VOL.80 NO.3 April 2007 $5.00
SAN FRANCISCO MEDICINE JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY
Innovations in Food and Health
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CONTENTS SAN FRANCISCO MEDICINE April 2007 Volume 80, Number 3 Innovations in Food and Health FEATURE ARTICLES
MONTHLY COLUMNS
10 Abstinence from Red Wine: Is Abstaining Hazardous to Your Health? Arthur Klatsky, MD
4 On Your Behalf
12 The Enlightened Diet Deborah Kesten, MPH 14 Providing Effective Nutrition Advice Robert Baron, MD 15 Obesity: A Chemical Connection? Steve Heilig, MPH, and John Peterson Myers, PhD
7 President’s Message Stephen Follansbee, MD 9 Editorial Mike Denney, MD, PhD 35 Book Review: Fatal Harvest Steve Heilig, MPH 36 Hospital News
16 A Restaurateur’s Vision Bears Fruit: An Interview with Alice Waters Dave Weich
38 Classified Ads
19 Escape From Nutrition-ism: Michael Pollan’s Rules of Thumb Mike Denney, MD, PhD
39 In Memoriam Stephen J. Askin, MD
20 Nutrition and Food Production: What Role Should the Medical Profession Play? Ted Schettler, MD, MPH 22 Stop Diabetes with Diet: Lifestyle Tools for Type II Diabetes Prevention Nancy Bennett, MS, RD, CDE 24 Nature’s Way: Omega-3s for Cardiovascular Disease Phillip Frost, MD 26 Exploring Unhealthy Eating Habits Patricia Crawford, DrPH, RD
Editorial and Advertising Offices 1003 A O’Reilly San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Fax: 415.561.0833
28 Perspectives in Eating Disorders Adair Look, MD 30 The Villain in the Obesity Epidemic: Is High-Fructose Corn Syrup the Culprit? Lucy Crain, MD
Email: adenz@sfms.org Web: www.sfms.org Subscriptions: $45 per year; $5 per issue Advertising information is available on our website, www.sfms.org, or can be sent upon
31 Mercury Update Jane Hightower, MD 32 Improving the City’s Food Systems Paula Jones and Rajiv Bhatia, MD, MPH
www.sfms.org
request. Printing: Sundance Press P.O. Box 26605 Tuscon, AZ 85726-6605
April 2007 San Francisco Medicine
ON YOUR BEHALF
April 2007 Volume 80, Number 3
A sampling of activities and actions of interest to SFMS members Editor Mike Denney Managing Editor Amanda Denz Copy Editor Mary VanClay
Notes from the Membership Department
Cover Artist Amanda Denz Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin Toni Brayer
Arthur Lyons
Gordon Fung
Terri Pickering
Erica Goode
Ricki Pollycove
Gretchen Gooding
Kathleen Unger
Shieva Khayam-Bashi Stephen Walsh SFMS Officers President Stephen E. Follansbee President-Elect Stephen H. Fugaro Secretary Michael Rokeach Treasurer Charles J. Wibbelsman
April 5, 2007 The San Francisco Medical Society Tees up with the Presidio Golf Club! SFMS members are invited to a cocktail reception at the Presidio Golf Club on Thursday, April 5, from 5:30 to 7:30 p.m. Members are encouraged to invite nonmember physician peers as well. Get acquainted with this beautiful facility and its stunning views while enjoying beverages, hors d’oeuvres, and the camaraderie of the members of SFMS. For more information or to RSVP, contact Therese Porter at tporter@sfms.org or (415) 561-0850 extension 268 by March 30. This event is complimentary, but we do need your RSVP.
Editor Mike Denney Immediate Past President Gordon L. Fung SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors Term:
Carolyn D. Mar
Jan 2007-Dec 2009
Rodman S. Rogers
Brian T. Andrews
John B. Sikorski
Lucy S. Crain
Peter W. Sullivan
Jane M. Hightower
John I. Umekubo
Donald C. Kitt
Term:
Jordan Shlain
Jan 2005-Dec 2007
Lily M. Tan
Gary L. Chan
Shannon Udovic-
George A. Fouras
Constant
Jeffrey Newman
Term:
Thomas J. Peitz
Jan 2006-Dec 2008
John W. Pierce
Mei-Ling E. Fong
Daniel M. Raybin
Thomas H. Lee
Michael H. Siu
CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Judith L. Mates, Alternate Delegate San Francisco Medicine april 2007
May 3, 2007 Mark your calendars and get your clubs ready for the SFMS/Presidio Golf Club Golf Mixer & “Short Game Clinic” on Thursday, May 3, from 5:30 to 7:30 p.m. There will be a putting and chipping clinic with the Club’s golf pro, followed by beverages and hosted hors d’oeuvres in the Clubhouse. There will also be a no-host cocktail bar. Additionally, more information about the Presidio Golf Club—including a special membership offer exclusively for members of the San Francisco Medical Society—will be available. Members and nonmembers at all levels of skill and interest are encouraged to attend this evening of fun and fellowship. Members are especially encouraged to invite nonmember physician peers as well. The cost is $25 for members and $35 for nonmembers. If a nonmember decides to join SFMS, their event fee will be applied to their first year’s membership! For more information or to RSVP, contact Therese Porter at tporter@sfms.org or (415) 561-0850 extension 268. RSVP deadline is Monday, April 30th. This summer look for the return of the SFMS Gallery Mixer, a fun evening of great
art, terrific refreshments, and camaraderie that was a hit last year. Here’s an opportunity to reach out to fellow members and help make membership more worthwhile! SFMS has embarked on a program to mentor new members. Upon approval by the Board or Executive Committee, each new member is assigned an established SFMS member as a sponsor whose primary responsibility is to help the new member become better acquainted with the Society and its benefits. Sponsors are expected to connect at least once with the new member socially (over breakfast or coffee, for example) and to invite the member to at least one SFMS event (Annual Dinner, Legislative Day, Candidate’s Night, Mixer, etc.) during the course of their first year of membership. Sponsors will also be asked to report to the Board on the results of their interaction with the new member. Currently sponsors are drawn from the SFMS Board as well as the Executive and Membership Committees, but all members are encouraged to participate in this program. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 269 or tporter@sfms.org for more information or to volunteer. Help Grow the San Francisco Medical Society! Members reaching out to their physician peers provide a tremendously effective way to gain new members. If your physician peers are not yet members, encourage them to join! SFMS is always looking for feedback from its members, as well as suggestions for how to make membership more valuable and more fun. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 269 or tporter@sfms.org. www.sfms.org
National Provider Identifier: Seven Steps to Implementation Only five months remain until the NPI compliance date—are you ready to use your NPI? The following steps will assist you in your preparation: 1. Enumerate: Have you applied for your NPI(s)? Not only should individual providers have enumerated, but organizations and subparts should have enumerated also. 2. Update: Have you received your software application updates, upgrades, and/or changes relevant to NPI? Be sure that the updates not only address the HIPAA Transactions but include the CMS1500, UB04, and/or dental claim form changes. 3. Communicate: Have you communicated your NPI(s) to your health plans and the other organizations you work with? All covered providers must share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes. 4. Collaborate: Do you know the readiness of your trading partners (such as health plans, TPAs, clearinghouses, etc.)? It’s important to work with your trading partners to know their readiness with NPI and how it impacts you. 5. Test: Have you started testing the NPI, both internally and externally? Not only do you need to test the HIPAA Transactions, such as 837 Claims, but if you process 835 Remittance Advice, be sure to test that your system can process the NPI appropriately. Also, if you submit paper claims, be sure that you’ve tested that the data is being printed in the correct fields. 6. Educate: Have you educated your staff on the NPI and its use? It’s important that staff who may be using the NPI in day-to-day work (such as verification of eligibility) be aware of it and of the provider identifiers that it replaces. 7. Implement: Have you implemented the NPI into your business practices? Once testing is complete, changes will go into production. Given all the steps above, will you be ready by May 23, 2007? Go to the NPI page on the CMS website for all www.sfms.org
NPI-related information, www.cms.hhs. gov/NationalProvIdentStand/.
Order the 2007 California Physician’s Legal Handbook Physicians can now order the 2007 California Physician’s Legal Handbook (CPLH). This indispensable manual is published annually by CMA’s Center for Legal Affairs and answers the legal questions most frequently asked by physicians. It can be purchased as a seven-volume, 4,500-page print edition, an interactive CD-ROM, or an online subscription. To find out more visit www.cmanet.org or contact CMA’s legal information line at (415) 882-5144 or legalinfo@cmanet.org.
SFMS Supports Lawsuit on Mercury Labeling The SFMS has again joined in an amicus brief filed to support better labeling of canned tuna regarding mercury content and associated health risks. Spurred by growing research on this topic—including that by SFMS board member Jane Hightower, MD—a coalition of health groups seeks to give consumers better information on the risks of consuming mercury-laden fish. The SFMS delegation to the CMA has also successfully brought policy on this issue to the CMA and AMA. For information, contact Steve Heilig at heilig@sfms.org.
SFMS Seminar Schedule Please contact Posi Lyon to register at pylon@sfms.org or (415) 561-0850 extension 260. Friday, May 4, 2007 Managing Up—Masterful Management (for office managers and administrators) 9–11 a.m. (8:40 a.m. registration and continental breakfast) How to Manage Your Office Manager (for physicians) 12:15–1:45 p.m. (12 p.m. registration and lunch) These two seminars are designed to help physicians and their office managers set expectations, manage change, and design a practice culture
the helps the practice thrive. $99 per session for SFMS/CMA members/$85 for second attendee from same office/$149 for nonmembers Monday, June 18, 2007 Transitioning Your Practice—Retiring, Selling, or Buying a Practice This is a not-to-be-missed seminar designed for all physicians who are contemplating retirement, bringing in an associate, joining a practice as an associate, relocating, buying or selling a practice, or changing careers. 6–9 p.m. (5:45 p.m. dinner/registration) $149 for SFMS/CMA members/$199 for nonmembers Friday, October 12, 2007 Customer Service/Front Office Telephone Techniques This half-day practice management seminar will provide valuable staff training to handle phone calls and scheduling professionally and efficiently. 9 a.m.–12:30 p.m. (8:40 a.m. registration/ continental breakfast) $99 for SFMS/CMA members/$149 for nonmembers Friday, November 9, 2007 “MBA” for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of finance, operations, and personnel management. 9 a.m.–5 p.m. (8:40 a.m. registration/continental breakfast) $250 for SFMS/CMA members/$225 for second attendee from same office/$325 for nonmembers Corrections
In the December issue of San Francisco Medicine, we ran an article called “Health Savings Accounts: The Wave of the Future” (by Steve Askin, on page 18). In the article, Dr. Askin mentions that the money saved in a HSA can be withdrawn after age sixty-five without tax or penalty. After further investigation, Dr. Askin would like to clarify that this is not correct. In fact, the money can be withdrawn, but it is subject to regular income tax. In the January/February issue of San Francisco Medicine, we referred to Mark Espinosa as “President and CEO” of The Native American Health Center in the bio following his article on page 13. We would like to point out that his job title is actually Executive Director. April 2007 San Francisco Medicine
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president’s Message Stephen Follansbee, MD
You Are What You Eat
I
googled this title and guess what? I got only 72,100,000 results. I guess more than a few people think this is true. In this issue of San Francisco Medicine, the articles will address various innovations in the area of food and health. While readers may ask, “What could be less controversial?” the fact is that food and health have been topics of debate since long before medicine, as we know it, existed. Our patients often present us with a long list of questions regarding food and health. They are worried about diet and cancer, heart disease, diabetes, Alzheimer’s disease, depression, and arthritis, just to name a few concerns. But the relationship between diet and health can be divided roughly into two major categories: prevention and treatment. What dietary changes or innovations are necessary to prevent disease? What dietary changes or innovations have been shown to modify the course of disease? As physicians, what are our responsibilities in terms of advising patients on diet? We must listen. Patients usually want to know how to proceed with diet and nutrition; they are eager for our advice. But first we must listen to their concerns and ideas. That helps us frame the discussion in a way that will be useful for them. We must not be too quick to judge. Much of the information that our patients bring to us comes from other people who sincerely want to help. Of course we can discount advertisements and promotions for the “best” approach, and our patients do not want to spend excessive amounts of money based on misleading information. But a lot of the anecdotal information that our patients bring to our offices is provided by people who perceived a benefit or read of a benefit to others. They are not being malicious or greedy; they are just trying to help. So we must be understanding and patient with some of the ideas and concepts they bring up. We must be scientific. I think this issue of San Francisco Medicine will help establish a foundation for current knowledge in several areas. We know, for example, that omega-3 fatty acids do not help prevent cardiac arrhythmias, but they do have a role in lipid metabolism. We will learn more about their role in depression, since many ongoing studies are investigating this issue. We must not be afraid or reluctant to refer patients with important nutrition needs or concerns to experts or expert websites—as long as we help them sift through the results. On a roll with my research, I googled “food, dementia” and got 1,260,000 results. I now www.sfms.org
“know,” among other things, that dementia can be “prevented” by eating more blueberries, more dark chocolate, more fish (but read Jane Hightower’s article on mercury in fish first!), and by eating less of everything else. These are just a few points of view out there in cyberspace. I encourage patients to bring in such results of their research for me to review, because I think our scientific background as physicians affords us the ability to render expert opinion on these materials. Our scientific background teaches us not to react immediately to every new piece of information or advice, but to research the context of the results and integrate this information into what we already know. These are all ways we can act as individual doctors to best advise our patients. But we also have a role to play as members of the San Francisco Medical Society. The SFMS has taken important public positions in the area of food and nutrition. We are on record as concerned about childhood obesity and, under the guidance of former SFMS President Dexter Louie, we have participated in programs addressing the issue. We have supported efforts to get healthy foods into the schools. We have opposed the use of antibiotics in animal husbandry, under the direction of former SFMS President George Susens. We have supported the regulation and reporting of mercury content in fish products, under the guidance of SFMS Executive Board Member Jane Hightower. If you have concerns or ideas about how SFMS can be more proactive in these or other related areas, we would like to hear from you. If we are going to be innovative in our approach to food and health, we should not just be talking about what we eat, but about how we eat, how much we eat, and why we eat the way we do. We are committed to a healthy community. Read on, and learn. Eat happily and well! Dr. Follansbee is the 139th President of the SFMS. An infectious disease specialist, he practices with the Permanente Medical Group. He is Director of Travel Medicine as well as Director of HIV Services at Kaiser San Francisco. He has been Chief of Staff and Director of HIV Research and Treatment at Davies Medical Center, attending physician at S.F. General Hospital, Assistant Director of the Bay Area Consortium of AIDS Providers, and has served on the UCSF clinical faculty.
april 2007 San Francisco Medicine
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DEPARTMENT TITLE HERE Editorial Mike Denney, MD, PhD
Wuriupranili and Tukumbini
A
n ancient Australian aboriginal creation story tells of how mythical people at the beginning of time had to search for food in perpetual darkness of night, because there was no sun. One day, a tall, grey-feathered Bolga stork hurled the yolk of an emu egg into the sky, whereupon it struck some sticks of wood and burst into flames, lighting up the beauty and abundance of the earth. Thereafter, Wuriupranili, the Sun-Woman, carried this torch east to west across the heavens each day, returning through a tunnel under the earth at night. After she gathered food as she rose in the sky during the morning hours, in the heat of the day at high noon Wuriupranili would begin to cook for a later celestial feast. Within this new diurnal cycle, the rising of the sun each morning awakened Tukumbini, the yellow-faced honey-eater, who would then sing out a melodious birdcall to rouse the aborigines so that, like the Sun-Woman, they would gather food in the light of day for their dinner at sunset. Recognizing Tukumbini as the god of wisdom and instruction, Wuriupranili inspired him to teach the people how to recognize, gather, cook, and eat healthy, locallygrown foods that contained guruwari, the sacred life-sustaining essence of the earth. As in this issue of San Francisco Medicine we discuss food and health—practical and scientific nutritional ideas such as eating habits, integrative nutrition, eating disorders, world health, the benefits of wine, environmental food contaminants, and special diets for heart disease and diabetes prevention—we might pause to reflect upon the simple, down-to-earth dietary practices and teachings in the mythology of the indigenous aborigines, at 65,000 years the longest continuously intact local culture in the world. Certainly, if there is a modern-day personification of Wuriupranili, it might be internationally acclaimed chef and author Alice Waters, inventor of California cuisine, powerful advocate of sustainable agriculture, and founder of Chez Panisse restaurant in Berkeley. For many years, Waters rose with the dawn, gathered fresh, organically-grown vegetables and fruits from local farmer’s markets, spent the day preparing and cooking, and, to the delight of her customers, served a delicious and impeccably healthy feast during the evening dinner hours. She was named Best Chef in America by James Beard and one of the top ten chefs in the world by Cuisine et Vins de France. During this time, she published eight www.sfms.org
books about healthy natural foods and their preparation. Lamenting the ubiquity of processed and fast foods, her fundamental principle has been, “Allow food to be what it is.” Extending our aboriginal myth, we might visualize a modern Tukumbini, one to carry forward this earthbound dietary philosophy with wisdom, teaching, and intellectual fervor. That might well be Berkeley professor Michael Pollan, director of the Knight Program in Science and Environmental Journalism, who, Alice Waters has said, “forages in the overgrowth of our schizophrenic food culture” and “is the kind of teacher we all wish we had, one who triggers the little explosions of insight that change the way we eat.” Pollan has recently published two books about food and nutrition, The Botany of Desire and The Omnivore’s Dilemma, in which he elucidates the powerful connectedness of human beings with the plant world and describes how the current policies and practices of the modern food industry impact negatively upon the eating habits, nutrition, and health of Americans. Both Alice Waters and Michael Pollan advocate more basic and intuitive ways of eating. In an article on food and health published in The New York Times Magazine on January 28, 2007, Pollan discusses the process of what he calls nutritionism, the erroneous belief that the scientific study of individual components, nutrients rather than food, can offer solid conclusions about what to eat or what supplements to take. He says that nutrition-ism, with its inability to address the complexity and wholeness of the human relationship to food, has led to the opposite of health—to obesity, diabetes, heart disease, and malnutrition. Focusing upon food, not just individual nutrients, Pollan convincingly argues that we would be better off eating the way our grandparents, great-grandparents, and great-great grandparents taught us to eat. Thus, both Waters and Pollan ask for a return to more traditional ways to recognize, gather, cook, and eat healthy, locallygrown food. They acknowledge the intimate and complex connection of human beings to their planet. Yes, over these thousands of years, the sacred life-giving essence of the earth, the guruwari, remains with us in the spirits of Wuriupranili, the Sun-Woman, and Tukumbini, the teacher.
