will make it less likely, or better yet, impossible,  that these potentially violent people can or will use their favored means of killing…guns.

That means we need not only to enforce existing gun laws – but we need to enact new, more targeted firearm legislation that will allow us to craft solutions that are far more effective than what we have in place to date.

Years ago, when I was active in the violence prevention arena, I was interviewed by Voice of America. The interviewer asked me what I wanted to talk about. I said either gun violence or domestic violence. He said not to bother talking about gun violence because the rest of the world thought Americans were the laughing stock of the world when it came to firearm policy.

Pro-gunners often twist the facts to say that other countries have the same gun availability as the US. A common argument is to say, “Look at the Israelis. All the young people have guns". Yes, young adults in the Israeli Army all have Army issue rifles, but there are strict rules about when or where they can be used. That is a very different situation  from what we have in America.  Youngsters here tell me that if I give them “$20 and 20 minutes” they can get any type of gun I want -- no questions asked.

Come on, folks! There has to be a middle ground between “confiscating everyone’s guns” and free accessibility of guns for anyone, everyone, any time, any place.

Let’s not let the urgency of today’s situation be replaced by the rhetoric of people who have a lot to gain by continued sales of guns to as many people as want to get their hands on an instrument whose primary usage is shooting something living (yeah, I know about the joys of plinging and target shooting, but let's face it...most people who strongly advocate gun ownership aren't getting lathered up about their right to continue participating  in those activities).

Ok, you may want to label me a bleeding heart liberal. But I would more accurately be labeled as a  mother of kids who went off to college and survived. I can’t even imagine the pain of the parents of today’s victims of the gun violence on the Virginia Tech campus. You send your kids off to college with a sense that, because of their upbringing, they are ready to take on life’s challenges. But, how many parents prepare (or want to prepare) their kids for college by talking about how to avoid being shot. Come on, now. This is sick.

Let’s put all of the cards back on the table again. If aggressively limiting access to guns means fewer kids killed, let’s do it, now. We need to stop being afraid to be bold on the role of guns in violent death. We need to stop being manipulated by people who have a lot of gain by selling guns to anyone and everyone with a buck. We need to empower and fund reputable organizations to perform the research on violence and violence prevention. (It has effectively disappeared from the Center from Disease Control’s research agenda in the last six years).  We need to put the health and safety of our kids ahead any other political agenda...can we possibly value  gun ownership more than the safety of our kids at school?

If our past actions are a predictor of the future, then this is what will probably happen.  Time will pass and the rawness of our emotions, so exposed right now in the aftermass of the Virginia Tech Massacre, will dampen. We will start to waffle on any enthusiasm to pursue rational gun control...we simply won't care as much as the folks who profit from profligate sales of firearms.   And then we will be right back to where we have been for the last twenty or thirty years, waiting for one more (short-fused) time bomb to explode onto our campuses and into our national psyches.  

How many more school kids need to get shot to death? How much more campus blood and gore do we need to see?  How many more unbearable tragedies do American families need to endure before we finally stand up and demand a change in our national firearm policy?

Pat Salber, MD, MBA

Photo from USA Today, by Jeff Mitchell, Getty ImagesAccording to a front page story in USA Today, there has been a “mind-boggling” increase in the number of people who are severely obese (aka morbid obesity). A study, published in the journal Public Health, by RAND Corporation researcher Roland Sturm, documents that there are 2.6 million more people with a body mass index of 40 or higher than there were just five years ago. Overall almost 25% of people are now considered obese, up from 20% in 2000. A staggering 66% of people in the US are either overweight or obese.

To help us visualize what this means, USA Today published a chart to accompany the article. Here is what it takes to be obese or severely obese:

Height                    Obese                    Severely Obese

5 foot 4                             174                                             232

5 foot 10                          209                                              278

George Blackburn, associate director of nutrition at Harvard Medical School is quoted as saying the increase in the percent of severely obese people is a catastrophe.

All this fat is not going to melt away without effort — effort on the part of individuals, communities, and society as a whole. For Americans to lose all that weight and get physically fit will require both personal and collective responsibility.

We need more bike paths; attractive, easy to use stairwells; safe neighborhoods; availability of inexpensive healthy foods; PE in schools; exercise breaks at work; and, in general, an American lifestyle that makes it easier to do the right thing for our health and well-being, than the wrong.

Failure to make significant changes in our work and family lives will indeed lead to a health catastrophe – more and more childhood and adult obesity, epidemics of diabetes, heart disease, high blood pressure and abnormal lipids and other obesity-linked diseases.

So, let’s get on with it…let’s work together to get the lifestyles we want and need.  I really hope I am not writing about severe obesity levels of 30% in 2012.

Pat Salber

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