april 2007 San Francisco Medicine
Innovations in Food and Health
Abstinence from Red Wine Is Abstaining Hazardous to Your Health? Arthur Klatsky, MD
H
ardly a month goes by without the appearance of a research finding suggesting that drinking red wine is good for you. The media publicity is never nuanced or subtle, so the headlines blare. Here are several recent ones: “Procyanidinrich red wines reduce heart attack and mortality,” “Resveratrol, a red wine ingredient, improves health and survival in mice on a high-fat diet,” and “Cabernet sauvignon red wine reduces the risk of Alzheimer’s disease.” With the hint of greater longevity, what nonred-wine drinker wouldn’t feel pressure to start a red wine habit? What person over sixty-five years old wouldn’t consider a lifestyle change that promised a lower chance of Alzheimer’s? The public has heard the implied message. A 60 Minutes TV broadcast (CBS, Nov. 17, 1991) attributed lower heart attack risk in France partially to red wine. This explanation of the “French Paradox” (low coronary disease death rate despite relatively unfavorable lifestyle habits) has become widely known. Red wine sales in the U.S. skyrocketed in the 1990s and remain high. In a recent Kaiser Permanente (KP) survey, 80 percent of those interviewed had heard of presumed benefit from alcohol and half of these volunteered that this was true only of red wine (Klatsky et al 2003). Social and medical harm from heavier drinking has been evident for millennia, but the concept of a safe drinking limit was also accepted. Perhaps better than “safe” is the word “sensible,” since no level is absolutely safe for all persons. Modern population cohort studies confirm the increased risks of heavy drinking, defined as > 3 standardsized drinks per day (Corrao et al 2004). The same studies show that light to moderate drinkers have lower risks of coronary artery disease (CAD), ischemic stroke, and type 10 San Francisco Medicine april Medicine April 2007
II diabetes mellitus. Thus, for total mortality, the composite is a J-shaped curve, with lowest risk among drinkers who take < 3 drinks per day, and highest risk from numerous conditions among heavy drinkers. The lower mortality risk of lighter drinkers is due mostly to less CAD. Light drinkers have about 30 percent lower CAD mortality risk and an approximately 10 percent lower total mortality risk
“Hardly a month goes by without the appearance of a research finding suggesting that drinking red wine is good for you.” (Klatsky 2003). Consistency in studies, relative specificity of benefit for CAD, and plausible biological mechanisms for protection by alcohol against CAD support a causal protective effect. Some earlier studies were unable to separate ex-drinkers from lifelong abstainers or to control for baseline CAD risk. Skeptics have repeatedly cited this problem as the explanation of spurious benefit really due to prior movement of high-risk persons into the nondrinking reference group (Shaper, Wannamethee, and Walker 1988) (Fillmore, Kerr, and Stockwell 2006). This “sick quitter” hypothesis has been refuted by a number of studies, including KP analyses. Studies that separate ex-drinkers from lifelong abstainers or control for baseline CAD risk also consistently show that drinkers have lower CAD risk than lifelong abstainers. Although there have been no randomized, controlled trials of CAD outcome events, many epidemiolo-
gists now feel that there is little doubt that alcohol exerts a protective effect against CAD (Klatsky 1992) (Klatsky, Friedman, and Armstrong 2003). Plausible biological mechanisms for CAD protection by alcohol start with higher levels of protective high-density lipoprotein (HDL) cholesterol in drinkers (Dreon and Krauss 1997). The evidence for this effect of alcohol is compelling. Several analyses in different cohorts show that HDL effect explains about 50 percent of the alcohol-CAD benefit. This is an effect of alcohol, without specificity for wine. Antithrombotic effects, less specifically an alcohol effect, are also supported by substantial data (Zakhari 1999). Less established mechanisms for CAD benefit of alcohol include improved endothelial function and reduced insulin resistance. The evidence that mechanisms of benefit have to do with ethyl alcohol means that any nonalcohol-related benefit from a specific beverage type, such as red wine, would be additional to that from alcohol. Support for the hypothesis that wine may be more beneficial than liquor or beer is of two major types. The first consists of international comparisons showing lower CAD mortality in wine-drinking countries (e.g., France) than in countries where beer or distilled spirits are the preponderant alcoholic beverages (Rimm et al 1996). Called ecological studies, these analyses relate mean consumption data to aggregate mortality. Since traits of individuals are not involved, these ecological studies are not well controlled for confounding explanations. The second type of evidence, the type frequently receiving media hyperbole, is the presence of potentially beneficial nonalcohol compounds in wine (Booyse and Parks www.sfms.org
2001). Usually found more concentrated in red wine, these substances are mostly phenolic compounds with antioxidant and antithrombotic properties. Since oxidation of low-density lipoprotein (LDL) cholesterol is an integral part of development of atherosclerotic plaques, it follows that antioxidant compounds in the diet represent an appealing hypothesis for benefit. Diets rich in natural antioxidants seem to be associated with better health outcomes, although trials of antioxidant supplementation have been disappointing. Many feel that red wine could be considered a fermented food beverage with beneficial antioxidant ingredients. Epidemiologic studies with data about specific beverage types are fewer in number than those that deal with total alcohol consumption. They do not consistently and convincingly support specific additional benefit from wine. Important in this regard are good studies in beer-drinking populations showing apparent substantial CAD protection by that beverage (Keil et al 1997). A series of studies in Denmark show that wine drinkers have lower risk of total mortality, cancer, and stroke, but the Danish investigators point out that, compared to beer/liquor drinkers, wine drinkers have a healthier drinking amount and pattern (Gronbaek 2004). The Danish wine drinkers smoke less, exercise more, eat healthier diets, have higher socioeconomic status, and score higher on intelligence tests. It is well known that in epidemiologic studies, “healthy” traits tend to cluster in the same individuals. In observational studies, there may be residual confounding by uncontrolled or incompletely controlled traits. KP studies show evidence of CAD benefit from each major beverage type, with apparent benefit greatest for wine, next for beer, and least for spirits (Klatsky, Armstrong, and Freidman 1997). Importantly, the apparent effect was the same for white wine as for red wine. As in Denmark, our California wine drinkers had the healthiest lifestyle habits.
Wine has been called the “beverage of moderation.” To some extent this seems true in Denmark and in California, both of which include substantial numbers of persons that drink each beverage type. Yet in countries in which wine drinking preponderates, most heavy drinkers drink the prevalent, usually inexpensive beverage. Resultant wine-induced pathologies include liver cirrhosis, systemic hypertension, cardiomyopathy, and peripheral neuropathy (Klatsky 2002). Organ damage from chronic heavy drinking is related primarily to lifetime ethyl alcohol intake, not beverage choice. In the appropriate cultural milieu, some wine drinkers readily progress to heavy drinking. In the U.S., for low cost some alcoholics choose wine. The pejorative term “wino” arose because a proportion of down-andout alcoholics drink cheap fortified wine or jug wine. The acceptance of the specific benefits of red wine for CAD involves interpretive stretching of the data. For example, the truly fascinating resveratrol-longevity story involves up-regulation of a genetic system (the sirtuin genes) that influence metabolic processes promoting longevity (Baur et al 2006).Resveratrol has this effect and has shown the ability to increase longevity in several species. Extrapolation from the doses used in the mouse study to humans indicates that a comparable human resveratrol dose from drinking red wine would involve >1,000 glasses per day, hardly a practical proposition. In the oligomeric procyanidins (OPC) report, correlations were done between OPC content of wines and longevity in several areas, with the finding that both were highest in certain areas of France and Sardinia (Corder et al 2006). Found largely in grape seeds, the
“In view of the major health problems of heavier drinking, there are legitimate concerns about any medical advice that encourages drinking.”
www.sfms.org
OPCs are said by the authors to be the wine polyphenols with the strongest endothelial relaxant effect. These analyses were not controlled for other potential confounders; in the view of this commentator, these data do not suggest that wine drinkers would do well by switching to Sardinian wines. The Alzheimer’s report was another mouse study (Wang et al 2006). In view of the major health problems of heavier drinking, there are legitimate concerns about any medical advice that encourages drinking. Although it is likely that few heavy imbibers drink to improve their health, the concerns are based upon the fear that some persons might not be able to handle the knowledge of benefit responsibly, and might deliberately or inadvertently indulge in heavier drinking. Advice to persons who are already heavy drinkers needs no risk/benefit individualization. Since nothing in the medical literature justifies heavier drinking and increased risks predominate, all heavier drinkers should reduce intake or abstain. The advice problem can be ameliorated by individualization of advice to light drinkers and abstainers, taking into account risk/benefit factors such as age, sex, and personal and family history of problem drinking versus risk of CAD, certain cancers, or other illnesses (Klatsky 2004). Advice to drink must be weighed very carefully for nondrinkers. Abstainers usually have a valid reason for abstinence. Alcohol drinking is not at or near the top of the list of ways to reduce CAD risk; it comes well after smoking avoidance, proper diet and exercise, and attention to lipids, hypertension, diabetes, and obesity. However, the case that lighter drinking in a healthy pattern has health benefits has become compelling. Thus it is as inappropriate for public health officials to promote general abstinence as to advise the entire population to drink. Most adults already are established light-moderate drinkers. Except for special reasons, an esContinued on Page 17...
“However, the case that lighter drinking in a healthy pattern has health benefits has become compelling.”
April 2007 San Francisco Medicine 11
Innovations in Food and Health
The Enlightened Diet Asking the Right Questions to Achieve Integrative Nutrition Deborah Kesten, MPH
E
ven though we count calories, watch our weight, and figure fat grams, Americans are the fattest people in the world. Perhaps we’ve forgotten that food is more than an amalgam of nutrients. Along with healing us physically, it enhances emotions, satisfies the soul, and connects us to others and to the mystery of life. When I lecture about optimal eating, the question I’m asked most frequently is about the diet du jour. Many want to know what’s best: Is it the zone? Eat right for your type? What do I think about Ornish (high carbohydrate/low fat) vs. Atkins (high protein/high fat)? Which do I choose? The simple answer is that I don’t choose. Rather, I believe we’re asking the wrong question, so we’re getting the wrong answer—and ongoing weight gain. Let me explain. Given that American children, teens, and adults are more overweight than ever before (80 percent of adults over age twenty-five are either obese or overweight, up from 58 percent in 1983), it’s natural that when we think about nutrition, we focus on weight and fat, both in food and our bodies. We go on diets, analyze and obsess about food, turn to it as an enemy or friend, eat too much, eat too little, worry about it, avoid it, crave it, revere it, or believe that a particular nutrient will magically melt the pounds. Yet despite all of our conscientious attention to food and the incredible advances we’ve made in nutritional science, not only are our waistlines continuing to increase, so, too, are most food-linked ailments. From high blood pressure, heart disease, and diabetes to cancer, osteoarthritis, and depression, excess pounds are an ever-rising threat to our health and well-being. So we’re left wondering, what’s gone wrong? 12 San Francisco Medicine april Medicine April 2007
I’ve been pondering this question since graduate school when, in the eighties, I worked as the nutrition specialist with pioneering physician Dean Ornish, M.D., and colleagues, who demonstrated that lifestyle changes—stress management (yoga and meditation); a no-fat-added, plant-based diet; group support; and exercise—may reduce risk factors linked to heart disease, such as high cholesterol levels, high blood pressure, and being overweight. I began to realize that the biological and technical examination of nutrients—measuring and analyzing calories, fats, carbohydrates, protein, vitamins, and minerals—is just one part of the food and nutrition story; that food is a four-part gift that nourishes not only physical health but also our spiritual, emotional, and social well-being.
The Missing Ingredient Sometimes you have to go backward before you can move forward. I got my first clue about missing “nutrients” in our meals in New Delhi, India, where I had been invited to present a workshop at the First International Conference on Lifestyle and Health. One of the presenters was K.L. Chopra, father and mentor of doctor and writer Deepak Chopra. After his lecture, I interviewed Dr. Chopra for a magazine article I was planning to write about yoga and diet. What he said was to change my view of food forever: “Prana is the vital life force of the universe, the cosmic force, and it goes into you, into me, with food. When you cook with love, you transfer the love into the food and it is metabolized. In former days [based on the Hindu scripture, the Bhagavad Gita], the tradition was for the mother to cook the food with love and then feed it to the children; only then would she eat.”
Was it really possible to infuse food with loving consciousness? Fascinated by the possibility, I began a search through the major world religions (such as Judaism, Christianity, Islam, Buddhism, and Hinduism) and cultural traditions (such as yogic nutrition, the Japanese chanoyu (way of tea), Native American food beliefs, and African American soul food) for their teachings about food. I learned that our spiritual ancestors related to food as more than just sustenance for the body. For instance, Judaism’s dietary laws are designed to honor the sanctity of life that is in both animal- and plant-based foods; Christians honor the divine through the bread and wine (or grape juice) of Holy Communion; African Americans celebrate food, life, and friendship by spicing soul food with love; yogis eat, in part, to commune with food’s life-giving qualities; Muslims honor food for its divine essence; Buddhists pursue enlightenment by bringing a meditative awareness to food; the Chinese use food to communicate with ancient ancestors and gods; and the Japanese turn to tea ceremonies to renew the spirit.
Integrative Nutrition: The Four Facets of Food Not only do virtually all religions and cultural traditions encourage cooking with love, they also seem to integrate intuitively and instinctively what modern researchers are beginning to conjecture: that food empowers us to heal multidimensionally. In other words, we may use our incredible human consciousness and food in four ways: to prevent or reverse physical ailments (biological nutrition); experience the foodmood connection (psychological nutrition); reunite with the spiritual meaning of food www.sfms.org
(spiritual nutrition); and return to our heritage (social nutrition). Recognizing all four facets of food allows us to pay attention to the connections between food and body, food and mind, food and soul, and food and social well-being. When we do this, we gain a new focus for optimal dietary self-care, which I describe as integrative nutrition. The practice of integrative nutrition is both new and old. It is based on three worldviews about food and diet: Western nutritional science, which focuses on nutrients and physical health; Eastern healing systems that include nutrition, such as traditional Chinese medicine, Ayurveda, and Tibetan medicine; and timeless lifestyle wisdom gleaned from world religions and cultural traditions. Ultimately, integrative nutrition is not only about what to eat but also about how to eat for better health. It is the essence of the enlightened diet.
Six Elements of Enlightened Eating To be enlightened, according to the dictionary, is to be “freed from ignorance and misinformation.” To enlighten is to illuminate and furnish with spiritual insight. Enlightened Eating means turning to science to free ourselves from dietary misinformation and to spiritual tradition to infuse meals with meaning and love. To get an idea of what such a comprehensive approach means, here are the six nutritional truths of the enlightened diet that have nourished humankind for millennia, with examples of state-of-the-art science that are beginning to verify food’s multidimensional power to heal. 1. Unite with others through food. Food, eating, and dining have always been intimately interwoven with our relationships. In tribes and clans and through rituals and celebrations, connecting with others through food is our social legacy, a refuge where memories reside, a nourishing world wherein traditions endure. One of the first studies to demonstrate the link between a socially supportive dining environment and health and well-being was published in the June 16, 1951, issue of the medical journal The Lancet. The study was conducted by British nutritionist Elsie M. www.sfms.org
Widdowson just after World War II. When she arrived at two orphanages in Germany, she decided to take a year to study the effects of servings of food on the children’s weight and height gain. When she assessed the results, she learned that some children thrived—regardless of whether they received equal or additional food. The enigma was solved when Widdowson realized that a strict caretaker chose mealtime to administer public rebukes and to ridicule certain children. Those who were disciplined during mealtime gained the least weight and stature, regardless of their caloric intake. The implication: Dining in a pleasant, supportive atmosphere may improve physical and emotional well-being.
ference to health and well-being. When Meyer Friedman, M.D.—the researcher who gave us the term “Type A personality”—and colleagues fed a super-high fat snack to both time-urgent, angry, hostile Type As and more mindful, mellow Type Bs, and then magnified photographs of the tiny vessels in the whites of the participants’ eyes, they could actually see the capillaries of Type As becoming clogged, a phenomenon that Dr. Friedman called “sludging.” The Type Bs’ capillaries remained relatively clear. Such results suggest that if you happen to consume high-fat foods but you do so in a calm, relaxed, present frame of mind, you’re less likely to clog your vessels, and your risk of heart disease may be lower.
2. Be aware of feelings before, during, and after eating. By using their own minds and bodies as laboratories thousands of years ago, ancient yogis (called rishis) created a food philosophy (anna yoga) with feelings at its core. In essence, they learned that particular foods had sattvic, or calming, qualities that were believed to enhance deep meditation and encourage mind-body equilibrium. In the 1970s, Massachusetts Institute of Technology (MIT) researcher Judith Wurtman, Ph.D., confirmed in her high-tech laboratory what ancient rishis had discovered centuries before: Carbohydrate-dense, plant-based foods (fruits, vegetables, grains, etc.) do indeed calm and relax the mindbody. What is the mechanism? When you consume carbohydrate-dense foods (such as potatoes and rice), the hormone insulin is released in the pancreas. In turn, amino acids from the bloodstream are absorbed into the body—all except one: tryptophan; instead, it floods the brain, where it is converted into soothing serotonin, a naturally occurring hormone that promotes a feeling of calm and relaxation, which makes meditating easier.
4. Be grateful for food and its origins—from the heart. To have such an attitude of gratitude, to be truly grateful for the life that both plant- and animal-based foods gave so that you may thrive, may enhance both your health and your appetite. Groundbreaking research by my husband, Larry Scherwitz, Ph.D., published in Psychosomatic Medicine, suggests a link between excessive self-involvement (measured by the frequent use of pronouns I, me, my, and mine) and increased threat of heart disease. The antidote: “Each time you eat, focus on the food and meal instead of on yourself,” says Scherwitz. “It may make you less prone to heart disease.”
3. Bring moment-to-moment nonjudgmental awareness to each aspect of the meal. “Contemplating our food for a few seconds before eating, and eating in mindfulness, can bring us much happiness,” writes Buddhist Thich Nhat Hanh in Peace Is Every Step. Indeed, it may also make a dif-
5. Unite with the divine by flavoring food with love. Whether it’s Communion or soul food, virtually every religious and cultural tradition has a core belief that food can be transformed by love. The message that food could be spiritually imbued was brought home to me by Leonard Laskow, M.D., author of Healing with Love. Dr. Laskow’s method of infusing liquids and food with loving energy consisted of four steps, which he describes as: intentionality, heart focus, letting in the light, and food infusion. After the “infusion,” people can smell and taste a difference in the “loved” versus “unloved” nourishment. Hundreds of studies on the exContinued on Page 29... April 2007 San Francisco Medicine 13
Innovations in Food and Health
Providing Effective Nutrition Advice Integrating Evidence-Based Medicine, Common Sense, and Social Activism Robert Baron, MD
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ew topics in medical practice receive more attention in the lay media than nutrition. Each week brings new information about the advantages and disadvantages of specific diets, foods, and nutrients. Patients are confused and physicians are ill prepared to provide definitive answers. At the same time, patients and physicians are fully aware that what we eat has a major impact on our risk of developing a long list of chronic illnesses. And as physicians, all of us should be aware that changes in diet provide a powerful potential tool for management of these same illnesses. The question is, what level of evidence is needed in order to provide patients with sensible nutrition advice? The complexity of nutritional science has made it difficult to design and implement definitive randomized trials. On the other hand, observational studies have often provided misleading information. We are forced to understand the strengths and weaknesses of the evidence that we have and combine it with a healthy dose of biologic common sense. What do we know? Most convincingly, we know that we eat too many calories. The increase in overweight and obesity in the United States and a growing list of other nations clearly provides no identifiable health benefit (with the exception of increased bone mineral density). In fact, the United States is poised to reverse beneficial health trends for the first time in history. Debating the ideal body mass index for optimal health, the exact impact of obesity on mortality, and whether obesity is a greater threat to health than tobacco are all distractions from the basic point: There is no health advantage to being obese. We know that we are not active 14 San Francisco Medicine april Medicine April 2007
enough. All lines of evidence support the concept that decreased physical activity is associated with weight gain and that increased physical fitness (at any body weight) improves health outcomes.
“Each week brings new information about the advantages and disadvantages of specific diets, foods, and nutrients. Patients are confused and physicians are ill prepared to provide definitive answers.” We know that we do not eat enough plant foods. Vegetables and fruits should be the backbone of every diet. Current dietary guidelines recommend nine servings per day for adults who require 2,000 calories per day. Finally, we know that we eat way too much out of bags, boxes, and cans. Highcalorie snack foods, convenience foods, and beverages are directly related to our increased weight and to our reduced vegetable and fruit consumption. As Marion Nestle writes in What to Eat (North Point Press 2006), the basic principles of a good diet can be summarized in fifteen words: eat less, move more, eat lots of fruits and vegetables, go easy on junk foods.
Manipulating Macronutrients A substantial amount of recent nutritional science has been devoted to defining the optimal balance of macronutrients
(fat, carbohydrates, and protein) in the diet. Efforts over the last several decades to demonstrate substantial health advantages of a low-fat diet have been largely negative. Reducing fat without reducing total calories has little direct impact on health outcomes. For example, the recent Women’s Health Initiative clinical trial of low-fat diets showed no improvement in weight, breast cancer, colon cancer, any and all other cancers, cardiovascular disease, or any and all causes of death. Similarly, studies evaluating carbohydrate restriction, particularly for weight loss, have also showed no clear advantages over more traditional “balanced” diets. More recent studies have focused on Mediterranean-style diets, emphasizing the role of “good fats and good carbs” rather than a restriction of either. The evidence supporting this approach is as strong as any. The bottom line, however, is this: Total calories trump macronutrient composition. For most clinical circumstances, e.g., for health promotion, disease prevention, and treatment of most chronic illnesses, calorie restriction (with a concurrent increase in physical fitness) will have greater impact on health outcomes than changes in macronutrient composition.
Supplementing Micronutrients Few areas of nutrition have been subject to more study, including a large number of excellent randomized trials, than micronutrient (vitamin and mineral) supplementation. Observational studies have long suggested that individuals who consume greater amounts of a variety of vitamins and minerals (particularly those with antioxidant activity and those involved in homocysteine metabolism) had improved www.sfms.org
health outcomes. Dozens of randomized trials, however, have convincingly demonstrated the opposite. For example, no improvement in clinical outcomes can be identified from supplementation with antioxidant supplements or with a variety of Bvitamin supplements. This literature should provide future caution for those drawing premature conclusions from observational studies of diet and nutrition. What has been established is that vitamin and mineral supplements can prevent vitamin and mineral deficiencies. Patients with inadequate vitamin and mineral intakes should take simple multivitamin and mineral supplements. For example, individuals with inadequate dietary folate intake need folate supplementation during their reproductive years. Similarly, those with inadequate dietary calcium intake will likely benefit from calcium supplements during times of bone development. Providing levels of micronutrients greater than those needed for adequacy is not only unproven to be effective, but in many cases is proven to be ineffective.
Making Dietary and Physical Activity Changes Unfortunately, knowing what to recommend to patients is only one aspect of the battle for good nutrition and physical
fitness. Powerful commercial influences in both the food industry and those industries that effect physical activity make adhering to recommended behaviors extremely difficult. Patients must make substantial efforts just to maintain their current weight and level of fitness. Making changes that lead to weight reduction and improved fitness require near-heroic measures. Randomized trials, however, demonstrate that both eating and exercise behavior can be changed. Although the mean impact is often modest, approximately one-quarter of patients demonstrate more significant changes. The National Weight Control Registry suggests that such changes can be maintained for the long term. Patients who are able to lose weight and keep it off continue to eat low-calorie diets (approximately 1,400 calories per day), exercise moderately for approximately one hour per day, and monitor their weight regularly. Physicians must become skilled in teaching behavior-change techniques to patients who are ready to make changes. Useful skills include goal-setting, self-monitoring, stimulus control, and cognitive skills. Working closely with dieticians, psychologists, and other skilled professionals is essential. Studies that have most convincingly achieved behavior change, such as the Diabetes Prevention Program, have used very
Obesity: A Chemical Connection? One of the more interesting developing lines of research in the etiology of the obesity and diabetes epidemics focuses on the possible role of industrial chemicals— pollutants—on metabolism, endocrine function, and conditions such as diabetes. This line of inquiry has accelerated in just the past few years, with a growing literature indicating that some of the chemicals widely found in human bodies can disrupt normal development and function. The chemicals in question enter our bodies via food, water, air, and in utero. Both animal and human studies are finding some striking leads when looking at chemicals widely present in our bodies at concentrations similar to those studied. Most recent among these are a rodent study that found that fetal www.sfms.org
intensive interventions including multiple visits with nonphysician providers. But physicians will also need to become activists to change our food and exercise environment. Radical changes in how food is produced, transported, sold, and purchased, and how our time is spent in transportation and at school, work, and leisure activities will be necessary to achieve the nutrition and physical activity outcomes that we desire. Robert B. Baron, MD, MS, is a Professor of Medicine, Associate Dean for Graduate and Continuing Medical Education, and Vice Division Chief of the Division of General Internal Medicine at the University of California, San Francisco (UCSF). A practicing internist for more than twenty years, he has been recognized as one of “America’s Top Doctors” and as one of the “Outstanding Primary Care Physicians in the U.S.” In addition to his practice in primary care, he maintains a special interest in nutrition and management of obesity. He founded and continues to direct the UCSF Weight Management Program.
Steve Heilig, MPH, and John Peterson Myers, PhD
exposure to diethylstilbestrol (DES) can lead to grotesque obesity in adult mice. In humans, studies of pesticide compounds and PCBs indicated a link with increased insulin resistance, as well as interacting with existing obesity to increase the risk of type II diabetes. A link between PCBs and confirmed diagnosed diabetes was found in women in another recent study. Most recently, in March a study found a link between phthalates, a class of chemicals often found in plastics and other common products, and obesity and diabetes in men. Spurred by the widely observed severe declines in sperm count and testosterone levels also linked to these chemicals—the researchers hypothesize that phthalates are likely just a part of the mutifactorial
picture, which includes the widelyknown issues of diet, lack of exercise, food industry practices, socioeconomic status, and so on. They tested their prediction using data from the CDC and found the prediction confirmed by statistical analysis. This one study with humans leaves much to be done, but their findings are also consistent with a growing consensus and predictions going back well over a decade that some widely used and present chemicals can act as endocrine disrupters via other pathways at concentrations far below earlier suspected, and that widely accepted standards of risk assessment and regulation do not address such factors. For more information see www.ourstolenfuture.org and www. healthandenvironment.org. April 2007 San Francisco Medicine 15
Innovations in Food and Health
A Restaurateur’s Vision Bears Fruit Excerpts from an Interview with Alice Waters Dave Weich
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n 2001, thirty years after its founding by Alice Waters, Chez Panisse was named the best restaurant in America by Gourmet magazine. The precocious upstarts in Berkeley have certainly come a long way. On opening night in 1971, the staff of the restaurant that would change American cuisine boasted a nearly complete lack of industry experience. No single factor can explain the remarkable success of Chez Panisse, but near the top of any list would be the staff’s early recognition that the best food comes from the freshest, highestquality local ingredients. If that seems like an obvious statement in 2007, American foodies have Waters to thank. As Russ Parsons noted in the Los Angeles Times, “There is probably no restauranteur in America who has done more for the farmer’s market movement than Alice Waters.” The following are excerpts from an interview with Alice Waters. Dave Weich: Your books aren’t entirely about how to prepare food. They’re also about where to find it, how to know when it’s ripe, and so forth. Alice Waters: That’s what’s really important: that people know what’s in season, what it looks like when it’s ripe, what the different varieties are and what they each taste like, and the reason that we need to 16 San Francisco Medicine april Medicine April 2007
buy them from local, organic suppliers. It’s also a point of view. I’m trying to bring you around the table to eat with your friends. That’s how I think of eating. Growing up in New Jersey, your family had a garden, right? Did you sit around the table together to eat? What were meals like in your home?
Waters: At that time, in the fifties, you had to sit at the table; that was just part of growing up. I didn’t know any families that didn’t gather at the table. And even if the food was not brilliant, it was nutritious, and we had that exchange going on. My mother was a great cook, but what she’s known for is the duration of her meals.
Well, for quite awhile. I appreciate it a lot more looking back. I know so many families now that don’t cook, that might only sit at the table together on holidays or special occasions. Waters: I’m sort of shocked by that. My whole purpose now is to try to educate people about the relationship of food to culture and food to agriculture. We really need to be engaged in that process and bring our children into the whole experience. It’s around the table and in the preparation of food that we learn about ourselves and about the world. Right now in this country we’re being educated by fast-food values. Unconsciously or consciously, that’s what’s happening, and they’re giving a very strong message: that it doesn’t matter whether we eat hamburgers and hot dogs every day of the week; it doesn’t matter whether you sit at the table by yourself, or if you eat in the car and just throw the stuff in the garbage. Food should be cheap and labor should be cheap and everything should be the same no matter where you go; whether it’s a McDonald’s in Germany or one in California, it should be the same. And this message is destroying cultures around the world. Needless to say, agriculture goes with it. We need to come to some consciousness about food, and right away.
Waters: You mean you had to be there several hours? www.sfms.org
Eating with the fullest pleasure—pleasure, that is, that does not depend on ignorance—is perhaps the most profound enactment of our connection with the world. Waters: It’s fantastic. Still, there’s quite a movement toward organic agriculture and local ingredients right now. It’s not just you screaming out in the wilderness. Waters: There is a big movement, but big compared to big—it’s very small when you’re talking about one or two percent of food that is organically grown. It’s a huge increase, but it’s nothing in comparison to fast food. I worked for about twelve years in restaurants, but I never understood how delicious a tomato could be until I went to a tasting at a farmer’s market. Waters: I went yesterday to one downtown. When I find some things that I’ve not seen before, I’m always kind of thrilled. I found this red garlic, a variety of garlic that I hadn’t seen. I’m a garlic professional, you could say, but I hadn’t seen this beautiful variety with little maroon . . . almost stripes going around. Splendid. I have two heads that I bought and I’m taking home. That was a thrill for me. And I loved the woman who had salads. She had this black, wooden bowl where all the greens were mixed just like it
would come to your table—what a wonderful presentation! I met a guy, Ken, who has an artisan bread company; he’s doing all of his bread with organic flour. I was impressed with that. I also met Elizabeth Montes of Sahagún, who had such beautiful handmade chocolates. I was delighted that there was that kind of sophistication and life about things. There were hundreds of people there. That’s what markets need; they need a lot of buyers to encourage the farmers to come in. Elsewhere you’ve spoken about organic produce in major supermarkets; it’s great to have organic food out there, basically, but yet if it’s not being handled correctly or if it’s not fresh, it’s only giving people the wrong ideas about organic farming. Waters: It’s wonderful that you can get some of the fruits, particularly, but I find that a lot of them aren’t local. It’s not grown for shelf life. If it’s perishable at all, it’s immediately damaged. The berries, even salad greens . . . they just can’t be kept like that. And you’re paying more for them because you’re paying the middleman. Talk about the Edible Schoolyard project. Waters: It’s a project in a school in Berkeley—Martin Luther King Jr. Middle School, with about a thousand kids. And it’s an idea for a curriculum that could be put in every school in this country, from preschool all
the way through college. The purpose is to engage kids in the growing, the cooking, and the eating of their school lunches as a way of teaching them very important values. If we don’t learn to become stewards of the land, if we don’t understand where our food comes from, we’re headed for environmental disaster. I feel that I had a very good public school education, but never during those years was I offered the opportunity to learn about gardening or the cultivation of food. That seems so strange in hindsight. Waters: Doesn’t it? Maybe it was thought that you learned that at home. It’s just not part of biology and nutrition, which are considered serious things. But this other stuff is not serious. It’s thought not to be essential, but it’s fundamental to our lives. Fundamental to our lives? Waters: Yes. We eat every day, and if we do it in a way that doesn’t recognize value, it’s contributing to the destruction of our culture and of agriculture. But if it’s done with focus and care, it can be a wonderful thing. It changes the quality of your life. Editor’s Note: This interview was reprinted with permission from Powells.com, an independent Internet seller of used, new, and out-of-print books. It can be found, in its full length, at www.powells.com.
Red Wine Continued from Page 11...
tablished light-moderate drinker at average or greater than average CAD risk should not be advised to abstain. Studies have shown that this applies to those with and without pre-existent CAD, hypertension, and diabetes. Most medication-alcohol interactions are documented only with heavy alcohol intake; this should not be too readily generalized to a prohibition of all alcohol for these patients. But what about the issue of abstinence from red wine in the title of this article? The short answer is that the question of additional benefit from nonalcohol ingredients www.sfms.org
is unresolved. Red wine is obviously fine for the light-moderate drinker who prefers it, but the scientific knowledge offers insufficient basis for urging the man or woman who prefers another beverage to switch. Most of the CAD benefit derives from ethyl alcohol. If small amounts are taken in the optimal pattern, slowly and with food, it is likely that beer, liquor, white wine, and red wine would have fairly similar benefit. Most moderate drinkers are more interested in the sensory pleasures and relaxing effect than in health benefit. One hopes that the number of people who drink red wine
when they would prefer something else is not too large. Arthur L. Klatsky, MD, is a Senior Consultant in Cardiology and Adjunct Investigator for the Division of Research at Kaiser Permanente in Oakland. This article was reprinted with permission from The Permanente Press. It originally appeared in The Permanente Journal 2007 spring, 11(2):86-8, ©2007 The Permanente Press. A full list of references is available on our website, www.sfms.org.
April 2007 San Francisco Medicine 17
Innovations in Food and Health
Escape from Nutrition-ism Michael Pollan’s Rules of Thumb for Healthy Eating Mike Denney
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n perhaps the most compelling, eloquent, and comprehensive article on food and health ever written, which appeared in The New York Times Magazine on January 28, 2007, Michael Pollan, author of The Botany of Desire and The Omnivore’s Dilemma, takes on the government, the food industry, and agriculture, all of which have contributed to what he calls nutritionism, the distortion of common sense, taste, and tradition by turning our eating habits into a pseudoscience. Pollan skewers the concept of processed foods with such perspicacious comments as, “It’s a lot easier to slap a health claim on a box of sugary cereal than on a carrot” and “A health claim on a food product is a good indication that it’s not really food” and “Medicine is learning how to keep alive the people whom the Western diet is making sick.” Pollan begins his article, entitled Unhappy Meals, with the simple statements: “Eat food. Not too much. Mostly plants.” This, he says “is, more or less, the short answer to the supposedly incredibly complicated and confusing question of what we humans should eat in order to be maximally healthy.” After convincingly contradicting the basic assumptions of the reductive science of nutrients, Pollan offers guidelines on how we might escape the deleterious effects of the modern diet. He says, “Try these few (flagrantly unscientific) rules of thumb, collected in the course of my nutritional
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odyssey, and see if they don’t at least point us in the right direction.” 1. Eat Food. Though in our current state of confusion, this is much easier said than done. So, try this: Don’t eat anything your great-great-grandmother wouldn’t recognize as food. 2. Avoid even those food products that come bearing health claims. They’re apt to be heavily processed, and the claims are often dubious at best. 3. Especially avoid food products containing ingredients that are a) unfamiliar, b) unpronounceable, c) more than five in number—or that contain high-fructose corn syrup. 4. Get out of the supermarket whenever possible. You won’t find any high-fructose corn syrup at the farmer’s market; you also won’t find food harvested long ago and far away. What you will find are fresh whole foods picked at the peak of nutritional quality. Precisely the kind of food your greatgreat-grandmother would have recognized as food. 5. Pay more, eat less. The American food system has for a century devoted its energies and policies to increasing quantity and reducing price, not to improving quality. There’s no escaping the fact that better food—measured by taste or nutritional quality (which often correspond)—costs more, because it has been grown or raised less intensively and with more care.
6. Eat mostly plants, especially leaves. Scientist may disagree on what’s so good about plants—the antioxidants? Fiber? Omega-3s?—but they do agree that they’re probably really good for you and certainly can’t hurt. Also, by eating a plant-based diet, you’ll be consuming far fewer calories. 7. Eat more like the French. Or the Japanese. Or the Italians. Or the Greeks. Confounding factors aside, people who eat according to the rules of a traditional food culture are generally healthier than we are. Any traditional diet will do: If it weren’t a healthy diet, the people who follow it wouldn’t still be around. 8. Cook. And if you can, plant a garden. To take part in the intricate and endlessly interesting processes of providing for our sustenance is the surest way to escape the culture of fast food and the values implicit in it: that food should be cheap and easy; that food is fuel and not communion. 9. Eat like an omnivore. Try to add new species, not just new foods, to your diet. The greater the diversity of species you eat, the more likely you are to cover all your nutritional bases. The full text of Michael Pollan’s extensive article can be found at www.nytimes. com/2007/01/28/magazine/28nutritionism. t.html.
April 2007 San Francisco Medicine 19
Innovations in Food and Health
Nutrition and Food Production What Role Should the Medical Profession Play? Ted Schettler, MD, MPH
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ew topics are as fundamental and crosscutting as food. Meeting the basic need for nourishment is of great interest to a very large, diverse web of people, organizations, and institutions. They bring the perspectives of farming, nutrition, public health, spirituality, clinical medicine, economics, labor, ecosystem health, family and community, immigration policy, justice, land use, national security, pleasure, and convenience. This is a look from the perspective of the health care system. We know that what we eat is a major determinant of death and disease. The health care sector has an obvious interest and responsibility. It could be among the leaders in promoting healthy food and healthy agriculture. The quality of nutrition and the contaminants in food affect consumers most directly, but the entire agricultural system has numerous indirect impacts as well. Dominant forms of agricultural practices are often enormously destructive, causing soil erosion; desertification; salinization; soil, water, and air pollution; habitat loss; diminished biodiversity and soil fertility; genetic contamination; and social and economic disruption. These are very real public health concerns in the dynamic, richly interconnected, whole biotic communities where people live.
Food Production and Distribution in the U.S. In recent decades in the U.S., with some geographical variations, food agriculture has seen declining numbers of midsized farms; increasing concentration of large, industrial, vertically-integrated agricultural systems producing for large commodity markets (e.g., corn, soybeans, sugar, pork, beef); and some increase in 20 San Francisco Medicine april Medicine April 2007
small producers for differentiated markets (Kirschenmann 2005). Increasing concentration of people in large urban centers has led to redesign of food production systems and development of complex transportation systems to bring food to local markets. Today, food typically travels 1,500 miles from farm to fork, a 25 percent increase since 1980. Time delays
“What we eat is a major determinant of death and disease. The health care sector has an obvious interest and responsibility and it could be among the leaders in promoting healthy food and healthy agriculture.” due to transport over long distances increase opportunities for contamination and loss of nutrients. The entire system is increasingly dependent on fossil fuels for transportation, mechanized farming of crops and livestock, and petrochemical pesticides. Many food products are designed to meet the needs of today’s industrial agricultural system, with efficiency, durability, and marketability as drivers. Consequently, the nutritional quality of food often suffers, while the enormous environmental and social impacts of how it is produced are largely accepted as the cost of doing business in this way.
Nutritional Quality of Food Despite significant advances in the nutritional sciences, many people do not eat a healthy diet. The composition of food and the nature of the American diet are in large part a result of food production, distribution, and marketing interests, which are overwhelmingly based on products for large commodity markets. Highly processed food that is calorie rich and nutritionally poor is promoted, especially to children (Nestle 2006). Many food analysts and health professionals note with concern the prevalence of obesity, diabetes, heart disease, foodborne illnesses, some kinds of cancer and birth defects, dementia, and other health conditions that are linked to what we eat as well as the food production and distribution system more generally. These diseases cause suffering, are increasingly expensive to treat, and are obvious targets for preventive measures. Confined animal feedlots are just one example of the relationship between food production systems and nutrition. Beef cattle that are largely raised on corn in a feedlot and routinely treated with antibiotics and hormones reach marketable size more quickly than pastured animals. But the fat composition of the meat of the corn-fed animals contains a much higher ratio of omega-6 to omega-3 fatty acids than grass-fed counterparts (Wood 1999). Industrial poultry production has had a similar impact on chicken. Today’s typical diet in the U.S. has a far higher ratio of omega-6s:omega-3s than fifty to a hundred years ago, directly contributing to cancer, heart disease, arthritis, obesity, cognitive decline, and, in all likelihood, numerous other diseases (Allport 2006). www.sfms.org
Antibiotic Use Industrial agricultural systems that produce poultry, swine, beef, and farmed fish routinely use large amounts of antibiotics as growth promoters rather than as pharmaceutical agents to treat identified disease. More antibiotics are used in agricultural production than in clinical medicine. The routine use of antibiotics as growth promoters in animal husbandry contributes substantially to antibiotic resistance in bacteria that are human pathogens (Wegener 2003).
Pesticide Use The annual use of hundreds of millions of pounds of insecticides, herbicides, and fungicides in food production directly leads to significant populationwide, farmworker, and farm-community exposures, often exceeding established “safety” limits. It increases risk of some malignancies, neurodegenerative diseases, asthma, and birth defects (Ontario College of Family Physicians 2004).
Foodborne Infectious Illnesses Foodborne infectious agents are estimated to cause seventy-six million illnesses, 325,000 hospitalizations, and 5,200 deaths in the United States each year. Known pathogens account for an estimated fourteen million illnesses, 60,000 hospitalizations, and 1,800 deaths annually (CDC). In addition to bacterial and viral vectors, bovine spongiform encephalopathy (“mad cow” disease) is a growing concern in the U.S. Its spread depends on feeding practices in which animals that may end up in the food supply are fed animal products contaminated with the prion responsible for the disease. These practices are undergoing extensive modification following the identification of an infected animal in Washington in 2003.
Environmental Health Considerations Confined animal feedlot operations (CAFOs) and other large industrial farms are point sources for runoff of growth promoters such as arsenic, hormones, and antibiotics into local surface waters, and in some cases into ground water (USGS 2003). Studies of runoff from CAFOs show www.sfms.org
that hormones are present in surface waters at concentrations that are sufficient to alter fish reproduction and development (Soto 2004, Orlando 2004). Organic arsenic, used as a growth promoter in swine and chicken production, not only contaminates the meat with arsenic at levels of concern (Lasky 2004) but also is discharged into the environment when animal manure is spread onto the land. Once in soil or sediments, organic arsenic is converted to its more toxic inorganic form, making it water-soluble and allowing it to seep into surface and groundwater ultimately used for drinking (Gabarino 2003). Because of a dense concentration of animals in a relatively small space, CAFOs are also a source of noxious airborne emissions from manure lagoons that make people sick. Pesticide runoff and air emissions from agricultural operations contaminate waterways, rainwater, and air (USGS 1999). Drinking water in the Midwest is contaminated with atrazine during seasons of herbicide use (U.S. EPA), and air monitoring in California shows that pesticide drift from spraying operations exposes farm communities to unsafe levels (Pesticide Action Network, 2006). Wildlife studies in the field and in the laboratory show adverse impacts at current levels of exposure.
A Role for the Health Care System Hospitals and health care systems can play an important leadership role in addressing each of these concerns. Hospitals routinely feed patients, staff, visitors, and the general public, affording a perfect opportunity to directly influence health and disease risk as well as to model dietary patterns to others. This is reminiscent of the important role that hospitals played in the 1980s with the adoption of no-smoking policies as a demonstration of an important public health intervention. By adopting food procurement policies that show an understanding that the quality of nutrition and food production systems matter, health care institutions also recognize the inextricable links between individual, public, and ecosystem health, or what might be collectively called “ecological health.” An ethical dimension to this under-
standing also places medical ethics within an expanded framework of bioethics. Any viable system of ethics must preserve the ecosystems from which it arises and that sustain it (Elliott 1997, Pierce 2004). That is, the rules of ethics must conform to the rules of nature. Bioethics and medical ethics need to seek a more unified ecological moral framework. The health care system has a particular responsibility to address today’s ecological realities because of its mission, its opportunities, and the size of its ecological footprint. A reformulated bioethic and medical ethic will see beneficence, nonmalfeasance, and justice not only through the eyes of the patient and health care provider, but also from the perspective of the entire community and the natural environment.
Proposed Goals for Health Care Institutions • Adopt food procurement policies that provide nutritionally improved food for patients, staff, visitors, and the general public. • Adopt food procurement policies that support food production systems that are ecologically sound, economically viable, socially responsible, and morally feasible. • Adopt food procurement policies that reflect an ecological understanding of the dependence of human health on healthy ecosystems and that help promote sustainable agricultural practices.
Expected Benefits for Health Care Institutions • Health promotion and disease reduction • Reduced use of nontherapeutic antibiotics in food production with decreased risk of antibiotic-resistant organisms • Reduced pesticide use; reduced pesticide exposures to farmworkers, communities, consumers, and wildlife • Reduced ecological impacts of food production • Improved social and economic conditions in food-producing communities • Improved hospital-community relations Ted Schettler, MD, MPH, is the science director of the Science and Environmental Health Network. A full list of references is available on our website, www.sfms.org. April 2007 San Francisco Medicine 21
Innovations in Food and Health
Stop Diabetes with Diet Lifestyle Tools for Type II Diabetes Prevention Nancy Bennett, MS, RD, CDE
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he number of Americans with diabetes or pre-diabetes is staggering. There are currently 20.8 million persons with diabetes, 18.7 of whom have type II diabetes. According to a National Institutes of Health estimate, there are another 54 million Americans with pre-diabetes, defined by impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Some 20% to 34% of those with IFG will go on to develop Type II diabetes in five to six years; those with both IFG and IGT have a 38% to 65% chance of developing diabetes in the same time interval. The NIH paints a dire picture for the health of future generations in this country. They predict that one-third of all those born in the year 2000 will develop diabetes in their lifetimes. As diabetes is the leading cause of blindness, amputations, and kidney failure, it is imperative that health-promoting interventions begin early and continue throughout the patient’s lifetime if untold levels of suffering are be averted. As this threat to America’s public health is fueled by the obesity epidemic, these interventions need to be directed at stemming the tidal wave of obesity. Eighty percent of type II diabetes is caused by obesity and, according to the National Health and Nutrition Survey of 2003–2004, currently one-third of Americans are obese and another one-third are overweight. Though these facts are grim, there is a sliver of hope on the horizon. Researchers have shown that small losses in weight, coupled with activity, can reverse these
escalating trends in diabetes and profoundly impact the future of America’s health. The Diabetes Prevention Trial (DPP), completed in 2001, demonstrated that a loss of 7% to 10% body weight and an increase of 150 minutes of weekly activity decreases the risk for developing diabetes by 58%. The Finnish Diabetes Prevention Program duplicated these results and found that such lifestyle intervention programs can produce lasting results. Those who received lifestyle intervention were shown to have maintained a 58% lower risk for developing diabetes four years after the study interval. Researchers at the University of Colorado Health Sciences Center analyzed the DPP results and the relative contributions of changes in diet, physical activity, and weight loss to the reduction in diabetes incidence. They found that weight loss was most strongly associated with lower diabetes incidence, compared to diet and/or physical activity. On average, there was a 16% reduction in diabetes risk per kilogram weight loss (Hamman 2006). Though this research is indeed promising as far as averting this looming epidemic, losing weight—and maintaining that loss—is no easy matter. Simply eating fewer calories than one burns is easier said than done. Many a health professional has struggled right alongside patients in this arena. It might be helpful to focus interventions on those behaviors that lead to leanness. After all, the above studies focus on
“America is the land of plenty, and our growing waistlines are the consequence of eating large portions.”
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lifestyle interventions, not dietary restrictions; and, to this author’s knowledge, no one ever successfully “thought” their way to leanness, though their actions have lead them there. Therefore, focusing interventions on those key, simple, actionable steps that lead to leanness is helpful in directing our patients’ efforts to lose weight and maintain a leaner weight. One very realistic and practical approach to helping our patients lower their calorie intake and lose weight is to give them specific examples of how small substitutions in food choices can lead to large losses of weight over time. For example, sprinkling a tablespoon of toasted almonds on sautéed green beans instead of one tablespoon of melted butter saves seventy calories a day. Not only does this daily action translate into a seven-pound weight loss per year, it lowers the patient’s saturated fat intake as well. As many of these clients are at a higher risk for heart disease, small tips like this can help them translate the message “eat less saturated fat” into realistic, practical actions they can take on a consistent basis. In other words, the behavior becomes a lifestyle change rather than a “diet.” The sidebar on the opposing page lists other practical substitutions for common food choices that help to lower the intake of calories, refined carbohydrates, and saturated fat. America is the land of plenty, and our growing waistlines are the consequence of eating large portions. Feeling satiated with smaller portions is a challenge for many. Fortunately, certain food choices have been proven to promote the feeling of fullness while lowering the caloric density of the meal. Barbara Rolls, a professor of nutrition at www.sfms.org
Penn State University, has shown that those who begin meals with salads and/or brothbased soups eat fewer calories per meal, and, more importantly, they do not compensate by eating more later on in the day. Suggesting soup is a well-received message for those who complain that they cannot feel full with smaller portions of food. Another action step that promotes satiety with smaller portions is to choose foods that require chewing, such as fruits and vegetables. Though research tells us it takes twenty minutes for gastric hormones to signal satiety in the brain, most find eating slowly a difficult behavior to develop. Choosing foods that demand a lot of chewing aids in slowing down the speed in which people eat. Whole-grain breads for sandwiches at lunch and apples for dessert (in lieu of softer foods such as sandwich rolls and raisins) not only help boost satiety but increase your patient’s soluble fiber intake as well. Soluble fiber from whole grains, fruits, and vegetables slows gastric emptying, which promotes satiety. Soluble fiber has also been shown to flatten postprandial glucose curves, lower insulin levels, and decrease low-density lipoproteins. Another behavior that promotes satiety
with meals is the inclusion of lean protein with every meal or snack. Protein and fat delay gastric emptying and give meals or snacks “staying power.” Two such foods that are perfect for quick meals on the go are walnuts and dry-roasted edamame. These foods are also good sources of omega-3 fatty acids, which have been shown to reduce chronic inflammation. However, though these foods are delicious and healthy choices, they can be a concentrated source of calories. Experience has shown that handing patients a quarter-cup container can help them limit their portions to a level that does not interfere with weight loss efforts. Finally, encourage your patients to surround themselves with healthy foods. Those who are hungry will eat foods that are available. We live in a sea of fast-food chains and convenience markets filled with high-fat, high-fructose foods, so suggest to your patients that they carry some healthy snacks with them to work or school. Set them up for success by suggesting a few of the snack and meal ideas in the sidebar. Last, but not least, promote activity. Simply adding two thousand steps a day can lead to a ten-pound weight loss in a year. A pedometer is an inexpensive tool in
helping patients monitor and increase their activity levels. Increased activity not only helps patients burn more calories, it also helps decrease the insulin resistance that is at the very core of this disease. Health professionals play a pivotal role in shaping the health of future generations. We have an opportunity to show that simple, realistic actions can help people lose weight and lower their risk of developing diabetes. If we share our perception of diabetes as preventable, we will begin to help our patients live in the solution and, perhaps, stem the tide of this wretched disease. “Let history be the final judge of our deeds.”—John F. Kennedy
Choices for Losing Weight
Substitute These Foods…
With These Foods…
Substituting one food for another is a great way to subtract fat and calories from your diet without feeling the deprivation and suffering commonly associated with the famous four-letter word diet. Consider this: Every ten calories you subtract each day from your normal fare results in one pound of weight loss per year. Subtracting one hundred calories per day results in ten pounds per year and 250 calories per day results in twenty-five pounds lost per year. Imagine, losing two pounds every month just by choosing one food over another! The foods below list their calorie content in parentheses; see if there aren’t a few ideas you can realistically incorporate into your daily life. Who knows, you just may choose your way to leanness and drop your risk for diabetes too!
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Breakfast 2 oz. whole-milk cheese (220) 4 oz. sausage (432) ¼ C. raisins (120) ¾ C. granola (375) Lunch Quarter-pounder (530) 3 oz. hamburger (244) 3 oz. bologna (270) 1 large croissant (231) 1 C. cream of broccoli soup (234) Snacks 1 C. fruit-flavored yogurt (232) Flour tortilla (115) 3 oz. potato chips (330) Dove ice cream bar (260) 15 Triscuits (280) Dinner 4 Tbsp. blue cheese dressing (308) 6 oz. steak (344) 1 C. rice (266) 4 Tbsp. butter (400) 2 Tbsp. hollandaise sauce (200)
Nancy Bennett, MS, RD, CDE, is a consulting nutritionist and the principal author of Enlightening Choices. Her company provides nutrition consultations for a number of health care agencies, medical clinics, private physicians, corporations, and individuals within the San Francisco Bay Area. She earned her bachelor’s of science degree in Nutrition from the University of California at Berkeley in 1976, her master’s in Nutritional Science from the University of Bridgeport in 1992, and her Certificate of Diabetes Education in 2000.
2 oz. Laughing Cow reduced-fat cheese (70) 4 oz. Canadian bacon (180) ½ C. grapes (57) 1 C. Kashi Go Lean cereal (140) Grilled chicken sandwich (310) 3 oz. grilled chicken (140) 3 oz. ham (90) 2 slices rye bread (140) 1 C. minestrone (82) 1 C. sugar-free yogurt (90) Corn tortilla (67) 3 C. popcorn, air-popped (90) 2 Dove Miniature bars (100) 16 Wheat Thins (140) 4 Tbsp. light balsamic vinaigrette (200) 6 oz. chicken breast (200) 1 medium potato (140) 4 Tbsp. sour cream (120) 2 Tbsp. parmesan cheese (50) April 2007 San Francisco Medicine 23
Innovations in Food and Health
Nature’s Way Omega-3s for Cardiovascular Disease Phillip Frost, MD
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ature not only provides humans a full list of nutrients to forestall chronic disease (if we chose to eat them habitually) but stocks the lipidologist’s tool chest with offerings to thwart cardiovascular disease. Since the appreciation that the Greenland Inuit had a low mortality from Chronic Heart Disease (CHD) despite a diet rich in fat, the marine omega-3 fatty acids (n-3 FFAs) have been studied in the clinical arena. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), C-20 and C-22, respectively, are products of microalgae, are essential fatty acids, and are concentrated in marine animals. DHA is produced commercially from microalgae and is FDA-approved for infant formula. EPA and DHA in fish and in concentrates have been studied together and as components. EPA and DHA not only provoke lipoprotein concentrations but have other potential health benefits.
Recent Observations Multiple studies suggest that higher intake of the marine n-3 fatty acids in the diet reduce the risk of sudden death. In Seattle, a total of 334 case patients with primary cardiac arrest attended by paramedics were studied, along with 493 population-based control cases. Diet histories were taken from spouses and blood specimens collected from cases (n=82) and controls (n=108). Compared to no fish intake, an intake of 5.5g of n-3 FFAs per month was associated with a 50% reduction in risk of primary cardiac arrest. Compared with a red blood cell (RBC) n-3 FFA level of 3.3% of total FFAs (lowest quartile), an RBC n-3 FFAs of 5.0% of total FFAs was associated with a 70% reduction in the risk of primary cardiac arrest 24 San Francisco Medicine april Medicine April 2007
(Siscovick 1995). This result was echoed in the Physician’s Health Study conducted in apparently healthy men. Ninety-four men in whom sudden death occurred as the first manifestation of CHD were matched with 184 controls. As compared with men whose blood levels of long-chain n-3 FFAs were in the lowest quartile, the relative risk of sudden death was significantly lower in the third quartile (adjusted relative risk [RR] was 0.28) and lower yet in the fourth quartile (RR 0.19) (Albert 2002). The GISSI-Prevenzione Investigators recruited 11, 234 subjects who had survived a recent (<3 months) myocardial infarction (MI) and were randomly assigned supplements of n-3 FFAs 1 g, vitamin E, both, or neither for 3.5 years. Primary endpoint was combined death, nonfatal MI, and stroke. Results were provided in two-way and fourway analyses, respectively. Treatment with n-3 FFAs, but not vitamin E, significantly lowered risk of primary endpoint (RR decrease 10% and 15%). Benefit was attributed to decrease in risk of death (14% and 20%) and cardiovascular death (17% and 30%) (GISSI 1999). The relationship between n-3 fatty acids (EPA + DHA) intake and cardiovascular disease has been reviewed recently (He 2004, Studer 2005, Wang 2006). The He review looked at accumulated evidence on fish consumption and CHD mortality and concluded, “The pooled multivariate relative risks for CHD mortality were 0.89 (95% CI, 0.79 to 1.01) for fish intake one to three times per month, 0.85 (95% CI 0.76 to 0.96) for once per week, 0.77 (95% CI 0.66 to 0.89) for two to four times per week, and 0.62 (95% CI 0.46 to 0.82) for five or more times per week.” The Studer review concluded, “Statin
and n-3 fatty acids are the most favorable lipid-lowering interventions with reduced risk of overall and cardiac mortality. Any potent reduction in cardiac mortality from fibrates is offset by an increased risk of death from noncardiovascular causes.” In the editorial accompanying the Wang review, it is stated, “In total, the evidence indicates that increased consumption of the n-3 fatty acids EPA and DHA, either through fish or supplements or both, reduced the rates of all-cause mortality, myocardial infarction, and sudden cardiac death.” Important is that no or very few complications of supplements were encountered (Deckelbaum 2006). The NIH convened a working group on future clinical research directions on omega3 fatty acids and cardiovascular disease (CVD) on June 2, 2004. They concluded that the body of evidence is consistent with the hypothesis that intake of omega-3 fatty acids reduced CVD but that a definitive trial is needed (NIH 2004). There is recent trial data from Japan now that the five-year Japan EPA Lipid Interventions Study (JELIS) has been presented. Subjects with a total cholesterol >250 mg./dL were recruited, 14,981 in primary prevention and 3,664 in secondary prevention arms. All were randomized to low-dose statin (10 mg. pravastatin or 5 mg. simvastatin) or low-dose statin plus EPA (1800 mg. daily) in a randomized, open-label, blinded end point trial. Primary endpoint was defined as major coronary events: sudden death, fatal and nonfatal MI, and unstable angina including hospitalization for documented ischemic event and angioplasty/stenting or coronary artery bypass grafting. At mean follow-up of four to six years, there was a significant 19% www.sfms.org
lower event rate in the EPA plus statin compared with statin alone. This was true in both strata, but in subgroup analysis it was significant only in the secondary strata (Koba 2006).
tarium since 1994, as have many other lipidologists. It is particularly useful for patients with type II diabetes where the primary lipoprotein abnormality includes elevated VLDL and associated low HDL.
The Lipidologist’s Perspective
An illustrative Case
mortality. Higher dosage regimens (about 3–4 g.) lead to reduced VLDL cholesterol and triglycerides, a modest increase in HDL cholesterol, and, on occasion, increase in LDL cholesterol, a response similar to that observed with the fibrate drug class. In contradistinction to the fibrates, there are no known drug interactions with the n-3 fatty acids, and specifically no increased risk of the myopathy syndrome when prescribed with statins. Also in contradistinction to the fibrates, studies to date demonstrate not only reduced cardiac events but reduced total mortality. The n-3 FFAs are valuable agents used in combination lipid perturbing regimens.
Early data suggested that normalizing Sixty-five-year-old sedentary woman blood cholesterol and associated lipoprotein referred for lipid management in 1990 (curabnormalities was likely to reduce CVD rent age 82). Past history: Type II diabetes events and total mortality. History has mellitus, 1984. Interval history: Subsequent proven this to be the case. diagnosis of angina pectoris, resolved with The question now is how to achieve diabetes, lipid management. PE: She was lipid goals. To an investigator active in stud- obese (BMI 37.7), normotensive. Weight ies of diet and single therapeutic agents, it unchanged over interval seventeen years. became evident that combination regimens Clinical course: She failed efforts to would be required in most cases to achieve control diabetes with diet and sulfonylureas. goals. The ATP III updated goals for high- After years of discussion, she acquiesced in Dr. Frost is a Clinical Professor in the risk individuals are an LDL cholesterol fall 1993 to initiating insulin therapy, first Department of Medicine, Cardiovascular (well) below 70 and non-HDL cholesterol NPH and then 70/30 bid. Diabetes regimen Research Institute (CVRI) at UCSF. He at(again well) below 100 mg./dL. Normaliz- expanded with the addition of metformin tended UCLA School of Medicine, interned ing HDL cholesterol is important (Grundy in fall 1995, and pioglitazone in summer in New York City, and completed his medical 2004). Common lipoprotein abnormalities 2004. residency at Stanford University. After two include not only elevated LDL but elevated In reviewing individual values and years in the USPHS, he was an NIH Special VLDL (surrogate triglycerides) and low pooled data presented in the chart below, Fellow in Metabolism CVRI, UCSF. He has HDL. While most therapeutic regimens are the lipids clearly track to the combined lipid been an active clinical investigator since 1969. statin-based, we need effective, safe statin regimen (n-3 fatty acids [EPA + DHA] 3.0 He currently sees patients with lipid disorders at combinations. N-3 fatty acids clearly step g. plus simvastatin 40 mg.) and diabetes the UCSF Lipid Clinic and in his private practo the plate. EPA + DHA predominately control. tice. He can be reached with questions at phf@ lower the triglyceride-rich lipoproteins. The long-chain omega-3 fatty ac- stopheartattack.org or by telephone at (415) In a blinded comparison of gemfibrozil ids EPA and DHA are likely to protect 673-2241. A full list of references is available 1,200 mg. with 3,225 mg. EPA + DHA in against CVD by lipid independent and on our website, www.sfms.org. hypertriglyceridemic subjects, both agents lipid dependent mechanisms (Din 2004). lowered total cholesterol, triglycerides, and Low dose (about 1 g. of EPA plus DHA) VLDL and raised HDL similarly. LDL cho- consumed as fish or supplements is associlesterol increase was attributable largely to ated with reduced sudden death and total an increase in the less dense LDL subspecies (Stalenhoff 2000). In Lipids—HbA1c—Lipid Regimen terms of lipoprotein response, we Date Total Triglycerides HDL Non-HDL HbA1c Lipid can think of n-3 fatty acids as Cholesterol Cholesterol Regimen Cholesterol nature’s fibrate but, as noted above, 1990 10.8 319 616 35 286 None with additional attributes. The (9.8-11.6) (252-337) (287-373) (554-786) (35-35) response to statin, EPA + DHA, 1991 to 376 12.2 988 36 269 Gemfibrozil and combinations has been studied (9.6-14.1) 1,200 (193-343) 1993 (223-540) (356-2086) (33-40) and the lipoprotein response to 1993 to 293 9.9 422 36 254 Gemfibrozil combination is additive (Contacos (8.1-11.2) 1,200 (220-299) 1996 (256-332) (174-637) (27-42) 1993). Importantly, there have 1996 to 187 8 EPA + DHA 3g. 213 42 145 been no associated side effects with (6.9-8.7) Simvastatin 20 (37-45) (120-221) 2001 (160-258) (171-328) n-3 FFAs + statin, and specifically 2001 to 161 7.4 EPA + DHA 3g. 204 42 118 no increased risk of the myopathy (6.5-8.3) Simvastatin 40 (34-49) (96-185) 2004 (126-224) (115-278) syndrome, which is a concern with 2004 to 151 6.4 EPA + DHA 3g. 118 56 95 the statin fibrate combination. (5.8-6.5) Simvastatin 40 (53-60) (84-108) 2007 (137-165) (87-141) I have been using this combination as part of my armamen- Data are mean values and range in mg./dL or for HbA1c percent. www.sfms.org
April 2007 San Francisco Medicine 25
Innovations in Food and Health
Exploring Unhealthy Eating Habits A Longitudinal Study of Eating Behavior in Girls Patricia Crawford, DrPH, RD
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he number of overweight children in the United States today is associated with an unprecedented rise in type II diabetes. Consequently, there is an expectation that many children born today will have shorter life spans than their parents. Today’s children are three to four times more likely to be overweight than children thirty years ago, and rates are particularly high for African American youth. The NHLBI (National Heart, Lung, and Blood Institute) Growth and Health Study, the largest study of African-American girls’ health ever conducted, can provide new insights into this phenomenon and can help us understand how changing patterns of nutrition and physical activity since the 1970s may contribute to the alarming increases in childhood obesity. In 1987, during the period of soaring pediatric obesity rates, and in response to rapid increases in rates of obesity and heart disease in African American women, the National Heart, Lung, and Blood Institute of the National Institutes of Health funded the ten-year NHLBI Growth and Health Study (NGHS) to look at the development of obesity and cardiovascular disease (CVD) risk factors in black and white girls. Participants were selected from Contra Costa County, California; Cincinnati, Ohio; and Washington, D.C. NGHS recruited more than 2,300 girls, ages nine and ten, at schools (in California and Ohio) and from a large HMO (in D.C.). The study enrolled
approximately equal numbers of black and white girls, with a wide range in household income and parental education within each racial group. The study was remarkable in its very high retention rate; 89 percent of the original cohort was measured in the tenth year of follow-up. During the course of the NGHS study, we measured the girls and collected information on their dietary and physical activity patterns each year for ten years. To our surprise, nearly a quarter of the white girls (22 percent) and nearly a third of the black girls (31 percent) were overweight (BMI > 85th percentile) at ages nine and ten when they were initially enrolled in the study. This was a doubling of the rate from the previous decade, as measured by the CDC’s National Health and Nutrition Examination Survey. At ages nineteen and twenty, 41 percent of the white girls and 57 percent of the African American girls were overweight. While rates went up for both black and white girls, the absolute increase was considerably higher for black girls. Using our wealth of annual NGHS study data on dietary and physical activity patterns, we were able to examine whether children’s food and activity environments varied by race and whether the variations might contribute to differing patterns of weight gain in the two groups of girls. What kinds of changes in children’s food and activity environments did we see, and what racial differences did we observe?
“Today’s children are three to four times more likely to be overweight than children thirty years ago, and rates are particularly high for African American youth.”
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First, we observed frequent consumption of food from fast-food restaurants by all children. This agrees with other analyses showing that both children and adolescents are obtaining less of their energy intake at home than in earlier eras, and more at restaurants and fast-food outlets. Portion sizes have increased, and patrons are often encouraged to purchase meals that contain more calories through “value” marketing or “supersizing.” Further, fast food and restaurant foods are typically calorically dense, nutrient-poor, and highly palatable, and frequent patronage has been associated with diets high in fat and calories. Children who ate at fast-food establishments two or more times a week were more likely to increase their relative BMI (body mass index) than those who patronized fast-food establishments once a week or less. We found that fast-food intake rose with increasing age in girls of both races, but across all ages, from nine to nineteen, black girls consumed fast food more frequently than did white girls. Second, we observed high consumption of sweetened beverages. In both black and white girls, consumption increased with age. Further, of all beverages consumed, increased soda consumption predicted the greatest increase in BMI. This may be in part a result of difficulties in physiological compensation for energy consumed as a liquid compared to a solid, and in part a result of the relation between consumption of soda and other eating habits. At each annual visit, black girls consumed less milk than white girls, and the increased rate of soda consumption throughout childhood was greater among black girls than white girls. Apart from these frequently discussed diet markers, what about overall dietary www.sfms.org
quality? Dietary patterns of eating were examined using cluster analysis to classify individual girls into discrete patterns over the ten years of the NGHS study. Eight patterns were identified: four for white girls and four for black girls. Only one could be classified as a “healthy pattern,” and it was followed by only white girls. Only 6 percent of the girls in NGHS had diets classified as “healthy.” Further, the healthy pattern was the only pattern associated with a smaller increase in adiposity over the childhood years. On average, more than two-thirds of the girls at any given age were not meeting dietary fat recommendations, with white girls only somewhat more likely to meet the guidelines. Further, nearly half of all girls had diets below recommended levels in vitamins A and C, calcium, iron, and zinc. We found that black girls were more than twice as likely as white girls to frequently engage in a spectrum of weightrelated eating practices, including eating while watching TV, eating while doing homework, skipping meals, eating in the bedroom, eating when not hungry, and eating snacks. For most of the behaviors, girls who frequently practiced a behavior had higher caloric intakes compared with those who practiced it infrequently. Although the likelihood of a girl frequently engaging in some, but not all, of these eating practices decreased with an increase in parents’ income and education level, even when controlling for socioeconomic status (SES), black girls remained more likely to engage in these eating behaviors than white girls. In fact, NGHS was the first to report that the relationship
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between SES and weight differed for black and white girls. Both low household income and parental education are risk factors for pediatric overweight in white girls, but no such association was found for black girls. The NGHS also documented a dramatic decline in leisure time physical activity in both black and white girls from ages nine to twenty, but the decline for African American girls was greater. A direct association between hours of TV viewing and increases in BMI was observed. We documented average daily television time of 3.6 hours per day for white girls aged nine to ten compared with 5.2 hours per day for black girls. The impact of television viewing may be more significant than videogame playing, because it can reduce energy expenditure and increase energy intake: TV influences the type and amount of foods consumed by viewing children. A typical child watches about 40,000 commercials on TV each year, a number that has doubled during the years that have seen a large increase in the rate of pediatric overweight. In focus groups that we have conducted, mothers report knowing what to feed children, but not knowing how to get children to eat the healthy foods. Mothers report that their messages to their children are undermined by ever-present ads for fast foods and junk foods. Furthermore, television programming marketed primarily to African Americans has significantly more food and beverage ads and advertisements for unhealthful foods than general market programming. Overweight in both black and white girls in the NGHS study increased dramatically from nine to ten years of age to
nineteen to twenty years of age. Changes in nutritional patterns are clearly implicated among the reasons for this change. However, we recognize that observed increases in pediatric obesity are not caused by people taking less personal responsibility for their well-being, but rather by profound changes in the world around us. It behooves all of us—health professionals, parents, and citizens—to advocate not only for an environment safe from imminent danger, but also an environment safe from risk of chronic disease. Our nation’s economic and social environment must support people in their actions toward achieving and maintaining healthy lifestyles. Without this, we will all pay the future costs for conditions that are the consequences of an overweight society. In the words of one expert, “If you have malaria, you drain the swamp. If you have death on the roads, you impose seatbelts.…” If you have obesity, you create healthier food and activity environments. Patricia Crawford, DrPH, RD, is Adjunct Professor in the School of Public Health and the Department of Nutritional Sciences and Toxicology at the University of California, Berkeley. She is Codirector of the Center for Weight and Health and is a Cooperative Extension Nutrition Specialist. Dr. Crawford has led seminal studies in the longitudinal development of obesity and is currently Principle Investigator on studies exploring environmental, family, and policy approaches to childhood obesity. She is widely published, serves on several advisory boards, and is a consultant on numerous collaborative projects.
April 2007 San Francisco Medicine 27
Innovations in Food and Health
Perspectives in Eating Disorders What Physicians Should Know Adair Look, MD
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mily,” a twenty-year-old college student, came to treatment just after having attempted suicide by overdosing on old pain medications she found in her parents’ bathroom. She admitted that, before the attempt, she had become despondent over her unstoppable need to chew large quantities of food and spit it out without ever swallowing any of it. She was wasting away, now carrying only eighty pounds on her five-foot, five-inch frame. Emily had been chewing and spitting out her food as a way to soothe herself since the sixth grade but had never been able to tell anyone because she was too embarrassed. “Who ever heard of something so gross? I couldn’t tell anyone!” she stated. Emily is one of approximately five million people in the United States who suffer from an eating disorder, while many more suffer from disordered eating that borders on a full-fledged disorder. In addition, eating disorders carry the highest mortality risk of any psychiatric illness. Patients often come to treatment for reasons seemingly unrelated to their eating disorders. Although there is overlap in symptomotology, eating disorders are currently categorized into three distinct diagnoses: anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS). Many patients, like Emily, do not fit neatly into these categories. “Sarah” was forty-two when she presented to her internist with a concern for chronic halitosis. After an exhaustive medical workup, Sarah finally admitted to regurgitating her food two to three times per day. After her divorce ten years prior, she began regurgitating her food from stress. She welcomed its soothing effect and the fact that it made her weight easier to manage,
28 San Francisco Medicine april 2007
so she continued the behavior despite its inconvenience and its effect on her breath. Sarah’s eating disorder, rumination, is far more prevalent than most treaters are aware. Kjelsas shows in his 2004 article that 3% of young women have AN, 8% have BN, and about 14% meet criteria for EDNOS. O’Brien (1995) and Fairburn (1984) showed that 17% to 33% of patients with BN engage in rumination at some time in their history.
“Patients often come to treatment for reasons seemingly unrelated to their eating disorders.” Regardless of the commonality of the presenting symptoms, the immediate concerns in treating eating-disordered patients include refeeding syndrome, metabolic abnormalities, and cardiac abnormalities. Refeeding syndrome occurs when underweight patients have starved themselves to the extent that their cardiac tissue has atrophied, and when they are given increased fluids and solids, their cardiac capacity becomes overloaded. This results in dependent edema, tachycardia, increased jugular venous pressure, and cardiac rhythm abnormalities. Metabolic abnormalities can in fact help diagnose eating disorders, as seen with “Kay.” Kay, a thirty-year-old woman, presented with low body weight and a low potassium and high CO2, though she denied vomiting to decrease caloric intake. A salivary amylase was drawn and proved elevated, indicating repeated vomiting. Once confronted with the results, Kay was able to admit to purging up to twelve times
per day. Less immediate but equally damaging effects of eating disorders are exemplified by “Alyssa,” a twenty-seven-year-old woman with an eating disorder. Since age twelve, Alyssa has restricted calories and excessively exercised. During her first year of law school, her weight decreased to 92% of her ideal body weight (twenty pounds under normal weight for her), and she sustained a femoral neck fracture. She was able to normalize her weight over the next two years, but she then began excessively exercising again and fractured the metatarsals in her left foot. She suffers from female athletic triad: disordered eating, amenorrhea, and osteoporosis. Three to 66% of female athletes are affected, according to Yeager (1993). The amenorrhea is hypothalamic in nature. During extreme stress, whether physiologic or psychiatric, the hypothalamic-pituitary-adrenal axis is activated to stop unnecessary bodily functions, resulting in cessation of reproductive function. It is intended to be a “protective mechanism” of the body, a reaction to stress. In fact, increase in stress causes increase in amenorrhea in 100% of prisoners prior to execution, as found by Chrousos (1998). In 2005, Abraham showed that amenorrhea is also found in 24% of patients with EDNOS and 15% of patients with bulimia. Osteoporosis, the third aspect of female athletic triad, commonly leads to bone fractures, as seen in the femoral neck fracture Alyssa sustained. Anorexic patients often cite the fact that weight-bearing exercise leads to increase in bone density. However, excessive weight-bearing exercise leads to decrease in bone mineral density, and osteoporosis often persists after weight restoration occurs and hormonal levels normalize. www.sfms.org
Mood disorders are common in eatingdisordered patients, with comorbid Axis I diagnoses in 73% of patients with AN and in 60% of patients with BN (Herzog 1992). Recent research has focused on the connection between eating disorders and mood, showing that serotonin is involved in modulating impulsivity, obsessionality, mood, and appetite. Patients with bulimia show a decrease in naturally occurring serotonin and a decrease reactivity to serotonin. Patients with anorexia also show a decrease in serotonin activity and reactivity, but these levels increase after weight recovery has been achieved. “Pamela” was unable to keep her weight above one hundred pounds, despite being five foot, nine inches tall. She was also profoundly depressed and often contemplated suicide. She was eventually able to increase her body weight because her psychopharmacologist explained that SSRIs do not work as effectively on underweight people and that a minimum body weight must be achieved for full effect to occur. Treatment of eating disorders is difficult. However, it is most effective when using a multidisciplinary treatment team including a psychopharmacologist, a therapist,
a nutritionist, and a primary care physician. There are currently limited psychopharmacologic interventions for the treatment of eating disorders. Fluoxitine has been shown to decrease the urges to binge and to purge, as have desipramine and imipramine (Becker 1998). Topamax has been shown to decrease the urge as well, but it has the worrisome side effect of weight loss (Hedges 2003). Anorexia has been more difficult to treat both pharmacologically and therapeutically. Antipsychotics have begun to show promise with abnormal or inaccurate body image issues, but nothing has been shown to treat the underweight state of anorexia. Cognitive behavior therapy has proven to be effective in improving the outcome of patients with BN but not with AN. Eating disorders carry with them a stigmatization that makes patients ashamed of and secretive about their behavior. One tactic to engage them in treatment is to isolate their illness as a force outside of their person. “Angel” called her eating disorder “the it” and gradually began to conceptualize it as an entity unto itself. She was able to accept the support of her treatment team with the understanding that “the it” was stronger
than any one member of the team—but that together, she and her treaters were stronger. Angel was in treatment for seventeen years before she could eat out with her family. She is well versed in the high relapse rate of patients with eating disorders, but her committed relationship with her treatment team has kept her alive through three ICU stays and two suicide attempts. Often the triumphs of working with eating-disordered patients are found in the small steps they achieve, such as eating more than one thousand calories for seven days straight. At other times the rewards are more remarkable: After eleven years of amenorrhea, Alyssa recently gave birth to her first child.
change of consciousness in plants and food have been published, such as in the classic, The Secret Life of Plants by Peter Tompkins and Christopher Bird. Other research by Bernard Grad, PhD, also suggests that plants and food somehow sense and respond to verbal and nonverbal communication from humans. Indeed, Grad has been able to demonstrate that plants fed a “cared-for” solution of water thrived. His conclusion: “If a person’s mood could influence a … solution … it seemed natural to assume that a cook’s mood could influence the quality of food prepared for a meal.”
fornia, Berkeley, he said, “Fast food is the spiritual antithesis [of the dietary tenets of the Qur’an].” This means that by “treating food as an industrial artifact that is consumed without any devotional context” is to negate that food is a divine gift. Many of us are part of a vast, uncontrolled experiment in “industrial” eating. The data is clear that consuming lots of processed, high-fat foods that have been depleted of many beneficial nutrients contributes to obesity and related ailments.
ing process, a real-world experiment that is resplendent with possibilities in how to nourish every aspect of our being each time we eat.
6. Eat fresh whole food in its natural state as often as possible. Virtually every world religion and cultural tradition encourages eating fresh, whole foods. For instance, when I interviewed Hamid Algar, Ph.D., professor of Islamic Studies at the University of Cali-
The six elements of the enlightened diet are a template not only for what to eat and how to eat but also how to live: consciously, filled with a sense of wonder inherent in the alchemical union between human beings and food. This integration of nutritional science and spirit is an ongo-
Adair Look, MD, is an Attending Psychiatrist in the Women’s Health department of California Pacific Medical Center.
The Enlightened Diet Continued from Page 13...
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An Experiment in True Nourishment
Deborah Kesten, MPH, is the awardwinning author of Feeding the Body, Nourishing the Soul (Conari Press, 1997) and The Healing Secrets of Food (New World Library, 2001). A pioneer in the field of integrative nutrition, she has worked as the nutrition specialist with Dean Ornish, M.D., on his first clinical trial for reversing heart disease. Kesten has presented workshops and participated in research internationally and was honored as “a healer for the new millennium” by Healthy Living magazine. She and her husband, Larry Scherwitz, live in Northern California. This article was first published in Spirituality & Health magazine, winter 2003, www. spiritualityhealth.com.
April 2007 San Francisco Medicine 29
Innovations in Food and Health
A Villain in the Obesity Epedemic Is High-Fructose Corn Syrup the Culprit? Lucy Crain, MD
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n 2006, the Center for Science in the Public Interest (CSPI) threatened a lawsuit against Cadbury Schweppes for falsely advertising 7 Up as “all natural,” citing that it contains high-fructose corn syrup (HFCS). Although the Federal Drug Administration has no definition of “natural,” CSPI claimed that HFCS was not natural, due to the significant amount of processing and use of one or more genetically modified enzymes required to produce it. Cadbury Schweppes announced in January 2007 that it would cease describing 7 Up as “all natural.” Since the 2004 publication by Dr. George Bray and associates of an article suggesting a causal association of HFCS in the obesity epidemic, ongoing controversy continues about the role played by this ubiquitous sweetener. Dr. Bray and his coauthors noted that the consumption of HFCS increased more than a thousand percent between 1970 and 1990, exceeding changes in intake of any other food or food group (Bray, Neilson, and Popkin 2004). Others argue that increased food and drink portion sizes and American lifestyle changes, such as more fast foods and eating out, decreased exercise, and more computer and video time versus sports or outdoor activities, also have etiologic roles. Eager to discount any causal role of HFCS, the U.S. Farm and Corn Refiners lobbies have pointed to increasing rates of obesity and diabetes in countries such as Mexico, where HFCS is not a common ingredient
in foods and drinks. (It is clear that high U.S. sugar tariffs and import quotas make domestically grown, corn-based sweeteners more economically advantageous.) So, what is this possibly unnatural, ultra-sweet high-fructose corn syrup, of which the average American consumed 19.2 kg. per in 2004 (versus 20 kg. of sugar), just thirty years after it was developed and promptly included in many processed foods, soda beverages, and other food items in the United States? (The average Australian consumed 56.2 kg of sugar in 2002). HFCS includes a group of corn syrups that have undergone enzymatic processing in order to increase their fructose content, then are mixed with glucose or pure corn syrup in varying amounts. For example, HFCS 90 is approximately 90 percent fructose and 10 percent glucose and is most commonly used in baked goods. HFCS 55 is most commonly used in soft drinks, and HFCS 42 (42 percent fructose and 58 percent glucose) is most often used in sports drinks. The process for enzymatic conversion of d-glucose to d-fructose was originally developed by U.S. scientists Richard Marshall and Earl Kool in 1957 and subsequently refined by Japanese researchers in the 1970s, before widespread introduction into U.S. food production (Marshall and Kool 1957). This provided major economic advantages for the corn market in the U.S., where the price of sugar is artificially higher than its global price. HFCS is rarely used in Europe and other parts of the world, except for Japan, where
“Consumption of HFCS increased more than a thousand percent between 1970 and 1990, exceeding changes in intake of any other food or food group.”
30 San Francisco Medicine April 2007
its use is increasing. High-fructose corn syrup is produced by milling corn to corn starch, then further processing the corn starch to yield corn syrup, which is almost pure glucose. Enzymes are then added to change the glucose into fructose. The process is complex and requires numerous enzymatic additions, along with other sugars, in multiple stages to break down the sugar chains and convert them to fructose and glucose. This yields HFCS 90 (90 percent fructose). The other common formulations, noted above, are produced by combining the HFCS with desired proportions of 100 percent glucose corn syrup. Bray and associates note that the digestion and metabolism of fructose is different from that of glucose, with hepatic metabolism of fructose favoring new lipogenesis. Fructose (unlike glucose) does not enhance leptin production or stimulate insulin secretion, suggesting that dietary fructose may contribute to weight gain. Cane sugar is essentially pure sucrose, a disaccharide, equally consisting of fructose and glucose. In contrast to fructose, glucose absorption and metabolism is dependent on insulin stimulation to effect the transport mechanism and trigger insulin receptors. Leptin release is stimulated by insulin and is known to inhibit food intake and lessen hunger and gains in body fat. While there is a provocative temporal association of HFCS with the growing epidemics of obesity and type II diabetes, there are confounding covariables that make it difficult to label this food and drink sweetener as the prime culprit in the epidemics. Possible taxation on its inclusion in foods and beverages may be the only logical means to decrease or eliminate its use Continued on Page 33... www.sfms.org
Innovations in Food and Health
Mercury Update Where Things Stand as of April 2007 Jane Hightower, MD
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he issue of mercury pollution continues to bring us lively discussions pitting health impacts against economic ones. The American Medical Association (AMA), as a result of a resolution brought by the Illinois delegation, recently addressed the current state of mercury pollution. It identified the chlor-alkali manufacturing industry (which produces chlorine) as one of the chemical industries that was still continuing to dump mercury into the environment. While fifty-three plants in the USA had changed to a non-mercury system, nine plants in eight states still had not. These Hg-cell plants emit Mercury (Hg) into the air and water, and their contamination results in the accumulation of mercury and subsequent methylmercury in the surrounding fish and other wildlife. In recent years, sixty-five tons of mercury was unaccounted for by these plants, which prompted a 2003 EPA statement declaring, “The fate of all the mercury consumed at mercury-cell chlor-alkali plants remains somewhat of an enigma.” The industry, in turn, claimed the remainder mercury was contained on site within the manufacturing infrastructure and processing equipment. The AMA addressed the Clean Air Mercury Rule in its report as well, stating that the trading of air pollutants that the government was using as a mercury pollution control method was potentially harmful for vulnerable populations, and that the rule that was currently in place by our government was inconsistent with the AMA’s health-protective approach to air pollution. In the end, the AMA urged state governments to be proactive in protecting citizens from harmful mercury emissions, and for the reduction in mercury use in manufacturing whenever possible. It recommended inwww.sfms.org
creased vigilance, monitoring, and tracking of mercury use and emissions in chlor-alkali facilities that use mercury in the manufacturing processes. Lastly, the AMA encouraged the U.S. government to assume a leadership role in reducing the global mercury burden and work toward promoting binding, health-protective international standards (American Medical Association 2006). The federallyfunded Women, Infants, and Children program (WIC) had a recent victory. This program gives vouchers for the purchase of select food items to pregnant or nursing mothers, to include twenty-four ounces of albacore tuna per month. The women previously had no other nondairy protein options in the program. Quietly, on August 7, 2006, the Federal Register announced a proposed rule that stated, “for ease of administration by State agencies, to accommodate participant preferences, and to minimize intake of mercury, this proposed rule would authorize the following varieties of canned fish—light tuna, salmon, and sardines.” It also proposed to raise the amount of canned fish allowed to thirty ounces per month. The purchase of albacore tuna was no longer allowed with the federal government voucher (Federal Register 2006). In February of 2006 I published a paper on the prevalence of elevated mercury levels in the blood of Asians, Pacific Islanders, and Native Americans, otherwise known as “Other” by the Centers for Disease Control
(CDC). Although the CDC had been using this group’s data for the final analysis and interpretation of our United States population as a whole, the category itself was not entered into the tables of their reports. While the U.S. population as a whole had the prevalence of 5.66% being over 5.8 mcg/L Hg in their blood, the “Other” group was 16.59% over (Hightower 2006). It is still unclear why the CDC leaves the “Other” group off of their tables, but for California, it is especially important. In the 2000 United States Census, 4.1 million people identified themselves as Native American or Alaskan Native; 12.5 million identified themselves as Asian or Pacific Islander, with 51 percent residing in the West. This becomes even more important for our ongoing California Proposition 65 court battle over whether the mercury advisory should be placed near or on cans of albacore tuna. The tuna industry has convinced the judge in the case, through less-than-credible evidence by industry experts, that methylmercury was “naturally occurring” in the fish, which gave them a break under the statute. Also, the judge allowed a terrific amount of watering down through “averaging” of data, to the point of allowing the average albacore mercury levels to be averaged with the average chunk light mercury levels (albacore has three times more mercury than chunk light). As for the human data that is now available to the Continued on Page 33...
“The AMA encouraged the U.S. government to assume a leadership role in reducing the global mercury burden and work toward promoting binding, health-protective international standards.”
April 2007 San Francisco Medicine 31
Innovations in Food and Health
Improving the City’s Food System A Public-Private Partnership Works toward a Healthier San Francisco Paula Jones and Rajiv Bhatia, MD, MPH
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ike many urban centers, San Francisco faces significant challenges to creating and maintaining a healthy food system for all residents. Hunger and food insecurity are on the rise, and there is an ever-growing demand for food pantries and other forms of emergency food assistance. At the same time, the overabundance of cheap food of low nutritional quality contributes to an epidemic of obesity, diabetes, and other diet-related diseases. San Francisco takes pride in its high-quality and ethnically diverse restaurants, but many residents also lack affordable, healthy food options in their own neighborhoods. With federal and state budgets tightening, San Francisco risks cuts to crucial federal nutrition programs that serve our most vulnerable residents. Additionally, our food choices have resulted in environmental issues, including air and water pollution from food production, distribution, and processing; pesticide exposure; hazards to farmworkers; and the loss of California’s farm lands. San Franciscans recognize that all these food issues are linked together and that they are significant for public health, social justice, and ecological sustainability. These problems also require working across traditional sectors, using a systems-based approach. As a result, many government agencies, community-based organizations, residents, and businesses are now aiming to harness their collective power to find multiobjective solutions at every potential level of action. In 2005, in an action consistent with this systems approach, the San Francisco Food Alliance published the San Francisco Collaborative Food System Assessment to provide a baseline picture of San Francisco’s food system that includes retailers, distributors, federal nutrition programs, community 32 San Francisco Medicine april Medicine April 2007
gardens, school gardens, farmer’s markets, and regional agriculture. Food systems actors are working together through a diverse array of other collaborations, such as the San Francisco Unified School District Student
“Hunger and food insecurity are on the rise, and, at the same time, the overabundance of cheap food of low nutritional quality contributes to an epidemic of obesity, diabetes, and other diet-related diseases.” Nutrition and Physical Activity Committee, the Board of Supervisor’s Food Security Task Force, the Green Schoolyard Alliance, and the Shape Up Coalition. One key goal shared by many food systems stakeholders has been to increase the amount and quality of food resources for the city’s most vulnerable families. For example, approximately 40,000 San Franciscans are eligible for but not enrolled in the Food Stamp Program—the most widely used federal nutrition support program. Last fall, the San Francisco Human Service Agency, working in conjunction with the Food Security Task Force, was awarded $1 million by the USDA to improve food stamp access in San Francisco. San Francisco Food Systems, in partnership with the San Francisco Department of Public Health (SFDPH) Human Service Agency, worked with local farmer’s markets to implement systems
to ensure that low-income San Franciscans can use their food stamp benefits at San Francisco’s farmer’s markets. Another priority focus area has been the quality of food in public schools. In 2003, SFUSD’s Student Nutrition and Physical Activity Committee developed a nutrition policy that included high-priority pilot programs aimed at improving the utilization and quality of the school meal program. SFUSD, with the support of several committee members, has subsequently piloted many innovative programs, including the Grab ’n’ Go breakfast and daily offerings of fruit bars, and it has developed a model Wellness Policy. Through a partnership with The Fruit Guys, a locally owned produce company, SFUSD students have had access to organic and sustainably produced fruit through the school breakfast and lunch program. In 2006, SFUSD won the Congressional Victory against Hunger Award for its work to improve school meals. The Department of Children, Youth and their Families (DCYF) has also provided leadership to ensure that during the summer months, San Francisco’s school children have healthy meals in their neighborhoods. During the school year, approximately 21,000 school children eat free lunches at school, while during the summer months, only about 5,000 children participate in the federally sponsored Summer Food Service Program operated through neighborhood organizations. DCYF, along with the San Francisco Food Bank and many other community partners, has focused on three areas: enlisting more neighborhood organizations to participate, developing marketing information to inform parents, and including more varieties of summer fruit in the program. www.sfms.org
Work to provide healthier food resources at the neighborhood level has also enlisted small businesses. The Good Neighbor Project in Bayview Hunters Point is a collective effort by Literacy for Environmental Justice, the SFDPH, the Department of the Environment, and the Mayor’s Office of Economic Development, joining with San Francisco Community Power, Rainbow Grocery, and the San Francisco Produce Terminal. This collective has worked to support small business by providing the necessary refrigeration, in-store marketing materials, and branding to encourage shoppers to purchase healthier foods. There are now several Good Neighbor merchants in Bayview, including SuperSave and the Bayview Hunters Point Farmer’s Market. In 2006, Assemblymember Mark Leno used these programs as models in legislation that created a statewide “Healthy Purchase” pilot program to give corner store owners in lowincome areas assistance in providing fresh fruits and vegetables to their customers. The focus on vulnerable populations, schools, and neighborhoods is now trickling up to city level. An example of a citywide
food systems action is the 2006 Sustainable Food Policy by San Francisco Department of Public Health. This policy requires SFDPH to increase the amount of local, sustainable foods offered by contractors and served in the public hospitals and at department events. This SFDPH policy will ultimately serve as the foundation for a citywide sustainable-food purchasing policy. Other citywide strategies to improve our food system will require attention to land-use planning, in order to support neighborhood supermarkets and community gardens, and to fiscal mechanisms to support healthy choices. There is no shortage of ideas, and San Francisco is an ideal environment to support experimentation and innovation. Support for San Francisco’s local efforts and more long-lasting changes in regional and nationwide food systems also requires attention to federal policy. For example, the 2007 U.S. Farm Bill authorizes hundreds of billions of dollars in spending and affects the quality of food in every city. Fortunately, the broad participation in food systems efforts has led to awareness on the part of City lead-
Mercury Update Continued from Page 31...
court, the judge decided that a rat study from 1980 represented the “best quality” and that it yielded the lowest No Observable Effect Level (NOEL) for humans. In this study, sixteen pregnant rats were given varying doses of methylmercury during four days of gestation. The subsequent eighty pups were then put through a series of tests, to include pressing levers to obtain food. I saw nowhere in this paper that the rats were trying to get into Princeton. The Faroes and now even the Seychelles have seen adverse effects on the human fetus, but the industry argued about what “type” of studies could be allowed under the statute. It was a complicated mess and is now on appeal (Hightower 2006, the People vs. the State of California 2006, Bornhausen 1980). All in all, our Proposition 65 statute seems to be there to protect the “ordinary” or “average” consumer. According to the National Health and Nutrition Examination Survey (NHANES) data, not only www.sfms.org
do coastal people have higher mercury levels than inland people because of their increased fish consumption, we also have the “Other” people in higher numbers. Our “ordinary” in California is not the “ordinary” of Nebraska. As for fish consumption in adults, both men and women, the current advice is that two three-ounce servings or one six-ounce serving per week is where the benefits outweigh the risk, but up to twelve ounces is acceptable if the fish are low in contaminants (Mozaffarian 2006). Jane Hightower, MD, specializes in internal medicine at California Pacific Medical Center in San Francisco and has done extensive research on mercury exposure from fish in adults. She is a member of the San Francisco Medical Society and currently serves on the SFMS Board of Directors. A full list of references is available on our website at www. sfms.org.
ers of the impact of federal policy, and San Francisco has begun advocating for changes in the Farm Bill. These efforts call on the federal government to protect and enhance federal nutrition programs, support regional fruit and vegetable growers, and support ecologically sustainable farming practices. Establishing a coherent and healthy food system in a global economy is a daunting task, but effective solutions can be found by working across sectors with government agencies, community organizations, and businesses. Using a food systems approach, we hope San Francisco will help point the way forward. Paula Jones is the Director of San Francisco Food Systems at the SFDPH, and Rajiv Bhatia, MD, MPH, is the Director of Occupational and Environmental Health at the SFDPH. High-Fructose Continued from Page 30...
but is probably premature until and unless future research convincingly establishes its causal role. Selective elimination of HFCS from anyone’s diet is challenging, as it is contained in almost all U.S.-produced processed or prepared foods and is difficult to avoid if one eats out. Cautious reading of labels of any frozen, baked, or canned goods to prevent consumption of items containing HFCS is encouraged, along with exercise, well-balanced meals, and healthy lifestyles. Lucy Crain, MD, MPH, FAAP, is a member of the SFMS Board of Directors and a First Five San Francisco County Commissioner. She is Past President of the California District of the American Academy of Pediatrics and a former member of the national Board of Directors of the AAP. Since her retirement from full-time pediatric practice and teaching at UCSF, Dr. Crain continues to teach at UCSF as a member of the voluntary clinical faculty and consults at Lucile Packard Children’s Hospital at Stanford in the Child Development Clinic. Mel Heyman, MD, also contributed to this article. Dr. Heyman is Chief of Pediatric Gastroenterolgy at UCSF. A full list of references is available on our website at www.sfms.org.
April 2007 San Francisco Medicine 33
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book review Steve Heilig, MPH
What’s Gone Wrong with How We Produce Food? Fatal Harvest: The Tragedy of Industrial Agriculture Edited by Andrew Kimbrell ISLAND; 396 Pages; $75, $45 PAPERBACK
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here’s nothing more fundamental than food, and affluent Americans have more of it, with more variety to choose from, than anyone in history. But how many of us know where our food was actually produced, by whom, and with what resources and additives? How does the path from modern farm to kitchen affect people and the planet? “Fatal Harvest” is a huge work that addresses those sweeping questions. It is a beautiful, photo-laden, 5 1/2-pound treatise that might be called a coffee-table book—if the content weren’t so disturbing. Even a casual browser of these pages is warned to think twice about eating or drinking much of what is sold as food nowadays. It is an encyclopedia of what’s gone wrong with how we provide food in the modern world. “We eat our daily bread without being conscious of the massive loss of topsoil, diversity, and farm communities involved in its production,” writes editor Andrew Kimbrell. “We happily munch on hamburgers without a thought to the forest and prairie being destroyed for cattle grazing or the immense cruelty in the raising and slaughtering of the animals. Mothers continue to prod their children to eat their vegetables, unaware of the pesticide poisoning of our waters, farmworkers, and wildlife that is involved.” If these unappetizing charges sound mostly like environmental issues, they are, but they have seldom been presented as such. Farmer and philosopher Wendell Berry wrote the still-classic agricultural critique “The Unsettling of America” in 1977, and his new essays bookend this volume. He argues that the environmentalist agenda “has rarely included the economics of land use, without which the conservation effort becomes almost inevitably long on sentiment and short on practicality.” In other words, saving wilderness, however important, is not enough. What Berry and the many authors say we must conserve, and revitalize, is the smaller, decentralized farm, which was the norm until the past century of industrialization and consolidation. But is this vision realistic? Yes, say these authors, for it’s essential to the health and welfare of not only humans but all life as well. “A grassroots public movement for organic, ecological, and humane food is now challenging the decades-long hegemony of the corporate, industrial model,” Kimbrell notes. He then turns the examination of that model over to three dozen authors from diverse backgrounds who, in aggregate, present a devastating, perhaps overwhelming critique of modern “farming.” The attacks range from those based on abstract concepts to presentations of technical alternatives. Readers will confront convincing evidence that many of the promises of modern technological farming have not been fulfilled, and in fact have been counterproductive in many ways. Our foods—vegetables, nuts, grains, www.sfms.org
beans, fruits, coffee, dairy products, meats—you name it—are contaminated with unnecessary levels of pesticides, antibiotics and other dangerous chemicals. The amount and types of fertilizers used, which undeniably have increased farm yields in the past, are wasteful and vastly polluting. Water, an increasingly scarce necessity—“It is not a matter of ‘if’ but rather of when the West’s water resources will be completely depleted”—is squandered and polluted as well. Industrial agriculture also kills off nature itself, from the biodiversity of plants needed to maintain healthy soil to the birds and bees that help pollinate crops. And vast levels of human starvation and malnutrition persist despite the much-vaunted green revolution, which was supposed to solve that emotionally ungraspable tragedy. In fact, the suffering is worsening: “Since 1950, about one-third of American cropped land has been abandoned because of problems with soil erosion.” These failures, these authors hold, are both technological and economic. Quick fixes like genetically engineered, or GE, food and irradiation are shown to be chimeras with huge risks, which government watchdogs refuse to investigate fully, let alone regulate: “The FDA’s response to the potential toxicity problem with GE foods was, and continues to be, to ignore it.” Patenting of seeds and genes for profit promises more starvation than solutions. Overall, the corporate takeover of agriculture sacrifices food quality and safety to phantom efficiency, the smaller farmer to bankruptcy and despair, and the health and survival of millions to the bottom line. Gloomy? Yes. Unappetizing? Yes again. But the provoking of our gag reflex is intentional. “Fatal Harvest” aims for outrage, even in the otherwise unconcerned affluent gourmand: The loss of choices in foods is hammered home over and over again with astonishing illustrations of all the varieties of fruits and vegetables we are now denied because of “efficient” modern farming. The solutions? More organic farming, local control and a “natural systems” agriculture that works by “emphasizing Nature’s wisdom over human cleverness,” as farmer and professor Wes Jackson argues in perhaps the most important practical contribution herein. Many others, including local luminaries such as chef Alice Waters and Anuradha Mittal from the pioneering think tank Food First, offer supporting evidence and perspectives. The changes they urge will be vastly difficult to effect, more because of political obstacles than any other hurdles. But where is there more important a need? This book review originally appeared in the San Francisco Chronicle. april 2007 San Francisco Medicine 35
hospital news Kaiser
Robert Mithun, MD
Incorporating healthy food practices into the culture of the San Francisco Medical Center is one of the explicit goals of Kaiser Permanente’s Comprehensive Food Policy. As professed in the vision statement of the policy, “Kaiser Permanente aspires to improve the health of our members, employees, our communities, and the environment by increasing access to fresh, healthy food in and around our Kaiser Permanente facilities. We will promote agricultural practices that are ecologically sound, economically viable, and socially responsible by the way we purchase food.” Launched in fall 2005, the Healthy Picks program has successfully converted 50 percent of the regional vending machine items to healthy choices, including fresh fruit, dried fruits without added sugar, green tea drinks, and water. Subsequently, Kaiser expanded the project to hospital cafeterias and inpatient menus, and it has recently begun using fresh, seasonal produce from small, local farms in patients’ meals. All new food contracts are aligned with the philosophy and practice detailed in Kaiser’s National Food Purchasing and Labeling Guidelines. Whenever possible, the organization will choose to contract with those vendors who buy from locally owned and operated farms and businesses that supply seasonal and fresh products. We endeavor to purchase USDA Organic, Fair Trade, Food Alliance, Protected Harvest, or other third party-certified food from our vendors. Additionally, several Kaiser facilities host weekly farmer’s markets, easily accessible to members, physicians, and staff. The vendors offer produce and other products from a small geographic area, which allows for the least amount of environmental impact. Nutrition and medicine, once viewed by the medical community as very distant cousins, are now commonly held by many disciplines as being equally integral to good health and overall well-being. 36 San Francisco Medicine april 2007
CPMC
Damian Augustyn, MD
The Department of Urology held its First Annual Urology Update on Saturday, February 10, 2007, at the Mandarin Oriental Hotel in downtown San Francisco. Attended by urologists throughout the Sutter Health System, the program addressed the latest cutting-edge therapies, innovative surgical techniques, and practice management updates. The Department of Orthopaedic Surgery is proud to present “Hot Topics in Surgery of the Shoulder, Elbow, and Hand” on Friday, July 27, 2007, at the Miyako Hotel in San Francisco. An internationally recognized faculty will cover a variety of topics, including management of shoulder osteoarthritis in the young patient, “reverse” total shoulder replacement, options for treatment of large and massive rotator cuff tears, management of the stiff elbow, management of nonunions and radial nerve palsy in the humerus, and the use of pyrocarbon implants in the hand. Our guest speaker will be Dr. Wayne “Buzz” Burkhead, current President of the American Association of Shoulder and Elbow Surgeons. For more information, please contact Beverly Hoover at (415) 600-6484. Please save the date for the Second Annual CPMC Pediatric Hospitalist Medicine Conference. This two-day conference will take place October 25–26, 2007, at the Sir Francis Drake Hotel in San Francisco.
St. Luke’s
Jerome Franz, MD
March at St. Luke’s was dedicated to the reduction of medication errors. After last year’s report by the Institute of Medicine on the number of injuries suffered in this country from medications, and in line with JCAHO’s new requirements, St. Luke’s—like most hospitals—has launched a major effort to change our ways. The Director of Pharmacy, John Qaqundah, has led the program, holding in-services for all clinical employees, presenting a Grand Rounds on medication errors, and discussing the new policy with the medical staff at “Doctor Talk.” He deserves much credit for his persistence. Acknowledging our role as the fourth campus of CPMC, the medical staff leadership at St. Luke’s has entered into a strong partnership with administration to ensure a future for health care South of Market. The key is building practices of primary and specialty care that will continue to thrive, even if we are ultimately forced to close acute care due to seismic requirements. But we have not yet given up hope for our hospital, whose mission and rich history of providing care to an underserved population has inspired our careers. More in future columns.
Send Your Message to 2,500 Health Care Professionals The San Francisco Medical Society offers multiple advertising opportunities ranging from full-page, 4-color display ads to classified ads with discounted rates for members. Please contact Amanda Denz for more information, (415) 561-0850 extension 261 or adenz@sfms.org.
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hospital news Saint Francis
Guido Gores, MD
This spring brings appointment changes to Saint Francis Memorial Hospital, and this will be my last column as Chief of Staff. The nominee for my successor is Wade Aubry, MD, who will author this column moving forward. Dr. Aubry is an endocrinologist and internist and is a longtime member of the SFMH staff. He is an Associate Clinical Professor of Medicine at UCSF and a former Senior Vice-President and Chief Medical Officer for Blue Shield of California. For the past several years, he has served as the Chairman of the Saint Francis IRB. Dr. Aubry is also coauthor of the recently published False Hope: Bone Marrow Transplantation for Breast Cancer (Oxford University Press, 2007). Nominee for Secretary/Treasurer is family practitioner Patricia Galamba, MD. Dr. Galamba is Medical Director of the SFMH Palliative Care Program and a Trustee of the Board as well as Chair of the Bioethics Committee. Nominees for Medical Executive Committee Members at Large are Ronald Valmassy, DPM; Gifford Leoung, MD; Phillip Piccinnini, MD; and Peter Teng, MD. We welcome them to their new positions. At Saint Francis Memorial Hospital, innovation in nutrition and food was the subject of a recent Grand Rounds. The speaker was former staff member Melina Jampolis, MD, who spoke about healthy eating, diet fads, nutritional facts, the glycemic food index, and the role of metabolism. Dr. Jampolis serves as Discovery Network FitTV’s Diet Doctor and is the author of the recently published book No-Time-to-Lose Diet: The Busy Person’s Guide to Permanent Weight Loss (Nelson Books, 2007). I will be returning to full-time patient care and the practice of medicine. As I step down, I’d like to thank my colleagues for all their hard work and cooperation during my tenure. It’s been a pleasure working with you all.
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St. Mary’s
Kenneth Mills, MD
In a recent article in The New York Times, writer Michael Pollan examined diets and the history of dietary science in America. He concluded that despite all the proposed innovations in dietary recommendations, very little actually seems to be making any significant difference to the health of Americans. In Pollan’s article, he discussed nutritionism—an ideology in which the key to understanding foods is a focus on the individual nutrients. This ideology has driven much of diet research, both currently and in the past. Unfortunately, studying nutrients individually does not account for other effects, such as the concurrent influence of other nutrients, lifestyle factors, or even cultural and biological factors. According to Pollan, the Western diet we Americans have become accustomed to has a surfeit of meats and processed foods, with lots of added sugars and fats. What are missing are the fruits and vegetables. Nutritionism takes this Western diet as a given and simply tries to modify it by telling people to eat more of this nutrient (such as “whole grains”) and less of that nutrient (such as saturated fats). After decades of nutrient-based advice, obesity and diabetes are on the rise. The Western diet is glamorous, and 17,000 new food products are introduced every year. Americans now find themselves relying on science, journalism, and marketing to help decide what to eat. Pollan says that there are simpler solutions to this problem. Among his suggestions are: don’t eat anything that your great-great-grandmother wouldn’t recognize as food; and avoid foods that bear health claims, since they are usually heavily processed. At St. Mary’s, we try to provide meals that are both enjoyable and nutritious. We don’t follow fads. Eating in a manner that is both healthy and realistic can be confusing, given all the conflicting advice. At St. Mary’s, our registered dietitians and Nutrition Services staff help sort it all out.
UCSF
Ronald Miller, MD
UCSF welcomes the arrival of the first member of a team that is developing the first headache clinic in the West with an inpatient component for diagnosis and treatment. Assistant Professor Abraham Nagy has begun seeing patients, and in the coming months he will be joined by other neurologists, fellows, residents, nurses, and support staff. He comes to UCSF from the Headache Group at the Institute of Neurology, University College of London, Queen Square. Leading the team will be Peter J. Goadsby, MD, PhD, who will arrive at UCSF Medical Center in the next few months. Rounding out the team of attendings will be Manjit S. Matharu, MB, ChB, MCRP, who was a clinical fellow with Goadsby and Nagy. “Our goal is to provide consultation for the worst of the worst,” Nagy says. “The goal is not to provide continuing care, but to give patients the tools, which may include medication or lifestyle changes, to deal with their headaches.” There are plans to begin clinical trials as well as basic research, once the entire team is here. “More people suffer from headaches than those who suffer from diabetes and heart disease combined,” Nagy says. “While [headaches] may not be treated as seriously as some other afflictions, we have to remember a day with a migraine is a day a person is not able to function.” Nagy is currently seeing patients in the outpatient clinic at 400 Parnassus, but when the entire team is assembled, its members will be seeing inpatients and outpatients at Mt. Zion. For appointments, call the Neurology Clinic at (415) 353-2273.
april 2007 San Francisco Medicine 37
Veterans
Diana Nicoll, MD, PhD, MPA
Americans tend to be overweight, and unfortunately veterans are no exception. Karen Arnold, MA, RD, Chief of the Nutrition and Food Service at SFVAMC, acknowledges that 73 percent of veterans are overweight and nearly a third are obese. In response, body mass index (BMI) is now routinely calculated for every new patient at SFVA Medical Center and community outpatient clinics. Veterans with elevated BMIs are referred through the VA’s electronic medical records system to appropriate weight-loss interventions. To meet the demand, new classes, individual counseling, and ongoing support groups have been formed. Medical Center inpatient meals have been modified to meet current guidelines and recommendations for good nutrition. Goals include limiting fat to no more than 30 percent of calories, increasing monounsaturated fats, eliminating trans fats, and reducing sodium levels to less than three grams per day. Meals also include more fiber than before, with larger portions of vegetables and 100 percent whole wheat bread and rolls. VA nursing home care is transitioning to resident-centered care, which promotes the idea that the nursing home is the resident’s home, whatever the length of stay. Dietarily, this means more choice, flexibility of meal times, and liberalized diets. The VA employee cafeteria switched to trans fat-free cooking oil in mid-2006. Employees can find noontime healthy cooking demonstrations and information tables covering current nutrition and health topics. To promote employee health and wellness, there are noontime walks, “Move to Music” programs, and after-work yoga classes. The SFVAMC Nutrition and Food Service is developing partnerships with local small farms to bring fresh, locally grown produce to its menus and to support local agriculture. 38 San Francisco Medicine april 2007
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Special Event
June 27, 2007 New Orleans Common Ground Clinic and Road Recovery Benefit Concert The Great American Music Hall Sponsored by the Smith Family Foundation. For more information please see www.FreeCC.org.
New SFMS Members
interested in sponsoring a new member?
The San Francisco Medical Society would like to extend a warm welcome to the following new members:
SFMS has embarked on a New-Member Sponsorship program. Upon approval by the Board or Executive Committee, each new member is assigned a sponsor, an established SFMS member whose primary responsibility is to help the new member become better acquainted with the Society and its benefits. Sponsors are expected to connect at least once with the new member socially (over breakfast or coffee, for example) and to invite the member to at least one SFMS event (such as the Annual Dinner, Legislative Day, Candidate’s Night, or a Mixer) during the course of their first year of membership. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org for more information or to volunteer.
From the Permanente Medical Group: Aaron M. Lewis, MD Ingrid T. Lin, MD Students: Alvin Teodoro UCSF Rajesh Jaganath UCSF
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In Memoriam Stephen J. Askin, MD Robert A. Major, MD Dr. Major was born in Hearne, Texas, on December 20, 1920, and died at Palo Alto on January 11, 2007. He is predeceased by his parents, Maggard Key Major and Leta Allen Major, and his brothers, Alexander David Major, MD, Millard Holland Major, and John William Major, MD. Bob graduated from Bowie High School (Bowie, Texas) in 1936; he graduated from Texas A&M in 1938. His medical education was at Baylor Medical School in Dallas Texas, graduating in May, 1942. He joined the Army Medical Corps and was sent to Europe in July, 1944, with the Fifth Auxiliary Surgical Group from Texas, landing on Utah Beach in August. He worked as an anesthesiologist and assistant surgeon, serving in field hospitals in Holland, Belgium, France, and Germany as part of General Patton’s Ninth Army. He was discharged in May 1946 as Major Major. Back in Texas, Bob went into practice with his physician brothers, David and John. They practiced in Nocona at a new hospital built for them by their parents; they had a large and successful practice there. However, in 1956, Dr. Major made a big move west to open a practice in San Francisco on Taraval Street. In that same year, he married Patricia Carson, who was to be his wife of more than fifty years.Bob continued to practice out of his Taraval Street office until his retirement a few years ago. He was on staff at St. Luke’s Hospital, California Pacific Medical Center, and St. Mary’s Hospital. He was active at St. Luke’s, where he was well known as an excellent clinician and surgical assistant. With his outgoing personality and sense of humor, he had many friends. When he attended hospital parties wearing a pair of Texan boots, he could be the life of the party. He seemed to thoroughly enjoy caring for his patients, but he recently requested these words on his tombstone: “He’s Not on Call Anymore.” His affiliations included membership in the American Medical As-
sociation, American Academy of General Practice, American Academy of Family Physicians, and American Board of Family Medicine. He was director of the California Academy of Family Practice, editor of the GP Journal for six years, Assistant Clinical Professor at UCSF, and Assistant Clinical Professor at Stanford. Ruben E. Montes, MD Ruben E. Montes, Jr., a neurologist and Director of the Stroke Center at Kaiser Permanente of San Francisco, died at home on January 17, 2007, at the age of 41. He was also a prominent figure skating judge, following a successful career in competitive figure skating. Dr. Montes is survived by his partner of twelve years, David Lewis; his parents, Ruben Montes, Sr., and Mary Montes; and his sisters, Marisa Montes and Dr. Marisol Montes Ortiz. Dr. Montes completed his early schooling in the Monterey area where he grew up, finishing high school at the Robert Louis Stevenson School. He attended Dartmouth College and graduated from U.C. at Berkeley with a bachelor’s degree in biology. His medical school was UCSF; he completed a medical/neurology residency at Stanford and a neurology fellowship at Harvard. He then began practice in neurology at Kaiser and was appointed Director of the Stroke Center. Young Ruben began ice skating at age ten, and, given his love of the sport, became quite proficient. He entered competitions and won gold medals in singles as well as pairs competitions. After he retired from competition he became a skating judge, quickly rising to become a U.S. national and international judge and the first judge of the Puerto Rican Figure Skating Association.
Broadway Medical Clinic, LLP Portland, Oregon
BC/BE Internist sought for highly respected established multi-specialty group practice. Thriving outpatient practice with some inpatient responsibilities. Minimal call of 1:10 and four day workweek allows balance of work and lifestyle. Excellent support staff and full business office maximizes your time in providing patient care. Site offers full lab, xray, ultrasound, digital mammography, DEXA, treadmill and Holters. Very flexible vacation and generous CME, medical and 401(k) plan. Portland is a fantastic city with multiple cultural activities, outdoor recreation and within a short drive to the rugged coast or mountains. Practice medicine as you envision in a well compensated fee for service practice. Please respond by March 31, 2007. Contact Dr. James Johnson at jcjohnson@ broadwaymedicalclinic.com or fax resume to 503-382-7706. www.sfms.org
april 2007 San Francisco Medicine 39
Northern California Physician Opportunities Sutter Health offers a wide variety of practice styles, geographies, and life styles. With facilities in Northern California from the Oregon Border to the Central Valley, and from the Pacific Coast to the Sierra Foothills, you have boundless career opportunities to fit your goals. We have open opportunities in a variety of specialties. Contact us for more information.
Sutter Health Physician Recruitment 866-448-7070 916-454-6645 fax docjobs@sutterhealth.org www.sutterhealth.org
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